Advena Living Of Clay Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Clay Center, Kansas.
- Location
- 715 Liberty, Clay Center, Kansas 67432
- CMS Provider Number
- 175351
- Inspections on file
- 14
- Latest survey
- August 7, 2025
- Citations (last 12 mo.)
- 1 (1 serious)
Citation history
Health deficiencies cited at Advena Living Of Clay Center during CMS and state inspections, most recent first.
A dietary staff member prepared food in the kitchen without wearing a hairnet, only donning it after leaving and returning to the cooking area. Facility policy requires immediate use of hairnets in food preparation and service areas, and this lapse resulted in noncompliance with sanitary dietary standards.
A facility-wide assessment failed to specify required staffing levels for each unit and shift, omitting details on the number of RNs, LPNs/LVNs, CMAs, and CNAs needed based on patient acuity and census. The assessment also did not address staffing for evenings and weekends, impacting all residents in the facility.
The facility did not submit accurate PBJ staffing data to CMS, failing to properly report licensed nurse coverage and weekend staffing hours. Although internal records showed no missed coverage, some agency and fill-in shifts were not accurately reflected in the PBJ submissions, resulting in the facility being flagged for low weekend staffing and lack of 24-hour licensed nurse coverage.
Surveyors found that two residents' respiratory equipment, including a CPAP device and nasal cannula tubing, were not stored in a sanitary manner, and that staff did not have access to PPE in the soiled laundry sorting area. Staff interviews confirmed that proper storage and PPE use were not consistently followed, in violation of the facility's infection control policies.
A resident with multiple chronic conditions did not have fully developed Care Area Assessments (CAAs) in their MDS documentation, with missing analysis for areas such as self-care mobility, urinary incontinence, pain, and pressure ulcers. The administrative nurse confirmed that CAAs should include analysis, and the facility could not provide a policy for MDS or CAA development.
A resident with cognitive impairment and speech difficulties did not have their care plan updated to include specific strategies for effective staff communication when stuttering was not understood. Despite staff awareness of the resident's communication challenges and facility policy requiring person-centered care plans, the plan lacked guidance on how staff should interact with the resident to address these needs.
Two residents at risk for pressure ulcers did not receive proper care when their low air-loss mattresses were not set to the correct weight and pressure-relieving boots were not applied as required. Staff relied on the equipment provider to set mattress settings and only checked the devices if alarms sounded, with no consistent monitoring or documentation. Care plans lacked specific instructions for these interventions, and the facility could not provide a policy on pressure ulcer prevention.
A resident with dementia, muscle weakness, and a history of falls was found multiple times with their soft-touch call light on the floor and out of reach, despite care plan and facility policy requiring it to be accessible at all times. Staff interviews confirmed the call light should have been within easy access, but this was not maintained, placing the resident at risk for preventable accidents.
A resident with multiple chronic conditions, including COPD, was found with her CPAP mask placed on her bed and between the side rail and mattress, rather than stored in a sanitary container as required. Staff interviews confirmed that respiratory equipment should be kept in plastic bags, but the facility lacked a policy and the care plan did not address proper cleaning or storage of the CPAP mask.
A resident with a history of PTSD and anxiety did not have trauma-informed care strategies included in their care plan, despite documented symptoms and facility policy requiring such interventions. Staff were unaware of trauma-specific needs, and assessments were not consistently updated to address ongoing concerns, resulting in unmet psychosocial needs.
Two residents using bed rails with low air-loss mattresses did not receive required safety assessments addressing the specific risks of this combination. Documentation and care plans lacked evidence of risk evaluation or education for residents or their representatives, and staff interviews revealed uncertainty about responsibilities for ensuring bed system safety. Facility policy requiring interdisciplinary assessment of bed system risks was not followed.
A resident with severe cognitive impairment and a history of behavioral issues did not have adequate interventions in place to address wandering, aggression, and distress caused by other residents entering his room. Despite documented behavioral episodes and staff awareness of these concerns, the care plan lacked specific strategies, and staff were not consistently present to monitor or intervene, resulting in ongoing behavioral disturbances and unmet care needs.
