Citations in Kansas
Statistics, citations and compliance trends for long-term care facilities in Kansas.
Statistics for Kansas (Last 12 Months)
Financial Impact (Last 12 Months)
Compliance trends in Kansas
Data through Mar 2026Comparisons below measure the most recent period Apr 2025 – Mar 2026 against the prior period Apr 2024 – Mar 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Latest Citations in Kansas
Surveyors identified unsanitary food storage and preparation conditions, including food debris in a reach-in freezer, an unknown spilled liquid in a reach-in refrigerator, missing two-inch air gap on an ice machine drain, dirty carts used for clean dishes, and a steamtable shelf with built-up food debris. A dietary staff member acknowledged these areas needed cleaning, and it was determined the facility lacked a cleaning schedule or policy for kitchen cleanliness.
The facility failed to complete and analyze Care Area Assessments (CAAs) for multiple residents after Admission, Annual, and Significant Change MDS assessments triggered areas such as cognition, mood/behavior, functional status, urinary incontinence/indwelling catheter, nutrition, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, and visual function. Instead of documenting individualized analysis of underlying causes and contributing factors, an LPN reported she had stopped writing CAA notes and relied mainly on check-off worksheets and the fact that triggers appeared in the MDS CAA section. No facility policy on CAAs was provided to surveyors, and the CAAs consistently lacked required analytical documentation for residents with diverse and significant clinical needs.
A resident with dementia, severe cognitive impairment, and an indwelling urinary catheter was repeatedly observed sitting in common areas with his catheter drainage bag resting on his lower leg, visibly filled with dark amber urine and lacking a privacy cover, despite a care plan directing staff to cover the drainage bag. CNAs reported that the bag often slid down from the resident’s thigh, that they did not use catheter dignity bags on their hall, and that they simply moved the bag back up when it slid down. An administrative nurse stated she had not considered the use of dignity bags on the memory care unit, even though the facility’s resident rights policy affirms each resident’s right to a dignified existence, privacy, and confidentiality.
Two residents with documented cognitive ability to participate in care planning were not invited to any care plan meetings, and their EMRs lacked evidence of care plan conferences, invitations, or Interdisciplinary Care Conference assessments. Administrative staff stated that invitations should be mailed or hand-delivered and uploaded to the EMR, and that an Interdisciplinary Care Conference note should be completed, but none of this documentation existed for these residents, contrary to facility policy and federal requirements for resident and/or representative participation in care planning.
A resident with C-diff and CHF, newly admitted and with a baseline care plan that did not address call light use, was repeatedly found without access to a call light. Surveyors observed the resident yelling for help with her room door closed and later noted the call light on the floor under the bed and again on the floor while the resident sat in a recliner and stated she wanted to return to bed but could not do so independently. Staff reported using a binder clip to attach the call light to the resident’s clothing because the cord lacked a clip, acknowledged the resident sometimes threw the call light to the floor, and stated that call lights should be kept within residents’ reach. An administrative nurse confirmed the expectation that call lights be accessible at all times and was unsure about the use of a binder clip, and no facility policy on call lights was provided.
Surveyors found that a resident’s bathroom and handwashing area were not maintained in a safe, sanitary, and comfortable condition, including a loose baseboard with black substance behind it, a cracked toilet seat, and an empty, improperly mounted hand soap dispenser. Maintenance staff confirmed these conditions, noted that the soap dispenser was nonfunctional, and reported that although a QR code system existed for reporting maintenance issues, these problems had not been reported. Maintenance staff also stated there were no facility policies for maintenance repair in resident rooms and no policy provided for ensuring a safe, homelike environment.
Multiple residents were affected by inaccurate MDS assessments, including a resident with dementia and an indwelling catheter who was miscoded as always incontinent of urine and independent in ADLs despite staff and EMR documentation showing long-term catheter use and total dependence for dressing and wheelchair positioning. Another resident with a history of stroke was incorrectly coded as having a restraint, even though bed grab bars were used as enablers to assist with repositioning and did not limit voluntary movement. A resident with diabetes and unsteadiness experienced two documented falls that were not captured on the MDS, and another resident with diabetes, depression, CAD, and CKD was actively receiving hospice services per EMR, social services, and staff interviews, yet hospice was not coded on the MDS. The consultant MDS nurse confirmed these were significant coding errors not in accordance with the RAI User’s Manual.
