Access Mental Health
Inspection history, citations, penalties and survey trends for this long-term care facility in Peabody, Kansas.
- Location
- 500 Peabody, Peabody, Kansas 66866
- CMS Provider Number
- 17E210
- Inspections on file
- 35
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 39 (1 serious)
Citation history
Health deficiencies cited at Access Mental Health during CMS and state inspections, most recent first.
Surveyors found multiple food items in the kitchen and storage areas left open to air, including shredded potatoes, sausage patties, pudding mix, chocolate chips, dressing mix, and shredded cheese. Dented cans of apples and mushrooms were also present. Dietary staff were unaware of the requirement to keep food containers closed, and administrative staff confirmed that all food should be properly stored and dented cans returned or discarded, as per facility policy.
Staff transported soiled laundry in uncovered and overflowing containers through hallways, and clean laundry was processed on a damaged, unsanitizable table. Both CNA and laundry staff confirmed these practices, which did not comply with the facility's infection control policy for handling and processing linens.
The facility did not complete required Care Area Assessments (CAAs) with analysis of findings for several residents who triggered areas such as psychotropic drug use, dental care, behavioral symptoms, and cognitive loss/dementia. Staff interviews confirmed that the responsible nurse lacked education on proper CAA documentation, resulting in incomplete assessments and missing analysis of underlying causes and risk factors.
Several residents had inaccuracies in their MDS assessments, including incorrect documentation of hypoglycemic medications, misclassification of a bed positioning device as a restraint, and failure to record the use of WanderGuard alarms. These errors were acknowledged by the MDS nurse, who cited limited time and infrequent facility presence as contributing factors, and were identified through interviews, observations, and record reviews.
A medication error rate above five percent was identified when a nurse failed to prime insulin pens, did not verify orders with the MAR, and did not follow manufacturer instructions for injection duration while administering insulin to a resident with diabetes. The nurse was unsure of the correct technique, and facility policy requiring verification and proper administration was not followed.
Staff prepared and served a water-thin mixture described as broth instead of gravy over turkey and dressing, without following a written recipe or menu guidelines. Administrative staff confirmed the mixture was not appealing and did not meet expectations for palatability. The facility could not provide a policy on food palatability when requested.
Two residents and/or their representatives were not properly informed or provided with documented consent for the use of psychotropic medications, as required. Consent forms for several medications lacked the necessary signatures, and electronic medical records did not contain evidence of informed consent. Staff interviews revealed confusion about the consent process and responsibilities, leading to incomplete documentation.
A resident was admitted and did not have a complete person-centered baseline care plan developed within the required 48-hour timeframe. Key components of the care plan, including General Information and Initial Goals and Health Conditions, remained incomplete for an extended period. Staff interviews indicated a lack of awareness regarding the 48-hour requirement for baseline care plan completion.
Three residents were not offered the pneumococcal vaccine, and there was no documentation in their EMRs to show that the vaccine was provided or that informed declination was obtained. An administrative nurse confirmed the lack of documentation and cited insurance coverage issues as a barrier.
A resident experienced significant weight loss due to the facility's failure to implement timely nutritional interventions. Despite the resident's medical history and cognitive impairments, the facility did not provide adequate dietary support or communicate effectively with the registered dietician. The resident's care plan was only updated months after the initial weight loss, and the facility lacked a certified dietary manager, leading to continued weight decline and risk of malnourishment.
The facility did not ensure the director of food and nutrition services had the required CDM qualifications. Dietary BB, who lacked CDM certification, was unaware of the requirement, and the registered dietician was only available monthly. Administrative Staff A mistakenly believed that a registered dietician's presence sufficed. The facility failed to provide a policy on CDM qualifications, risking residents' dietary and nutritional needs.
The facility failed to adhere to proper meat thawing procedures, as a pork loin was observed thawing in a sink without running water. This practice, confirmed by dietary staff as incorrect, placed residents at risk for food-borne illnesses.
The facility failed to document and offer influenza and pneumococcal vaccinations to several residents, lacking informed declinations, consent, or physician-documented contraindications. This oversight increased the risk of influenza and pneumonia. Staff interviews revealed inconsistencies in offering vaccinations due to concerns about upsetting legal guardians and Medicaid coverage issues.
A resident with a history of mental health disorders was transferred to a psychiatric hospital without proper documentation, placing them at risk for uninformed care choices. The facility was unaware of the transfer until contacted by the hospital, revealing a deficiency in managing resident transfers and discharges.
The facility failed to provide written notification of transfers for two residents with mental health disorders, leading to uninformed care choices. One resident was transferred to a psychiatric hospital without documentation, while another was transferred to the hospital multiple times without written notice. The facility relied on phone notifications, lacking a policy for written transfer notifications.