A resident with moderate cognitive impairment, hallucinations, and daily wandering was repeatedly able to enter another resident's room, attempt to undress, and interact with personal belongings without effective staff intervention. Despite care planning and staff redirection efforts, the interventions were not successful in preventing these behaviors, and the resident continued to wander unmonitored, causing distress to others.
The facility did not consistently post daily nurse staffing reports that included the required resident census. On several occasions, either no staffing documentation was posted or the posted reports lacked census data. An administrative nurse confirmed that the census was only recorded on a dry-erase board and not included in the official staffing report, contrary to facility policy.
A resident with a history of heart conditions was found unresponsive and later pronounced dead after the facility staff failed to respond to the resident's call light for nearly two hours. Despite the resident's request for assistance, communicated through a laundry person, the nurse continued with other duties. The resident's call light went unanswered, and when the nurse finally attended, she did not initiate CPR, citing the resident's cold body temperature. The facility's staffing was insufficient, and the failure to follow CPR protocols resulted in the resident's death.
A resident with a full code status was found unresponsive and without a pulse, but the nurse on duty failed to initiate CPR or call emergency services, instead pronouncing the resident dead. The resident's call light had been on for nearly two hours without response, and the facility's staffing was limited to one nurse and one CNA for 18 residents. This failure to follow emergency procedures and respond to the resident's needs placed the resident and others in immediate jeopardy.
A resident with a history of heart conditions and depression died after her call light went unanswered for nearly two hours in a facility with insufficient staffing. Despite being a full code, CPR was not initiated by the licensed nurse who found her unresponsive. The facility had only one nurse and one CNA on duty for 18 residents, leading to critical deficiencies in care.
A resident with a history of heart conditions was found unresponsive and pulseless by a nurse who failed to initiate CPR, leading to the resident's death. The resident's call light went unanswered for nearly two hours despite multiple requests for assistance. The facility had only one nurse and one CNA on duty for 18 residents, which was insufficient to meet the residents' needs.
Failure to Follow Sanitary Food Preparation Standards
Penalty
Summary
During a kitchen inspection, sausages were observed cooking on the stove while a dietary staff member prepared food without wearing a hairnet. The staff member only put on a hairnet after leaving and then returning to the cooking area. According to the facility's policy, all food service employees are required to wear hairnets and follow safe sanitary practices when handling food. An interview with another dietary staff member confirmed that immediate use of hairnets is mandatory in food preparation and service areas. These actions were not in compliance with the facility's food preparation and service policy, resulting in a failure to follow sanitary dietary standards during food preparation.
Incomplete Facility-Wide Assessment of Staffing and Resource Needs
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment provided by the administrative nurse was last updated on 11/13/24 and did not specify the required staffing levels for each unit, nor did it identify the number of RNs, LPNs/LVNs, CMAs, and CNAs needed based on patient acuity and census. Additionally, the assessment lacked details regarding staffing requirements for each shift, including evenings and weekends. When questioned, administrative staff indicated that staffing information might be in a separate report, which was subsequently provided but was created after the initial request. This deficiency affected all 13 residents included in the sample, out of a total census of 23 residents.
Failure to Accurately Report Staffing Data in PBJ Submissions
Penalty
Summary
The facility failed to submit accurate direct care staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ), specifically regarding licensed nurse coverage and weekend staffing hours. CMS reports for two consecutive fiscal quarters indicated the facility was flagged for low weekend staffing and for not providing licensed nurse coverage 24 hours per day. However, a review of the facility's working schedules, time sheets, clock in/out records, and posted staffing hours for the identified dates did not reveal any missed coverage or gaps. During an interview, the administrative nurse confirmed that there were no missed licensed nurse shifts, as agency staff were used to fill any gaps. She acknowledged that some shifts may not have been accurately reported in the PBJ submission, particularly those involving agency and shift fill-ins. The facility's PBJ policy requires submission of complete and accurate payroll data that is verifiable and auditable, but the facility did not ensure the accuracy of the data submitted, specifically related to weekend staffing and licensed nurse coverage.
