Richmond Healthcare & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Richmond, Kansas.
- Location
- 340 E South Street, Richmond, Kansas 66080
- CMS Provider Number
- 175444
- Inspections on file
- 20
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Richmond Healthcare & Rehab Center during CMS and state inspections, most recent first.
A resident with stroke, dementia, and dysphagia was care planned as needing monitoring for chewing and swallowing problems and was admitted on a CCHO/LCS diet with regular texture. After episodes of coughing and difficulty swallowing meat, SLP evaluated the resident, and a FEES study recommended a minced and moist mechanical soft diet, medications in puree, upright positioning during and after meals, and double-swallow strategies. SLP documentation later described the resident as on a mechanical soft diet with thin liquids and pills crushed in puree, requiring total supervision at meals, but the EMR contained only an ongoing order for a regular-texture CCHO/LCS diet with no documented diet changes. The swallow study was scanned into the EMR under a miscellaneous tab without an alert, there was no documented provider notification or response, and the nurse who reported calling the provider and being told to continue the regular diet did not enter a progress note. Staff interviews showed uncertainty about how SLP recommendations and test results were communicated and processed, and no relevant policy was provided.
A CNA employed for over a year did not have a required annual performance evaluation completed, as confirmed by the administrative nurse responsible for staff reviews. Facility policy mandates yearly evaluations to guide in-service training and compliance, but this process was not followed for the CNA working night shifts.
The facility did not employ a full-time certified dietary manager, as required by its policy, to oversee food and nutrition services for 47 residents. Administrative staff confirmed the absence of a certified dietary manager, and dietary staff reported lacking certification and only receiving monthly visits from the dietary manager.
Surveyors found that during ongoing dining room construction, there were no barriers between the construction area and the kitchen, and the door between these areas remained open during meal preparation. Opened and undated food was found in a kitchenette freezer, and a CNA assisted multiple residents with meal service and feeding without performing hand hygiene. Staff interviews confirmed expectations for hand hygiene and proper food storage were not met, and facility policy requirements for sanitation and cross-contamination prevention were not followed.
Five CNAs employed for over a year did not complete the required 12 hours of annual in-service education, as confirmed by a review of training records and staff interview. The responsible administrative nurse acknowledged oversight of this requirement, and facility policy specified the training should be based on employment date.
The facility did not ensure individualized activities programming based on resident preferences during weekends, offering only limited options like coloring, puzzles, and movies. Resident Council and staff reported inconsistent and infrequent staff-led activities on weekends, with no designated staff assigned to lead them. The facility could not provide a policy on activities, and residents experienced slow weekends with minimal engagement.
Narcotic count sheets for several medication carts and rooms showed repeated missing signatures from both oncoming and off-going nursing staff, indicating that required shift-to-shift controlled substance counts were not consistently performed or documented. Staff interviews confirmed that nurses and CMAs were expected to count together at each shift change, but this was not reliably done, resulting in a failure to follow facility policy for controlled medication accountability.
Staff did not date vials of tuberculin test serum after opening, as observed in the medication room refrigerator. Nursing staff confirmed the vials were opened and undated, and were unsure of the appropriate duration for use after opening. This was not in accordance with the facility's medication storage policy, which requires proper labeling and dating of medications.
Surveyors found that linen carts were left uncovered, washcloths were stored in handrails outside rooms, and respiratory equipment such as nebulizer masks and oxygen cannulas were not stored in sanitary, labeled bags as required. Nursing staff confirmed these practices did not follow facility policy, and the facility lacked policies for proper linen and washcloth storage.
Staff assisted two residents with eating by standing over them throughout meal service, rather than sitting at their level as required by facility policy and staff expectations. Interviews with multiple staff confirmed that the standard practice is to sit next to residents during meal assistance to maintain dignity.
A resident with significant physical and cognitive impairments was transported in a wheelchair without foot pedals by both a nurse and a CNA, despite her care plan and facility policy requiring assistive devices for safety. Staff interviews indicated that some residents' preferences were considered, but the lack of foot pedals was not care planned for this resident.
A resident with severe cognitive impairment and multiple diagnoses was admitted to hospice services, as documented in the EMR and physician orders. However, the MDS assessment did not reflect the resident's hospice status, and the care plan only referenced consulting hospice for pain management. The MDS nurse, working remotely, was not notified in a timely manner, leading to incomplete documentation and a deficiency in the assessment process.
