Medicalodges Great Bend
Inspection history, citations, penalties and survey trends for this long-term care facility in Great Bend, Kansas.
- Location
- 1401 Cherry Lane, Great Bend, Kansas 67530
- CMS Provider Number
- 175522
- Inspections on file
- 26
- Latest survey
- December 22, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Medicalodges Great Bend during CMS and state inspections, most recent first.
Several residents experienced verbal and mental abuse when a CNA made derogatory remarks about their hygiene, attempted to physically force a resident out of bed, and neglected basic care tasks. Other staff members witnessed these actions but did not promptly report them, despite being trained on abuse and neglect policies.
Staff failed to promptly report observed and suspected abuse, including aggressive and verbally abusive behavior by a CNA toward multiple residents. Several staff members witnessed or were informed of inappropriate comments, harsh treatment, and attempts to physically force a resident, but did not immediately notify administration as required by policy. The affected residents included individuals with limited alertness, some of whom showed signs of distress.
A resident with severe cognitive impairment and a history of wandering exited the facility through an unsecured, unalarmed door, traversed hazardous outdoor areas, and suffered a fall resulting in facial abrasions and a UTI. Staff did not immediately notice the resident's absence, and the door alarm was found to be nonfunctional at the time, leading to inadequate supervision and failure to prevent the elopement.
The facility failed to ensure CNAs completed the required 12-hour in-service education, with CNA N completing only three hours and CMA T lacking dementia care training. This deficiency was confirmed by the Administrative Nurse and placed residents at risk for decreased quality of care.
The facility failed to secure an oxygen storage room, leaving it accessible to wandering residents, and did not update a resident's care plan with new interventions after multiple falls. This placed residents at risk for preventable accidents and injuries.
A facility failed to maintain a medication error rate below five percent, resulting in a 7.69% error rate. A CMA administered amlodipine and benazepril to a resident despite physician orders to hold these medications if blood pressure was below 100/65 mmHg. The resident's blood pressure was 128/60 mmHg, indicating the medications should not have been given. Both the CMA and a Licensed Nurse confirmed the error, and the facility lacked a policy on medication errors.
A facility failed to ensure that a Consultant Pharmacist identified and reported repeated medication administration errors for a resident with hypertension and severely impaired cognition. Despite physician orders to hold blood pressure medications if the resident's blood pressure was below certain parameters, staff administered the medications multiple times over several months. The CP's reviews lacked notes on these irregularities, and the facility's policy for reporting such errors was not followed.
A resident with hypertension received unnecessary medications due to the facility's failure to follow physician-ordered blood pressure parameters. Despite orders to withhold amlodipine and benazepril if blood pressure was below 100/65 mm/Hg, staff administered these medications multiple times over several months when the resident's blood pressure was below the threshold. Observations and interviews confirmed the errors, and the facility lacked a medication administration policy.
Failure to Protect Residents from Verbal and Mental Abuse by CNA
Penalty
Summary
Multiple residents were subjected to verbal and mental abuse by a Certified Nurse's Aide (CNA), who made derogatory and inappropriate comments about residents' hygiene and physical condition. Witness statements documented that the CNA made repeated negative remarks about a resident's smell and food intake, used sarcasm, and laughed at another staff member's discomfort. The CNA also sternly reprimanded another resident in a public setting, causing visible distress. Additionally, the CNA was observed ranting and cussing in front of residents and expressing frustration about work assignments. Further incidents included the CNA attempting to physically force a resident out of bed against their will, despite the resident's resistance and verbal refusal. The CNA was also described as rushing through care routines, neglecting basic hygiene tasks such as brushing hair, wiping hands or faces, and changing soiled clothing. Another resident was subjected to unprofessional and hurtful comments about their cleanliness. Staff members who witnessed these actions did not immediately report the incidents to administration, with some expressing uncertainty or reluctance to escalate the situation. Licensed and certified staff interviewed after the incidents acknowledged they were trained on abuse, neglect, and exploitation (ANE) policies but failed to recognize or report the abuse at the time. Some staff rationalized their inaction by believing the incidents were isolated or that the affected residents were not alert and oriented enough to understand the abuse. The facility's policy required immediate reporting and intervention for any suspected abuse, but this protocol was not followed during the events described.
