Apostolic Christian Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Sabetha, Kansas.
- Location
- 511 Paramount Street, Sabetha, Kansas 66534
- CMS Provider Number
- 175376
- Inspections on file
- 17
- Latest survey
- January 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Apostolic Christian Home during CMS and state inspections, most recent first.
The facility did not employ a full-time certified dietary manager for its 58 residents, risking inadequate nutrition. Dietary Staff BB had only partially completed a dietary manager course due to staffing shortages, and the Registered Dietician visited monthly. Administrative Staff A was aware of the certification issue. The facility's policy required a qualified dietitian to oversee services, which was not met.
The facility's assessment failed to specify staffing levels needed for each unit, shift, and per census, affecting all 58 residents. The assessment lacked details on the number of RNs, LPNs/LVNs, CMAs, and CNAs required, including for evenings and weekends. This deficiency was noted during an inspection, despite the assessment being revised in June 2024.
The facility failed to use foot pedals during wheelchair transports for several residents, including those who were severely cognitively impaired, leading to their feet sliding on the floor. Staff interviews revealed that foot pedals were only applied if residents could not lift their legs, contrary to the facility's policy requiring the safe use of assistive devices. This placed residents at risk for preventable accidents and injuries.
The facility failed to ensure the Consulting Pharmacist identified and reported irregularities in the use of antipsychotic medications for several residents, including those with Alzheimer's and dementia. The pharmacist did not recognize or report issues related to medication indications, placing residents at risk for unnecessary psychotropic medications and related complications. The facility's policy required monthly reviews and reporting of irregularities, which were not adhered to.
The facility failed to ensure appropriate indications or documented physician rationale for antipsychotic medications for several residents, including those with dementia and other mental health conditions. Residents were administered medications like Seroquel and Risperidone without documented rationale or evidence of non-pharmacological interventions, placing them at risk for unnecessary psychotropic medications and related complications.
A resident's PHI was exposed when a medication cart was left unattended in the dining room with an open laptop displaying sensitive information. A nurse left the screen unlocked, compromising privacy. Staff acknowledged the need for securing PHI, as per facility policy.
The facility failed to update care plans for two residents, one with increased aggressive behaviors and another with specific sleeping preferences and behaviors. Despite staff awareness, these changes were not documented, risking impaired care due to uncommunicated needs.
A facility failed to ensure a resident with a pressure injury on her left heel had pressure-reducing heel protectors and boots in place as ordered. Despite physician orders and care plans, the resident was observed without these devices while sitting in a Broda chair and lying in bed. Staff interviews revealed a lack of adherence to the prescribed care plan, with CNAs typically responsible for applying the devices. This oversight placed the resident at risk for further skin breakdown.
A resident with severe cognitive impairment and a history of falls was not provided with a Dycem mat in his wheelchair as required by his care plan, despite being at risk for falls. Observations showed the mat was missing during multiple inspections, and staff interviews revealed uncertainty about its placement, leading to a failure in ensuring a safe care environment.
The facility failed to sanitize shared medical equipment, such as blood pressure cuffs and pulse monitors, after each resident's use, as observed on multiple occasions in the main dining room. Despite having sanitizer spray available and a policy requiring equipment sanitization according to CDC guidelines, staff did not consistently follow these practices, placing residents at risk for infectious diseases.
The facility failed to offer the PCV20 vaccine or obtain informed declinations for two residents, despite their records showing previous vaccinations with PCV13 and PSV23. The facility relied on the WEB IZ system for immunization prompts and did not have an immunization policy, leading to this deficiency.
A resident with a history of pain and weakness was injured during transport in a facility van when the driver failed to secure her with a seatbelt. The resident, who was in a wheelchair, slid onto the van floor after the driver braked suddenly, resulting in fractures to her left tibia and fibula. The driver admitted to not using a seatbelt due to the resident's size and the short trip distance, highlighting a lack of training and adherence to safety protocols.