The facility failed to accurately code the MDS for two residents, leading to potential risks for inappropriate care. One resident's MDS included incorrect treatments not received, while another's omitted a PTSD diagnosis due to documentation issues. These inaccuracies risked inadequate care planning.
The facility failed to develop individualized trauma-based care plans for two residents with PTSD, placing them at risk for impaired care. R30's care plan lacked specific interventions to address her PTSD, while R39's care plan did not include strategies to mitigate triggers or prevent re-traumatization. Staff interviews revealed a lack of awareness and training regarding trauma-based care, and the facility was unable to provide a policy for person-centered care plans.
A facility failed to update a resident's care plan to address incontinence and behavioral needs. Despite a comprehensive assessment, the plan lacked specific interventions for managing the resident's incontinence and resistance to care, influenced by a history of homelessness. Staff acknowledged the need for individualized interventions, but the facility lacked a policy for developing person-centered care plans.
A resident with limited ROM and a history of cerebral infarction and hemiplegia did not receive a ROM program to maintain mobility. Despite the resident's desire to remain independent, the administrative nurse had not evaluated the resident for a restorative program due to time constraints. Facility policy required such evaluations, but this was not conducted, resulting in a deficiency.
A facility failed to implement individualized toileting interventions for a resident with bowel and bladder incontinence. Despite being a good candidate for retraining, the resident's care plan lacked specific instructions for a toileting program and did not address behaviors linked to previous homelessness. Staff were expected to provide reminders, but no structured retraining program was in place, placing the resident at risk for complications.
The facility failed to provide trauma-informed care for three residents with PTSD, as it did not identify trauma-based triggers or implement individualized interventions to prevent re-traumatization. Despite having policies in place, the facility's staff were unaware of the residents' PTSD diagnoses and did not perform necessary assessments or create care plans with specific interventions. This placed the residents at risk for decreased psychosocial well-being and ineffective treatment.
The facility failed to provide individualized behavioral care interventions for three residents with mental health diagnoses, including schizophrenia, PTSD, and bipolar disorder. The care plans lacked specific interventions for managing behaviors such as resistance to care, inappropriate toileting, and verbal outbursts. Staff interviews revealed a lack of awareness of individualized interventions, and the facility's policy on behavioral health services was not effectively implemented, placing residents at risk for continued behavioral episodes and unmet care needs.
The facility's Consultant Pharmacist failed to identify and report deficiencies in medication orders for two residents. One resident's diclofenac order lacked a specified dosage, while another resident's heart rate was outside physician-ordered parameters, and required lab tests were missing. These oversights placed the residents at risk for unnecessary medications and complications.
The facility failed to follow physician orders for lab tests and vital sign monitoring for a resident with diabetes and hypertension, and did not ensure proper dosing instructions for Voltaren gel for two residents. This led to risks of unnecessary medication use and potential side effects. The facility lacked policies related to physician orders and medication dosing.
The facility failed to ensure that PRN psychotropic medications for two residents had a 14-day stop date or specified duration, placing them at risk for unnecessary medication administration. One resident had PRN orders for hydroxyzine, Seroquel, and Haloperidol without proper documentation, while another had a PRN order for Trazodone lacking a stop date. Staff interviews revealed uncertainty about medication order requirements, and the facility lacked a policy for monitoring psychotropic medications.
The facility failed to document the COVID-19 vaccination status for two residents, lacking records of offers, declinations, or contraindications. Interviews indicated that the responsibility for tracking immunizations was with the Infection Preventionist, but the facility could not provide a policy or signed consents. This oversight increased the residents' risk for COVID-19.
A resident with a history of self-harm and aggressive behaviors was physically and chemically restrained by facility staff without proper physician orders or documentation. The resident, diagnosed with multiple mental health disorders, became combative and attempted self-harm, leading staff to use restraints without adequate assessment or care planning.
A resident with multiple mental health diagnoses exhibited severe aggressive and self-harming behaviors, leading to the use of unauthorized chemical and physical restraints by the facility. The facility failed to effectively implement the resident's care plan and lacked a policy for restraint use, resulting in inadequate management of the resident's agitation and placing him in immediate jeopardy.
Improper Food Storage and Handling in Dietary Department
Penalty
Summary
Surveyors observed multiple instances of improper food storage during a tour of the facility's kitchen and storage areas. In the standing freezer, a package of shredded potatoes was found open to air, and in a chest freezer, a box of pork sausage patties was also open to air. In the dry storage area, a package of lemon pudding mix, a large package of butterscotch chocolate chips, and a large package of Italian dressing mix were all found open to air. Additionally, a large can of sliced apples and a small can of sliced mushrooms were noted to be dented. In the standing refrigerator, a large package of yellow/white shredded cheese mixture was open to air. During interviews, dietary staff indicated they were not aware that food containers should be closed, and administrative staff confirmed that all food items should be closed and dented cans should be returned or discarded. The facility's policy required food and non-food supplies to be stored under sanitary and safe conditions, with dented cans to be returned or destroyed. The facility had a census of 42 residents, with one central kitchen and one dining area at the time of the survey.
