Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tonganoxie Terrace during CMS and state inspections, most recent first.
A resident was not adequately prepared for a safe transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences, resulting in a deficiency related to transfer/discharge planning.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
The facility failed to implement a water management program to prevent Legionella disease and did not ensure adequate infection control practices related to catheter care. Staff were unaware of the water management requirement, and multiple observations revealed improper handling of urinary catheters, including lack of privacy bags, inadequate disinfection, and poor hand hygiene. These deficiencies placed residents at increased risk for infection.
The facility failed to provide the required 12 hours of in-service education for CMAs and CNAs, placing residents at risk of receiving impaired care. This deficiency was confirmed by the Director of Nursing and was in violation of the facility's Competency of Nursing Staff policy.
The facility failed to ensure a safe environment and prevent accidents for residents. One resident burned his fingers while smoking due to inadequate safety assessments and preventive actions. Another resident with severe cognitive impairment was not re-evaluated for smoking safety for over two years. Additionally, the facility did not investigate or implement interventions to prevent falls and injuries for two residents, placing them at risk for further harm.
The Consultant Pharmacist failed to identify and report medications administered outside of physician-ordered parameters for several residents, including blood pressure medications and insulin. This oversight placed residents at risk for adverse side effects and unnecessary medications. Additionally, the CP did not address the inappropriate use of Seroquel for a resident with Alzheimer's.
The facility failed to properly label and manage insulin medications for three residents, leading to potential risks for ineffective medication administration. Insulin flex pens for two residents were not dated when opened, and an outdated insulin vial for another resident was not discarded. Administrative Nurse D confirmed that the facility's protocol requires nurses to date insulin when opened and discard it when outdated.
The facility failed to identify and investigate injuries of unknown origin in a resident with severe cognitive impairment and multiple medical conditions. The resident sustained two skin tears on separate occasions, but no investigation was conducted to determine the cause of the injuries, placing the resident at risk for ongoing abuse and/or neglect.
The facility failed to investigate two injuries of unknown origin for a resident with multiple health conditions, including dementia and congestive heart failure. Despite the facility's policy requiring investigation and reporting of all incidents, no investigation was conducted, placing the resident at risk for unidentified and ongoing abuse or neglect.
The facility failed to develop comprehensive care plans for three residents, leading to impaired care due to uncommunicated care needs. One resident's care plan lacked interventions for managing diabetes and preventing falls, another resident's care plan did not address behaviors and mood, and a third resident's care plan did not include smoking safety measures after a burn injury.
The facility failed to review and revise care plans for a resident with chronic pain and another with skin tears, leading to inadequate pain management and increased risk of injuries. The care plans lacked necessary interventions, and the facility did not investigate incidents or document alternative measures, resulting in uncommunicated care needs and impaired care.
The facility failed to provide necessary bathing services for three residents, leading to extended periods without showers and placing them at risk for impaired health. Despite being scheduled for regular showers, documentation showed multiple refusals without follow-up or reapproach by staff. Observations confirmed the residents' unkempt appearances, and staff verified the lack of adherence to the facility's policy on documenting refusals and follow-up actions.
The facility failed to provide appropriate catheter care and infection control practices for two residents, leading to increased risk of infection and other catheter-related complications. Observations revealed improper handling of urinary catheter bags, lack of privacy covers, and failure to disinfect catheter ports, contrary to the facility's policies.
The facility failed to provide non-medicinal pain relief measures and promote effective pain management for a resident with chronic pain. Despite receiving scheduled and PRN pain medications, the resident reported inadequate pain control. The care plan lacked direction for non-medication pain relief measures, and staff did not consistently offer or attempt alternative pain interventions. This placed the resident at risk for ongoing severe pain and impaired quality of life.
The facility failed to provide necessary dementia care and services for two residents, leading to unmanaged aggressive behaviors and expressions of wanting to die. The care plans lacked specific interventions, and staff were not adequately informed or trained to manage the residents' conditions effectively, placing them at risk for abuse and decreased quality of life.
The facility failed to notify the physician of abnormal blood sugars and did not monitor blood pressure before administering medication for a resident. Another resident received blood pressure medication and insulin despite physician orders to hold them if certain parameters were not met. These actions placed the residents at risk for adverse medication effects.
A resident with Alzheimer's received Seroquel without appropriate indication or documented physician rationale, including unsuccessful attempts for nonpharmacological symptom management. The facility's policy required addressing all potential causes of behavioral symptoms before considering antipsychotic medications, but this was not followed, placing the resident at risk for adverse side effects.