A resident with multiple medical and cognitive impairments, dependent on staff for ADLs, was repeatedly observed with matted hair, food-stained clothing, and an unshaven face. Despite care plans and facility policy requiring staff assistance with grooming and hygiene, staff did not provide the necessary care or document any refusals, resulting in a deficiency related to grooming and personal hygiene.
A resident with CHF and multiple comorbidities did not have weekly weights recorded as ordered by the physician to monitor for fluid overload. Staff interviews revealed inconsistent communication and lack of physician notification when weights were missed, and documentation did not show any resident refusal or physician notification regarding the missed weights.
Multiple residents with severe cognitive impairment and fall risk did not have required fall prevention interventions in place, such as perimeter mattresses, Dycem mats, foot pedals on wheelchairs, and accessible call lights. Staff interviews confirmed expectations for these interventions, but observations showed they were not consistently implemented, contrary to care plans and facility policy.
A resident with COPD and other medical conditions had their nebulizer mask and nasal cannula left exposed on a bedside table and oxygen tank handle, rather than being stored in a clean, labeled bag as required by facility policy. Staff interviews and documentation confirmed that respiratory equipment should be stored in a sanitary manner, but this was not followed, resulting in a deficiency.
A resident with severe dementia and multiple comorbidities was not consistently supervised or redirected, resulting in repeated incidents of wandering, attempts to exit secured areas, and entering other residents' rooms. Staff did not follow the care plan interventions for supervision and redirection, and the facility could not provide a dementia care policy when requested.
A resident with multiple complex medical conditions who was receiving hospice care did not have a coordinated plan of care that integrated services provided by both the facility and hospice. Staff interviews revealed uncertainty about hospice-provided services and a lack of documentation in the care plan regarding hospice involvement, supplies, and schedules, despite facility policy requiring such coordination.
A communication breakdown led to a failure in administering physician-ordered medications to 19 residents during a scheduled medication pass. The incident involved a misunderstanding between an administrative nurse and a CMA, resulting in several residents missing critical medications for conditions such as hypertension, asthma, and Alzheimer's disease.
A communication breakdown led to ten residents not receiving their prescribed psychotropic medications during a scheduled evening medication pass. The incident involved a misunderstanding between a CMA and an administrative nurse, resulting in several medications, including antidepressants and antipsychotics, being missed. The facility's policy required medications to be administered as ordered, but this was not adhered to due to the oversight.
Failure to Implement and Document Diet Changes After Swallow Study and SLP Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to act on speech therapy and swallow study recommendations for a resident with dysphagia and multiple neurologic and cognitive impairments. The resident had diagnoses including cerebral infarction, late-onset Alzheimer’s disease, generalized muscle weakness, dementia, and dysphagia. The admission MDS and associated CAAs documented that the resident required partial to moderate assistance with eating and other ADLs, had poor but improving appetite, and was on a CCHO/LCS diet with regular texture and consistency. The care plan identified risks for weight loss, swallowing and chewing problems, and directed staff to monitor intake, assure correct diet consistency for safe swallowing, and obtain speech therapy if chewing or swallowing problems were observed. Speech therapy notes documented that the resident had an episode of significant coughing and difficulty swallowing meat, after which nursing reportedly downgraded the diet to mechanical soft. On the following day, a FEES study was completed, which recommended a minced and moist mechanical soft diet with thin liquids, medications whole or cut in puree, and specific swallow strategies including maintaining upright positioning during and after meals and using a double swallow with every bite and drink. A subsequent speech therapy note recorded that the resident’s diet was mechanical soft with thin liquids and pills crushed in puree, and that the resident required total supervision at meals for safety. However, the EMR showed only a physician’s order for a CCHO/LCS diet with regular texture and consistency from admission through early February, with no documented diet changes or new diet orders reflecting the FEES recommendations. The swallow study report was uploaded into the resident’s EMR under the Misc tab by a licensed nurse, but the record lacked evidence that the provider was formally notified of the results or that any physician response was documented. Interviews with administrative and nursing staff revealed uncertainty about what happened with the swallow study and speech therapy recommendations, and staff described a process in which results were scanned into the EMR but might not generate alerts for review. The nurse who uploaded the swallow study stated she contacted the provider by phone, was told to continue the regular diet without changes, and did not document this contact or the provider’s response in a progress note. She also indicated she was unsure whether the provider had seen the speech therapy notes or recommendations. No relevant facility policy regarding handling orders and recommendations was provided upon request, and the EMR contained no evidence of diet order changes or documented physician rationale related to the swallow study and speech therapy recommendations during the resident’s stay.