Deficient Infection Control in Laundry Handling and Processing
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding the handling and processing of laundry. Observations revealed that a CNA transported soiled laundry in an uncovered bin down the hallway, with laundry overflowing from the container. On another occasion, the same CNA transported a closed dirty laundry bin with an open basket of soiled laundry placed on top, also overflowing. The CNA confirmed she was unaware that soiled laundry needed to be covered during transport. Administrative nursing staff confirmed that all laundry should be covered during transport to prevent cross-contamination and the spread of infection. Further observation in the laundry area, with laundry staff present, identified a wood table used for folding and processing clean laundry that had chipped laminate and exposed bare wood, creating a surface that could not be properly sanitized. Laundry staff acknowledged the unsanitizable condition of the table and agreed it required repair. The facility's infection surveillance policy requires proper cleansing and disinfection of surfaces and equipment used for handling, processing, and transporting linens, which was not followed in these instances.
Incomplete Care Area Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete Care Area Assessments (CAAs) that addressed the individual underlying causes, contributing factors, and risk factors for five residents. For these residents, the CAAs triggered by the Minimum Data Set (MDS) assessments, such as those related to psychotropic drug use, dental care, behavioral symptoms, and cognitive loss/dementia, lacked required analysis of findings. The documentation did not include an analysis of the residents' conditions or the factors contributing to their care needs, as required by facility policy and federal guidelines. Staff interviews revealed that the MDS nurse responsible for completing the CAAs was not adequately educated on how to complete the CAA notes, resulting in incomplete documentation. Administrative staff confirmed that the CAAs were not completed as they should have been and lacked necessary analysis and risk findings. The facility's policy required that each triggered CAA be fully assessed and documented, but this was not done for the identified residents, placing them at risk for inadequate care due to unidentified care needs.
Inaccurate MDS Documentation for Medications, Restraints, and WanderGuard Alarms
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for seven residents, resulting in documentation errors related to medication administration, use of physical restraints, and the presence of WanderGuard alarms. Specifically, two residents had their non-insulin hypoglycemic medications (Ozempic, Metformin, and Trulicity) incorrectly coded as insulin, and these medications were not properly documented in the MDS. One resident was incorrectly coded as having a physical restraint due to the use of a bed positioning device, despite using it for mobility and independence rather than restraint. Four residents with physician orders for WanderGuard alarms were not accurately documented as having these devices in their MDS assessments. These inaccuracies were identified through observation, interviews, and record reviews. The MDS nurse responsible for completing the assessments acknowledged making errors in coding medications and WanderGuard alarms, attributing some mistakes to limited time and infrequent presence in the facility. Another administrative nurse reported that she expected the MDS to be accurate and that she reviewed and signed off on the assessments, but errors still occurred. The facility's policy requires that assessments accurately reflect the resident's status at the time of assessment, which was not met in these cases.
Medication Error Rate Exceeds Five Percent Due to Insulin Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, when two insulin administration errors were observed out of 25 medication opportunities, resulting in an eight percent error rate. Specifically, a licensed nurse administered insulin to a resident with diabetes mellitus without priming either the insulin lispro or insulin glargine pens, did not verify the insulin orders against the medication administration record at the time of preparation, and did not follow manufacturer instructions for the duration the pen button should be depressed during injection. The nurse kept the insulin pen button pressed for only two seconds for both types of insulin, despite manufacturer instructions specifying five seconds for insulin lispro and ten seconds for insulin glargine to ensure full dose delivery. Interviews revealed that the nurse was unsure of the required duration for keeping the insulin needle in the skin and did not follow the facility's policy, which mandates verification of medication orders and adherence to proper administration technique. The administrative nurse confirmed the expectation that all medication orders be verified with the medication administration record prior to administration. The facility's policy also requires that the medication be administered at the proper time, in the prescribed dose, and by the correct route, with specific instructions for insulin pen use that were not followed in this instance.