A resident with multiple health conditions received midodrine and metoprolol outside of physician-ordered blood pressure parameters multiple times over three months. Staff lacked understanding and proper communication regarding medication orders, and the facility failed to perform competency checks despite re-education efforts.
Failure to Ensure Resident-Centered and Safe Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not completed, resulting in a deficiency related to resident-centered care and safe transition planning.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from facility staff, resulting in unmet care needs for those individuals. No additional details about the specific residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Water Management Program and Inadequate Catheter Care
Penalty
Summary
The facility failed to implement a water management program to prevent Legionella disease, as required by the Centers for Medicare and Medicaid Services (CMS). Maintenance and administrative staff were unaware of the requirement, and the facility had no current program in place. This failure placed residents at risk of contracting Legionella pneumonia, particularly those over the age of 50 or with weakened immune systems, chronic lung disease, or heavy tobacco use. Additionally, the facility did not ensure adequate infection control practices related to catheter care. Observations revealed that staff did not use privacy bags for urinary catheter drainage bags, allowing urine to be visible from the hall. Staff also placed measuring containers on bare floors, did not disinfect catheter ports, and failed to change gloves or wash hands between handling different types of catheters. These practices were observed with multiple residents, including one who had recently completed antibiotic treatment for a urinary tract infection. Interviews with various staff members confirmed that the observed practices were not in line with the facility's policies. Staff acknowledged that catheter bags should not be placed on the floor, should be kept in privacy bags, and that proper hand hygiene and disinfection protocols should be followed. The facility's policies directed staff to maintain a clean technique, keep catheter tubing and drainage bags off the floor, and prevent contact of the drainage spigot with nonsterile containers. The failure to adhere to these policies placed residents at increased risk for infection.
Failure to Provide Required In-Service Education for Nursing Staff
Penalty
Summary
The facility failed to provide the required 12 hours of in-service education for Certified Medication Aides (CMAs) and Certified Nursing Assistants (CNAs). Specifically, CMAs R, RR, and SS, as well as CNA P, lacked documentation of the required training. This deficiency was identified through a review of the facility's annual in-service documentation and was confirmed by Administrative Nurse D, who has been serving as the Director of Nursing since November 2023. Administrative Nurse D acknowledged the absence of evidence showing that the sampled CNA staff had completed the required 12 hours of in-service education. The facility's Competency of Nursing Staff policy mandates that all nursing staff meet specific competency requirements as defined by state law, including annual and facility-specific competencies. Despite this policy, the facility did not ensure that the required in-service education was provided. This failure placed residents at risk of receiving impaired care, as the staff may not have been adequately trained to meet the residents' needs as identified through assessments and care plans.
Failure to Ensure Safe Environment and Prevent Accidents
Penalty
Summary
The facility failed to ensure an environment free from preventable accident hazards for a resident who burned his fingers while smoking. The resident, who had intact cognition and several medical conditions including neuromuscular dysfunction of the bladder, diabetes mellitus, and pneumonia, was not properly assessed for smoking safety upon admission. Despite a care plan that required supervision and the use of a cigarette holder and smoking apron, the resident burned his fingers twice due to a lack of feeling in his fingers. The facility did not conduct a timely smoking safety assessment or implement preventive actions to prevent future burns, placing the resident at risk for injuries and pain related to burns. Another resident with bilateral above-the-knee amputations, diabetes mellitus, dementia, and anxiety was also not properly assessed for smoking safety. The resident's last smoking safety assessment was conducted over two years ago, and the facility failed to re-evaluate the resident's ability to smoke safely on a quarterly basis as required by their policy. This oversight placed the resident at risk for preventable accidents and related injuries. Additionally, the facility failed to investigate and implement interventions to prevent falls and injuries for two other residents. One resident with congestive heart failure, diabetes mellitus, osteoporosis, dementia, and anxiety experienced multiple skin tears, but the facility did not investigate the incidents or develop preventive measures. Another resident with dementia, diabetes mellitus, and hypertension had a history of falls but lacked care-planned interventions to prevent further falls. The facility did not complete a fall investigation for one of the resident's falls and failed to implement resident-centered interventions to prevent falls, placing the resident at risk for further injuries.