Failure to Timely Report Suspected Abuse and Aggressive Staff Behavior
Penalty
Summary
The facility failed to report suspected and observed abuse of six residents by a Certified Nurse's Aide (CNA). Multiple staff members witnessed or were aware of aggressive, verbally abusive, and unprofessional behavior by the CNA toward residents, including making derogatory comments about a resident's hygiene, speaking harshly to residents, and attempting to physically force a resident out of bed against his will. Witness statements documented that the CNA made repeated negative remarks about a resident's smell, yelled at another resident, and was generally snappy and cold toward residents during care routines. Other staff, including a Certified Medication Aide (CMA), another CNA, and a Licensed Nurse (LN), observed or were informed of these incidents but did not immediately report them to administration as required by facility policy and their training on abuse, neglect, and exploitation (ANE). Some staff expressed uncertainty or minimized the incidents, with one stating she thought it was an isolated event and another not wanting to create conflict with a coworker. The lack of timely reporting delayed the facility's awareness and response to the suspected abuse. The residents involved included individuals who were not alert and oriented, and some were visibly upset or verbally expressed distress during or after the incidents. Staff statements and facility documentation confirmed that the required immediate reporting of suspected abuse to administration and authorities did not occur as mandated by policy, resulting in a deficiency related to the timely reporting of suspected abuse, neglect, or theft.
Failure to Prevent Elopement and Ensure Door Security for Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with diagnoses including Alzheimer's disease, dementia, anxiety, unsteadiness, and muscle weakness, was identified as high risk for elopement and falls. The resident's care plan and assessments documented severe cognitive impairment, wandering behaviors, poor safety awareness, and a need for close monitoring and staff assistance with mobility and activities of daily living. Despite these risks, the resident was able to exit the facility through an unlocked and unalarmed door in the 200 hall, which failed to secure properly due to the alarm being unhooked, reportedly by contractors. The mag-lock on the door did not engage, allowing the resident to leave the premises unsupervised. After exiting, the resident traversed a hazardous environment, including cracked sidewalks, uneven grassy areas, a parking lot with large potholes, and several curbs. The resident ultimately fell between two apartment buildings behind the facility. The incident was discovered when a community member called 911, and facility staff identified the resident on an ambulance stretcher. The resident sustained facial abrasions and a urinary tract infection, requiring hospital evaluation and treatment. Staff statements confirmed that the resident was last seen at the nurse's station and that there was a delay in realizing the resident was missing, leading to a search and eventual discovery of the incident by observing the ambulance outside. Facility records and staff interviews revealed that the door alarm was not functioning at the time of the incident, and the required supervision and monitoring for a high-risk resident were not adequately provided. The facility's elopement policy required individualized care planning and routine security monitoring, but these measures were not effectively implemented, resulting in the resident's unsupervised exit and subsequent injury.
Removal Plan
- 1200-pound mag-locks were installed on all doors.
- The door at the end of 200 hall was secured, and the mag-lock was functioning.
- The alarm was rewired and in working order.
- All staff were re-educated on the facility's elopement policy.
- Stop signs were placed on each exit door, and the signs also requested contractors to alert staff before using the exit doors so staff could stay at the exit doors until the contractors were done.
- The facility's Elopement Book was reviewed for accuracy.
- R1 was put on one-to-one.
- The findings of the incident were taken to an emergency QAPI.
Deficiency in CNA In-Service Education
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) completed the required 12-hour in-service education, which is necessary for maintaining the quality of care for residents. Specifically, CNA N had only completed three of the required 12 in-service hours, and CMA T lacked dementia care training. This deficiency was identified during a review of the facility's 12-hour annual in-service documentation for five certified staff members who had been employed at the facility for at least one year. The Administrative Nurse confirmed that the staff did not meet the required education topics and/or hours. Additionally, the facility was unable to provide a policy for the required services, which contributed to the deficiency and placed residents at risk for decreased quality of care.