A resident with C. diff and CHF was admitted, and while a baseline care plan documenting contact precautions was created, the resident later reported not knowing what a baseline care plan was. The resident was also found yelling for help with her call light on the floor under the bed. Nursing staff stated that baseline care plans are started on the day of admission and reviewed with residents, but also indicated that residents and families are not given written copies. An administrative nurse claimed a 48-hour interdisciplinary care conference had been completed, yet no corresponding documentation existed in the EMR, and explanations about who was responsible and why it was missing were inconsistent. No facility policy for baseline care plans was provided.
A resident with dementia and severe cognitive impairment was inaccurately assessed and care planned as needing only setup or independent assistance with dressing, despite actually requiring total staff assistance. The EMR lacked clear ADL documentation, and the ADL CAA did not trigger, leading to inaccurate MDS entries and a care plan that did not match the resident’s functional status. Surveyors observed the resident sitting in a wheelchair wearing dirty, food-stained pants and being taken to the dining room without a clothing change, with the soiled pants not changed until later when two CNAs provided total assistance. Staff, including CNAs, an LN, and an administrative nurse, acknowledged that the resident needed total help with dressing and should always be in clean clothing, revealing a failure to provide appropriate ADL support and maintain clean attire.
A resident with dementia and severe cognitive impairment was transported multiple times in a wheelchair without staff ensuring that his feet remained safely on the foot pedals. Although assessments inaccurately documented that he was independent with walking using a walker and/or wheelchair, his care plan did not instruct staff on proper use of wheelchair foot pedals. During observed transports by CNAs, the resident’s shoed feet repeatedly fell off the pedals and skimmed the floor between them. Staff acknowledged that his feet did not stay on the pedals and that the pedals were not effectively adjusted, and nursing leadership confirmed expectations that feet should remain on the pedals during transport. No wheelchair safety policy was provided.
Unsanitary Kitchen Conditions and Lack of Cleaning Policy
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions when surveyors observed multiple cleanliness and equipment issues in the kitchen. During an initial kitchen tour on 04/27/26 at 08:57 AM, the three-door reach-in freezer was found with food debris on the bottom shelf, and the three-door reach-in refrigerator had an unknown spilled liquid on the bottom shelf. The drain to the ice machine did not have the required two-inch air gap. Two black two-tiered plastic carts used to store clean dishes had food debris on the bottom tier, and the bottom shelf of the steamtable, which was used to store plate covers, had a buildup of food debris. On 04/28/26 at 01:57 PM, a dietary staff member confirmed these areas required cleaning, and it was identified that the facility did not have a cleaning schedule or a policy regarding kitchen cleanliness. No specific residents, medical histories, or clinical conditions were mentioned in the report in relation to this deficiency.
Failure to Complete and Analyze Care Area Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive Care Area Assessments (CAAs) with analysis of underlying causes, contributing factors, and risk factors for multiple residents following MDS assessments. Record review showed that numerous residents had Admission, Annual, or Significant Change MDS assessments that triggered CAAs in areas such as mood/behavior, cognitive loss/dementia, functional abilities, communication, urinary incontinence/indwelling catheter, nutritional status, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, visual function, and psychosocial well-being. For each of these triggered areas, the corresponding CAAs lacked analysis of the findings. This pattern was identified for residents with a wide range of clinical issues, including dementia, incontinence, falls, pressure ulcers, nutritional concerns, psychotropic medication use, pain, and functional decline. During an interview, a licensed nurse reported that she had stopped writing CAA notes the previous year after being told to do so by someone she could not identify. She stated that she did not write anything on the triggered CAAs and that, at times, she would document risk concerns only on a main check-off worksheet, relying on the fact that the triggers were already reflected in the MDS CAA section. The facility did not provide a policy regarding CAAs when requested. These findings demonstrate that the facility did not ensure that comprehensive assessments were fully completed as required when residents were first admitted and periodically thereafter.
