Attica Long Term Care Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Attica, Kansas.
- Location
- 302 N Botkin, Attica, Kansas 67009
- CMS Provider Number
- 17E534
- Inspections on file
- 16
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Attica Long Term Care Facility during CMS and state inspections, most recent first.
A resident with dementia experienced significant unintended weight loss after staff failed to provide adequate nutritional care, did not consistently implement or document nutritional supplements, and did not follow the Registered Dietician's recommendations or notify the physician as required. The resident's meal intake was low, and staff interviews revealed gaps in communication and documentation regarding nutritional interventions.
Staff failed to follow infection control protocols, including proper hand hygiene when delivering clean laundry and during resident care, and did not maintain a sanitary environment in the laundry area. Observations included staff not sanitizing hands before or after entering rooms, using dirty gloves to handle clean briefs, and improper storage of clean and dirty linens, with no facility policy provided for laundry processing.
Several residents with mental health diagnoses were prescribed psychotropic medications, including antianxiety, antidepressant, and antipsychotic agents, without documented informed consent or education about the medications' benefits, risks, and alternatives. Facility staff confirmed that consent was not obtained, citing a misunderstanding of policy requirements.
A resident with dementia and severely impaired cognition experienced significant weight loss over several months, with documented weights declining from 135 to 120 pounds. Despite care plan interventions and facility policy requiring physician notification for significant weight loss, there was no evidence that the physician was informed in a timely manner. The RD noted poor meal intake and recommended an appetite stimulant, but staff interviews revealed confusion about the notification process, and the physician was not notified until much later.
A resident with dementia and physical weakness, who was fully dependent on staff for ADLs, was observed over two days with long, jagged, and dirty fingernails. Staff confirmed the resident relied on them for nail care, which was only performed on shower days, and the facility could not provide a nail care policy.
A resident with dementia and moderately impaired cognition, who was able to ambulate independently, did not receive an ongoing, individualized activity program based on his preferences for reading, music, and religious practices. Documentation showed only two activity events in a month, and staff were unclear about his interests, resulting in a lack of engagement and failure to meet his assessed needs.
Multiple residents with cognitive impairment and mobility needs were not consistently provided with safe wheelchair transport, as staff failed to ensure the use of foot pedals during assisted mobility. One resident with a history of falls did not receive individualized fall prevention interventions after a fall, and another was observed being pushed in a wheelchair without foot pedals. Staff interviews confirmed inconsistent practices and the absence of a facility policy regarding wheelchair positioning and foot pedal use.
The facility did not ensure the laundry folding counter and linen storage closet were maintained in good repair, as evidenced by a patched hole in the counter and broken ceiling tiles with exposed gaps. Staff interviews confirmed that maintenance requests and routine inspections were not effectively carried out, leading to an unsanitary environment.
Failure to Provide Adequate Nutrition and Follow RD Recommendations
Penalty
Summary
A resident with dementia and severely impaired cognition experienced significant unintended weight loss of 11.48% over three months due to the facility's failure to provide adequate nutritional care and follow the Registered Dietician's (RD) recommendations. The resident was admitted with a weight of 135 pounds and was on a liberalized geriatric diet, with care plans indicating she made her own food choices and required staff to offer snacks and fluids throughout the day. Despite these interventions being documented, the resident's electronic medical record (EMR) showed a steady decline in weight, with no evidence of additional nutritional orders or consistent documentation of supplement intake. The RD noted limited meal intake, with most meals consumed at less than 26% and staff reporting the resident often preferred to sleep and declined food, stating she was not hungry. The RD recommended a trial of an appetite stimulant and nutritional shakes, but the clinical record lacked evidence that these recommendations were implemented or that the physician was notified of the significant weight loss. Staff interviews confirmed that while attempts were made to offer protein shakes, these were not documented, and there was uncertainty about whether RD recommendations were communicated to the provider or followed up with appropriate orders. Facility policy required staff to notify the physician of significant weight loss and document decisions for supplements, but the record showed these steps were not consistently taken. The resident's weight continued to decline, and staff and consultants acknowledged gaps in communication and documentation regarding nutritional interventions and physician notification. The failure to implement and document appropriate nutritional interventions and to follow RD recommendations contributed directly to the resident's ongoing weight loss.
