Azria Health Great Bend
Inspection history, citations, penalties and survey trends for this long-term care facility in Great Bend, Kansas.
- Location
- 1560 K 96 Hwy, Great Bend, Kansas 67530
- CMS Provider Number
- 175291
- Inspections on file
- 26
- Latest survey
- September 23, 2025
- Citations (last 12 mo.)
- 22 (1 serious)
Citation history
Health deficiencies cited at Azria Health Great Bend during CMS and state inspections, most recent first.
A cognitively impaired resident with a history of wandering eloped from the facility without staff knowledge and was found outside in a facility van during extreme heat, after the door alarm failed to activate and the care plan lacked elopement interventions. Additionally, another resident sustained skin tears of unknown origin during a transfer, but the facility did not complete a thorough investigation or obtain required witness statements.
The facility did not employ a full-time certified dietary manager to oversee food and nutrition services for its residents. Dietary staff confirmed they were not certified, and administrative staff verified this. The facility also lacked a policy for employing a certified dietary manager, affecting residents on specialized diets.
Staff did not consistently use Enhanced Barrier Precautions (EBP) or properly disinfect shared medical equipment. For example, a nurse failed to disinfect a glucometer after use on a resident, and staff did not wear gowns or gloves during high-contact care for residents with open wounds or indwelling devices, despite facility policy and posted instructions. These lapses were confirmed by administrative staff and placed residents at risk for infection.
Surveyors found that two residents' insulin pens were not properly labeled with opened or expiration dates, and one pen was used well past its expiration. Additionally, a treatment cart containing medications was left unlocked and unattended in a hallway, making medications accessible to unauthorized individuals. Both issues were confirmed by nursing staff as contrary to facility policy.
A resident with severe cognitive impairment and multiple diagnoses received PRN lorazepam for agitation without a 14-day stop date or documented physician rationale for continued use. Staff confirmed the medication was administered without the required documentation, contrary to facility policy requiring a specified duration and rationale for ongoing PRN psychotropic medication orders.
A resident with multiple medical conditions and moderate cognitive impairment sustained skin tears and bruising on the left lower leg during a staff-assisted transfer. The facility did not thoroughly or promptly investigate the injury, failed to obtain proper witness statements, and did not follow its own policy for investigating injuries of unknown origin.
The facility did not notify the Office of the Long-Term Care Ombudsman when two residents with significant medical conditions were transferred to the hospital. In both cases, documentation and staff interviews confirmed that the required notifications were missed, despite facility policy mandating written notice to the Ombudsman at the time of transfer or discharge.
Two residents with significant medical needs did not consistently receive required bathing assistance, as documented by extended periods without baths or showers and confirmed by staff interviews and resident observations. Despite some refusals being recorded, there were numerous undocumented gaps in care, and both residents were observed with poor hygiene. Staff reported offering alternative bathing times and notifying nursing staff of refusals, but facility records and observations showed that consistent bathing services were not provided according to care plans and policy.
A resident with hemiplegia and a partially contracted right hand did not receive appropriate range of motion (ROM) services or restorative care, as required by facility policy. The care plan lacked interventions to prevent contractures, staff were unaware of the need for splint use, and there was no active restorative program in place. The resident reported not receiving ROM exercises, and the splint was not consistently applied.
A resident with a history of constipation experienced an eight-day period without a documented bowel movement, during which staff failed to provide or document required bowel management interventions and assessments, despite existing care plans, standing orders, and facility policy.
A certified medication aide crushed and administered an extended-release metoprolol tablet to a resident, despite the medication label stating it should not be crushed. The aide continued with administration after being questioned, and a review found that the medication order and the medication card did not match, with the pharmacy not being notified of the order change in a timely manner. This resulted in a significant medication error due to failure to follow prescriber orders and facility policy.
A resident with multiple chronic conditions and severe cognitive impairment was admitted to hospice care, but the facility did not update the care plan to reflect hospice services as required by policy. This failure to coordinate care planning between the facility and hospice provider placed the resident at risk for inadequate end-of-life care.
The facility did not submit complete and accurate direct care staffing information through the PBJ system, as required by CMS. Although internal schedules showed adequate staffing, the PBJ reports indicated excessively low weekend staffing for two quarters. Administrative staff stated that daily schedules and updates were sent to the regional office, but the data submitted did not accurately reflect actual staffing levels.
A resident with significant mobility limitations and cognitive impairment developed a facility-acquired unstageable pressure ulcer on the left heel after the care plan failed to include timely interventions for repositioning and offloading. Staff were unable to confirm consistent use of pressure-relieving boots or clear communication of preventive measures, and the facility lacked documentation of a pressure ulcer prevention policy.
A resident with Alzheimer's and at risk for elopement exited a facility unsupervised due to inadequate staff supervision and inaudible door alarms. The resident, who used a wheelchair, was found in the parking lot after leaving the smoker's room. Staff failed to hear the alarm, contributing to the incident.