Failure to Maintain Dignity and Privacy for Resident with Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to a dignified existence by not maintaining privacy for his urinary catheter drainage bag as directed in his care plan. The resident had diagnoses including bladder calculus and dementia, with a BIMS score of one indicating severe cognitive impairment, and was dependent on staff for toileting hygiene with an indwelling urinary catheter and constant urinary incontinence. His care plan, revised 03/23/26, instructed staff to cover his drainage bag with a privacy cover. However, during observations on 04/27/26, the resident was seen sitting in his wheelchair at his room doorway and later in the dining room with his catheter drainage bag resting on his lower left leg, supported by his shoe, containing dark amber urine and visible to visitors and other residents, without a privacy cover. Staff interviews confirmed that the catheter drainage bag frequently slid from the resident’s left thigh down to his lower leg and that staff did not consistently reposition it or use dignity/privacy bags. One CNA stated he had never placed a dignity bag on the resident’s drainage bag, and another CNA reported that staff on their hall did not utilize catheter dignity bags, instead just moving the bag back up when it slid down. An administrative nurse acknowledged she had not considered staff use of dignity bags for urinary catheters on the memory care unit. The facility’s Resident Rights policy, approved 12/2024, stated that each resident has the right to a dignified existence including privacy and confidentiality, which was not followed in this case.
Failure to Involve Cognitively Able Residents in Care Plan Meetings
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were given the opportunity to participate in the development and implementation of their person-centered plans of care. For one resident with a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognition, the electronic medical record showed an admission MDS and a Significant Change MDS, but there was no documentation of any care plan meeting in the prior four months. This resident reported not being invited to any care plan meeting. For a second resident with a BIMS score of 14, indicating intact cognition, the electronic medical record contained an admission MDS and a Quarterly MDS, but there was no documentation of a care plan meeting in the prior two months. This resident also reported not being invited to any care plan meeting. Administrative staff reported that residents and/or family members were supposed to be mailed or hand-delivered invitations to attend care planning meetings and that a copy of the invitation should be uploaded into the EMR. They further stated that an Interdisciplinary Care Conference assessment should be completed in the EMR during the care plan meeting. However, the administrative nurse confirmed that there was no documentation of invitations, Interdisciplinary Care Conference assessments, or completed care plan meetings for the two residents. The facility’s care planning policy stated that social services should attend care plan meetings and that the team presents information to the resident and/or representative about progress toward care plan goals, and referenced federal law requiring resident and/or representative participation in care plan meetings to the extent possible, but this process was not carried out or documented for the two residents identified.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach and to reasonably accommodate the resident’s needs and preferences. The resident had documented diagnoses of C-diff and CHF, and her baseline care plan dated 04/23/26 directed staff to evaluate for changes in level of consciousness but did not include any direction regarding call light use or accessibility. On 04/28/26 at 08:06 AM, surveyors observed the resident’s room door closed while she yelled loudly for help several times. When a licensed nurse entered the room, the resident was lying on her left side in bed, stated she wanted to get up, and reported she could not find her call light. The call light was observed on the floor under her bed. Later that morning, a CNA attached the call light to the resident’s shirt using a black and silver binder clip because the call light cord did not have its own clip. On 04/29/26 at 12:15 PM, the resident was seated in a recliner with the call light again lying on the floor out of her reach; she reported she wanted to go to bed and could not get herself back into bed. Staff interviews revealed that the CNA used the binder clip to keep the call light attached to the resident, and the licensed nurse stated staff should make sure the call light is clipped to the resident’s clothes and reported that the resident would throw her call light on the floor. An administrative nurse stated she expected staff to ensure all residents always have their call lights in reach and was unsure about using a binder clip to hold a call light in place. The facility did not provide a policy regarding call lights.
Failure to Maintain Safe and Sanitary Resident Bathroom Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, functional, sanitary, and comfortable environment in Resident 87’s bathroom and handwashing area. During an environmental tour with Maintenance Staff UU, surveyors observed an approximately four-foot section of loose baseboard to the left of and behind the toilet, with a black substance present on the wall and floor behind the loose baseboard. They also noted an approximately three-inch crack in the toilet seat and an empty hand soap dispenser hanging above the handwashing sink, mounted with exposed lag bolt fasteners. Maintenance Staff UU confirmed these conditions, acknowledged that the soap dispenser did not work, and stated that the toilet seat should be replaced, the bathroom baseboard removed, the black substance tested for mold, and the sheetrock removed and replaced. Further interview with Maintenance Staff UU revealed that the facility had implemented a QR code system for staff and visitors to report maintenance items, but the issues in this resident’s bathroom had not been reported through that system. He also reported that there had been a leak behind the handwashing sink that had flowed into the bathroom area, leading to the sink’s replacement, but he had received no report of the specific deficiencies observed in the bathroom. Additionally, Maintenance Staff UU stated that the facility did not have policies for maintenance repair in residents’ rooms, and the facility did not provide a policy for ensuring a safe, homelike environment.