Infection Control Deficiencies in Hand Hygiene and Laundry Services
Penalty
Summary
Facility staff failed to implement adequate infection control practices, specifically regarding hand hygiene and laundry services. Observations revealed that dietary staff delivering clean laundry to resident rooms did not sanitize their hands before or after each delivery. Additionally, a CNA was observed wiping a resident's buttock with gloved hands and, without changing gloves or performing hand hygiene, proceeded to place a clean brief on the resident. Multiple staff interviews confirmed that hand hygiene was expected before and after entering resident rooms and when handling laundry, but these practices were not consistently followed. The facility's own hand hygiene policy, which aligns with CDC guidelines, was not adhered to during these observed events. Further observations in the laundry area showed improper separation of clean and dirty items, with a dirty linen cart placed against the clean linen folding counter and non-linen items stored on the clean linen processing area. The environment was also found to be unsanitary, with a dusty bar of soap hanging from the ceiling and dirty air conditioning vents blowing towards the clean linen counter. Staff interviews indicated that each department was responsible for cleaning its own area, but there was no facility policy provided regarding laundry processing or maintaining the cleanliness of the laundry area.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were fully informed and provided informed consent regarding the use of psychotropic medications, as required by facility policy. Multiple residents with diagnoses such as PTSD, anxiety, depression, panic disorder, bipolar disorder, and dementia were prescribed various psychotropic medications, including antianxiety agents, antidepressants, and antipsychotics. Despite these prescriptions, the electronic medical records (EMRs) and electronic health records (EHRs) for these residents lacked documentation that informed consent was obtained or that education was provided about the medications' benefits, risks, and alternatives. For example, one resident with PTSD, anxiety, and depression was prescribed lorazepam, mirtazapine, and sertraline, but there was no evidence in the EMR of informed consent for these medications. Another resident with panic disorder, major depressive disorder, and bipolar disorder was prescribed buspirone, desvenlafaxine, lorazepam, and olanzapine, again without documentation of informed consent. Additional residents with depression, adjustment disorder, insomnia, and dementia were also prescribed psychotropic medications such as bupropion, citalopram, and duloxetine, with no evidence that they or their representatives were informed about the medications or provided consent. Interviews with facility staff confirmed that informed consent for psychotropic medications had not been completed for these residents. The administrative nurse indicated a misunderstanding of the facility's policy, believing that consent was only necessary for new medications started at the facility, not for those continued upon admission. The facility's policy, however, clearly required informing residents, families, or representatives of the benefits, risks, and alternatives for each psychotropic medication prior to adding, discontinuing, or changing any such medication.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of significant weight changes in a resident with dementia and severely impaired cognition. The resident was admitted with a weight of 135-136 pounds and was noted to have no known weight loss at admission. Over the course of several months, the resident experienced a significant weight loss, dropping to 120 pounds as documented in the quarterly Minimum Data Set. The care plan indicated that the resident made her own food choices, was on a liberalized geriatric diet, and required staff to cue her for meals and encourage fluid and snack intake. Weights were to be recorded weekly, and the facility policy required the nursing director to notify the physician of significant weight loss. Despite these interventions and policies, the electronic medical record showed a progressive decline in the resident's weight, with no evidence that the physician was notified after weights of 127.5 pounds and 119.5 pounds were recorded. The registered dietician documented limited meal intake, with most meals consumed at less than 26% and only 14 meals charted over two weeks. Staff reported the resident often preferred to stay in her room, slept late, and declined meal and snack offers, stating she was not hungry. The dietician recommended considering an appetite stimulant due to the ongoing weight loss and poor intake, but there was no documentation that these recommendations or the significant weight loss were communicated to the physician in a timely manner. Interviews with staff revealed a lack of clarity regarding the process for notifying the physician about weight loss and following up on the dietician's recommendations. The administrative nurse stated that the dietician provided a weekly list of residents with weight loss and that nurses were responsible for discussing recommendations with the physician. However, the consultant physician confirmed she was not notified of the resident's weight loss until much later, at which point she ordered nutritional supplements. The facility's failure to promptly notify the physician of the resident's significant weight loss constituted the identified deficiency.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
A resident with diagnoses of dementia and weakness, who was assessed as having moderately impaired cognition and being dependent on staff for all activities of daily living (ADLs), did not receive appropriate nail care. The resident's care plan and assessments indicated a need for staff assistance with personal hygiene, including nail care. Despite these documented needs, observations over two consecutive days showed that the resident's fingernails were long, jagged, and dirty. Interviews with certified nurse aides confirmed that the resident was dependent on staff for all ADLs, including fingernail care, and that nail care was typically performed on shower days. An administrative nurse stated that staff were expected to ensure the resident's fingernails were smooth and clean. The facility was unable to provide a policy for nail care.
