Andbe Home, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Norton, Kansas.
- Location
- 201 W Crane Street, Norton, Kansas 67654
- CMS Provider Number
- 175506
- Inspections on file
- 16
- Latest survey
- July 15, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Andbe Home, Inc during CMS and state inspections, most recent first.
The facility failed to maintain safe water temperatures, with readings up to 161°F in resident-accessible areas, posing burn risks. Additionally, a resident with a history of falls did not receive updated interventions, leading to repeated falls. Maintenance staff rerouted hot water without proper monitoring, and care plans were not adjusted despite multiple incidents.
The facility failed to meet food service safety standards, affecting 34 residents. Observations showed missing thermometers in refrigerators, expired and unlabeled food items, and uncovered ice cream being transported. The Dietary Manager and staff confirmed these issues, which violated the facility's policies on food storage and cleanliness.
The facility failed to implement a water management program for Legionella prevention, placing 34 residents at risk. Despite annual city water testing and the use of an osmosis water filtration system, the facility lacked documentation of Legionella preventative measures, such as risk assessments and identification of potential problem areas. Administrative Staff A confirmed the absence of a Legionella prevention plan.
The facility failed to dispose of expired medications, risking residents' safety. Observations revealed expired medications in the north medication cart and east medication room, confirmed by an LN. Despite a policy requiring regular checks and disposal, expired medications were not appropriately managed.
The facility failed to maintain resident dignity during meal assistance, as a CNA was observed standing over two residents while feeding them, contrary to the facility's policy. This behavior was noted on multiple occasions, placing the residents at risk for impaired dignity.
A resident with a urinary catheter experienced unsanitary catheter care, as the tubing frequently touched the floor while self-propelling in a wheelchair. A CNA failed to change gloves after perineal care and did not wash hands, touching various surfaces with soiled gloves. The facility lacked policies on catheter tubing positioning and proper glove and handwashing procedures.
A resident with multiple health conditions, including dysphagia, did not receive uninterrupted assistance during meals, as required by the facility's policy. Observations showed a CNA frequently interrupted feeding to assist another resident, compromising the resident's meal intake and placing them at risk for weight loss. Staff confirmed the resident's weight loss and inconsistent meal intake, acknowledging the need for continuous support.
A resident with chronic pain did not receive prescribed Norco medication due to unavailability, leading to unrelieved pain. The medication was not reordered or followed up on in a timely manner, resulting in the resident experiencing significant pain and difficulty sleeping. The facility lacked a policy for reordering medications, contributing to the oversight.
The facility's kitchen staff failed to follow a recipe for preparing a pureed diet, leading to inconsistencies in food preparation. A dietary staff member estimated serving sizes and used unmeasured amounts of liquids, without following a specific recipe, under the supervision of the Dietary Manager. The facility lacked specific recipes for pureed diets, which placed a resident at risk for impaired nutrition.
Unsafe Water Temperatures and Inadequate Fall Prevention
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, specifically regarding water temperatures in resident-accessible areas. Observations revealed that water temperatures in several resident rooms and common areas were excessively high, reaching up to 161 degrees Fahrenheit, which posed a significant risk of burns to residents. The maintenance staff had rerouted hot water from the laundry heater to the resident areas without adequately monitoring or documenting the water temperatures, leading to dangerously high temperatures in resident-accessible sinks. Additionally, the facility failed to implement effective interventions to prevent falls for a resident with a history of multiple falls. Despite the resident's care plan indicating the use of alarms and other preventive measures, the resident continued to experience falls, some resulting in injuries. The care plan was not updated with new interventions after each fall, and the existing measures were not effective in preventing further incidents. The facility's policies required regular monitoring and documentation of water temperatures and the implementation of specific interventions to prevent falls. However, these protocols were not followed, resulting in immediate jeopardy for residents due to the risk of burns from hot water and the continued risk of falls for a resident with a history of falling. The lack of documentation and failure to adjust care plans contributed to the deficiencies identified by the surveyors.
Removal Plan
- Maintenance Staff U adjusted the valve on the hot water line so the excessively hot water for the laundry would not go into the residential hot water line which was set at 120 degrees F.
