Advanced Health Care Of Overland Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Overland Park, Kansas.
- Location
- 4700 Indian Creek Parkway, Overland Park, Kansas 66207
- CMS Provider Number
- 175542
- Inspections on file
- 16
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Advanced Health Care Of Overland Park during CMS and state inspections, most recent first.
The facility failed to submit completed abuse/neglect investigations to the State Agency (SA) within the required five working days for two residents. In one case, a resident’s representative reported that the resident used the call light for urgent medical assistance during the night, staff did not respond in a timely manner, and the resident remained unattended while in acute physical distress. In another case, a resident with a clogged catheter was reportedly pushed into the lobby for discharge so a new admission could use the room, and the resident was instead sent to the hospital at the representative’s request. Although both allegations were reported to the SA, the completed investigations were not submitted on time due to miscommunication and assumptions between administrative staff, and the facility’s abuse policy did not specify the required timeframe for submission to the SA.
The facility failed to complete and submit required abuse/neglect investigations after allegations from two residents’ representatives. In one case, a resident’s representative reported that the resident used the call light for urgent help during the night, was left unattended while in acute distress, and vomited without timely staff response. In the other case, a resident’s representative alleged the resident had a clogged catheter and was pushed into the lobby for discharge so a new admission could take the room, leading the representative to cancel the discharge and request hospital transfer. Although staff obtained witness statements, reviewed the chart, and in one case reviewed video footage, the facility did not produce the written investigative summaries and complete documentation required by its abuse policy, and only partial materials were available when requested by the SA and surveyors.
The facility failed to maintain sanitary dietary standards, with multiple instances of improperly labeled and undated food items found in the kitchen's storage areas. Dietary staff acknowledged the requirement for labeling and dating food packaging, as per the facility's policy, but the failure to adhere to these standards placed residents at risk of food-borne illnesses.
The facility failed to implement a policy to prevent employing staff with criminal backgrounds, as evidenced by not conducting a required background check for an LN hired to work weekends. The LN was initially hired for home health and hospice services, and the facility did not perform its own check when the LN transitioned to the facility. This oversight placed residents at risk for abuse and neglect.
The facility failed to secure hazardous materials, such as medicated ointments and bleach wipes, in unlocked treatment carts accessible to eight cognitively impaired residents. Staff interviews confirmed that these items should be locked away, as per the facility's policy, to prevent accidents and injuries.
A resident with a history of fractures and mild cognitive impairment was found without access to her call light, which was on the floor and out of reach. Despite facility policies and staff statements emphasizing the importance of call light accessibility, the resident's call light was not within reach, placing her at risk for unmet care needs.
A facility failed to provide a resident with a CMS Notice of Medicare Non-Coverage (NOMNC) Form upon discharge from Medicare A services. The resident, with intact cognition, was discharged home without receiving the required notice, despite having benefit days remaining. The facility's policy required providing the NOMNC at least two days before service termination, which was not followed.
A resident with pancreatic cancer and at risk for skin breakdown did not receive consistent bathing opportunities as per the care plan. Despite a policy for twice-weekly baths, records showed missed opportunities, and the resident reported poor hygiene conditions. Upon hospital transfer, the resident was found with a pressure injury and poor hygiene, highlighting documentation and care inconsistencies.
A resident with an indwelling urinary catheter was at risk for complications due to improper positioning of the urine collection bag above bladder level, contrary to facility policy. Staff interviews confirmed the requirement for the bag to be below bladder level for proper drainage.
The facility failed to serve meals at appropriate temperatures, affecting two residents who reported receiving cold meals, particularly during breakfast. Temperature tests confirmed the food was below the safe range. Staff interviews revealed concerns about meal delivery times and the need for temperature checks, highlighting a deficiency in maintaining food service standards.
The facility failed to maintain sanitary infection control standards for biliary drains and Foley catheters, placing residents at risk for infections. Observations showed catheter and drainage bags resting on the floor, contrary to policy. Staff interviews confirmed expectations for proper placement, but compliance was lacking.
Failure to Submit Completed Abuse/Neglect Investigations Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to submit completed abuse/neglect investigations to the State Agency (SA) within the required five working-day timeframe for two residents. For one resident, the facility reported an allegation to the SA that the resident’s representative had emailed the facility stating that, between 2:00 AM and 3:00 AM, the resident activated the call light for urgent medical assistance, staff did not respond in a timely manner, and the resident remained unattended while in acute physical distress. The intake was documented at 3:00 PM the same day, and the facility spoke with the resident, who did not remember what time she vomited. Although the allegation was reported to the SA, the facility did not submit the completed investigation within five working days as required. For the second resident, the facility reported an allegation to the SA that the resident had a clogged catheter and staff pushed him into the lobby for discharge so a new admission could have his room. The resident’s representative canceled transportation for the discharge, and the resident went to the hospital at the representative’s request. This allegation was also reported to the SA, but the completed investigation was not submitted within five working days. During interviews, an administrative nurse stated she did not submit the completed investigations for either resident to the SA, and an administrative staff member stated he assumed the nurse had submitted one investigation and did not submit the other because he thought she had done so. The facility’s abuse policy required the Administrator or DON to complete a written investigation summary within five working days of the reported occurrence but did not address the timeframe for submitting completed investigations to the SA.
