Aberdeen Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Olathe, Kansas.
- Location
- 17500 W 119th Street, Olathe, Kansas 66061
- CMS Provider Number
- 175448
- Inspections on file
- 17
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Aberdeen Village during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, prior stroke, insomnia, and major depressive disorder was maintained on Quetiapine for “unspecified dementia with psychotic disturbances” without a CMS-approved indication and without behavioral monitoring. The MDS showed severe cognitive impairment but no documented behaviors, and the care plan referenced resisting care and yelling out but did not include a clear psychiatric indication for antipsychotic use. The resident was observed calm and behavior-free, while the EMR lacked behavior tracking tied to the antipsychotic. A consultant pharmacist recommended gradual dose reduction, which the provider declined, and staff acknowledged that antipsychotics are not indicated for dementia alone and that the resident’s representative refused medication changes, leaving the facility unable to document an appropriate rationale consistent with its own psychotropic medication policy.
Surveyors found that a resident was maintained on Quetiapine for an indication of unspecified dementia with psychotic disturbances without a clearly documented CMS-approved psychiatric indication. The MDS showed no documented behaviors during the assessment period, and the care plan referenced behaviors and use of Quetiapine but did not specify a psychiatric indication or include behavioral monitoring. The consultant pharmacist’s monthly reviews recommended gradual dose reduction, which the provider declined, but did not address the inappropriate dementia-related indication, and the facility could not produce documentation supporting an appropriate indication despite acknowledging that antipsychotics are not indicated for dementia alone.
A resident with Alzheimer's and moderate cognitive impairment eloped from a facility due to inadequate supervision and unsecured exits. The resident, who required assistance for ambulation and was at risk for falls, left the facility unnoticed and was found by law enforcement at a nearby gas station. The facility's elopement risk assessment did not identify the resident as at risk, and the care plan did not address elopement potential.
The facility failed to follow sanitary dietary standards, including improper food storage, lack of temperature log checks, and inadequate hand hygiene by dietary staff, placing residents at risk of foodborne illnesses.
The facility failed to store medications and biologicals appropriately when the medication room was found unlocked and a resident's insulin pens were not labeled with the open date. Staff were expected to ensure the medication room was locked at all times and insulin pens were labeled and stored properly.
The facility failed to ensure adequate infection control standards, including the use of enhanced barrier precautions, PPE, and proper indwelling catheter maintenance. Inspections revealed missing signage and PPE in residents' rooms and improper handling of a urinary catheter bag. Staff acknowledged awareness of the requirements but did not consistently implement them, placing residents at risk for infections.
The facility failed to honor a resident's request to move to the TV room during breakfast and did not maintain another resident's dignity during transfers in a common area, leading to exposure. Staff ignored the first resident's repeated requests and did not assist him, while the second resident was exposed during transfers due to improper handling by the staff.
The facility failed to ensure a resident received necessary assistive services for transfers, leading to the use of a gait belt that exposed the resident's skin and did not provide adequate support. Staff were inconsistent in following the care plan, which indicated the use of a pivot disc and walker.
The facility failed to ensure a resident's low air-loss mattress pump was set correctly according to their weight, and did not complete weekly wound assessments for another resident with a pressure ulcer. These deficiencies placed the residents at risk for complications related to skin breakdown and pressure ulcers.
A facility failed to provide appropriate treatment for a resident with an indwelling catheter by allowing the catheter drainage bag to rest on the floor. The resident had a history of frequent UTIs and required assistance for proper hygiene. Observations and staff interviews confirmed the improper placement of the catheter bag, which should have been stored in a dignity bag attached to the bed.
A resident's CPAP mask was repeatedly observed to be laid directly on the bedside table without containment, contrary to facility policy. Staff interviews confirmed the improper storage practice, which increased the resident's risk for respiratory infection and complications.
The facility failed to identify a resident's low air-loss mattress and bolstered overlay as potential risks in the side rail assessment, placing the resident at risk for inadequate care due to unidentified care needs. Staff were unsure if the assessments differentiated between mattress types and overlays, contrary to facility policy.