Failure to Ensure Palatable and Properly Prepared Meals
Penalty
Summary
The facility failed to ensure that meals were prepared in a manner that preserved or promoted palatability for its residents. During the preparation of a noon meal consisting of turkey, stuffing, mixed vegetables, and a dinner roll, a dietary staff member prepared a gravy by combining chicken base, water, and an unspecified amount of corn starch without following a written recipe. The resulting mixture was water-thin and described as a broth rather than a traditional gravy. The dietary staff member was unable to provide a recipe for the gravy, stating that she had memorized it from experience. Administrative staff observed the meal service and confirmed that the mixture served over the turkey and dressing did not resemble gravy and was not appealing. Additionally, the facility was unable to provide a policy related to food palatability when requested. The lack of adherence to standardized recipes and absence of a relevant policy contributed to the deficiency in meal preparation and presentation.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents and/or their representatives were properly informed and provided with documented consent regarding the use of psychotropic medications. Review of the Psychoactive Medication Therapy Informed Consent Form logbook revealed that consent forms for multiple psychotropic medications, including Invega, Haldol, Abilify, lithium, Ativan, trazodone, and Zyprexa, lacked signatures from the appropriate residents or their guardians. Specifically, consent forms for one resident were missing the resident's signature, while consent forms for another resident were missing the guardian's signature. Additionally, the electronic medical records for both residents did not contain documentation of informed consent for these medications. Interviews with facility staff indicated confusion and lack of clarity regarding the process for obtaining and documenting informed consent. Social Services staff reported being newly assigned to the task and were unaware of the requirement for guardian signatures when applicable. Administrative nursing staff acknowledged the missing signatures and described a practice of signing consent forms in advance or delegating the task to others, which resulted in incomplete documentation. The facility's policy required discussion of risks and benefits with residents or responsible parties, but this was not consistently documented or followed.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a person-centered baseline care plan within the required 48-hour timeframe for a newly admitted resident. The resident's electronic health record showed that only some components of the baseline care plan were completed over a period of days, with two essential components—General Information and Initial Goals and Health Conditions—remaining incomplete as of nearly two weeks after admission. Interviews revealed that the nurse responsible for admitting the resident did not complete the baseline care plan as required, and administrative staff were unaware of the 48-hour completion requirement. The facility's policy stated that an initial person-centered care plan should be developed within 48 hours of admission, but this was not followed in the case reviewed.
Failure to Offer and Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer the pneumococcal vaccine to three residents, as evidenced by the absence of documentation in their electronic medical records showing that the vaccine was offered, provided, or that informed declination was obtained. Specifically, the records for these residents did not contain evidence of education regarding the benefits and potential side effects of the immunization, nor any indication that the vaccine was administered or declined. An administrative nurse confirmed these findings and noted that while the facility attempts to vaccinate eligible residents, insurance coverage issues sometimes prevent administration. The facility's immunization policy requires that each resident or their representative receive current education and be offered the influenza and pneumococcal vaccines, but this process was not documented for the affected residents.
Failure to Implement Nutritional Interventions for Resident
Penalty
Summary
The facility failed to identify and implement nutritional interventions for a resident, referred to as R27, who experienced significant weight loss over two separate periods. Initially, between January and June, R27 lost 19.52% of her body weight without any documented intervention or prescribed weight loss program. Despite the resident's medical history, which included schizophrenia, asthma, and a history of fractures, the facility did not provide adequate nutritional support or monitoring during this time. In the subsequent period from August to January, R27 continued to lose weight, amounting to a 16.84% decrease. The facility's records showed a lack of timely dietary supplementation and intervention, as R27's care plan was only updated in November to include one-to-one assistance during meals and supplemental shakes. The facility's failure to act promptly on R27's weight loss and dietary needs was compounded by inadequate communication with the registered dietician, who was not informed of the resident's significant decline and was not included in care plan meetings. Observations and interviews with staff revealed that R27 required constant supervision and assistance during meals due to cognitive impairments and behaviors that affected her eating. Despite these needs, the facility did not have a certified dietary manager, and the registered dietician reported a lack of communication regarding changes in residents' weights and dietary intake. The facility's nutritional services policy, which required monitoring and intervention for residents at risk of significant weight loss, was not effectively implemented, leading to R27's continued weight decline and risk of malnourishment-related complications.
Lack of Certified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the director of food and nutrition services possessed the required qualifications of a Certified Dietary Manager (CDM). During an observation on January 13, 2025, at 07:17 AM, Dietary BB admitted to not having CDM certification, although she had completed her Safe Serv courses. She was unaware of the need to obtain CDM certification. Additionally, the registered dietician was only present at the facility once a month. On January 15, 2025, at 03:42 PM, Administrative Staff A expressed the belief that the presence of a registered dietician negated the necessity for the dietary manager to be certified. The facility was unable to provide a policy regarding the CDM qualifications when requested. This deficiency placed residents at risk for unmet dietary and nutritional needs.
Improper Thawing of Meat in Kitchen
Penalty
Summary
The facility, with a census of 45 residents, was found to have a deficiency in its food handling practices. During an initial tour of the kitchen, a pork loin was observed thawing in a three-bin wash sink without water running over it. This method of thawing meat does not comply with professional standards, which require meat to be thawed on the bottom shelf of the refrigerator or in a tub with running water if thawed in the sink. Dietary staff confirmed the correct procedures for thawing meat, indicating a failure to adhere to these standards. This oversight placed residents at risk for food-borne illnesses due to potential bacterial growth.