- The water heaters were adjusted to maintain an acceptable level between 105-120 degrees F.
- Education was provided to the maintenance supervisor of the water temperature requirements and documentation of auditing water temperature.
- Accident education was assigned to all staff.
- Medical Director was notified.
Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, impacting all 34 residents who received meals from the facility's kitchen. Observations revealed multiple deficiencies, including the absence of thermometers in the nourishment refrigerator/freezers and the presence of expired food items, such as a package of simply steamed cauliflower. Additionally, the kitchen's two-door silver fridge lacked a backup thermometer and contained unlabeled and undated food items, including eggs and cheese. The facility also had issues with unlabeled and undated bins of powdered milk, noodles, and flour. Furthermore, two ceiling vents in the kitchen were observed with a gray fuzzy substance. Staff were observed transporting uncovered bowls of ice cream in the facility halls, which was verified by a CNA who acknowledged that the ice cream should have been covered. The Dietary Manager confirmed the issues with labeling and dating food items and the lack of thermometers, stating that nursing staff were responsible for placing thermometers in the nourishment center refrigerators. The facility's policies on cleaning, sanitation, and food storage were not followed, as evidenced by the lack of compliance with maintaining cleanliness, proper food storage, and temperature monitoring, placing residents at risk for foodborne illness.
Failure to Implement Legionella Prevention Program
Penalty
Summary
The facility, with a census of 34 residents, failed to implement a water management program specifically for Legionella disease prevention. This deficiency was identified through interviews and record reviews, revealing that the facility did not have documentation of Legionella preventative measures, such as risk assessments and identification of potential problem areas. The facility's Water Temperature Check Log only documented temperature checks for laundry, kitchen, common areas, and resident rooms on a weekly basis, but lacked any measures for Legionella prevention. Administrative Staff A confirmed that while the city tested the water annually and the facility used an osmosis water filtration system for drinking water, there was no Legionella or waterborne pathogen prevention plan in place. This oversight placed the residents at risk of contracting Legionella pneumonia.
Expired Medications Not Disposed of Properly
Penalty
Summary
The facility failed to appropriately dispose of expired medications, which placed residents at risk of receiving ineffective medication. During an observation on June 10, 2024, at 08:15 AM, it was found that the north medication cart contained expired medications, including a bottle of stool softener with an expiration date of December 2023, a bottle of calcium complete with an expiration date of June 2023, and a bottle of liquid Gerilanta with an expiration date of December 2023. Licensed Nurse J confirmed that these medications should have been disposed of. Additionally, at 08:52 AM, the east medication room was observed to contain expired medications, including a bottle of extra strength pain relief Tylenol/diphenhydramine with an expiration date of May 2024 and a bottle of gas relief with an expiration date of February 2024, which were also verified by LN J as needing disposal. On June 13, 2024, Administrative Nurse D confirmed that staff were responsible for checking medication carts and rooms for expired medications twice weekly and disposing of them. The facility's Medication Labeling and Storage policy, dated February 2023, stated that staff should contact the dispensing pharmacy for instructions on returning or destroying discontinued or outdated medications. Despite these procedures, the facility did not dispose of expired medications as required, leading to the deficiency noted in the report.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain and enhance the dignity and respect of residents during meal assistance, as observed with two residents, R5 and R33. Certified Nurse Aide (CNA) O was seen standing over these residents while assisting them with eating, which is against the facility's policy. On multiple occasions, CNA O stood over R5 and R33 while feeding them, instead of sitting beside them, which is considered a more dignified approach. This behavior was observed during meal times on two consecutive days, where CNA O alternated between standing and sitting while assisting the residents. The facility's policy, dated March 2022, clearly states that residents should be assisted with meals in a manner that meets their individual needs, ensuring safety, comfort, and dignity. This includes not standing over residents while feeding them. Both Dietary Staff BB and Administrative Nurse D confirmed that staff should not stand over residents during meal assistance. The failure to adhere to this policy placed the residents at risk for impaired dignity, as the staff's actions did not align with the facility's standards for respectful and dignified care.