Inappropriate Antipsychotic Use Without CMS-Approved Indication
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure a resident remained free from chemical restraint through the inappropriate use of an antipsychotic medication without a CMS-approved indication. The resident had diagnoses including Alzheimer’s disease, cerebral infarction, insomnia, and major depressive disorder, with a BIMS score indicating severe cognitive impairment but no documented behaviors on the MDS during the assessment period. The care plan, initiated months earlier, described behaviors of resisting care and yelling out related to depression, anxiety, and dementia, and noted the use of Quetiapine (Seroquel) for these behaviors, but it did not include a psychiatric indication for the antipsychotic. The physician’s order renewed Quetiapine 12.5 mg daily for “unspecified dementia with psychotic disturbances,” and the resident had been admitted on this medication and diagnosis. Record review showed no behavioral monitoring related to the antipsychotic use, despite the resident’s psychotropic CAA identifying antipsychotic use and risk for adverse effects. Consultant pharmacist documentation over several months included a recommendation for gradual dose reduction of Quetiapine, which the provider declined, citing risk of decompensation, but the recommendations did not address the lack of an appropriate CMS indication for use in dementia. The facility was unable to provide a documented rationale for continued Quetiapine use without an appropriate CMS indication when requested. Observations showed the resident calm, engaged in group activity, and without behaviors at the time of surveyor observation. Interviews with facility staff confirmed that antipsychotics are not indicated for dementia alone and that dementia was the listed indication, with staff acknowledging that the resident’s representative refused changes to the medication or its indication. The facility’s own policy required psychotropic drugs to be used with specific diagnoses and to be closely monitored, but this was not supported by the documentation for this resident’s antipsychotic therapy.
Failure to Ensure Appropriate CMS-Approved Indication for Antipsychotic Therapy
Penalty
Summary
Surveyors identified a deficiency in the facility’s drug regimen review process related to the use of an antipsychotic medication for a resident with dementia. The resident’s EMR listed diagnoses of Alzheimer’s disease, cerebral infarction, insomnia, and major depressive disorder, with a BIMS score indicating severe cognitive impairment. The MDS showed the resident was independent in activities of daily living and did not exhibit behaviors during the assessment period, though it documented antipsychotic use. The CAA noted antipsychotic use and risk for adverse effects from Seroquel. The care plan, initiated earlier, described behaviors of resisting care and yelling out related to depression, anxiety, and dementia, and stated that Quetiapine (Seroquel) was used for these behaviors, but it lacked a clear psychiatric indication for the medication. The EMR contained a renewed order for Quetiapine 12.5 mg daily with an indication of unspecified dementia with psychotic disturbances, and there was no behavioral monitoring documented related to the antipsychotic use. Review of the consultant pharmacist’s monthly recommendations from May through February showed that the pharmacist recommended a gradual dose reduction of Quetiapine to the lowest effective dose, which the medical provider declined, citing risk of decompensation. The pharmacist’s recommendations did not address the use of the antipsychotic with the indication of dementia, and the facility could not provide documentation supporting a CMS-approved indication for the continued use of Quetiapine despite a request for such rationale. Observations showed the resident calm and engaged in group activity without behaviors. Interviews revealed that the consultant pharmacist stated the resident was admitted on the antipsychotic and that the representative refused changes or discontinuation, and that the medication was believed to be needed for dementia-related hallucinations and delusions. A nurse and an administrative nurse both stated that antipsychotics were not indicated for dementia alone and required a psychiatric diagnosis, and that the resident had been admitted with the medication and dementia diagnosis. This sequence of actions and inactions demonstrated a failure to ensure the consultant pharmacist addressed the lack of an appropriate CMS indication for the antipsychotic during the monthly drug regimen review, contrary to the facility’s drug regimen review policy.