Failure to Complete and Submit Abuse/Neglect Investigations for Two Residents
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to complete and submit thorough abuse/neglect investigations for two residents after receiving allegations from their representatives. For the first resident, who had been admitted and later discharged home, the State Agency (SA) received an intake alleging that between 2:00 AM and 3:00 AM the resident activated the call light for urgent medical assistance, staff did not respond in a timely manner, and the resident remained unattended while in acute physical distress, including vomiting, which she later reported to her representative. The facility interviewed the resident, who did not recall the time she vomited, and staff were interviewed about events on and around the alleged date. However, when surveyors and the SA requested a completed investigation, the facility only produced staff witness statements and did not provide a written investigative summary or other required documentation. For the second resident, who had been admitted and later transferred to the hospital, the SA received an intake alleging that the resident’s catheter was clogged and that staff pushed the resident into the lobby for discharge so a new admission could use the room; the representative canceled the discharge and arranged for hospital transfer. Facility staff reported that the DON/designee reviewed catheter care notes and that an administrator reviewed video footage of the discharge and documented a brief note, and two nurses were contacted for their recollection of events. Despite these steps, the facility again failed to provide a completed investigation to the SA or onsite surveyors, supplying only staff witness statements. Interviews with the Administrative Nurse and Administrative Staff revealed that each assumed the other had submitted the completed investigations, and no written summary consistent with the facility’s abuse policy—requiring a completed investigation with a written summary of findings within five working days—was produced for either allegation.
Deficient Food Storage Practices
Penalty
Summary
The facility failed to maintain sanitary dietary standards related to food storage, as observed during a survey. Multiple instances of improperly labeled and undated food items were found in the kitchen's dry food storage room, main kitchen area, and walk-in freezer. These included containers of pistachios, puree pasta mix, honey wheat flavoring, potato pearls mashed potatoes, white rice, browning and seasoning sauce, bran flakes, brown powder, pie filling mix, yellow cake mix, pretzels, carrots, green beans, hashbrowns, and steaks. The lack of labeling and dating on these items was noted during observations conducted on specific dates and times. Dietary staff acknowledged the requirement for food packaging to be labeled and dated when opened, as per the facility's Food Storage policy. This policy, created in January 2021, mandates that all high-risk foods be visibly date-marked to indicate their safe use-by dates. The policy also requires that all containers be legibly and accurately labeled and dated, and that frozen foods be covered, labeled, and dated. Despite these guidelines, the facility's failure to adhere to these standards placed residents at risk of food-borne illnesses and food safety concerns.
Failure to Conduct Timely Background Checks for Staff
Penalty
Summary
The facility failed to develop and implement a policy that effectively prohibited and prevented the employment of staff with criminal backgrounds. This deficiency was identified when the facility did not conduct a required criminal background check for a Licensed Nurse (LN) who was hired to work weekends. The LN was initially hired for home health and hospice services under the same company, which had completed a background check. However, when the LN transitioned to work at the facility, the facility did not perform its own background check, as required. The facility's policy allowed for a 10-day period after employment to conduct background checks, which contributed to the oversight. The facility's undated Abuse Policy and Procedure stated that it would not knowingly employ individuals with a history of abuse, neglect, or other misconduct. Despite this, the facility's failure to conduct a timely background check for the LN placed all residents at risk for abuse, neglect, misappropriation, or mistreatment. The administrative staff acknowledged the oversight and the lack of documentation for the LN's background check, highlighting a gap in the facility's hiring and documentation processes.
Failure to Secure Hazardous Materials in LTC Facility
Penalty
Summary
The facility failed to ensure a safe environment free from hazardous chemicals and materials for eight cognitively impaired independently mobile residents. During a walkthrough of the facility's Two Hall, an unlocked wound treatment cart was found containing medicated ointments and Sani-Cloth bleach wipes, both labeled with warnings to keep out of reach of children. A similar unsecured cart was found in One Hall, containing bottles of diclofenac, disposable medical scalpels, and bleach wipes. These items were accessible to residents, which was against the facility's policy. Interviews with staff, including a CNA, a licensed nurse, and administrative staff, confirmed that treatment carts should be locked when not in use, and chemical cleaning products should always be secured. The facility's Accident and Incident policy, revised in June 2024, stated that the environment should be free from potential hazards, including chemicals. The failure to secure these items placed the residents at risk for preventable accidents and injuries.
Failure to Ensure Resident's Call Light Accessibility
Penalty
Summary
The facility failed to ensure that a resident, identified as R75, had access to her call light to communicate her needs or call for help. R75's medical records indicated she had a history of fractures, insomnia, and repeated falls, with a mild cognitive impairment. Her care plan required that her call light be within reach due to her limited mobility and risk of falls. However, during an observation, it was noted that R75's call light was on the floor and out of her reach, which she confirmed she could not safely access. A CNA later entered the room and corrected the situation by placing the call light back on the bed. Interviews with staff, including a CNA and a licensed nurse, confirmed that call lights should always be within reach of residents, either clipped to their clothing or on the bed. The facility's policy also stated that call lights should be accessible. Despite these guidelines, the facility did not ensure R75's call light was within reach, placing her at risk for unmet care needs.