Inaccurate MDS Coding for ADLs, Restraints, Falls, and Hospice Services
Penalty
Summary
The deficiency involves the facility’s failure to complete accurate Minimum Data Set (MDS) assessments in accordance with the Resident Assessment Instrument (RAI) User’s Manual, resulting in multiple residents’ clinical status not being correctly reflected. For one resident with dementia and severe cognitive impairment, the Significant Change and subsequent Quarterly MDS assessments coded him as always incontinent of bladder and independent with eating and upper body dressing, with use of a walker and wheelchair. However, the electronic medical record showed ongoing indwelling catheter care each shift and no documentation of walker use, wheelchair mobility, or dressing requirements during the review period. Staff interviews revealed that this resident had an indwelling catheter for more than a year, had not walked for several years, and was dependent on staff for all ADLs, including dressing and wheelchair positioning, contradicting the MDS coding. Observations showed the resident slumped in a wheelchair, wearing a hospital gown over clothing, with a visible catheter bag on his lower leg and feet frequently skimming the floor despite foot pedals being present, further indicating dependence and catheter use not accurately captured on the MDS. Another deficiency involved a resident with a history of stroke, hemiplegia, and hemiparesis whose Significant Change MDS coded the use of “other restraint.” During observation, the resident was seen in bed with bilateral grab bars at the head of the bed and her right arm positioned on a pillow. The resident reported using the grab bars to help move and reposition herself in bed. CNAs and administrative nursing staff confirmed that the facility did not use restraints and that the grab bars were used as enablers to assist residents with repositioning and to increase independence. Administrative staff acknowledged that the MDS coding for restraints was inaccurate because the grab bars did not limit the resident’s voluntary movement or access to her body. A further inaccuracy was identified for a resident with diabetes, atrial fibrillation, unsteadiness of feet, and a toe fracture. Both a Significant Change and a Quarterly MDS documented intact cognition, partial/moderate assistance with transfers, no ambulation, and no falls. However, progress notes in the EMR documented two unwitnessed falls during the look-back period, including one where the resident was found on the floor next to the bed with a forehead skin tear and another where the resident was found sitting on a fall mat on the floor with a scratch on the ankle. These documented falls were not reflected on the MDS. In addition, another resident with diabetes, depression, CAD, and chronic kidney disease had a Significant Change MDS that coded no hospice services, while the EMR contained a hospice certification and physician orders initiating hospice services, and social service notes and staff interviews confirmed that hospice services, including bathing by a hospice aide, were being provided during the look-back period. The consultant MDS nurse confirmed that these assessments were inaccurate and not completed in accordance with the RAI User’s Manual, constituting significant errors in coding for urinary status, ADL dependence, restraints, falls, and hospice services. The consultant MDS nurse stated that the resident with the indwelling catheter should have been coded as not rated for urinary continence due to catheter placement rather than as always incontinent, and that his ADL status should not have been coded as independent given his dependence on staff for dressing and wheelchair positioning. For the resident with grab bars, the nurse confirmed that the grab bars were used as enablers and not as restraints, making the restraint coding inaccurate. For the resident with documented falls, the MDS failed to capture falls that occurred within the look-back period, and for the resident receiving hospice services, the MDS did not reflect hospice care that was active during the look-back period. These miscodings met the RAI Manual’s definition of significant error, in which the resident’s overall clinical status is not accurately represented on the assessment and the error has not been corrected by a more recent assessment.