Consultant Pharmacist Fails to Identify and Report Medication Errors
Penalty
Summary
The Consultant Pharmacist (CP) failed to identify and report medications administered outside of physician-ordered parameters for several residents, placing them at risk for adverse side effects and unnecessary medications. For Resident 15, the CP did not report that midodrine was administered 29 times when the resident's blood pressure was above the ordered parameters. Despite the pharmacist's recommendation to obtain hold parameters for another medication, there was no mention of the errors related to midodrine administration. This oversight was confirmed by the administrative nurse and a certified medication aide who admitted to not understanding the symbols indicating when to hold the medication. For Resident 31, the CP did not identify that staff failed to obtain blood pressure readings before administering lisinopril, a medication for hypertension, 78 times. The administrative nurse verified this oversight and expressed confusion as to why the pharmacist had not identified the issue. The facility's policy required the CP to perform a thorough medication regimen review to prevent and resolve medication-related problems, but this was not adhered to in this case. Resident 6 also experienced similar issues, with blood pressure medications and insulin being administered multiple times when the physician's orders indicated they should be held. The CP's monthly reviews did not note these discrepancies, and the administrative nurse confirmed the oversight. Additionally, Resident 4 was given Seroquel for an inappropriate indication (Alzheimer's), and the CP failed to recommend an appropriate indication for its continued use. The administrative nurse verified that the pharmacist had sent monthly reviews but did not address the inappropriate use of Seroquel.
Failure to Properly Label and Discard Insulin
Penalty
Summary
The facility failed to properly label and manage insulin medications for three residents, leading to potential risks for ineffective medication administration. Specifically, the insulin flex pens for two residents were not dated when opened, and an outdated insulin vial for another resident was not discarded. These observations were made during a survey of the facility's medication carts, where it was found that the Humalog flex pens for two residents lacked both an open date and a discard date. Additionally, a Lantus vial for another resident had an open date that indicated it should have been discarded but was still present in the medication cart. Administrative Nurse D confirmed that the facility's protocol requires nurses to date insulin when opened and discard it when outdated. The facility's Insulin Administration policy also mandates that the expiration date be recorded on the vial when opened. The failure to adhere to these protocols was verified by the administrative nurse, who acknowledged that the night nurse should check for expired medications and that every nurse administering medications should ensure they are not outdated. This lapse in protocol placed the residents at risk for receiving ineffective medications.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure staff identified injuries of unknown origin as potential allegations of abuse and report them to the administrator for investigation. This deficiency was observed in the case of a resident with severe cognitive impairment and multiple medical conditions, including congestive heart failure, diabetes mellitus, osteoporosis, dementia, and anxiety. The resident, who was dependent on staff for most activities of daily living and used a wheelchair for mobility, sustained two skin tears on separate occasions. The first injury was a large skin tear on the right lower extremity, and the second was a skin tear on the right lateral calf. Despite these injuries, the facility's records lacked any investigative notes, and administrative staff were unaware of how the injuries occurred, indicating that no investigation was completed to determine the cause of the injuries. The facility's policy on Accident and Incidents-Investigating and Reporting required that all accidents or incidents involving residents be investigated and reported to the administrator. However, the facility staff failed to follow this policy, as evidenced by the lack of investigation into the resident's injuries. The administrative nurse confirmed that the facility did not investigate the incidents to determine their cause. This failure to identify and investigate injuries of unknown origin placed the resident at risk for unidentified and ongoing abuse and/or neglect.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to investigate two injuries of unknown origin for a resident, which could have ruled out possible abuse or neglect. The resident had a history of congestive heart failure, diabetes mellitus, osteoporosis, dementia, and anxiety, and was dependent on staff for most activities of daily living. The resident's medical records documented a large skin tear on the right lower extremity on one occasion and a skin tear on the right lateral calf on another occasion. Despite these injuries, the facility did not conduct any investigation to determine the cause of the injuries, as confirmed by the administrative nurse. The facility's policy required that all accidents or incidents involving residents be investigated and reported to the administrator, with specific data included in the report. However, the facility did not follow this policy for the resident's injuries. The lack of investigation placed the resident at risk for unidentified and ongoing abuse or neglect. The facility's failure to investigate these injuries was a clear violation of their own policies and procedures, as well as a failure to ensure the safety and well-being of the resident.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to impaired care due to uncommunicated care needs. Resident 31, diagnosed with dementia, diabetes mellitus, and hypertension, had a care plan that lacked interventions for managing diabetes and preventing falls. Despite multiple falls and blood sugar levels outside the ordered parameters, the care plan did not provide adequate direction to staff, and the physician was not notified of abnormal blood sugar levels on numerous occasions. Observations revealed that Resident 31 was often left unattended, increasing the risk of falls and further injury. Resident 77, with diagnoses including vascular dementia, depressive disorder, and diabetes mellitus, exhibited behaviors such as refusing care, expressing a desire to die, and urinating on the floor. The care plan did not address these behaviors or provide interventions for managing the resident's mood and verbalizations of wanting to die. Despite multiple incidents of aggressive behavior and statements about self-harm, the facility did not follow up with psychiatric evaluations or implement consistent safety checks. Staff were aware of the resident's behaviors but did not take appropriate actions to address them in the care plan. Resident 29, admitted with neuromuscular dysfunction of the bladder, diabetes mellitus, and pneumonia, began smoking at the facility but did not have a comprehensive care plan for smoking safety. After burning his finger while smoking, the resident's care plan was updated to include supervision and the use of a cigarette holder and smoking apron. However, the facility failed to perform a smoking assessment when the resident started smoking and did not document the burn on the skin assessment. Staff did not reassess the resident's smoking practices after the incident, leading to continued risk of injury.