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a cognitively impaired resident, who required staff assistance for activities of daily living, including safe ambulation with a walker, and was at risk for falls. On the early morning of 10/17/24, a Certified Nurse Aide (CNA) heard the resident's toilet flush and checked on her. The resident indicated she did not need assistance, and the CNA left to assist another resident, assuming the resident would return to bed. However, the resident subsequently left her room, took the elevator to the first floor, and exited the facility without staff knowledge or supervision. The resident, who had a diagnosis of Alzheimer's disease, unspecified dementia, osteoporosis, syncope, and a history of falls, was found by law enforcement at a nearby gas station and returned to the facility. The resident's electronic medical record indicated moderate cognitive impairment and a need for supervision during ambulation. Despite these needs, the resident's care plan did not address elopement potential prior to the incident. The facility's elopement risk screen conducted before the incident indicated the resident was not at risk for elopement, and there were no previous elopement attempts recorded. The facility's investigation revealed that the resident was able to exit the facility through a series of doors that did not have adequate security measures to prevent such an occurrence. The main entrance doors were accessible without a keypad lock, and there was no staff present in the main lobby area after 01:00 AM to monitor the resident's movements. The facility's failure to provide adequate supervision and secure the facility's exits allowed the resident to leave the premises unnoticed, placing her in immediate jeopardy.
Removal Plan
- A WanderGuard was placed on R1 with orders to monitor and document function each shift.
- R1's care plan was updated to include an intervention and monitoring for R1's WanderGuard.
- Staff completed an updated Elopement screening on R1 to reflect R1's new risk and behavior.
- The facility contacted maintenance and the facility door contractor to inspect the unit door's locking systems to ensure there was no other point of failure.
- The facility ordered parts to have a set of double doors coded with a keypad lock to prevent future elopements through those doors.
- Administrative Nurse D was in the process of providing education for all staff related to elopement, wandering, and missing residents.
Failure to Follow Sanitary Dietary Standards
Penalty
Summary
The facility failed to follow sanitary dietary standards related to cleaning, food storage, equipment storage, and food preparation practices. During an initial tour, it was observed that bowls were stored upright instead of inverted, and temperature logs for refrigerators, freezers, and the dishwasher lacked evidence of being checked on specific dates. Additionally, the walk-in freezer had uncovered and undated breaded chicken breasts, and open containers of cottage cheese and milk were not dated. A commercial meat slicer was found uncovered but not in use. These observations indicate a lack of adherence to proper food storage and equipment maintenance protocols, which are essential for preventing foodborne illnesses and ensuring food safety for residents. Further observations revealed that a dietary staff member did not perform hand hygiene before beginning food preparation and handled food and utensils with contaminated gloves. The staff member touched unclean surfaces and then directly handled food without changing gloves or performing hand hygiene. This practice continued as the staff member doffed gloves and proceeded to clean surfaces without washing hands, and later used an ungloved hand to grab a spatula by the end that touches food. Interviews with dietary staff confirmed that these actions were against the facility's policies, which require hand hygiene and proper use of gloves to prevent cross-contamination and foodborne illnesses. The facility's policies on hand hygiene and food storage were not followed, placing residents at risk of food safety concerns.
Failure to Secure Medication Room and Label Insulin Pens
Penalty
Summary
The facility failed to store medications and biologicals appropriately when the medication room on the second floor was found unlocked during an inspection. The room contained a secured digital medication storage system, a locked medication refrigerator, and a shelf with unsecured over-the-counter medications. Licensed Nurse J secured the room upon completion of the inspection. Additionally, an inspection of a medication cart revealed that a resident's insulin pens were not labeled with the open date, which is required to ensure proper usage and disposal within 28 days. Licensed Nurse G immediately removed the unlabeled insulin pens from the cart. Licensed Nurse J stated that staff were expected to ensure the medication room door was fully shut and locked at all times to prevent resident access to medications and nursing equipment. Administrative Nurse D confirmed that the medication rooms were expected to be locked at all times and that insulin pens should be labeled with the open date and stored in the medication carts. The facility's Medication Storage policy indicated that all medications and biologicals should be stored safely following the manufacturer's storage recommendations and properly labeled with the recommended expiration dates.