Missed Yearly Performance Evaluation for CNA
Penalty
Summary
The facility failed to complete a required yearly performance evaluation for one of five Certified Nurse Aides (CNA) reviewed, specifically for a CNA who had been employed for over 12 months. Record review showed that this CNA, hired on 03/06/23, did not have a yearly performance evaluation available upon request. During an interview, the administrative nurse responsible for conducting these evaluations confirmed that the review had not been completed for the CNA, who worked night shifts. The facility's policy requires yearly performance evaluations to identify training needs and ensure compliance with state and federal regulations, but this process was not followed for the identified CNA. This deficiency was identified during a review of personnel records and staff interviews, with no mention of corrective actions or follow-up steps taken at the time of the report.
Lack of Full-Time Certified Dietary Manager
Penalty
Summary
The facility failed to employ a full-time certified dietary manager to oversee food and nutrition services for its 47 residents. Administrative staff confirmed that there was no certified dietary manager currently employed, and dietary staff reported that while she had been with the facility for over a year, she was not certified and had not yet started classes to obtain certification. The dietary manager only visited the facility monthly. The facility's own policy required a qualified, competent, and skilled dietary manager to help oversee food and nutrition services, but this standard was not met, resulting in a lack of proper oversight for the ordering, preparation, and storage of food for all residents.
Failure to Maintain Sanitary Food Service and Storage Standards
Penalty
Summary
Surveyors observed multiple failures to maintain sanitary dietary standards in the facility. During a walkthrough, the dining room was found closed to residents due to ongoing construction after a roof collapse, with ceiling fixtures hanging and dust covering tables and floors. There were no barriers separating the construction area from the kitchen, and the door between the dining room and kitchen remained propped open during meal preparation for all meals on the day of inspection. Additionally, opened and undated ice cream was found in the Memory Care Unit's kitchenette freezer. Staff interviews confirmed that the dining room was off-limits due to the roof issue and that there was an expectation for staff to clean and check refrigerators outside the kitchen area. Further observations revealed that a CNA assisted multiple residents with meal service and feeding without performing hand hygiene at any point during the breakfast service. Staff interviews indicated that hand hygiene was expected between assisting different residents and after touching soiled surfaces, but this was not followed. Dietary staff also stated that plastic barriers should have been in place to prevent contamination from the construction area if doors were open. Review of facility policy confirmed requirements for proper cleaning, labeling, dating, and storage of food, as well as hand hygiene and prevention of cross-contamination, all of which were not adhered to during the survey period.
Failure to Provide Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that five Certified Nurse Aides (CNAs), each employed for more than 12 months, completed the required 12 hours of in-service education within the past 12 months, as verified through a review of in-service records. The CNAs identified had not met the annual in-service training requirement based on their employment dates, as specified in the facility's policy. The Administrative Nurse confirmed responsibility for ensuring direct care staff received the required training, but the records showed that none of the sampled CNAs had completed the necessary in-service hours during the review period.
Failure to Provide Individualized Activities Programming on Weekends
Penalty
Summary
The facility failed to develop and implement individualized activities programming based on resident preferences for weekends. Review of activity calendars for three months showed that only a limited selection of activities, such as church services, coloring, puzzles, and movies, were provided on weekends. Resident Council members reported that weekend activities were inconsistent compared to weekdays, with a lack of staff-led activities and reliance on passive options like television, coloring pages, and puzzles. Staff interviews confirmed that there was no designated staff member assigned to lead activities on weekends, and that the Activities Coordinator was responsible for planning but not for ensuring implementation. Unit staff were expected to provide activities, but this was not consistently done. The facility was unable to provide a policy related to activities when requested. The lack of individualized and staff-led activities on weekends placed residents at risk for decreased psychosocial well-being, boredom, and isolation, as directly reported by the Resident Council. The sample included 12 residents out of a census of 47, and the findings were based on observation, record review, and interviews with residents and staff.