Lack of Certified Dietary Manager Puts Residents at Nutritional Risk
Penalty
Summary
The facility failed to provide the services of a full-time certified dietary manager for its 58 residents, which placed them at risk for inadequate nutrition. During an initial tour of the kitchen, Dietary Staff BB revealed that she had started a certified dietary manager course three years ago but had only completed three months due to staffing shortages that required her to return to full-time dietary duties. The Registered Dietician visited the facility monthly, but this was not sufficient to meet the facility's needs. Administrative Staff A acknowledged awareness of Dietary Staff BB's lack of certification and indicated an intention to investigate further. The facility's policy, revised in November 2024, required a qualified, competent, and skilled dietitian to oversee food and nutrition services, which was not adhered to, leading to the deficiency.
Inadequate Facility-Wide Assessment for Staffing Needs
Penalty
Summary
The facility failed to conduct a thorough facility-wide assessment to determine the necessary resources for competent resident care during both day-to-day operations and emergencies. The assessment, which was revised in June 2024, did not specify the staffing levels required for each unit, shift, and per census, including the number of RNs, LPNs/LVNs, CMAs, and CNAs needed. This lack of detailed staffing information affected all 58 residents residing in the facility. During an inspection on December 18, 2024, it was noted that the facility's assessment did not include staffing levels for each shift, including evenings and weekends. Administrative Staff A mentioned that the assessment was completed annually based on guidelines, considering the resident population, acuity, census, and needs. However, the assessment was found to be insufficient in determining the resources necessary for competent care, impacting all residents in the facility.
Failure to Use Foot Pedals During Wheelchair Transport
Penalty
Summary
The facility failed to ensure the use of foot pedals during wheelchair transports for several residents, including those who were severely cognitively impaired. Observations revealed that residents were being pushed in wheelchairs without foot pedals, causing their feet to slide along the floor. This was noted for multiple residents, including one who was repeatedly asked to keep their feet up while being transported. Staff interviews indicated that foot pedals were only applied if residents could not lift their legs, despite the facility's policy requiring the safe use of assistive devices. The facility's policy on assistive devices, revised in January 2024, mandates the supervision and safe use of equipment such as foot pedals. However, staff members, including CNAs and LNs, were observed not adhering to this policy, as they allowed residents' feet to slide on the floor during transport. An administrative nurse confirmed that foot pedals should always be applied for high fall risk residents, especially when being pushed long distances. The failure to utilize foot pedals placed residents at risk for preventable accidents and injuries due to unmet care needs.
Failure to Identify and Report Medication Irregularities
Penalty
Summary
The facility failed to ensure that the Consulting Pharmacist (CP) identified and made recommendations regarding the inappropriate indications for antipsychotic medications for several residents. Specifically, the CP did not recognize or report issues related to the medication indications for Residents 55, 8, 52, and 32. This oversight placed these residents at risk for unnecessary psychotropic medications and related complications. The facility's Medication Regimen Reviews policy, last revised in May 2024, required the CP to review each resident's medication regimen at least monthly and report any irregularities found during the review. Resident 55's records showed a diagnosis of Alzheimer's disease and other conditions, with a documented use of Seroquel for behavioral disturbances and paranoia related to dementia. However, there was no documented rationale for the use of Seroquel, and the Monthly Medication Reviews from August to December 2024 did not note any inappropriate indication of use. Similarly, Resident 8's records indicated the use of Seroquel for major depressive disorder without documented non-pharmaceutical interventions or informed consent, and the CP failed to report this irregularity. Resident 52's records documented the use of quetiapine fumarate for behavioral disorders associated with dementia, but there was no physician-documented rationale for its continued use. The CP's Monthly Medication Reviews did not address this issue. Resident 32 was prescribed risperidone for delusions, yet the EMR lacked a physician-documented rationale for its use. Again, the CP did not identify or report this irregularity. These deficiencies highlight the facility's failure to adhere to its own policies and procedures regarding medication regimen reviews, placing residents at risk for unnecessary medication administration and potential adverse effects.