Infection Control Deficiencies in Respiratory Equipment Storage and Laundry Practices
Penalty
Summary
Surveyors identified multiple infection control deficiencies related to the handling and storage of respiratory equipment and the use of personal protective equipment (PPE) in the facility. One resident's continuous positive airway pressure (CPAP) device was found lying on her bed, stuffed between the side rail and her low air loss mattress, rather than being stored in a sanitary manner. Another resident's nasal cannula tubing was observed draped over the back of her wheelchair, also not stored appropriately. Staff interviews confirmed that respiratory equipment not in use should be kept in a bag, and that it is the responsibility of nursing staff to ensure this practice is followed. Additionally, during a tour of the laundry room, cleaning rags were found left in the washer overnight, and the soiled laundry sorting area did not have PPE available for staff to use while sorting dirty laundry. The housekeeping supervisor confirmed the absence of PPE in the soiled sorting area. The facility's infection control monitoring policy requires regular surveillance of adherence to infection prevention practices, including the availability and use of PPE, but these practices were not followed as observed during the survey.
Incomplete Care Area Assessments in Resident MDS Documentation
Penalty
Summary
The facility failed to ensure that a resident's Admission Minimum Data Set (MDS) included fully developed Care Area Assessments (CAAs). Record review and interviews revealed that the CAAs for functional abilities (self-care mobility), urinary incontinence and indwelling catheter, pain, and pressure ulcer/injury lacked analysis or further development. The resident in question had a complex medical history, including multiple sclerosis, diabetes mellitus, edema, hypokalemia, COPD, muscle weakness, overactive bladder, urinary retention, anxiety, dementia, behavioral disturbance, hypertension, major depressive disorder, and obesity. During an interview, the administrative nurse confirmed that all CAAs should include analysis of findings and that this documentation flows into the plan of care. The absence of analysis in the CAAs could result in unidentified care needs for the resident. Additionally, the facility was unable to provide a policy regarding the development of MDS or CAAs.
Failure to Revise Care Plan for Effective Communication
Penalty
Summary
The facility failed to revise the care plan for a resident with anoxic brain damage, irritability/anger issues, developmental disorder of speech and language, and weakness, to address effective communication strategies. The resident had a documented history of stuttering and difficulty communicating, which sometimes led to frustration when staff could not understand them. The resident's care plan, although updated to address behavioral issues and medication administration, did not include specific preferences or directions for staff on how to communicate effectively with the resident when stuttering occurred. Staff interviews confirmed that all nursing staff had access to care plans and that communication strategies should be included in the care plan for this resident. Documentation in the medical record and communication notes indicated ongoing communication challenges and a request for speech therapy. The facility's policy required comprehensive, person-centered care plans to address each resident's physical, psychosocial, and functional needs, but the care plan lacked guidance for staff on effective communication with the resident.
Failure to Ensure Proper Use of Pressure-Relieving Devices for Residents at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to ensure that two residents at risk for pressure ulcers received appropriate care related to the use of low air-loss mattresses and pressure-relieving devices. For one resident with multiple diagnoses including obesity, schizoaffective disorder, and limited mobility, the low air-loss mattress was not set to the correct weight according to the manufacturer's guidelines. The mattress remained set at a higher weight than the resident's actual weight for several days, and staff reported that they only checked the mattress if an alarm sounded, relying on the equipment provider to set and manage the settings. The resident's care plan did not include specific instructions regarding the mattress settings. For another resident with multiple chronic conditions such as multiple sclerosis, diabetes, and obesity, the low air-loss mattress was observed to be set at a generic setting, and pressure-relieving boots intended to protect the resident's heels were not applied while the resident was in bed. The boots were found at the bottom of the bed on multiple occasions, leaving the resident's heels in direct contact with the mattress. Staff interviews revealed inconsistent practices regarding monitoring and application of pressure-relieving devices, and there was no documentation or sign-off process to ensure the correct use of the mattress or boots. Additionally, the facility was unable to provide a policy related to pressure ulcer prevention and care when requested. Both residents' care plans lacked direction for staff to monitor or adjust the low air-loss mattress settings, and there was no evidence of routine checks or documentation to ensure that pressure-relieving interventions were consistently implemented as required.