Failure to Provide and Communicate Baseline Care Plan to New Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide a summary of the baseline care plan to a newly admitted resident and to ensure that the baseline care plan process was completed and documented as required. The resident’s EMR documented diagnoses of C. difficile and CHF. The Entry MDS was completed on the admission date, and the admission MDS was noted as in progress with no information available. A baseline care plan dated the day after admission documented contact precautions, including staff use of gowns and masks when changing contaminated linens and proper handling and bagging of soiled linens. However, during an interview several days after admission, the resident reported she did not know what a baseline care plan was, indicating that the plan had not been explained or summarized to her. Further observations and interviews showed additional failures in implementing and communicating the baseline care plan. On one occasion, the resident was heard yelling for help with her room door closed; when a nurse entered, the resident stated she wanted to get up but could not find her call light, which was observed on the floor under the bed. A nurse reported that the baseline care plan was started on the day of admission and that nurses would review it with the resident, but also stated that the charge nurse would not provide a written copy of the baseline care plan to the resident or family. An administrative nurse reported she would review the baseline care plan with the resident and/or family and claimed to have completed a 48-hour interdisciplinary care conference, but there was no opened or completed conference note in the EMR. She gave inconsistent explanations regarding who was responsible and why the conference note was missing. The facility did not provide a policy for baseline care plans.
Failure to Provide Accurate ADL Assessment and Timely Clothing Changes
Penalty
Summary
The facility failed to provide appropriate assistance with activities of daily living (ADLs), specifically dressing and clothing changes, for a resident with severe cognitive impairment. The resident had a diagnosis of dementia and repeated Brief Interview for Mental Status (BIMS) scores of one, indicating severe cognitive impairment. Despite this, both a Significant Change MDS and a Quarterly MDS inaccurately documented that the resident required only setup assistance with lower body dressing. The ADL Care Area Assessment did not trigger, and the resident’s care plan, revised on 03/23/26, inaccurately instructed staff that the resident was independent with dressing. The electronic medical record lacked staff documentation of the resident’s ADL needs, resulting in care instructions that did not reflect the resident’s actual functional status. On the day of observation, the resident was seen sitting in a wheelchair wearing black pants with food crumbs on them in the morning, and later was transported by a CNA to the dining room still wearing the same dirty pants. The pants were not changed until early afternoon, at which time two CNAs provided total assistance to change the dirty pants, and the resident was unable to participate in dressing or undressing. During interviews, the CNAs, a licensed nurse, and an administrative nurse all stated that residents should always be dressed in clean clothing and confirmed that this resident required total staff assistance with dressing. These observations and interviews showed that the resident’s actual need for total assistance with dressing and clothing changes was not accurately reflected in the MDS, care plan, or ADL documentation, and that the facility did not ensure the resident was kept in clean clothing as expected by facility policy for ADL care.
Failure to Maintain Safe Wheelchair Foot Positioning During Resident Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision during wheelchair transport for a resident with dementia. The resident’s EMR documented a diagnosis of dementia and a BIMS score of one on both a Significant Change MDS and a Quarterly MDS, indicating severe cognitive impairment. These MDS assessments inaccurately documented that the resident was independent with walking using a walker and/or wheelchair, and the ADL CAA did not trigger. The resident’s care plan, revised 03/23/26, identified cognitive impairment due to dementia but did not include instructions for staff on the use of wheelchair foot pedals while propelling the resident. On multiple observed occasions, staff propelled the resident in a wheelchair without maintaining his feet safely on the foot pedals. During transport from his room to the dining room, the resident’s left shoed foot fell from the foot pedal and skimmed the floor between the pedals, and later, during transport from the dining room to the shower room, both shoed feet skimmed the floor between the pedals. CNAs reported that the resident’s feet never stayed on the foot pedals and described the pedals as useless because he could not keep his feet on them. A licensed nurse confirmed the resident’s feet did not always remain on the foot pedals when staff propelled him and stated the pedals should be adjusted to better fit his needs. An administrative nurse stated it was the expectation that staff ensure the resident’s feet remained on the foot pedals during transport and that pedals should be lowered if needed. The facility did not provide a policy regarding wheelchair safety.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Some of the Latest Corrective Actions taken by Facilities in Kansas