Failure to Reconcile and Account for Controlled Substances Between Shifts
Penalty
Summary
The facility failed to ensure that controlled substances were properly accounted for and reconciled between shifts. Review of narcotic count sheets for multiple halls over several months revealed numerous missing signatures from both oncoming and off-going nursing staff, indicating that required shift-to-shift narcotic counts were not consistently performed or documented. Staff interviews confirmed that the facility's policy required nurses or Certified Medication Aides (CMAs) to count controlled substances together at each shift change, and that staff were not to leave until the count was correct. However, the documentation showed repeated lapses in this process. The facility's own policy required all narcotics to be stored securely and for any discrepancies to be reported immediately, with staff not leaving the area until discrepancies were resolved or reported. Despite these requirements, the observed missing signatures and lack of reconciliation demonstrated that the facility did not consistently follow its own procedures for controlled medication accountability. This failure was identified through direct observation, record review, and staff interviews, and affected the facility's ability to ensure the security and proper management of controlled substances for its residents.
Failure to Date Opened Tuberculin Test Serum Vials
Penalty
Summary
Staff failed to appropriately store medications and biologicals by not dating vials of tuberculin test serum after they were opened. During an observation of the medication room refrigerator, two vials of opened tuberculin test serum were found to be undated. Licensed nursing staff confirmed that the vials were opened and undated, and were unsure of the duration for which the serum remained usable after opening. Administrative nursing staff also stated that the vials should be dated with either an open date or an expiration date upon opening. The facility's Medication Storage policy required that all medications requiring refrigeration be stored properly and that the pharmacy and medication room be routinely inspected for discontinued, outdated, defective, or deteriorated medications, including those with missing labels. Despite this policy, the opened vials of tuberculin test serum were not dated, which constituted a failure to follow established procedures for medication storage.
Infection Control Deficiencies in Linen and Respiratory Equipment Storage
Penalty
Summary
Surveyors observed multiple infection control deficiencies during their review of the facility. Washcloths were found placed in handrails outside residents' rooms on several halls, and a linen cart containing towels, washcloths, and bedding was left uncovered. Additionally, a resident's nebulizer mask was found lying directly on a bedside table, and an oxygen tank with a nasal cannula was stored on a stand at the foot of the bed, with the cannula wrapped around the handle. These items were not stored in a sanitary manner as required by facility policy. Interviews with nursing staff confirmed that all respiratory equipment not in use should be placed in appropriately labeled bags, and that linen carts should always be covered. Staff also stated that washcloths should not be stored on guardrails outside residents' rooms. The facility's policy on oxygen administration required delivery devices to be covered in plastic bags when not in use, but there was no policy provided for the storage of linens in carts or washcloths. These failures in infection prevention and control practices were identified as placing residents at risk for infectious diseases.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
Staff failed to provide a dignified care environment for two residents during meal service. On two separate occasions, a CNA and another unidentified staff member assisted residents with eating by standing over them for the entirety of their meals, rather than sitting at the residents' level. Interviews with staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that facility policy and expectations require staff to sit next to residents while assisting with meals to promote dignity. The facility's Resident's Rights policy also specifies the importance of ensuring a care environment that promotes dignity, choice, and respect for all residents.
Failure to Provide Wheelchair Foot Pedals During Resident Transport
Penalty
Summary
Staff failed to provide wheelchair foot pedals for a resident with multiple medical conditions, including muscle weakness, unsteadiness on feet, and impaired upper extremities, while she was being pushed in the hallway. Observations showed that the resident was transported by both a licensed nurse and a certified nurse's aide without foot pedals attached to her wheelchair, and staff asked her to hold her feet up during transport. The resident's care plan and assessments indicated she required assistance with activities of daily living and mobility, and that staff were to ensure her safety, including the use of appropriate assistive devices. Interviews with staff revealed that some residents do not like having foot pedals on their wheelchairs, and that staff sometimes allow residents to go without them if they express a preference. However, the facility's policy requires the use of adequate assistive devices to prevent accidents. The failure to provide foot pedals while pushing the resident in her wheelchair was not care planned and was inconsistent with both the resident's care needs and facility policy.
Failure to Accurately Document Hospice Admission on MDS Assessment
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for a resident regarding her admission to hospice services. The resident, who had diagnoses of dementia, anxiety, and major depressive disorder, was documented as being dependent on staff for activities of daily living and had a severely impaired cognition score. Although the resident's electronic medical record and physician orders indicated she was admitted to hospice services, the Significant Change MDS assessment did not reflect this status during the observation period. The care plan referenced consulting hospice for pain management, but the MDS lacked documentation of hospice services being provided. Interviews revealed that the MDS nurse worked remotely and relied on facility staff to communicate changes such as hospice admissions. The administrative nurse confirmed that a modification to the MDS should have been completed to indicate the resident's hospice status. The facility's policy required a Significant Change in Status Assessment when a resident enrolls in hospice, but this was not accurately documented, resulting in a deficiency related to the assessment process.