Inappropriate Use of Antipsychotic Medications
Penalty
Summary
The facility failed to ensure appropriate indications or documented physician rationale for the use of antipsychotic medications for several residents, placing them at risk for unnecessary psychotropic medications and related complications. Resident 55, diagnosed with Alzheimer's disease, was administered Seroquel for behavioral disturbances and paranoia related to dementia without documented rationale or evidence of non-pharmacological interventions. The care plan lacked documentation of behaviors and non-pharmacological interventions, and a gradual dose reduction was not completed. Resident 8, with diagnoses including diabetes mellitus, depressive disorder, and anxiety, received Seroquel for major depressive disorder without documentation of non-pharmaceutical interventions tried and failed prior to administration. The care plan lacked documentation related to the antipsychotic medication, and there was no evidence of informed consent for its use. Similarly, Resident 32, diagnosed with conditions including dementia and bipolar disorder, was prescribed Risperidone for delusions without a documented physician rationale for its continued use. Resident 52, with diagnoses such as cerebral infarction and vascular dementia, was given Quetiapine for behavioral disorders associated with dementia without a documented rationale. The facility's policy required that residents not receive medications without clinical documentation to treat specific conditions, yet this was not adhered to. The facility's failure to ensure appropriate indications or documented physician rationale for these medications placed the residents at risk for unnecessary psychotropic medications and related complications.
Resident PHI Exposed on Unattended Medication Cart
Penalty
Summary
The facility failed to maintain the privacy of a resident's protected health information (PHI) when a medication cart was left unattended in the main dining room. On December 17, 2024, at 07:37 AM, a laptop on the medication cart displayed the PHI of a resident, including medications, date of birth, allergy information, and code status, which was visible to anyone passing by. Licensed Nurse G left the computer screen unlocked and open, thereby compromising the resident's privacy. On December 18, 2024, Licensed Nurse H acknowledged that the medication cart should be double locked, the computer screen closed, or the PHI hidden from view. Administrative Nurse D confirmed that nursing staff are expected to close the computer screen before leaving the medication cart unattended. The facility's policy on confidentiality and personal privacy, last reviewed in August 2024, mandates the protection and safeguarding of resident confidentiality and personal privacy. The failure to adhere to this policy resulted in a breach of the resident's privacy.
Failure to Update Care Plans for Behavioral and Preference Changes
Penalty
Summary
The facility failed to revise the care plan for Resident 33 to reflect his increased behavioral episodes. Resident 33, who has severe cognitive impairment and multiple medical conditions including epilepsy and major depressive disorder, exhibited aggressive behaviors during care and transfers. Despite documented incidents of physical aggression and resistance to care, the care plan did not include interventions or triggers related to these behaviors. Staff interviews confirmed that Resident 33 could become aggressive and that the care plan should have reflected these behavioral concerns. Additionally, the facility did not update Resident 32's care plan to include her sleeping preferences and behavior of yelling for help. Resident 32, who has severe cognitive impairment and multiple diagnoses including dementia and bipolar disorder, was observed sleeping on couches in common areas and calling out for help. Staff were aware of these preferences and behaviors, but they were not documented in the care plan. Interviews with staff revealed that while they knew of Resident 32's habits, these were not formally included in her care plan. The facility's failure to update the care plans for both residents placed them at risk for impaired care due to uncommunicated care needs. The facility's policy requires that care plans reflect current conditions and changes, but this was not adhered to in these cases. The lack of updated care plans meant that important information about the residents' needs and preferences was not formally communicated to all staff, potentially impacting the quality of care provided.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure that pressure-reducing heel protectors and boots were in place for a resident with a pressure injury on her left heel. The resident, who had diagnoses including a pressure ulcer, dementia, major depressive disorder, and anxiety, was observed without the necessary protective devices on multiple occasions. Despite physician orders and care plans specifying the use of bilateral heel protectors during the day and Thera-boots at night, the resident was seen without these devices while sitting in a Broda chair and lying in bed. This oversight was noted during observations on two consecutive days, with the resident's heels directly on the bed and a pressure-reducing boot found on the floor of her closet. Interviews with facility staff revealed a lack of adherence to the prescribed care plan. A CNA indicated that the presence of heel protectors would be known through the Kardex, charge nurse information, and if the devices were in the room. A licensed nurse stated that the devices were listed on the Treatment Administration Record and should be signed off every shift, but acknowledged that CNAs were typically responsible for applying them. An administrative nurse expressed an expectation that the devices should have been in place as ordered. The facility's Support Surface Guidelines policy, revised in September 2024, was intended to guide the use of pressure-reducing devices, but the failure to implement these measures placed the resident at risk for further skin breakdown and worsening of pressure ulcers.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to ensure a safe care environment for a resident, identified as R35, who was at risk for falls due to severe cognitive impairment and a history of repeated falls. R35's care plan required the use of a Dycem mat in his wheelchair to prevent slips and falls. However, observations revealed that while a Dycem mat was present in R35's recliner, it was consistently missing from his wheelchair during multiple inspections. This oversight occurred despite the care plan's clear instructions and the facility's policy to provide ongoing monitoring and assessment of individuals at risk for falls. Interviews with staff, including a CNA and an administrative nurse, highlighted a lack of clarity and consistency in ensuring the Dycem mat was in place for R35's wheelchair. The CNA acknowledged R35's impulsive behavior and fall risk but was uncertain about the presence of a Dycem mat in his wheelchair. Similarly, the administrative nurse was unsure if R35 had two Dycem mats or if staff were expected to move the mat between his recliner and wheelchair. This lack of adherence to the care plan and facility policy placed R35 at risk for preventable falls and injuries.