- Re-educated all facility staff on abuse, neglect, and exploitation (ANE) to reinforce abuse-prevention expectations (J - F0600 - KS)
- Implemented a facility visitor sign-in sheet to improve oversight of individuals entering the building (J - F0600 - KS)
- Implemented a specific visitor log for the affected resident (R1) to track and monitor visitors (J - F0600 - KS)
Failure to Prevent Armed Workplace Violence Between CNAs on Resident Unit
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision to prevent accidents, specifically by failing to prevent two CNAs from bringing firearms into the building and engaging in gunfire on a resident unit. On the night of the incident, one CNA (CNA M) walked down the Northeast (NE) corridor, unlocked an exit door, then returned toward the nurses’ station. He reached into his jacket, turned toward the dining room where another CNA (CNA N) was located, and fired multiple shots into the dining room. Video surveillance reviewed by administrative staff showed this sequence of events, including CNA M unlocking the NE corridor door, returning toward the nurses’ station, drawing a gun from his jacket, firing into the dining room, and then fleeing out the NE corridor door. In response to the gunfire from CNA M, CNA N returned an unknown number of rounds down the East Hall, where nine residents resided. A bullet grazed the wall near the room of one resident (R2), leaving a four- to six-inch graze mark, and a bullet, possibly the same one, struck the doorframe of another resident’s room (R1). Subsequent observation of the East Hall revealed a round indentation on the lower part of R1’s doorframe and a graze mark on the wall near R2’s room. In the dining room across from the East Hall, there were two bullet holes in the window and two to three bullet holes in the wall. Staff on duty reported hearing gunshots and screams, seeing smoke and shell casings near the nurses’ station, and then moving to call 911 and check on residents. Residents described being awakened and startled by the gunfire. R1, seated in a wheelchair in his room, reported initially thinking the sounds were pots and pans clanging, then realizing they were three to four shots, one of which hit his doorframe; he thought the shooter might be coming into his room for him. R2, also in a wheelchair in his room, stated that the gunshots startled him awake and that he was scared for a few seconds. Staff interviews revealed that earlier in the shift, CNA N felt uneasy about CNA M and went out to his car to retrieve his gun, which he then brought into the facility without reporting his concern to anyone. Another nurse (LN I) and a CNA (CNA O) described an escalating verbal argument between CNA M and CNA N in the dining area, including demeaning and vulgar comments, with CNA M pacing and attempting to leave while CNA N continued to pull him back into the conversation, before CNA M walked down the NE hall, returned, and began firing. The facility’s employee handbook, in effect at the time, prohibited acts or threats of violence and the possession of weapons of any kind on the property, but both CNAs nonetheless possessed guns inside the facility and engaged in gunfire on the East unit, placing residents in immediate jeopardy.
Removal Plan
- The facility began staff education on workplace violence, reporting protocols, security, anti-harassment and anti-retaliation protections, and technology and social media controls (education ongoing).
- The facility contracted with a security agency for a nighttime security guard.
- The facility notified the residents' representatives of the incident.
- The facility had a psychologist visit with residents possibly affected by the incident.
Failure to Protect Cognitively Impaired Resident From Suspected Sexual and Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from abuse and to respond appropriately to injuries of unknown origin, including bruising and vaginal bleeding. The resident had hemiplegia and severe cognitive impairment, required extensive assistance with ADLs, and depended on staff for care. Her care plan noted participation in activities but did not address the involvement of her son, identified as her representative and alleged perpetrator (AP), in her care, and listed another son as DPOA. Prior skin and weekly assessments documented no bruising or vaginal bleeding up to mid-March, and the last weekly skin assessment before the incident showed no bruises or open lesions. On the night in question, a CNA observed significant bruising on the resident’s right leg around late evening and reported it to the charge nurse (LN G). LN G assessed the bruising, determined it was probably from the wheelchair or therapy, and did not report it as an injury of unknown origin to administration. Later that night, around early morning, the same CNA observed bright red blood in the resident’s brief and vaginal