Failure to Ensure Call Light Accessibility for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident's call light was within reach, as required by the resident's care plan and facility policy. The resident in question had diagnoses including dementia, muscle weakness, and a history of repeated falls, and was assessed as having severe cognitive impairment and a high risk for falls. The care plan specifically instructed staff to keep the resident's soft-touch call light within reach at all times. However, during multiple observations, the call light was found on the floor underneath the bed, out of the resident's reach, while the resident was in bed. Interviews with facility staff confirmed that the call light should have been placed within easy access for the resident, in accordance with both the care plan and facility policy. The failure to properly position the call light did not align with the instructions to provide a safe care environment and appropriate assistive devices for residents at risk for falls. This inaction placed the resident at risk for preventable accidents and injuries.
Failure to Store CPAP Mask in a Sanitary Manner
Penalty
Summary
The facility failed to ensure that a resident's continuous positive airway pressure (CPAP) mask was stored in a sanitary manner when not in use. The resident, who had a medical history including multiple sclerosis, diabetes mellitus, chronic obstructive pulmonary disease (COPD), and other chronic conditions, was observed resting on her bed with the CPAP mask placed on the bed and stuffed between the side rail and her low air-loss mattress. The resident reported that she removed the mask herself and was not provided with a bag for storage, nor was she informed by staff about the need to store the mask in a sanitary way. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that respiratory equipment was expected to be stored in a plastic bag when not in use, and that such bags were available in resident rooms. However, the facility did not provide a policy regarding the storage of respiratory equipment, and the resident's care plan lacked instructions for cleaning and storing the CPAP mask. This lapse in practice was identified during a review of the resident's records and direct observation.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to identify, implement, and utilize trauma-based care strategies for a resident with a documented history of post-traumatic stress disorder (PTSD). The resident's electronic medical record (EMR) included diagnoses of general anxiety disorder, schizoaffective disorder, and PTSD. The resident was dependent on staff for all activities of daily living and had a history of depression, anxiety, and recent legal issues. Despite these documented concerns, the care plan did not include specific interventions or strategies related to trauma-informed care or address the resident's PTSD. Assessments in the EMR indicated the resident experienced symptoms such as nightmares, anxiety, and feelings of detachment, but there was no evidence of ongoing trauma or PTSD-related assessments beyond an initial screening. Staff interviews revealed a lack of awareness regarding the resident's trauma history and no knowledge of trauma-specific interventions. The care plan only referenced general behavioral health consults and did not provide guidance for staff on managing trauma-related symptoms or triggers. Observations showed the resident experiencing high anxiety and physical symptoms such as shaking, which she attributed to her PTSD and anxiety. The facility's policy required comprehensive trauma screening and individualized interventions, but these were not reflected in the resident's care plan or in staff practices. The lack of trauma-informed care placed the resident at risk for decreased psychosocial well-being and increased behavioral symptoms.
Failure to Assess Bed Rail Safety with Low Air-Loss Mattresses
Penalty
Summary
The facility failed to ensure that two residents who used bed rails in conjunction with low air-loss mattresses received appropriate safety assessments that acknowledged the specific risks associated with this combination. For one resident with diagnoses including general anxiety disorder, obesity, schizoaffective disorder, and post-traumatic stress disorder, documentation showed she was dependent on staff for all activities of daily living and used a low air-loss mattress with bilateral assist rails. However, her care plan and electronic medical record lacked any assessment or documentation addressing the risks of using bed rails with her low air-loss mattress, despite facility policy requiring such evaluation. Another resident with multiple diagnoses, including multiple sclerosis, diabetes, edema, COPD, muscle weakness, dementia, and obesity, also used half-bed rails on both sides of the bed to assist with repositioning. The care plan indicated the use of bed rails, but the side rail assessment did not include consideration of the low air-loss mattress. There was no evidence in the medical record that the risks and benefits of bed rail use with the low air-loss mattress were reviewed with the resident or representative, nor that education was provided regarding these risks. Interviews with staff revealed uncertainty about whether bed rail assessments covered the risks associated with low air-loss mattresses and who was responsible for ensuring the safety of the bed system after mattress changes. Observations confirmed that both residents were using bed rails with low air-loss mattresses, and staff acknowledged that safety checks and measurements specific to this setup were not consistently performed. The facility's own policy required interdisciplinary assessment of the sleeping environment, including bed system risks, but this was not followed in these cases.