Failure to Sanitize Shared Medical Equipment
Penalty
Summary
The facility failed to ensure proper sanitization of shared medical equipment, specifically blood pressure cuffs, pulse monitors, and oxygen saturation equipment, after each resident's use. This deficiency was observed on multiple occasions in the main dining room, where licensed nurses did not sanitize the equipment before or after use on residents. On December 16, 2024, a licensed nurse did not sanitize the pulse monitor or blood pressure cuff before or after taking a resident's measurements. Similar observations were made on December 17 and 18, 2024, where another licensed nurse failed to sanitize the equipment before and after use. Interviews with staff revealed that there was an expectation for all nursing staff to sanitize shared equipment after each use, and sanitizer spray was available for this purpose. However, the practice was not consistently followed, as evidenced by the observations. The facility's policy, dated September 2024, outlined the requirement for cleaning and disinfecting resident-care equipment according to CDC guidelines, categorizing items based on their risk of infection. Despite these guidelines, the failure to sanitize equipment placed residents at risk for infectious diseases.
Failure to Offer PCV20 Vaccine
Penalty
Summary
The facility failed to offer and administer or obtain informed declinations for the Pneumococcal Conjugate Vaccine (PCV20) for two residents, identified as R32 and R53. R32's clinical record showed that the PCV13 was administered on 11/30/17, and the PSV23 was administered on 08/30/13, but lacked documentation that the PCV20 was offered or declined, or that there was a historical administration or a physician-documented contraindication. Similarly, R53's clinical record indicated that the PCV13 was administered on 09/27/18, and the PSV23 on 09/02/19, but also lacked documentation regarding the PCV20. Administrative Nurse D stated that the facility relied on the WEB IZ system to prompt when an immunization was needed and did not offer the PCV20 if a resident had received PCV13 and PCV23. The facility did not provide an immunization policy, leading to the deficiency of not offering the PCV20 or obtaining informed declinations for these residents.
Failure to Secure Resident in Transport Leads to Injury
Penalty
Summary
The facility failed to provide a safe environment, free from preventable accidents, for a resident who was involved in an accident while being transported in the facility's van. The resident, who had a history of pain, fibromyalgia, and weakness, was using a wheelchair and required assistance with most activities of daily living. On the day of the incident, the resident was strapped into the van with the wheelchair secured, but a seatbelt was not placed around her. As a result, when the driver braked suddenly, the resident slid out of the wheelchair onto the van floor, sustaining fractures to her left tibia and fibula. The incident occurred when the transportation staff member, responsible for driving the van, did not secure the resident with a seatbelt, citing the resident's size and the short distance of the trip as reasons for the oversight. The driver admitted to not using a seatbelt because he was unsure if it could fit around the resident and did not consider it necessary for the short journey. This lack of proper restraint led to the resident sliding out of the wheelchair when the van braked suddenly, resulting in significant injuries. Interviews with staff revealed that there was a lack of training and awareness regarding the necessity of using seatbelts for residents in wheelchairs during transport. The facility's policy required that all residents be properly secured with seatbelts, but this was not adhered to in this case. The failure to follow established safety protocols and ensure the resident was adequately secured in the van directly contributed to the accident and the resident's subsequent injuries.
Removal Plan
- An OT evaluation for R1 was ordered.
- All facility transportation was suspended until training and competencies were completed by transportation staff.
- R1's Care Plan was updated.
- Transportation EE and Transportation FF completed transportation competencies.
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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