Inadequate Infection Control Standards
Penalty
Summary
The facility failed to ensure adequate infection control standards related to enhanced barrier precautions, wearing personal protective equipment (PPE), and indwelling catheter maintenance. During inspections, it was observed that several residents' rooms lacked the necessary signage and PPE for enhanced barrier precautions. Specifically, rooms of residents with wound care and indwelling urinary catheters did not have the required signage or PPE posted. Additionally, a certified nurse aide entered a resident's room with a bacterial urinary infection and performed peri-care without donning the required PPE, despite the presence of a contact isolation sign and PPE outside the room. Further observations revealed that a resident's urinary catheter bag was improperly placed on the floor, which is against the facility's infection control policy. Interviews with staff confirmed that they were aware of the requirements for enhanced barrier precautions and PPE usage, as they had recently undergone training on these topics. However, the staff failed to consistently implement these precautions, placing residents at risk for infectious diseases. The facility's policies on infection control and catheter care were not adequately followed, leading to these deficiencies.
Failure to Honor Resident Requests and Maintain Dignity
Penalty
Summary
The facility failed to honor a resident's request during dining and maintain another resident's dignity during care in a common area. One resident repeatedly asked to be moved to the TV room during breakfast, but staff ignored his requests and did not assist him, even though his wheelchair was locked and he could not move himself. The resident expressed frustration and was visibly distressed, coughing and spitting out food without receiving timely assistance from the staff. Eventually, a social services staff member moved him to the TV room after he had been ignored for an extended period. Another resident, who had severe cognitive impairment and required substantial assistance with transfers, was exposed during transfers in the common area. The licensed nurse used a gait belt to lift the resident, causing her shirt to rise and expose her skin from the waist to the breast area. This occurred on multiple occasions, and the staff acknowledged that the resident should not have been exposed in a common area. The facility's policy on resident rights and dignity was not followed, leading to the resident's exposure and potential negative psychosocial outcomes. The facility's policy emphasized the importance of treating residents with respect and dignity, ensuring their rights to a dignified existence and self-determination. However, the staff's actions and inactions in these instances did not align with the policy, resulting in deficiencies that compromised the residents' dignity and self-worth.
Failure to Provide Necessary Assistive Services for Transfers
Penalty
Summary
The facility failed to ensure that Resident 46 received the necessary assistive services for transfers, which placed the resident at risk for loss of independence, decreased self-esteem, and impaired dignity. Resident 46 had a history of cerebral infarction, dementia, and depression, and was documented to have severely impaired cognition. The resident's care plan indicated the use of a pivot disc and walker for transfers. However, observations on multiple occasions showed that staff did not use these assistive devices during transfers, instead using a gait belt that exposed the resident's skin and did not provide adequate support for weight-bearing. Interviews with staff revealed inconsistencies in their knowledge and application of the resident's care plan. Certified Nurse Aide M and Licensed Nurse G both indicated that the resident was transferred with a gait belt and one staff person, but were unsure about the use of a pivot disc and walker. Administrative Nurse D confirmed that staff should follow the care guide, which is based on the care plan, and that any changes in a resident's status should be reported for re-evaluation. The facility's policy on Resident Rights and Responsibilities emphasized the importance of treating residents with dignity and providing person-centered care, which was not upheld in this case.