Failure to Review and Revise Care Plans for Pain Management and Skin Tear Prevention
Penalty
Summary
The facility failed to review and revise the care plan for a resident with chronic pain, leading to inadequate pain management. The resident, who had diagnoses including alcohol dependence, chronic pain in the right shoulder, and dorsalgia, reported constant severe pain that interfered with sleep and activities. Despite receiving scheduled and PRN pain medications, the care plan lacked non-medication pain relief measures. Observations and interviews revealed that the resident's pain was not adequately managed, and alternative pain relief interventions were not offered or documented by the staff. The facility's care planning policy was not followed, resulting in uncommunicated care needs and impaired care for the resident. Another resident with diagnoses including congestive heart failure, diabetes mellitus, osteoporosis, dementia, and anxiety experienced skin tears that were not adequately addressed in the care plan. The resident, who had severely impaired cognition and was dependent on staff for most activities of daily living, had a care plan that directed staff to use pressure-reducing measures and provide substantial assistance with transfers. However, after skin tears occurred, the care plan was not updated with new interventions to prevent further injuries. The facility also failed to investigate the incidents, leaving the causes of the skin tears unknown. Observations and interviews confirmed that the facility did not follow its care planning policy, resulting in uncommunicated care needs and increased risk of injuries for the resident. The facility's failure to review and revise care plans for pain management and skin tear prevention led to impaired care for the residents. The care plans did not include necessary interventions, and the facility did not investigate incidents or document alternative measures. This lack of communication and adherence to care planning policies placed the residents at risk for inadequate care and further injuries.
Failure to Provide Necessary Bathing Services
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene, including bathing, for three residents, placing them at risk for impaired health and decreased psychosocial well-being. Resident 4, diagnosed with Alzheimer's, major depressive disorder, congestive heart failure, and atrial fibrillation, required substantial assistance for most activities of daily living, including bathing. Despite being scheduled for showers twice a week, documentation revealed multiple instances where the resident refused showers without any follow-up or reapproach by staff, resulting in the resident not receiving a shower for extended periods. Resident 41, with diagnoses including bilateral above-the-knee amputations, diabetes mellitus, dementia, and anxiety, also required extensive assistance for bathing. The resident's records showed numerous refusals of showers without follow-up or reapproach, leading to significant gaps between showers. Observations confirmed the resident's unkempt appearance, and staff verified the lack of documentation and follow-up for missed showers. Resident 30, who had chronic pain and dorsalgia, required partial moderate assistance for bathing. Despite having intact cognition and no rejection of care behavior, the resident's records indicated consistent refusals of showers without evidence of reapproach or alternative hygiene options being offered. Staff interviews revealed a lack of coordination and follow-up for missed showers, and observations confirmed the resident's unclean state. The facility's policy required documentation of refusals and follow-up actions, which were not adhered to, resulting in the failure to provide necessary care and bathing services for these residents.