Failure to Document and Offer Vaccinations
Penalty
Summary
The facility failed to offer or obtain informed declinations, consent, or a physician-documented contraindication for influenza and pneumococcal vaccinations for several residents, including R5, R16, R19, R27, and R30. The clinical records of these residents lacked documentation indicating whether the influenza and PCV20 vaccinations were offered, declined, or administered, and there was no physician-documented contraindication. This oversight placed the residents at an increased risk for influenza, pneumonia, and related complications. Interviews with facility staff revealed that the pharmacy administered immunizations annually, and residents were typically offered vaccinations upon admission. However, it was noted that some residents or their legal guardians reported prior immunizations, and in some cases, the facility did not offer vaccinations due to concerns about upsetting legal guardians. Additionally, the facility did not offer the PCV20 vaccine to residents at risk of pneumonia because Medicaid did not cover the cost. The facility's immunization policy emphasized the importance of offering vaccines unless contraindicated or refused after appropriate education, but this policy was not consistently followed, leading to the identified deficiencies.
Failure to Document Resident Transfer to Hospital
Penalty
Summary
The facility failed to document the transfer of a resident, identified as R39, to an acute hospital, which placed the resident at risk for uninformed care choices. R39 had a history of mental health disorders, including PTSD, major depressive disorder, suicidal ideations, bipolar disorder, anxiety, and borderline personality disorder. Despite having intact cognition and being independent with her functional abilities, R39 was transferred to a psychiatric hospital without proper documentation of when, where, and why the transfer occurred. The facility's records, including the Electronic Medical Record (EMR) and Progress Notes, lacked documentation regarding the transfer, and the facility did not provide a policy on transfer and discharge when requested. Interviews with facility staff revealed that R39 was on therapeutic leave with her mother when she attempted suicide and was subsequently taken to a psychiatric hospital by her mother. The facility was unaware of R39's admission to the hospital until they received a call from the hospital stating that R39 had been discharged and needed to be transported back to the facility. The lack of documentation and communication regarding R39's transfer to the psychiatric hospital highlights a deficiency in the facility's procedures for managing resident transfers and discharges.
Failure to Provide Written Notification of Transfers
Penalty
Summary
The facility failed to provide written notification of transfer for two residents, R39 and R20, during facility-initiated transfers. R39, who had a history of mental health disorders including PTSD, major depressive disorder, and bipolar disorder, was transferred to a psychiatric hospital without written notification. The facility did not document the transfer in R39's progress notes, and staff stated that since R39 was on leave with her mother at the time of the transfer, they did not issue a written notification. This oversight placed R39 at risk for uninformed care choices. R20, who had diagnoses of bipolar disorder, epilepsy, and anxiety, was transferred to the hospital on multiple occasions without receiving written notification of the transfers. The facility's records showed that R20 was transferred and admitted to the hospital on several dates, but there was no evidence of written notice provided to R20 or his legal representative. The facility relied on phone notifications to the resident's legal guardian or family representatives, which did not meet the requirement for written notification. The facility was unable to provide a policy related to facility-initiated transfers for both residents. This lack of documentation and failure to provide written notifications for transfers placed both residents at risk of uninformed choices and miscommunication regarding their care needs.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for two residents, leading to potential risks for inappropriate comprehensive care. Resident 28's MDS was incorrectly coded to include treatments and services such as dialysis, hospice care, and mechanical ventilation, which the resident did not receive. This error was acknowledged by the administrative nurse responsible for completing the MDS, who admitted to making a mistake. The facility was unable to provide an MDS Accuracy policy upon request, highlighting a lack of procedural guidance. Resident 39's MDS assessments failed to include a diagnosis of post-traumatic stress disorder (PTSD), despite the resident having a documented history of PTSD. The omission was attributed to difficulties in obtaining documentation from the resident's previous facility, resulting in the PTSD diagnosis being excluded from the MDS. This oversight meant that the resident's care plan did not address PTSD-related triggers or interventions, potentially impacting the resident's care and well-being. Both cases demonstrate a failure in the facility's processes for accurately completing MDS assessments, which are crucial for developing appropriate care plans. The inaccuracies in the MDS coding for these residents placed them at risk for receiving care that did not fully address their needs. The facility's inability to provide relevant policies further underscores the deficiencies in their assessment and documentation procedures.
Failure to Develop Individualized Trauma-Based Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, R30 and R39, which included individualized person-centered interventions for their trauma-based care. R30's care plan lacked specific interventions to address her PTSD, despite her diagnoses of PTSD, tardive dyskinesia, schizoaffective disorder, and anxiety. The care plan did not identify ways to decrease exposure to triggers that could re-traumatize her. Staff interviews revealed a lack of awareness and training regarding trauma-based care plans, with some staff unaware of which residents had PTSD or how to prevent re-traumatization. R39's care plan also failed to address her PTSD, despite her diagnoses of PTSD, major depressive disorder, suicidal ideations, anxiety, bipolar disorder, and borderline personality disorder. The care plan included general interventions for aggressive behaviors but did not include specific strategies to mitigate triggers or prevent re-traumatization related to her PTSD. Interviews with administrative nurses confirmed that R39's care plan was not individualized to her specific needs and behaviors. The facility was unable to provide a policy related to the development of person-centered care plans, and staff interviews indicated a lack of trauma-based assessments and individualized interventions. The absence of a social service staff member further contributed to the deficiency in addressing the residents' trauma-based care needs. This lack of comprehensive care planning placed both residents at risk for impaired care and re-traumatization due to uncommunicated care needs.