Failure to Provide Sanitary Catheter Care
Penalty
Summary
The facility staff failed to provide sanitary catheter care for Resident 11, who had a urinary catheter due to neuromuscular dysfunction of the bladder and urine retention. Observations revealed that the resident's catheter tubing frequently touched the floor while self-propelling in a wheelchair, which was confirmed by a licensed nurse who acknowledged that the tubing should be kept off the floor. Additionally, the resident had a history of positive urinary tract infections, including a hospitalization for sepsis secondary to a UTI. Further deficiencies were noted during catheter care provided by a certified nurse aide (CNA). The CNA did not change gloves after providing perineal care and continued to touch various surfaces, including the resident's wheelchair and clothing, with soiled gloves. The CNA also failed to wash hands after completing the care. The facility did not have a policy regarding the positioning of catheter tubing or the proper procedure for changing gloves and handwashing during catheter care, contributing to the unsanitary conditions observed.
Failure to Provide Uninterrupted Meal Assistance
Penalty
Summary
The facility failed to provide uninterrupted assistance to Resident 5 during meals, which placed the resident at risk for weight loss. Resident 5 had a history of epilepsy, generalized anxiety disorder, major depressive disorder, cerebral infarction, and dysphagia. The resident required maximal staff assistance for eating, as documented in the Minimum Data Set (MDS), and was on a pureed diet with nectar thick liquids. Despite these requirements, observations revealed that the Certified Nurse Aide (CNA) assisting Resident 5 frequently interrupted the feeding process by attending to other residents, which compromised the resident's meal intake. Observations on multiple occasions showed that CNA O alternated between assisting Resident 5 and another resident, R33, during meal times. CNA O was seen standing over Resident 5 and feeding her intermittently, which is against the facility's policy that requires staff to sit beside residents while assisting them with meals. This inconsistent assistance was noted during breakfast and lunch, where CNA O repeatedly left Resident 5 to assist other residents, resulting in Resident 5 not receiving the continuous support needed to ensure adequate food intake. Interviews with staff, including Licensed Nurses and Dietary Staff, confirmed that Resident 5's weight had decreased significantly, and the resident's meal intake was inconsistent. Staff acknowledged that uninterrupted assistance could potentially improve Resident 5's eating habits. The facility's policy on meal assistance emphasized the importance of providing support in a manner that ensures safety, comfort, and dignity, which was not adhered to in this case, leading to the deficiency.
Failure in Pain Management Due to Medication Unavailability
Penalty
Summary
The facility failed to ensure adequate pain management for a resident with chronic pain, leading to unrelieved pain. The resident, who had diagnoses of peripheral neuropathy and phantom leg syndrome, was prescribed Norco, an opioid pain medication, to be administered three times a day. However, the medication was unavailable on multiple occasions, and the resident did not receive the prescribed doses. This resulted in the resident experiencing significant pain and difficulty sleeping, as documented in the progress notes and observed by staff. The deficiency occurred due to a failure in the medication reordering process. Although the medication was initially reordered, there was no follow-up when it was not delivered. Staff did not adhere to the facility's expectation of reordering medications seven days in advance or following up with the pharmacy if the medication was not delivered within two days. The facility did not provide a policy regarding the reordering of medications, contributing to the oversight and resulting in the resident's pain management needs not being met.
Failure to Follow Recipe for Pureed Diets
Penalty
Summary
The facility's kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor, and appearance, specifically in the preparation of a pureed diet for one resident. During an observation, it was noted that the dietary staff did not follow a recipe while preparing the pureed diet. The dietary staff member, DS CC, blended pork chops and mixed vegetables without measuring the portions or following a specific recipe, instead estimating the serving sizes. This was done under the supervision of the Dietary Manager, DM BB, who later confirmed that the facility did not have specific recipes for pureed diets. The facility's policy, revised in 2017, required dietary staff to prepare pureed diets according to provided recipes, measuring food, liquid, and thickener as directed. However, the facility lacked specific recipes for each pureed food item, leading to inconsistencies in preparation. The Dietary Manager acknowledged that different liquids were used to puree food items, but there was no standardized method or recipe for each type of food. This lack of adherence to a standardized recipe placed the resident at risk for impaired nutrition.
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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