Failure to Assist Resident with Grooming and Facial Shaving
Penalty
Summary
Staff failed to provide necessary assistance with grooming and facial shaving for a resident with multiple medical conditions, including anxiety, bipolar disorder, diabetes mellitus, sleep apnea, asthma, muscle weakness, cognitive communication deficit, hypertension, major depressive disorder, and dysphagia. The resident's medical records indicated severe impairment in upper extremities and dependence on staff for toileting, bathing, and grooming. Care plans and assessments documented the need for staff assistance with ADLs, including reminders for hygiene and offers of sponge baths, but there was no documentation of refusals for bathing or shaving. Observations revealed the resident was left with matted hair, food-stained clothing, and an unshaven face on multiple occasions. Interviews with CNAs and nursing staff confirmed that it was their responsibility to ensure residents were clean, groomed, and shaven, and that refusals should be documented. However, the resident's EMR lacked such documentation, and the facility's policy required maintenance of grooming and hygiene for residents unable to perform ADLs. The failure to assist the resident with grooming and facial shaving constituted a deficiency in care.
Failure to Follow Physician's Order for Weekly Weights in Resident with CHF
Penalty
Summary
The facility failed to follow a physician's order for weekly weights for a resident with multiple complex medical conditions, including congestive heart failure (CHF), diabetes mellitus, chronic obstructive pulmonary disease (COPD), anemia, obesity, hypoxia, and muscle weakness. The resident's care plan and physician orders specifically required weekly weights to monitor for fluid overload due to diuretic use. Review of the Medication Administration Record (MAR) over a 15-week period showed that weights were not recorded on several scheduled dates, and there was no documentation that the physician was notified of missed weights or that the resident refused to be weighed. Interviews with staff revealed that CNAs were informed by nurses about which residents needed to be weighed, and if a weight was missed, they would attempt to obtain it the following day. However, the licensed nurse interviewed stated that she would not notify the physician of missed or refused weights. The administrative nurse indicated that if a weight could not be obtained, the physician should be notified, but there was no evidence this occurred. The facility's policy required consistent provision of physician-ordered services, but this was not followed in the case of weekly weights for this resident.
Failure to Implement and Maintain Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure a safe care environment for multiple residents by not consistently implementing individualized fall prevention interventions as outlined in their care plans. One resident with severe cognitive impairment, bilateral lower extremity impairment, and a history of falls was observed without a perimeter mattress, despite this being a documented intervention following a recent fall. Staff interviews confirmed that fall interventions were expected to be in place, but observations on multiple days showed the perimeter mattress was missing. Another resident, also with severe cognitive impairment and a history of repeated falls, was care planned to have a Dycem mat in her wheelchair to prevent slipping. Observations revealed that the Dycem mat was not present in her chair on multiple occasions. Staff acknowledged that the Dycem was sometimes not replaced after transfers, and there was uncertainty about whether it was still needed after a change to a different type of wheelchair. The care plan still included this intervention, and staff were expected to ensure all interventions were in place each shift. A third resident with dementia, muscle weakness, and a history of falls was observed with her call light out of reach and being pushed in a wheelchair without foot pedals, contrary to her care plan interventions. Staff interviews confirmed that foot pedals should be used when pushing residents who cannot lift their feet and that call lights should always be within reach. The facility's own policies required individualized interventions to be implemented correctly and consistently, but these were not followed, placing residents at risk for preventable accidents and injuries.
Failure to Store Respiratory Equipment in a Sanitary Manner
Penalty
Summary
Staff failed to store a resident's nebulizer mask and nasal cannula in a sanitary manner, as observed during a survey. The resident, who had multiple diagnoses including COPD, required supplemental oxygen and nebulizer treatments per physician orders. On observation, the nebulizer mask was found lying directly on the bedside table and the nasal cannula was wrapped around the handle of an oxygen tank at the foot of the bed, rather than being stored in a clean, labeled bag as required by facility policy and staff statements. The resident's care plan and physician orders specified the need for regular cleaning and proper storage of respiratory equipment, but lacked specific instructions for storing the nebulizer when not in use. Interviews with staff confirmed that respiratory equipment should be placed in a labeled bag when not in use, and the facility's policy required delivery devices to be covered in plastic bags. The failure to follow these procedures resulted in the equipment being left exposed, which was identified as a deficiency by surveyors.