Deficient Catheter Care and Infection Control Practices
Penalty
Summary
The facility failed to provide appropriate care and services to prevent potential infection of the urinary system for two residents, R29 and R17, during care for their urinary catheters. For R29, the facility did not maintain proper infection control practices. Observations revealed that the urinary catheter bag was frequently placed on the floor without a privacy cover. Additionally, staff did not use disinfectant wipes on the catheter port and placed a measuring canister on a visibly soiled floor. These actions were contrary to the facility's policy, which required maintaining a clean technique and ensuring the catheter tubing and drainage bag were kept off the floor. R29 had a history of neuromuscular dysfunction of the bladder, diabetes mellitus, and recurrent urinary tract infections, which placed him at higher risk for complications. Despite these conditions, the facility's staff failed to adhere to proper catheter care protocols, leading to an increased risk of infection and other catheter-related complications for R29. Similarly, R17's care was compromised due to improper handling of the urinary catheter and nephrostomy bags. Observations showed that the urinary catheter drainage bag was hung on the side of the bed without a privacy bag, making the urine visible from the hall. Staff placed a measuring container on the bare floor and did not disinfect the catheter port before and after emptying the urine. Additionally, staff did not change gloves or wash hands between handling the Foley and nephrostomy bags. These actions were inconsistent with the facility's policy, which required maintaining a clean technique, using alcohol wipes on the port, and changing gloves between tasks. R17 had a history of diabetes mellitus, obstructive and reflux uropathy, paraplegia, and recurrent urinary tract infections, making her particularly vulnerable to infections. The facility's failure to follow proper catheter care protocols placed R17 at increased risk for infection and other catheter-related complications. The facility's policies on catheter care, dated 2014, directed staff to maintain an accurate record of daily output, keep the tubing free of kinks, and always position the drainage bag lower than the bladder. Staff were also required to maintain a clean technique when handling or manipulating the catheter, tubing, or drainage bag, and to ensure the catheter tubing and drainage bag were kept off the floor. Despite these clear guidelines, the facility failed to ensure appropriate catheter care and services for both R29 and R17, leading to deficiencies in infection control practices and placing the residents at risk for catheter-related complications.
Failure to Provide Non-Medicinal Pain Relief Measures
Penalty
Summary
The facility failed to provide non-medicinal pain relief measures and promote effective pain management for a resident (R30) who experienced almost constant severe pain. R30 had diagnoses of alcohol dependence, chronic pain in the right shoulder, and dorsalgia. Despite receiving scheduled and PRN pain medications, including Tylenol and oxycodone, R30 reported that his pain control was inadequate. The care plan for R30 lacked direction for non-medication pain relief measures, and the EMR did not show evidence that staff consistently offered or attempted non-pharmacological interventions to treat pain. Observations and interviews revealed that R30 was not offered alternative pain interventions such as heat or cold therapy, aromatherapy, or music therapy, and staff primarily relied on medication to manage his pain. R30's care plan directed staff to administer analgesia per orders, evaluate the effectiveness of pain interventions, and notify the physician if interventions were unsuccessful. However, the care plan did not include specific non-medication pain relief measures. The facility's Pain-Clinical Protocol policy stated that staff should provide elements of a comforting environment and appropriate physical and complementary interventions, but this was not consistently implemented for R30. The resident's pain level remained high, and he frequently sought pain medication, indicating that the current pain management strategies were ineffective. Interviews with staff members, including a CNA and a licensed nurse, confirmed that non-medication pain relief interventions were not consistently offered to R30. The administrative nurse acknowledged that staff should have offered alternative pain relief measures and documented their attempts. The facility's failure to provide non-medicinal pain relief measures and promote effective pain management for R30 placed the resident at risk for ongoing severe pain and impaired quality of life.
