Advena Living Of Cherryvale
Inspection history, citations, penalties and survey trends for this long-term care facility in Cherryvale, Kansas.
- Location
- 1001 W Main Street, Cherryvale, Kansas 67335
- CMS Provider Number
- 175335
- Inspections on file
- 26
- Latest survey
- September 4, 2025
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Advena Living Of Cherryvale during CMS and state inspections, most recent first.
Surveyors found that the kitchen had unsanitary conditions, including handwashing sinks with brown stains and grime, and a broken, uncovered trash can located near the food preparation area. Dietary staff confirmed the issues and the facility lacked a policy for trash disposal and hand sanitation equipment.
Multiple areas of the facility, including the hallway outside the kitchen and the laundry area, were found with broken tiles, standing water, missing flooring, exposed pipes, unsanitizable surfaces, and exposed electrical components. Staff and maintenance personnel were often unaware of these issues until they were reported, and the process for reporting maintenance concerns was inconsistently followed, resulting in unsafe and unsanitary conditions.
Multiple environmental hazards, including exposed drywall, damaged ceilings, dirty floors, cracked tiles, and live open electrical outlets, were observed in resident rooms and common areas. Staff interviews revealed a lack of awareness and inconsistent use of the maintenance reporting system, resulting in unaddressed hazards and failure to maintain a safe, clean, and homelike environment as required by facility policy.
A resident with multiple chronic conditions was administered several medications together after breakfast, despite orders requiring some to be given before meals and others with or after food. Staff confirmed the medications were not given as prescribed, contributing to a medication error rate of 17%, exceeding the required threshold.
Numerous handrails in a resident hallway were found to be loose and easily moved by hand during a facility tour. Maintenance and administrative staff were unaware of the issue, despite facility policies requiring a safe environment and prompt reporting of damaged equipment.
Several residents were administered psychotropic medications, including antipsychotics and antianxiety drugs, without proper informed consent being obtained or documented prior to the initiation or change of these medications. Facility staff confirmed that required consents were missing, delayed, or incomplete, contrary to facility policy.
A resident with a history of depression, psychotic disturbance, and anxiety, requiring assistance with daily activities, was not consistently included or invited to participate in her care plan meetings. Staff interviews and record reviews confirmed a lack of documentation and notification regarding the resident's involvement in care planning, contrary to facility policy.
A resident with multiple mental health diagnoses was prescribed PRN clonazepam for anxiety and sleeplessness without a required 14-day stop date or physician justification for continued use. Facility staff confirmed the absence of a stop date or rationale, and no policy was provided to support compliance with regulations regarding PRN psychotropic medications.
A resident with Parkinson's disease, CHF, and DM was transferred to the hospital, but the facility did not notify the Ombudsman as required by policy. The electronic medical record lacked documentation of this notification, and staff confirmed the omission.
A deficiency was cited for not providing enough food and fluids to maintain a resident's health, as required. The report indicates that the facility did not meet the necessary standards for nutrition and hydration, but does not include further details about the circumstances or the resident's condition.
A resident in need of pain management did not receive safe and appropriate pain management services, resulting in a deficiency related to the facility's failure to meet the resident's needs.
A resident with a history of stroke, hypertension, and chronic kidney disease continued to receive Xarelto, an anticoagulant flagged by the consultant pharmacist for increased bleeding risk in older adults. The pharmacist recommended considering a switch to Eliquis, but the facility did not obtain a physician response or follow up on this recommendation for over 42 days, and lacked a policy for such follow-up.
Surveyors found that staff did not properly secure medications, leaving delivery boxes containing various drugs and biologicals on the floor of an Environmental Services closet instead of storing them in the medication room or cart as required by facility policy. Interviews confirmed that medications should not have been stored outside designated secure areas.
Unsanitary Kitchen Conditions Due to Improper Trash Disposal and Handwashing Sink Maintenance
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the kitchen, specifically regarding the storage and preparation of food. During an initial kitchen tour, the handwashing sinks were found to have brown stains and grime buildup around both the inner and outer edges. Additionally, a foot-operated trash can had a broken lid, which was found lying on the floor behind the trash can in a pile of used coffee grounds. The open trash can was located adjacent to the food preparation area, next to the steam table and a rack of clean dishes. Dietary staff confirmed that the trash should be contained to ensure food sanitation and prevent contamination. On a follow-up tour, the same uncovered trash can was observed at the handwashing sink in the food preparation area, and staff verified that it was the same broken trash can from the previous day. The facility did not provide a policy addressing trash disposal and hand sanitation equipment in the kitchen. These observations were made while the facility had a census of 26 residents and one main kitchen. No specific residents were directly involved or affected at the time of the deficiency.