Failure to Address and Monitor Behavioral Health Needs
Penalty
Summary
The facility failed to adequately identify, implement, and monitor the behavioral care needs of a resident with a history of post-traumatic stress disorder, traumatic brain injury, and severe cognitive impairment. Despite documentation in the resident's medical records and care assessments indicating significant cognitive and behavioral challenges, including confusion, disorientation, and use of multiple psychotropic medications, the care plan lacked specific interventions to address the resident's wandering, behavioral episodes, and issues with other residents entering his room. Multiple behavior notes in the electronic medical record documented repeated incidents of wandering, aggression, yelling profanity, throwing items, and urinating in inappropriate areas. These behaviors disturbed other residents and led to complaints. Staff interviews confirmed that the resident had exhibited aggressive and wandering behaviors, and that there were ongoing concerns about another resident entering his room and handling his belongings, which upset him. Observations showed that staff were not consistently present to monitor or intervene when the resident or others engaged in problematic behaviors. The facility's own policy required comprehensive assessment and behavioral interventions for residents in need, but these were not fully implemented or monitored for this resident. As a result, the resident was at risk for continued behavioral episodes and unmet care needs.
Failure to Provide Effective Dementia-Related Behavioral Services
Penalty
Summary
The facility failed to provide appropriate dementia-related behavioral services to a resident diagnosed with acute encephalopathy, abnormal behaviors, and acute kidney injury, who exhibited moderate cognitive impairment, hallucinations, delusions, and daily wandering. Despite being care planned as an elopement risk and requiring supervision for certain activities, the resident was repeatedly observed entering another resident's room, attempting to change clothes, and interacting with personal belongings without staff intervention. Progress notes and staff interviews confirmed ongoing incidents of the resident entering the same male resident's room, attempting to undress, and being redirected multiple times, with staff acknowledging the ineffectiveness of their interventions to prevent these behaviors. Observations documented that the resident was able to wander unmonitored into other residents' rooms, causing distress to the male resident involved, who reported the issue to staff on several occasions. The facility's policy required individualized care interventions and the use of the least restrictive approaches, but the interventions implemented were not successful in addressing the resident's wandering and inappropriate room entry behaviors. The lack of effective behavioral services and monitoring resulted in repeated incidents and placed the resident at risk for decreased quality of life and impaired dignity.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to consistently post daily nurse staffing information that included the resident census, as required. On multiple occasions, surveyors observed that either no staffing documentation was posted in the facility or that the posted staffing reports did not include the daily census. Specifically, on two separate days, no staffing information was posted in the designated area, and on two other days, the posted reports were missing the required census data. An administrative nurse confirmed that the charge nurse was responsible for posting staffing information in the lobby, but stated that the census was only recorded on a dry-erase board and not included on the official staffing report. The facility's policy requires that staffing hours be maintained for at least 18 months and made available upon request.
Neglect and Mistreatment Leading to Resident's Death
Penalty
Summary
The facility failed to ensure a resident remained free from neglect and mistreatment, leading to a severe incident. The resident, who had a history of non-ST elevation myocardial infarction, cardiomyopathy, hypertension, depression, atrial fibrillation, and bradycardia, was found unresponsive and later pronounced dead. On the day of the incident, the resident was initially assessed by a licensed nurse at 07:39 AM, who noted the resident was in a panicked state due to breathlessness. Despite the resident's request for assistance at 09:30 AM, communicated through a laundry person, the nurse continued with other duties and did not attend to the resident promptly. The resident activated the call light at 09:42 AM, which went unanswered for one hour and forty-five minutes. During this time, a certified nurse aide acknowledged seeing the call light but did not respond, as she was occupied with other duties and assumed the resident only needed the nurse. The nurse eventually noticed the call light at 11:20 AM and found the resident unresponsive at 11:26 AM. The nurse did not initiate CPR, citing the resident's cold body temperature as an indication that resuscitation was impossible. The facility's staffing on the day of the incident included only one nurse and one CNA for 18 residents, which was deemed insufficient by the CNA. The facility's policies required CPR to be initiated unless a DNR order was in place, which was not the case for the resident. The failure to respond to the call light and initiate CPR as per policy resulted in the resident's death, highlighting a significant deficiency in care and response protocols.