Deficiencies in Safety and Fall Prevention
Penalty
Summary
The facility failed to maintain a secure environment free from accident hazards by not ensuring that the oxygen storage room was consistently locked. During a walkthrough, it was observed that the room containing 38 fully pressurized supplemental oxygen cylinders was unsecured, despite having a numerical keypad lock that should auto-lock when closed. Staff interviews revealed that the room should always be locked to prevent wandering residents from accessing it, but a staff member had inadvertently left it open after retrieving an oxygen bottle for a resident. Additionally, the facility did not adequately address the fall risks for a resident identified as R33, who had a history of multiple falls. R33's medical record documented several conditions, including diabetes, chronic pain, anxiety disorder, and insomnia, and noted that the resident had experienced 41 falls since admission. Despite having a care plan in place, the facility failed to update it with new interventions for 22 of these falls, as required by their risk management policy. This lack of intervention left R33 at continued risk for falls and injury. The facility's failure to secure the oxygen storage room and to implement effective fall prevention strategies for R33 highlights deficiencies in maintaining a safe environment and in managing individual resident care plans. These oversights placed residents, particularly those who are cognitively impaired and independently mobile, at risk for preventable accidents and injuries.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 7.69% error rate. This deficiency was identified during a survey involving a sample of 12 residents from a total census of 37. The specific incident involved a Certified Medication Aide (CMA) administering amlodipine and benazepril to a resident, despite the physician's orders to hold these medications if the resident's blood pressure was below 100/65 mmHg. On the day of the incident, the resident's blood pressure was recorded at 128/60 mmHg, indicating that the medications should not have been administered according to the physician's parameters. The CMA later verified the physician's orders and acknowledged the error in administering the medications. A Licensed Nurse also confirmed that the medications should not have been given due to the resident's blood pressure being out of the specified parameters. The facility was unable to provide a policy related to medication errors upon request, which contributed to the deficiency. This oversight placed the resident at risk for significant medication errors and potentially affected all residents receiving medications at the facility.
Failure to Identify and Report Medication Administration Errors
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and notified the facility and physician about the repeated administration of two blood pressure medications, amlodipine and benazepril, to Resident 21 when the resident's blood pressure was below the physician-ordered parameters. This occurred multiple times in April, May, June, and July 2024. The resident, who had a diagnosis of hypertension and severely impaired cognition, was dependent on staff for all activities of daily living. The physician's orders specified that the medications should be held if the blood pressure was less than 100/65 mm/Hg, but staff administered the medications despite these parameters being exceeded. The Medication Administration Record (MAR) showed that the medications were given 11 times in April, 16 times in May, 10 times in June, and 8 times in July when the blood pressure was below the specified limits. The CP's Medication Regimen Reviews for these months did not include notes on these irregularities. Observations and interviews confirmed that the medications were administered incorrectly, and the facility's policy required such findings to be communicated to the director of nursing and the medical director. However, the CP did not inform the facility of these ongoing medication errors, placing the resident at risk for unintended results from the medications.
Failure to Adhere to Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to adhere to physician-ordered blood pressure parameters for a resident diagnosed with hypertension, leading to the administration of unnecessary medications. The resident, who had severely impaired cognition and required assistance for daily activities, was prescribed amlodipine and benazepril with specific instructions to hold the medications if blood pressure readings were below 100/65 mm/Hg. Despite these orders, the medications were administered multiple times over several months when the resident's blood pressure was below the specified threshold. Observations and interviews confirmed that staff repeatedly administered the medications outside the prescribed parameters. On one occasion, a Certified Medication Aide was observed administering the medications after obtaining a blood pressure reading that should have prompted withholding the drugs. Both a Licensed Nurse and an Administrative Nurse verified the ongoing medication errors, and the facility was unable to provide a medication administration policy upon request. This practice placed the resident at risk for unnecessary medications and related complications.
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.
Trusted by long-term care providers and associations.