Failure to Provide Adequate Dementia Care and Behavioral Health Services
Penalty
Summary
The facility failed to provide the necessary dementia care and services to attain or maintain the highest level of practicable physical, mental, and psychosocial well-being for two residents, R26 and R77. R26 had diagnoses of mild cognitive impairment, cognitive communication deficit, and cerebral infarction. Despite displaying aggressive behaviors such as hitting, biting, and attempting to pull her roommate out of bed, the facility did not investigate the incident to identify potential triggers or causative factors. Additionally, R26's care plan lacked specific interventions related to her cognitive impairment and behaviors, and staff were not adequately informed or trained to manage her behaviors effectively. R77 had diagnoses of vascular dementia, depressive disorder, cerebral infarction, hemiparesis/hemiplegia, epilepsy, and diabetes mellitus. Despite multiple instances of expressing a desire to die, refusing care, and displaying aggressive behaviors such as kicking and scratching staff, the facility did not provide adequate person-centered interventions. The care plan for R77 lacked direction regarding his mood and verbalizations of wanting to die. The facility also failed to follow up with a Geri-Psych hospital for placement and did not implement consistent safety checks or alternative interventions when R77 refused to see a therapist. The facility's Behavioral Health Services policy stated that residents would receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being. However, the facility did not adhere to this policy for both R26 and R77. The lack of person-centered interventions and failure to investigate and address the residents' behaviors placed them at risk for abuse and decreased quality of life.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to notify the physician of blood sugars outside of ordered parameters for Resident 31 and did not monitor Resident 31's blood pressure before administering medication for high blood pressure. Resident 31 had diagnoses of dementia, diabetes mellitus, and hypertension. The care plan for Resident 31 lacked interventions or directions for monitoring side effects from medications related to diabetes and hypertension. The Treatment Administration Record (TAR) documented multiple instances where blood sugars were outside the ordered parameters, and the physician was not notified. Additionally, there was no documentation of blood pressure being checked before administering lisinopril for 78 administrations since the start of the medication. The facility also failed to hold blood pressure medication and insulin when the medication was out of the physician-ordered parameters for Resident 6. Resident 6 had diagnoses of hypertension and diabetes mellitus and was independent for most activities of daily living. The Medication Administration Record (MAR) documented several instances where blood pressure medications and insulin were administered despite the physician's orders to hold them if certain parameters were not met. Specifically, hydralazine, Cozaar, and metoprolol were administered multiple times when the systolic blood pressure was less than 110 mmHg, and Humalog insulin was administered when the finger stick blood sugar was less than 110 mg/dL. Observations and interviews with staff confirmed these deficiencies. Administrative Nurse D verified that the care plan for Resident 31's diabetes should have been completed and that blood sugars outside of the ordered parameters were not reported to the physician. Additionally, it was confirmed that staff had not obtained Resident 31's blood pressure before administering blood pressure medication. For Resident 6, it was verified that staff should have held the insulin and blood pressure medications as ordered when the parameters were not met. The facility's policies on administering medications and monitoring vital signs were not followed, placing the residents at risk for adverse medication effects.
Inappropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure an appropriate indication or a documented physician rationale for the continued use of antipsychotic medication for a resident diagnosed with Alzheimer's. The resident's electronic medical record lacked documentation of unsuccessful attempts for nonpharmacological symptom management and a risk versus benefits analysis for the continued use of Seroquel. The resident's care plan noted the use of antipsychotic medication and the need for monitoring side effects, but the physician's order did not provide a valid indication for the medication's use. Observations revealed that the resident received Seroquel despite spitting out other medications, and the administrative nurse confirmed the inappropriate indication for the antipsychotic medication. The facility's policy on antipsychotic medication use required that all potential causes of behavioral symptoms be identified and addressed before considering such medications. However, the facility did not adhere to this policy, as evidenced by the lack of documented rationale and nonpharmacological interventions for the resident. This failure placed the resident at risk for adverse medication side effects, as the facility did not ensure the antipsychotic medication was used appropriately and with proper documentation.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to prevent significant medication errors for a resident diagnosed with end-stage renal disease, hypertension, diabetes mellitus, hypotension, and heart failure. The resident's care plan required staff to administer medications as ordered and monitor for side effects. However, the resident's Medication Administration Records (MAR) for January, February, and March 2024 documented multiple instances where the resident received midodrine and metoprolol outside of the physician-ordered blood pressure parameters. Specifically, midodrine was administered 74 times when the resident's blood pressure was above the ordered parameters, and metoprolol was administered three times when the resident's blood pressure was below the ordered parameters. These errors were not consistently identified or corrected by the staff, despite education and recommendations from the pharmacist regarding the errors in February 2024. Interviews with staff revealed a lack of understanding and proper communication regarding the medication orders and blood pressure parameters. A Certified Medication Aide admitted to not understanding the symbols indicating when to hold the medication, and a Licensed Nurse stated that he did not always check the MAR for blood pressure readings before administering medication. The Administrative Nurse acknowledged that re-education had been provided but no competency checks were performed on the staff who made the errors. The facility's policy required immediate action in the event of significant medication errors, but this was not effectively implemented, placing the resident at risk for adverse medication reactions and physical decline.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tonganoxie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillside Village Of De Soto Rehabilitation And Nur | 10.5 mi | — | 7 | 0 |
| Bonner Springs Nursing & Rehab Center | 11.1 mi | — | 0 | 0 |
| Medicalodges Eudora | 11.6 mi | — | 1 | 1 |
| Lawrence Memorial Hospital Snf | 12.4 mi | — | 0 | 0 |
| Lansing Care And Rehab | 14.3 mi | — | 22 | 0 |
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