Failure to Revise Care Plan for Resident's Incontinence and Behavioral Needs
Penalty
Summary
The facility failed to revise the care plan for Resident 3 to accurately reflect his care needs related to incontinence, activities of daily living (ADLs), and behaviors. Despite having a comprehensive assessment that identified his needs, the care plan lacked specific interventions and instructions for managing his incontinence and behavioral issues. The resident, who has a history of schizophrenia, diabetes mellitus, and asthma, was noted to be occasionally incontinent of his bladder and required supervision during ADLs. However, the care plan did not include a toileting program or strategies to address his resistance to care, which was influenced by his previous lifestyle of homelessness. Observations and interviews revealed that the care plan did not provide individualized interventions for the resident's behaviors, such as defecating in inappropriate places due to his past experiences. Staff members, including a Certified Medication Aide and an Administrative Nurse, acknowledged the resident's history of rejecting care and the need for a care plan that includes specific behaviors and interventions. The facility was unable to provide a policy related to the development of a person-centered care plan, which contributed to the deficiency in addressing the resident's care needs effectively.
Failure to Implement ROM Program for Resident
Penalty
Summary
The facility failed to implement a range of motion (ROM) program for Resident 16, who was at risk of decreased mobility and potential development of contractures. Resident 16's medical history included schizophrenia, cerebral infarction, hemiplegia, chronic pain, insomnia, and PTSD. The resident had limited ROM on one side of the body and required partial to moderate assistance with dressing. Despite these needs, there was no evidence in the electronic medical record (EMR) that ROM or restorative care was provided to the resident. Observations and interviews revealed that Resident 16 expressed a desire to maintain mobility and independence. However, the administrative nurse responsible for evaluating residents for restorative programs had not assessed Resident 16 due to time constraints. Both the certified medication aide and a licensed nurse acknowledged that the resident would benefit from a ROM program. The facility's policy stated that residents should be evaluated for restorative programs upon admission and after significant changes in condition, but this was not done for Resident 16, leading to the deficiency.
Failure to Implement Individualized Toileting Interventions
Penalty
Summary
The facility failed to implement individualized toileting interventions for a resident, identified as R3, who was occasionally incontinent of bowel and bladder. Despite being noted as a good candidate for retraining in multiple assessments, R3's care plan lacked specific instructions for a toileting program or the use of incontinence products. The care plan also failed to address R3's history of defecating and urinating in his room, a behavior linked to his previous homelessness. Staff were expected to provide reminders for toileting every two hours, but there was no evidence of a structured retraining program being in place. R3's medical history included schizophrenia, diabetes mellitus, and asthma, with a BIMS score indicating intact cognition. The resident was independent in most activities of daily living but required supervision and encouragement due to resistive behavior. Interviews with staff revealed that R3's incontinence and behavioral needs were not adequately documented in the care plan, and the facility did not have a retraining program for incontinence. This oversight placed R3 at risk for complications related to incontinence, as the facility's policy required individualized continence management programs based on pattern evaluations.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for three residents diagnosed with posttraumatic stress disorder (PTSD), namely R30, R16, and R39. The facility did not identify trauma-based triggers or implement individualized interventions to prevent re-traumatization. For R30, the care plan lacked specific interventions to decrease exposure to triggers, despite her intact cognition and history of verbal behaviors. Staff members, including a Certified Medication Aide and a Licensed Nurse, were unaware of which residents had PTSD or required trauma-based care plans. R16, who had moderately impaired cognition and a history of schizophrenia and PTSD, also did not have a care plan with individualized interventions to prevent re-traumatization. The facility's staff, including the MDS coordinator and an administrative nurse, acknowledged the absence of trauma-based assessments and interventions, citing the facility's small size and lack of social service staff as reasons for not having individualized care plans. R39's care plan did not address her PTSD, despite her intact cognition and history of major depressive disorder and bipolar disorder. The facility failed to perform a trauma-informed care assessment upon her admission, and staff were unaware of her PTSD diagnosis until a month after her admission. The facility's Behavioral Health Services policy stated that residents with a history of trauma should receive appropriate treatment, but this was not implemented for R39, placing her at risk for decreased psychosocial well-being and ineffective treatment.