area, along with what he thought might be clotted blood or a sore, and again reported this to LN G. LN G, relying on the AP’s report that the resident had been scratching and might have a yeast infection, instructed the CNA to apply antifungal powder or cream without personally assessing the vaginal area and without reporting the bleeding and possible injury to administration or the provider. During this time, the AP remained in the room with the resident, often with the door closed, and staff had previously reported feeling awkward and uncomfortable performing peri care while he was present. On the following day, a day-shift CNA providing peri care observed dried blood on the resident’s labia and vaginal area and notified another nurse (LN I), who noted dried blood and bruising on the right hip and leg and reported this to the charge nurse (LN H). Despite this, an earlier skilled evaluation by LN H that same day inaccurately documented no skin issues. Later that afternoon, a two-nurse assessment by LN H and LN I revealed a large bruise on the right hip and leg resembling the shape of a hand, extensive maroon/purple bruising and petechiae around and into the vagina, small lacerations and shearing injuries to the labia, and bruising on the lower abdomen and thighs. The resident displayed increased anxiety and repeatedly said “Oh God” during the assessment and was unable to explain how the injuries occurred. Multiple staff statements documented that the AP stayed in the room almost continuously with the door closed, remained present during intimate cares, acted nervous and fidgety, sometimes took over incontinent care, and left the building frantically after the injuries were discovered. The facility’s failure to recognize and report the initial bruising and vaginal bleeding as potential abuse, to promptly assess the resident, and to remove or restrict the AP allowed him to remain alone with the resident for many hours while her injuries progressed, resulting in a finding of immediate jeopardy. Additional documentation from the hospital and law enforcement supported concerns of sexual assault. The hospital record noted bleeding in the vaginal area with signs of injury, scattered bruises on the extremities, hips, and thighs, and documented that staff had concern for possible sexual assault. Hospital staff also recorded that the resident became agitated and yelled statements such as “Noooo why would a man do that” when her genitalia were cleaned, and that access to her hospital records was blocked from the patient portal due to reasonable belief that sharing them could result in harm to her life or physical safety. Witness statements from CNAs described the resident asking, “why she let that man do that” and saying “Son, why would you do this to me?” during care, though it was not documented that these statements were reported at the time. Law enforcement officers and the SANE examiner later described the resident’s wounds as among the worst they had seen and indicated that a warrant was required for the SANE exam because the AP, listed as legal representative, had left and could not be contacted. Throughout the period leading up to the discovery of the full extent of the injuries, staff had observed the AP’s constant presence, closed-door behavior, and controlling involvement in care, and some staff had reported discomfort and concerns to charge nurses, but these concerns were not acted upon prior to the incident. The facility’s abuse, neglect, and exploitation policy required prevention of all types of abuse and ensuring resident safety regarding visitors and representatives, but staff did not implement protective measures in response to the AP’s behavior or the resident’s injuries and statements. The failure to promptly recognize, assess, and report bruising and vaginal bleeding of unknown origin, combined with allowing the AP to remain alone with the resident with the door closed and to participate in intimate care despite staff discomfort and the resident’s cognitive impairment, led to the determination that the resident was not kept free from abuse and experienced preventable and intentional physical and sexual abuse and psychosocial trauma. The delay of approximately 16 hours from the initial report of bruising of unknown origin to notification of administrative staff, and the inaccurate documentation of no skin issues by LN H earlier on the day the injuries were identified, were key factors in the deficiency finding.
Removal Plan
- Re-education for abuse, neglect and exploitation (ANE) for all facility staff.
- Implemented a protection plan for Resident 1 (R1) requiring all cares be performed with two staff.
- Implemented a protection plan for R1 requiring the room door to remain open unless private cares were being provided.
- Implemented a protection plan for R1 requiring that if the alleged perpetrator (AP) entered the facility, law enforcement (LE) would be notified immediately.
- Implemented a protection plan for R1 requiring a staff member to go to R1's room and remain with her until law enforcement arrived if the alleged perpetrator entered the facility.
- Implemented a sign-in sheet for all visitors to the facility.
- Implemented a specific visitor log for R1.