Failure to Maintain Safe and Sanitary Environment in Key Facility Areas
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in several key areas, including the hallway outside the kitchen and the laundry area. Observations revealed multiple broken tiles and standing water in the hallway leading from the kitchen to the outside, which was being tracked into the kitchen. Dietary staff confirmed that water entered the hallway during rain and had to be mopped up to prevent it from entering the kitchen, while the broken tiles prevented proper sanitation. Maintenance staff were unaware of the broken and missing tiles until notified, and acknowledged that the area could not be properly sanitized. Additional observations found missing linoleum flooring behind the nurse's desk, with staff reporting that maintenance concerns should be entered into a computerized notification system, though this was not always done consistently. In the laundry area, there were several unsanitary and unsafe conditions, including an exposed, uncapped sewage pipe between washers, an unsealed and flaking ceiling in the dryer room, and heavily scuffed and chipped paint on walls, door frames, and storage cabinets, exposing wood and making the surfaces unsanitizable. A wall-mounted thermostat was also found without a cover, exposing electrical components. Maintenance staff stated they were unaware of these issues until recently and reiterated that all concerns should be reported through the facility's computerized work order system, but acknowledged that this process was not always followed by staff.
Failure to Maintain Safe and Homelike Environment Due to Unaddressed Environmental Hazards
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in both resident rooms and common areas, as evidenced by multiple observations of environmental hazards and lack of timely maintenance. Surveyors observed dark spots and missing molding with exposed and broken drywall in one resident's room, damaged ceiling areas with exposed sheet rock, and dirty, stained floors. Another resident's room had a large area of exposed drywall and missing paint, with a dirty and sticky floor. The north hallway and rooms had chipped, cracked, and bubbled floor tiles, with some areas exposing the concrete underneath. Additional observations included a significant ceiling and wall crack extending between two rooms, a broken wall tile in the dining room, and multiple open 220-volt electrical outlets in both the dining room and north resident hall, all of which were live with electricity and located close to the ground. Interviews with maintenance and administrative staff revealed a lack of awareness regarding several of these hazards, and a breakdown in the facility's process for reporting and addressing maintenance concerns. Staff were expected to use a computerized maintenance management system (TELS) to report issues, but this was not consistently followed, resulting in unaddressed hazards. Maintenance staff indicated delays in repairs due to waiting for quotes or materials, and some hazards had not been reported or tracked as required by facility policy. Facility policies required a safe, clean, and comfortable environment and prompt maintenance service, but these were not adhered to, leading to the observed deficiencies.
Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a 17% error rate during medication administration. Out of 26 medications observed, four were administered in error. Specifically, a resident with a history of GERD, chronic pain, diabetes, and gastrointestinal issues was prescribed multiple medications with specific administration instructions, such as taking certain medications before meals, on an empty stomach, or with food. During observation, a Certified Medication Aide administered several of these medications together after the resident's breakfast, contrary to the prescribed instructions that required some to be given before meals and others with or after food. The resident also refused one medication, and another was held due to blood pressure readings. Staff interviews confirmed that the medications were not administered according to the physician's orders, with both the medication aide and a licensed nurse acknowledging the error. The nurse further verified that the resident had ongoing issues with vomiting and weight loss, and that the medications were intended to prevent these symptoms when given as ordered. The facility's policy required medications to be administered per the physician's schedule, and the error was confirmed by administrative staff, who noted that certain medications, such as Carafate, should be given separately to avoid interference with absorption.
Loose Handrails in Resident Hallway
Penalty
Summary
The facility failed to provide safe and functional handrails in one of two hallways, as observed during a facility tour when numerous handrails in the north resident hallway were found to be loose and easily moved by hand. Maintenance staff interviewed at the time were unaware of the loose handrails, and administrative staff also stated they were not aware of any such issues in the facility. The facility's policies require staff to maintain a safe environment and to report and repair damaged equipment, but these procedures were not followed, resulting in the deficiency being identified during the survey. The facility had a census of 26 residents at the time of the observation. No specific residents or their medical histories were mentioned in relation to the deficiency.
Failure to Obtain Informed Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were fully informed and provided with informed consent regarding the use of psychotropic medications. Specifically, three residents with diagnoses including schizophrenia, anxiety, bipolar disorder, and depression were administered antipsychotic, antianxiety, and antidepressant medications without proper documentation of informed consent prior to the initiation or change of these medications. In one case, a resident received Seroquel and Zyprexa for schizophrenia and clonazepam for anxiety, but the informed consent for these medications was either delayed or incomplete, with some consents signed months after the medications were started and others missing entirely for as-needed orders. Another resident with anxiety and bipolar disorder was prescribed clonazepam, desvenlafaxine, lamotrigine, and Latuda, but the electronic medical record lacked any documentation of informed consent for these psychotropic and antipsychotic medications. Similarly, a third resident with anxiety and depression was prescribed lorazepam and mirtazapine, yet there was no evidence of informed consent for these medications in the medical record. Interviews with administrative and licensed nursing staff confirmed that facility policy required informed consent to be obtained before starting or changing psychotropic medications, but this was not consistently followed. Observations and record reviews revealed that the facility's own policy mandated obtaining informed consent from residents or their representatives prior to the administration of antipsychotic medications. Despite this, the required consents were either missing, delayed, or incomplete for multiple residents receiving high-risk psychotropic drugs. Staff interviews further verified that the process for obtaining and documenting informed consent was not adhered to as required by facility policy.