Failure to Implement Individualized Behavioral Care Interventions
Penalty
Summary
The facility failed to implement individualized behavioral care interventions for three residents, R3, R30, and R39, who were reviewed for behavioral services. For R3, the facility did not provide adequate interventions for his behavioral symptoms, which included resistance to care, defecating on the floor, and urinating in inappropriate places. Despite having a care plan that identified potential aggressive behaviors, the plan lacked specific interventions for his refusals to complete self-care and his incontinence issues. Progress notes repeatedly documented his resistance to care and inappropriate toileting behaviors, but they did not specify what behavioral interventions were used during these episodes. R30's care plan was also found lacking in individualized interventions for her behavioral symptoms, which included verbal behaviors and refusal to take medications. Although she had a history of PTSD and other mental health diagnoses, her care plan did not include specific interventions to address her triggers or prevent re-traumatization. Staff interviews revealed a lack of awareness of individualized interventions for her behaviors, and the facility's policy on behavioral health services was not adequately implemented to ensure person-centered care. Similarly, R39's care plan did not address her PTSD diagnosis or provide specific interventions for her anxiety, depression, and bipolar disorder. Her care plan included general strategies for managing aggressive behaviors but did not identify triggers or interventions specific to her mental health needs. Interviews with administrative nurses confirmed that her care plan was not individualized, and the facility's policy on behavioral health services was not effectively applied to meet her needs. These deficiencies placed the residents at risk for continued behavioral episodes and unmet care needs.
Consultant Pharmacist Fails to Identify Medication Order Deficiencies
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported deficiencies in medication orders for two residents, R5 and R19. For R5, the CP did not report that the physician's order for diclofenac, a non-steroidal anti-inflammatory medication, lacked a specified dosage. This oversight was noted in the Medication Regimen Review (MRR) for November and December 2024. Interviews with facility staff revealed a lack of awareness regarding the necessity of specifying a dosage for topical medications like diclofenac, which placed R5 at risk for unnecessary medications and related complications. For R19, the CP failed to identify and report that the resident's heart rate was outside the physician-ordered parameters on multiple occasions over a 73-day period. Additionally, the CP did not report the absence of physician-ordered laboratory test results in R19's clinical record. The facility was unable to provide these test results upon request, indicating a lapse in monitoring and documentation. Interviews with staff highlighted a breakdown in communication and responsibility for notifying physicians about out-of-parameter vital signs and ensuring laboratory tests were conducted as ordered. The facility's Drug Regimen Review policy mandates that the CP perform a drug regimen review for each resident at least monthly, including monitoring for irregularities in medication orders and ensuring appropriate documentation and notification of any issues. The failure to adhere to this policy for both R5 and R19 resulted in deficiencies that placed the residents at risk for unnecessary medications and related complications.
Failure to Follow Physician Orders and Ensure Proper Medication Dosing
Penalty
Summary
The facility failed to ensure that the physician's orders were followed for Resident 19's laboratory tests to monitor high-risk medications and did not notify the physician when heart rates were outside the ordered parameters. Resident 19, who had diagnoses of diabetes mellitus and hypertension, was supposed to have regular laboratory tests and monitoring of vital signs as per physician orders. However, the facility's records lacked evidence of these tests being conducted, and there was no documentation of physician notification when the resident's heart rate was outside the specified parameters on multiple occasions. For Resident 16, the facility did not ensure proper dosing instructions for the application of Voltaren gel, a topical pain reliever. Resident 16, who had multiple diagnoses including schizophrenia and chronic pain, was prescribed Voltaren gel to be applied to specific areas. However, the facility staff were unsure about the dosage requirements, and the facility was unable to provide a policy related to physician orders, leading to a risk of unnecessary medication use and potential side effects. Similarly, Resident 5's physician order for diclofenac gel lacked a specified dosage amount. Resident 5, who had a history of schizophrenia and a stress fracture, was at high risk of falls and was prescribed diclofenac gel for knee pain. The facility failed to identify and report the missing dosage information, which could lead to unnecessary medication use and related complications. The facility was unable to provide a policy regarding unnecessary medications, further contributing to the deficiencies observed.
Failure to Ensure PRN Psychotropic Medications Have Stop Dates
Penalty
Summary
The facility failed to ensure that as-needed (PRN) psychotropic medications for two residents, R30 and R16, had a 14-day stop date or a specified duration with supporting physician documentation. This oversight was identified during a review of the residents' electronic medical records (EMR) and interviews with facility staff. The absence of a stop date or specified duration for these medications placed the residents at risk for unnecessary medication administration and potential adverse side effects. Resident R30 had a history of posttraumatic stress disorder, tardive dyskinesia, schizoaffective disorder, and anxiety. The resident's care plan included the administration of psychotropic medications as ordered by the physician. However, the EMR revealed that PRN orders for hydroxyzine, Seroquel, and Haloperidol lacked a 14-day stop date or a physician-ordered specific duration. Additionally, a physician order to discontinue Seroquel was not followed, as it was not discontinued as ordered. Interviews with facility staff indicated a lack of clarity regarding the requirement for a duration in PRN psychotropic medication orders. Resident R16, diagnosed with schizophrenia, cerebral infarction, hemiplegia, chronic pain, insomnia, and PTSD, also had PRN orders for Trazodone without a 14-day stop date or specified duration. The facility was unable to provide a policy related to monitoring psychotropic medications, and staff interviews revealed uncertainty about the requirements for PRN psychotropic medication orders. This deficiency in medication management practices placed both residents at risk for unnecessary medication administration and possible adverse side effects.