Failure to Provide Resident-Centered Activity Program
Penalty
Summary
The facility failed to implement an ongoing, resident-centered activity program for a resident diagnosed with dementia and moderately impaired cognition. The resident's medical record and assessments indicated that it was important for him to have access to reading materials, listen to music, participate in religious practices, keep up with the news, and engage in favorite activities. Despite being able to ambulate independently and having no impairment in range of motion, documentation showed only two activity events over a one-month period, with no further evidence of participation in activities. Observations on multiple occasions revealed the resident sitting in a common area with the television on, but not engaging with it or any other activities. Interviews with staff indicated uncertainty about the resident's activity preferences, with some staff only aware that he enjoyed talking or one-to-one activities. The facility's policy required activities to be based on comprehensive assessment and care plans tailored to resident preferences, with documentation of participation. However, the lack of documented activities and staff awareness demonstrated a failure to provide a resident-centered activity program as required.
Failure to Prevent Accident Hazards and Ensure Safe Wheelchair Use
Penalty
Summary
The facility failed to ensure that areas were free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents. One resident with dementia and weakness, who was dependent on staff for wheelchair mobility and had moderately impaired cognition, was observed being transported in a wheelchair with her feet not consistently on the foot pedals. Staff confirmed that her feet did not always stay on the pedals during transport, and the facility did not have a policy regarding wheelchair positioning or foot pedal use. Another resident with a history of falls, memory impairment, and confusion, who was on hospice services, experienced a fall while attempting to retrieve an item from her bedside table. The care plan for this resident included reminders to use the call light and wait for staff assistance, but lacked further interventions after the fall. Staff interviews indicated that the intervention of re-educating the resident to use the call light was not appropriate given her cognitive status, and that she often got up without waiting for help despite the call light being within reach. A third resident with severe cognitive impairment and peripheral vascular disease was observed being pushed in a wheelchair without foot pedals. Staff acknowledged that foot pedals should be used when assisting residents in wheelchairs, but in this case, the pedals were not available. The facility did not provide a policy for wheelchair positioning, including the use of foot pedals, and staff interviews confirmed inconsistent practices regarding their use.
Failure to Maintain Safe and Sanitary Laundry and Linen Storage Areas
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the laundry and linen storage areas. Observations revealed that the clean clothes folding counter in the laundry area had a large patched hole, measuring three feet long and six inches wide, covered with plain plywood, and several chipped areas. Additionally, the clean linen storage closet had multiple ceiling tiles with broken areas, creating large gaps, and one tile had a large hole inadequately covered with plastic, leaving gaps exposed. Interviews with housekeeping, maintenance, and administrative staff confirmed that there was a repair request system in place and that maintenance items related to residents were prioritized. However, staff acknowledged that a work order should have been submitted to repair or replace the broken counter and that ceiling tiles should be clean and intact. Facility policies required routine inspections and maintenance of fixtures and equipment, including weekly checks of the laundry area, but these procedures were not effectively implemented, resulting in the observed deficiencies.
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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