Failure to Include Resident in Care Plan Development
Penalty
Summary
The facility failed to include a resident or her representative in the development and planning of her care plan. The resident had a history of depression, psychotic disturbance, mood disturbance, and anxiety, and her cognitive status varied from moderate impairment to intact cognition according to her MDS assessments. Documentation showed that the resident required varying levels of assistance with mobility, hygiene, dressing, and eating, and was prescribed antidepressant and opioid medications. While there was evidence of the resident's attendance at care plan meetings on two specific dates, there was no documentation that she was invited to or included in any subsequent care plan meetings. Interviews with the resident and facility staff confirmed that the resident had not been informed or invited to her care plan meetings after the documented dates. Staff responsible for notifying residents and maintaining records were unable to provide documentation of invitations or attendance for recent care plan meetings. The facility's policy stated that residents and their representatives should be encouraged to participate in care planning and that meetings should be scheduled at convenient times for them, but this was not consistently documented or followed in practice.
Failure to Ensure 14-Day Stop Date or Justification for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a 14-day stop date or a physician's justification for continuation was in place for an as-needed (PRN) psychotropic medication prescribed to a resident. The resident, who had diagnoses including schizophrenia, cerebral edema, and adjustment disorder with anxiety, had an order for PRN clonazepam for sleeplessness and anxiety without a specified stop date or documented rationale for use beyond 14 days. Review of the resident's electronic health record and medication administration records confirmed the absence of a stop date or physician justification for the ongoing PRN order, despite facility staff acknowledging that such medications should have a 14-day limit unless otherwise justified. Observations of the resident showed them in various settings within the facility, and interviews with nursing and administrative staff confirmed the lack of compliance with the 14-day stop date requirement for PRN psychotropic medications. The facility was unable to provide a policy regarding 14-day stop dates for psychotropic medications. This deficiency was identified through record review, staff interviews, and direct observation, and it placed the resident at risk of unnecessary psychotropic medication use and related adverse effects.
Failure to Notify Ombudsman of Resident Hospital Transfer
Penalty
Summary
The facility failed to notify the Ombudsman of a resident's transfer to the hospital, as required by facility policy. The resident in question had diagnoses of Parkinson's disease, congestive heart failure, and diabetes mellitus, and was transferred to the hospital as documented in the electronic medical record (EMR). However, the EMR did not contain any documentation that the Ombudsman was notified of this transfer. During an interview, the administrative nurse confirmed that the Ombudsman had not been notified. The facility was unable to provide evidence of such notification, despite a policy stating that the Ombudsman must be informed of all resident transfers or discharges.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Failure to Follow Up on Pharmacist's Anticoagulant Recommendation
Penalty
Summary
The facility failed to acknowledge and/or act on the consultant pharmacist's recommendation regarding the use of an anticoagulant medication for a resident with a history of stroke, hypertension, chronic kidney disease, and moderate cognitive impairment. The pharmacist had identified that the resident was receiving Xarelto, which is listed in the 2019 Beers Criteria as having an increased risk of serious bleeding in adults over 75 years when used long-term. The pharmacist recommended considering discontinuation or replacement of Xarelto with Eliquis and sent this recommendation to the physician for follow-up. Despite this recommendation, there was no evidence in the clinical record that the facility obtained a response from the physician or followed up on the pharmacist's recommendation for over 42 days. The administrative nurse confirmed that the lack of follow-up was an oversight and the facility did not have a policy in place to address follow-up on consultant pharmacist recommendations. This inaction resulted in the resident continuing to receive the medication without documented physician review or response to the identified irregularity.
Improper Storage of Medications in Unsecured Area
Penalty
Summary
Staff failed to ensure proper storage of resident medications, as observed when delivery boxes containing various stock medications were found sitting on the floor in the Environmental Services closet. The medications included A&D Ointment, aspirin, folic acid, probiotic, Voltaren Gel, Allegra, niacin, and Senna-Plus. According to interviews with administrative staff, medications were supposed to be taken directly to the medication room upon delivery and stored either in the medication cart or medication room, not in other locations. The facility's policy, dated 11/20, required all drugs and biologicals to be stored in a safe, secure, and orderly manner. The observed practice of leaving medication boxes in an unsecured area outside the designated medication storage locations was inconsistent with both facility policy and accepted professional principles. This practice was identified during a survey when the facility census was 26 residents across two halls.
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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