Failure to Follow Mechanical Soft Diet Orders Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident with food in the physician-ordered mechanical soft, ground meat form. The resident had diagnoses of dysphagia, oropharyngeal phase dysphagia, and Alzheimer’s disease, with a BIMS score of four indicating severe cognitive impairment. Her MDS and CAAs documented that she coughed or choked during meals or when swallowing medications and that she required a mechanically altered diet. The care plan and EMR orders specified a regular diet with mechanical soft texture, ground meat with gravy or sauce (no dry meat), and multiple restrictions including no soft tortilla shells, no salad, no raw onions, no raw vegetables, and tortilla chips to be crushed or broken. An intervention also directed staff to cut up her food and remind her to take only one bite at a time. Despite these documented needs and orders, on the day of the incident the resident was served a whole chicken strip instead of ground meat. A nurse’s note recorded that the resident received a whole chicken strip for lunch and choked on a bite of chicken. Staff statements confirmed that dietary staff provided a whole chicken strip, and one dietary staff member stated he had chopped one up but then set it aside and gave her a whole chicken strip because he could not remember if they were supposed to be chopped for her. This action directly conflicted with the resident’s ordered mechanical soft diet with ground meat and the facility’s own policies requiring foods to be cut, chopped, or ground to meet individual needs and specifying that meat, fish, and poultry on mechanical soft diets should be chopped, flaked, or ground. When the resident began choking, another resident alerted staff in the dining room. Staff observed the resident choking, and a CNA and another staff member attempted and then performed the Heimlich maneuver, resulting in the resident expelling a chunk of food onto the floor and stating she felt better. A prior progress note also documented that the resident had experienced a possible choking episode in the dining room on an earlier date, during which she was observed coughing with blue lips, encouraged to cough up a moderate amount of mushy substance, and suctioned for a moderate amount of thick, clear mucus. The facility’s dietary and nursing staff interviews described an established process using diet cards and multiple verification steps to ensure correct diet texture and consistency, but staff acknowledged that this process was not thoroughly followed for this resident’s meal, resulting in her receiving a full chicken strip instead of the ordered mechanical soft, ground meat diet. This failure led to a choking episode that surveyors determined constituted Immediate Jeopardy.
Removal Plan
- Provide in-service education for dietary monitoring and ensuring proper diets are served to each resident for direct-care staff and kitchen staff
- Provide 1:1 education with the cook and dietary aide
- Implement disciplinary action for the cook and dietary aide
- Provide 1:1 in-service education with all staff who serve in the dining room
- Revise the dining room monitoring schedule to include manager coverage for all meals
- Verify all at-risk residents to ensure diets match their diet cards
- Provide RELIAS educational training for the cook
- Hold a QAPI meeting with the Director of Nursing, Administrator, and Medical Director
Failure to Supervise Elopement-Risk Resident and Identify Prolonged Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards, resulting in an elopement. A resident with a diagnosis of schizoaffective disorder, hallucinations, delusions, rejection of care, and wandering behaviors was assessed as having intact cognition with a BIMS score of 15 and was care planned as being at moderate to high risk for elopement. The resident’s care plan included interventions such as increased supervision during exit-seeking behaviors, placement in a room away from exits, lodging in a secure unit, medication review, psychiatric services as needed, and use of a WanderGuard with placement and function checks. The WanderGuard was intended to limit the resident’s ability to enter the backyard without staff present. Despite these identified risks and planned interventions, the resident was able to access the smoking patio and leave the facility without staff knowledge or supervision. At approximately 2:45 AM, the resident used a dining room chair placed on the smoking patio to climb over the tall fence surrounding the patio and exit the premises. The door to the patio remained unlocked, and although the WanderGuard alarmed at the door and indicated the need for staff assistance, the resident still gained access to the patio and then climbed the fence. The facility’s cameras later showed the resident using the chair to scale the fence. Staff statements indicated that the last known observations of the resident occurred between approximately 9:00 PM and 2:00 AM, with no indications of unrest reported at those times. After leaving the facility, the resident walked approximately 1.8 miles to a truck stop, remained there for several hours, and then walked back to the facility, returning around 11:45 AM. During this time, outdoor temperatures ranged from 29.9°F to 45.3°F. Staff were unaware of the resident’s absence for about nine hours due to a failure to complete resident safety rounds on both the night and day shifts. Multiple staff members, including CNAs, a CMA, and an LN, reported not completing rounds or not entering the resident’s room, with one nurse noting that the resident’s curtain was pulled and she did not verify his presence. The resident ultimately rang the front doorbell to re-enter the facility, at which point staff assessed him and confirmed he had no injuries. The surveyors determined that the failure to complete rounds and adequately supervise the resident, combined with the environmental setup that allowed use of a movable chair to climb the fence, resulted in an elopement that constituted immediate jeopardy.
Removal Plan
- Update R1's care plan.
- Place a WanderGuard on R1.
- Conduct education on elopement and rounds with staff.
- Give written warnings to staff for failure to complete rounds.
- Complete magnetic lock checks on the doors.
- Complete an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting.
- Complete an elopement drill.
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