Failure to Implement Pressure-Reducing Interventions and Complete Weekly Wound Assessments
Penalty
Summary
The facility failed to ensure that a resident's pressure-reducing interventions were implemented correctly. Specifically, the low air-loss mattress pump for a resident with severe cognitive impairment and a Stage 3 pressure ulcer was set at an inaccurate weight of 280 lbs, despite the resident weighing only 107 lbs. This discrepancy was observed over multiple days, and staff interviews confirmed that the mattress should have been set to 120 lbs according to the resident's current weight. The facility's policy required staff to check the bed function and settings each shift, but this was not adhered to, placing the resident at risk for complications related to skin breakdown and pressure ulcers. The facility also failed to complete weekly wound assessments for another resident with a history of cerebral infarction, early onset Alzheimer's disease, and hemiplegia. This resident had a Stage 2 pressure ulcer and was at moderate risk for pressure ulcer development. The resident's electronic medical record lacked evidence of weekly wound assessments over several weeks, with gaps of 14 and 34 days between documented assessments. Staff interviews revealed that the unit charge nurse and wound care nurse were responsible for weekly skin checks and wound assessments, but these were not consistently performed or documented. The facility's policies on skin integrity and pressure ulcer prevention required weekly skin evaluations by a licensed nurse and the implementation of wound treatment orders when pressure ulcers were present. However, these policies were not followed, resulting in missed assessments and inadequate monitoring of the resident's pressure injuries. This failure placed the resident at risk for further complications related to skin breakdown and pressure ulcers.
Failure to Properly Manage Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment for a resident with an indwelling catheter by allowing the catheter drainage bag to rest on the floor. The resident, who had diagnoses of bladder cancer, dementia, and urinary retention, had a history of frequent urinary tract infections (UTIs) and required assistance from staff for proper hygiene related to the care of his indwelling catheter. Observations revealed that the catheter bag contained dark amber urine and was placed directly on the floor at the foot of the resident's bed. Interviews with staff confirmed that the catheter drainage bag should never be placed on the floor and should be stored in a dignity bag attached to the bed to prevent infections. The resident's medical records documented multiple physician orders for antibiotics to treat recurrent UTIs, indicating a history of infection complications. Despite the facility's policy on catheter care, which mandates that catheter care be performed appropriately by qualified nursing staff to prevent complications, the facility failed to adhere to this policy. This deficiency placed the resident at risk for further catheter-related complications and UTIs, as evidenced by the improper placement of the catheter drainage bag on the floor.
Improper Storage of CPAP Mask
Penalty
Summary
The facility failed to ensure the proper storage of a resident's CPAP mask, which was observed to be laid directly on the bedside table without containment on multiple occasions. The resident, who had a history of obstructive sleep apnea and other medical conditions, was dependent on staff for all activities of daily living and had moderately impaired cognition. Despite physician orders to apply the CPAP at bedtime and remove it in the morning, the staff consistently placed the mask on the bedside table without using a sanitary storage method. Interviews with staff revealed a lack of adherence to the facility's policy on CPAP mask storage. A Certified Nurse's Aide stated that the mask was always placed on the bedside table, while a Licensed Nurse and an Administrative Nurse confirmed that the mask should be stored in a dated plastic bag. The facility's Oxygen Therapy policy also required that the device be stored in a plastic or other bag when not in use. The failure to follow these guidelines placed the resident at an increased risk for respiratory infection and complications.
Failure to Identify Risks Associated with Bed Rail Assessment
Penalty
Summary
The facility failed to identify a resident's low air-loss mattress and bolstered overlay as potential risks in the side rail assessment. The resident, who had severe cognitive impairment, Alzheimer's disease, major depressive disorder, a stage 3 pressure ulcer, and a history of falls, was using a low air-loss mattress and bolstered overlay provided by hospice services. Despite these devices being in place, the facility's assessment did not account for the specific risks associated with the mattress and overlay, which could lead to gaps between the rail and bed, possible strangulation hazards, and the effectiveness of the assist rails. Observations and interviews revealed that the facility's staff, including the licensed nurse and administrative nurse, were unsure if the risk assessments differentiated between mattress types and overlays. The facility's policy required continual assessment of assistive devices attached to beds to ensure safety, but the assessment for this resident did not identify the low air-loss mattress or bolstered overlay as risks. This oversight placed the resident at risk for inadequate care due to unidentified care needs.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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