Failure to Provide CPR to Full Code Resident
Penalty
Summary
The facility failed to provide cardiopulmonary resuscitation (CPR) to a resident who had a full code status, indicating a desire for resuscitative measures in the event of cardiac arrest. On the morning of the incident, the resident was found unresponsive, cold to the touch, and without a pulse by a licensed nurse. Despite the resident's full code status, the nurse did not initiate CPR or activate emergency medical services, instead pronouncing the resident dead. This failure to act according to the resident's advance directives and facility policy placed the resident and other residents with full code status in immediate jeopardy. The resident had a medical history that included non-ST elevation myocardial infarction, cardiomyopathy, hypertension, depression, atrial fibrillation, and bradycardia. Earlier that morning, the resident was alert and oriented, with vital signs taken by the nurse. However, the resident expressed feelings of breathlessness and panic, which were temporarily alleviated by the nurse's assistance. Despite these interactions, the resident's call light went unanswered for nearly two hours, during which time the resident's condition deteriorated. The facility's staffing on the day of the incident included only one nurse and one certified nurse's aide for 18 residents, which may have contributed to the delay in responding to the resident's call light. The nurse and aide were both certified in CPR, yet the nurse did not perform CPR when finding the resident unresponsive. The facility's policies on emergency procedures and abuse were not followed, as the nurse did not initiate CPR or call emergency services, and the resident's call light was neglected for an extended period.
Resident's Death Due to Inadequate Staffing and Unanswered Call Light
Penalty
Summary
The facility failed to provide sufficient nurse staffing with the appropriate competencies and skill sets, which resulted in a resident's needs not being met and ultimately led to the resident's death. The resident, who had a history of non-ST elevation myocardial infarction, cardiomyopathy, hypertension, depression, atrial fibrillation, and bradycardia, was found unresponsive and pulseless after her call light went unanswered for one hour and forty-five minutes. Despite being a full code, CPR was not initiated by the licensed nurse who found her. On the day of the incident, the facility had only one licensed nurse and one certified nurse aide on duty to care for 18 residents, including three residents requiring two-person assistance. The licensed nurse was informed by a laundry person that the resident needed her, but she continued with her duties without attending to the resident. The resident's call light was activated at 09:42 AM and remained unanswered until 11:27 AM when the licensed nurse finally entered the room and found the resident deceased. The facility's failure to respond to the resident's call light and the lack of immediate CPR initiation upon finding the resident unresponsive were critical deficiencies. The licensed nurse did not follow the facility's emergency procedure for cardiopulmonary resuscitation, which required CPR to be initiated unless a do-not-resuscitate order was in place. The incident highlighted a significant lapse in the facility's staffing and emergency response protocols, contributing to the resident's death.
Failure to Provide Competent Nurse Staffing Leads to Resident's Death
Penalty
Summary
The facility failed to provide competent nurse staffing, which resulted in a resident's needs not being met and ultimately led to the resident's death. The resident, who had a history of non-ST elevation myocardial infarction, cardiomyopathy, hypertension, depression, atrial fibrillation, and bradycardia, was found unresponsive and pulseless by a licensed nurse. Despite being certified in CPR, the nurse did not initiate cardiopulmonary resuscitation and instead pronounced the resident dead. On the day of the incident, the resident had requested assistance multiple times. At 9:30 AM, a laundry person informed the licensed nurse that the resident needed her, but the nurse continued with her duties without attending to the resident. The resident's call light was activated at 9:42 AM and went unanswered for one hour and forty-five minutes. During this time, the certified nurse aide also failed to respond to the call light, citing her duties in the COVID-19 rooms as the reason for not checking her pager. The facility's staffing on the day of the incident included only one nurse and one certified nurse aide for 18 residents, which was deemed insufficient by the certified nurse aide. The facility's emergency procedure policy required CPR to be initiated unless a Do Not Resuscitate order was in place, which was not the case for the resident. The failure to respond to the resident's call light and the lack of initiation of CPR were significant factors in the deficiency.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