Failure to Provide Dementia Care and Supervision
Penalty
Summary
The facility failed to provide appropriate dementia-related care services for a resident with severe cognitive impairment, as evidenced by multiple incidents of wandering, attempts to exit secured areas, and entering other residents' rooms without adequate staff intervention. The resident, who had diagnoses including dementia, anemia, thrombocytopenia, kidney disease, hypokalemia, hyperlipidemia, muscle weakness, difficulty walking, unsteadiness, lack of coordination, and major depressive disorder, was admitted to the memory care unit and identified as being at risk for elopement. The care plan specified the use of a Wander Guard bracelet and instructed staff to provide meaningful activities, directional cues, and redirection to prevent elopement behaviors. Despite these interventions being outlined, staff failed to consistently supervise and redirect the resident. On several occasions, the resident was observed wandering unsupervised, attempting to open exit doors, and entering another resident's room to go through personal belongings. Staff interviews confirmed expectations for close monitoring, supervision, and redirection of cognitively impaired residents, but these were not consistently implemented. Additionally, the facility was unable to provide a policy related to dementia care when requested.
Failure to Coordinate Hospice Services in Resident Care Plan
Penalty
Summary
The facility failed to ensure a coordinated plan of care was developed and available for a resident who was receiving hospice services. The resident had multiple diagnoses, including COPD, major depressive disorder, myocardial infarction, rhabdomyolysis, bipolar disorder, dysphagia, anxiety, muscle weakness, hypertension, unsteadiness of feet, and Parkinson's disease. The resident was cognitively intact and required significant assistance with activities of daily living. The care plan documented that the resident was admitted to hospice and outlined general interventions for symptom management and communication with hospice, but did not specify the coordination of care and services between the facility and hospice provider. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, revealed uncertainty and lack of clarity regarding what hospice provided for the resident, when hospice staff would be present, and what supplies or equipment were available. Staff indicated that this information was not included in the facility's care plan and relied on verbal communication from hospice staff. The facility's policy required coordination and documentation of care and services between the facility and hospice, but this was not reflected in the resident's care plan, resulting in a lack of a coordinated plan of care for the resident.
Medication Administration Failure
Penalty
Summary
The facility failed to ensure that 19 residents received their physician-ordered medications during the scheduled medication pass on the evening of April 8, 2024. This incident involved a misunderstanding between Administrative Nurse D and Certified Medication Aide (CMA) R, where Nurse D believed that CMA R had administered medications to all but one resident. However, it was later discovered that several residents had not received their medications as scheduled. The incident summary revealed that on the following day, CMA S contacted Administrative Nurse D to inquire about the previous evening's medication administration, leading to the discovery that many residents had missed their medications. The medications not administered included a range of critical drugs such as blood thinners, pain relievers, cholesterol-lowering medications, and treatments for conditions like Alzheimer's disease, asthma, and hypertension. The failure to administer these medications was attributed to a communication breakdown and a lack of oversight in ensuring that all medications were passed before the CMA left her shift. The facility's policy on medication administration, dated 2024, required that medications be administered as ordered by the physician and that staff review the Medication Administration Record to identify medications to be administered. Despite this policy, the facility did not ensure that the residents received their prescribed medications during the specified time frame, resulting in a significant medication error affecting multiple residents.
Medication Administration Failure
Penalty
Summary
The facility failed to ensure that ten residents received their physician-ordered psychotropic medications during the scheduled medication pass on the evening of April 8, 2024. The incident occurred when Certified Medication Aide (CMA) R left her shift, and Administrative Nurse D misunderstood her statement, believing that all medications had been administered except for one resident. However, it was later discovered that several residents had not received their medications. The medications missed included various antidepressants, antipsychotics, and antianxiety medications, which were crucial for the residents' treatment plans. The incident summary revealed that Administrative Nurse D was informed by CMA S the following day that several residents had not received their medications. Upon investigation, it was found that CMA R had only administered a handful of medications during the evening pass. The facility's policy on medication administration required that medications be administered as ordered by the physician, and staff were expected to review the Medication Administration Record to ensure compliance. The failure to administer the medications as scheduled was attributed to a communication breakdown and lack of verification by the night shift charge nurse.
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.
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