Failure to Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to offer or obtain informed declinations or a physician-documented contraindication for the COVID-19 vaccinations for two residents, identified as R16 and R5. Upon review of their clinical records, it was found that there was no documentation under the Immunization tab indicating that the COVID-19 vaccination was offered, declined, or administered. Additionally, there was no physician-documented contraindication present in their records. This lack of documentation and action placed these residents at an increased risk for COVID-19. Interviews with facility staff revealed that the responsibility for tracking immunizations was with Administrative Nurse D, who also served as the facility's Infection Preventionist. It was noted that the pharmacy visited the facility annually to administer immunizations, and residents were offered vaccinations upon admission. However, the facility was unable to provide a policy related to the administration of COVID-19 vaccinations, nor could they provide signed consents or declinations for the residents in question. This oversight in documentation and procedure led to the identified deficiency.
Failure to Ensure Resident Remained Free from Restraints
Penalty
Summary
The facility failed to ensure that a resident, who had a history of self-harm and aggressive behaviors, remained free from physical and chemical restraints. On multiple occasions, the resident attempted to injure himself and became combative with staff, leading to the use of both chemical and physical restraints. The facility did not have physician orders for the use of these restraints, nor did they document any assessments or person-centered care planning related to the restraint use. The resident had multiple diagnoses, including bipolar disorder with psychotic features, major depressive disorder, ADHD, PTSD, and autistic disorder. Despite these conditions, the facility did not assess the resident's mental status adequately and failed to identify any medical or behavioral symptoms that warranted the use of restraints. The care plan for the resident included monitoring behavior episodes and attempting to determine underlying causes, but it did not include any specific strategies for managing the resident's aggressive behaviors without resorting to restraints. During the incidents, the resident exhibited severe agitation and aggression, including making threats, attempting self-harm, and physically attacking staff. The facility staff responded by physically restraining the resident with the help of multiple staff members and using a bedsheet to further restrain him. The resident was also chemically sedated with medications like Haldol and Ativan. These actions were taken without proper documentation or physician orders, placing the resident in immediate jeopardy.
Removal Plan
- The facility completed a violence risk screening on all current residents.
- The facility revised care plan for residents identified at high risk for assault identified in the screening tool.
- The facility began educating staff on the Federal Guidelines on the use of restraints.
- The facility assigned online training for Handling Aggressive Behaviors, Overview of Abuse and Neglect of Individuals with IDD, Understanding Wandering and Elopement, and the Meaning Behind Behaviors.
Inadequate Response to Resident's Aggressive Behavior
Penalty
Summary
The facility failed to appropriately acknowledge and respond to a resident's behaviors related to his psychosocial disorder and physical aggression. The resident, diagnosed with bipolar disorder, major depressive disorder, ADHD, PTSD, and autistic disorder, exhibited severe aggressive and self-harming behaviors over several days. On multiple occasions, the resident made threats to harm himself and others, engaged in self-injurious actions, and became physically aggressive towards staff, necessitating intervention to prevent harm. The facility's response included the use of chemical and physical restraints without proper physician orders, as evidenced by the lack of documentation in the Electronic Medical Record. The resident's care plan, which was supposed to address his behavior problems, was not effectively implemented. Staff interventions were inadequate, as they failed to de-escalate the resident's agitation and resorted to physical restraint methods that were not authorized or documented. The facility also lacked a policy for the use of restraints, further complicating the situation. The resident's aggressive episodes were exacerbated by anxiety related to legal issues, and the facility's attempts to manage these episodes included calling law enforcement and administering medications like Haldol and Ativan. Despite these efforts, the facility's actions were insufficient to prevent the resident from harming himself and others, leading to the use of unauthorized restraints and placing the resident in immediate jeopardy.
Removal Plan
- The facility completed a violence risk screening on all current residents.
- The facility revised care plan for residents identified at high risk for assault identified in the screening tool.
- The facility began educating staff on the Federal Guidelines on the use of restraints.
- The facility assigned online training for Handling Aggressive Behaviors, Overview of Abuse and Neglect of Individuals with IDD, Understanding Wandering and Elopement, and the Meaning Behind Behaviors.
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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