Failure to Provide NOMNC Form to Resident
Penalty
Summary
The facility failed to provide a resident, identified as R82, with a Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) Form CMS-10095 upon discharge from Medicare A services. R82 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition, and was discharged home without anticipation of returning to the facility. The Beneficiary Protection Notification Review showed that R82 began Medicare Part A skilled services on 07/08/24, with the last covered day being 08/29/24. Despite having benefit days remaining, the facility initiated her discharge from skilled services. Upon request on 09/24/24, the facility was unable to provide a completed NOMNC for R82. An administrative nurse acknowledged the missing documentation and stated that the facility was working to address the issue. The facility's policy, revised in 09/2022, required providing the NOMNC at least two days prior to termination of services, which was not adhered to in this case.
Inconsistent Bathing Opportunities for Resident
Penalty
Summary
The facility failed to provide consistent bathing opportunities for a resident, identified as R18, who was at risk for skin breakdown and pressure injuries due to immobility and other medical conditions. R18's medical records indicated a need for supervision and assistance with activities of daily living, including bathing. Despite the care plan specifying twice-weekly showers, the Treatment Administration Report (TAR) showed missed bathing opportunities on several occasions, with only one bath documented since admission. R18 reported feeling unwell and noted that her drainage bag often fell on the floor, contributing to her discomfort. Observations revealed poor hygiene, with greasy hair, untrimmed nails, and a strong odor of urine and body odor in her room. Upon transfer to an acute care facility, R18 was found to have a pressure injury and poor hygiene, as reported by a consultant. Interviews with facility staff, including a CNA and a licensed nurse, confirmed that bathing schedules were in place, but documentation of refusals or missed baths was inconsistent. The facility's policy required documentation of completed, missed, or refused bathing opportunities, which was not adhered to in R18's case. This lack of consistent care and documentation placed R18 at risk for decreased psychosocial well-being and other complications.
Inadequate Foley Catheter Care for a Resident
Penalty
Summary
The facility failed to provide appropriate Foley catheter care for a resident, identified as R16, by not maintaining the urine collection bag below the level of the bladder, which is necessary for proper drainage. R16's medical history includes chronic kidney disease, spinal stenosis, hemiplegia, hemiparesis, and anxiety disorder. The resident was dependent on staff for various activities of daily living and had an indwelling urinary catheter. Observations revealed that the urine collection bag was positioned on the center of the footboard, higher than the bladder, with foamy yellow urine pooled in the drainage tubing towards the body. Interviews with facility staff, including a CNA, LN, and an administrative nurse, confirmed that urinary catheters should be positioned below the bladder level to ensure proper drainage and prevent contamination. The facility's policy on indwelling urinary catheter care, revised in July 2023, also stipulated that the drainage bag should remain below the bladder level, off the floor, and in a privacy bag. The failure to adhere to these guidelines placed R16 at risk for catheter-related complications, including urinary tract infections.
Deficiency in Serving Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at a palatable, safe, and appetizing temperature for two residents, R75 and R76. Observations and interviews revealed that residents frequently received cold meals, particularly during breakfast. R75 reported that the food was often cold in the mornings, and although staff were available to reheat the food upon request, she did not want her food reheated. Similarly, R76 stated that breakfast was often cold by the time it reached her room. Temperature tests conducted on their breakfast trays confirmed that the food items, including scrambled eggs, oatmeal, and cherry crumble, were served at temperatures significantly below the appropriate range. Interviews with staff members further highlighted the issue. A Certified Nurse's Aide (CNA) acknowledged that residents had concerns about the temperature of food delivered to their rooms and suggested that staff should test food temperatures before serving. Dietary Staff BB mentioned that a recent mock survey had identified concerns with meal service, and the facility should be using heaters and testing trays to maintain appropriate food temperatures. The facility's Food Service policy indicated that meals should be served within appropriate temperature ranges, but the practice of delivering meals to rooms without maintaining these standards led to the deficiency.
Infection Control Deficiency in Catheter and Drain Maintenance
Penalty
Summary
The facility failed to adhere to sanitary infection control standards concerning the maintenance of biliary drains and Foley catheters, which placed residents at risk for infectious diseases. During observations, it was noted that a resident's urinary catheter collection bag was resting flat on the floor beside her bed, and another resident's biliary drain tubing was running over her bed covers with the drainage collection bag also on the floor. These practices were contrary to the facility's policy, which mandates that drainage bags should remain below the level of the bladder, off the floor, and within a privacy bag. Interviews with staff revealed a lack of compliance with the facility's infection control policies. A CNA acknowledged that medical drains and catheter bags should never touch the floor and should be positioned below the bladder level to prevent backflow. A licensed nurse and an administrative nurse both confirmed that staff were expected to check the placement of catheter bags during each interaction with residents, ensuring they were off the floor and properly positioned. Despite these expectations, the facility's failure to maintain sanitary conditions for medical drains and catheters was evident, as observed by the surveyors.
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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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