Failure to Prevent Elopement and Incomplete Investigation of Injury
Penalty
Summary
A cognitively impaired resident with a history of falls and wandering was not adequately supervised, resulting in the resident eloping from the facility. The resident, who required staff supervision for ambulation and used a walker, was last seen in the lobby by staff, with her walker left behind. Staff discovered the resident missing and found her outside in the facility van during high temperatures, without knowledge of how she exited the building. The door alarm did not activate, and the care plan lacked specific interventions for elopement risk, despite documented wandering behavior and a history of elopement attempts. Additionally, the facility failed to conduct a complete investigation when another resident sustained two skin tears of unknown origin. The resident, who was dependent on staff for transfers and had moderate cognitive impairment, reported that her leg was injured during a transfer. The incident report did not include a dated witness statement, and the facility was unable to provide documentation from the staff member involved in the transfer. The facility's policy required thorough investigation and documentation of all injuries of unknown origin, but this was not completed as required. Both deficiencies were identified through observation, record review, and staff interviews. The lack of adequate supervision and incomplete investigation placed the residents at risk, with one incident resulting in immediate jeopardy due to the resident's unsupervised exit and exposure to unsafe conditions.
Lack of Certified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility failed to provide the services of a full-time certified dietary manager for its 61 residents who received meals from the kitchen. Observations showed that dietary staff prepared meals, but the staff member present was not a certified dietary manager. Interviews with dietary staff and an administrative nurse confirmed the absence of a certified dietary manager. Additionally, the facility was unable to provide a policy regarding the employment of a certified dietary manager. The sample included 17 residents, with three on a pureed diet and 15 on a mechanical soft diet, all of whom were affected by this deficiency.
Failure to Implement Enhanced Barrier Precautions and Disinfection Protocols
Penalty
Summary
Staff failed to consistently implement Enhanced Barrier Precautions (EBP) and proper disinfection protocols, as observed during care of residents with open wounds and indwelling devices. On multiple occasions, staff did not don gowns or gloves when providing high-contact care, such as incontinence care, wound care, and catheter care, to residents who had open wounds or urinary catheters. For example, two CNAs transferred a resident with open wounds and provided incontinence care without wearing EBP gowns, and a licensed nurse performed wound care on the same resident without donning an EBP gown. Administrative staff confirmed that EBP should have been used in these situations, and facility policy required gown and glove use for such high-contact care activities. Additionally, staff failed to properly disinfect a blood glucose meter used for multiple residents. A licensed nurse was observed obtaining a blood sugar reading for a resident and then placing the glucometer back in a drawer without cleaning or disinfecting it. The facility had two glucometers in use for seven residents, and the manufacturer's instructions, as well as facility policy, required cleaning and disinfection of the device after each use. Administrative staff verified that the glucometer should have been disinfected between uses. One resident with a urinary catheter was also not provided care according to EBP protocols. A CNA emptied the resident's catheter bag without wearing gloves or a gown, despite signage and care plan instructions indicating that EBP should be used for catheter care. The CNA acknowledged the omission when questioned, and administrative staff confirmed that EBP was required for such care. These failures were in direct violation of the facility's infection prevention and control policies and placed residents at risk for infection.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Surveyors observed that the facility failed to properly label and store medications in accordance with professional standards and facility policy. Specifically, two residents' insulin flex pens were not labeled with the date opened, and one pen was found in use 46 days past its expiration date. Additionally, another medication lacked both an opened date and an expiration date. These deficiencies were confirmed by both a licensed nurse and an administrative nurse, who acknowledged that insulin flex pens should be labeled with the date opened and discarded once expired. Facility policy and external medication guidelines require that such medications be labeled and discarded after a specified period, which was not followed in these instances. Furthermore, the facility failed to ensure that medications were only accessible to licensed staff. During the survey, a treatment cart containing insulin and other medications was found unlocked and unattended in a hallway, with no staff in sight. The responsible nurse was located in a resident's room, out of view of the cart, and later confirmed that the cart should have been locked when not under direct supervision. The facility's policy mandates that medication carts remain locked and inaccessible to unauthorized individuals when not attended by licensed staff.
Failure to Specify Duration and Rationale for PRN Antianxiety Medication
Penalty
Summary
The facility failed to ensure that a resident's as-needed (PRN) antianxiety medication, lorazepam (Ativan), had a 14-day stop date or a specified duration with a documented physician rationale for ongoing use. The resident in question had diagnoses including cerebral infarction, Alzheimer's disease, and dysphagia, and was noted to have severely impaired cognition, requiring extensive assistance with activities of daily living. The resident's care plan indicated the use of Ativan for end-of-life restlessness, and the physician's order directed staff to administer lorazepam 1 mg as needed for agitation, but did not include a stop date or specified duration. Review of the electronic health record revealed no evidence of a physician's rationale for the extended use of PRN lorazepam. Staff confirmed that the medication was administered without the required 14-day stop date or documentation supporting continued use. The facility's policy required that PRN psychotropic medications not be renewed beyond 14 days without a healthcare practitioner's evaluation and documented rationale, and that the duration be indicated in the order. This policy was not followed in this case.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly and promptly investigate an injury of unknown origin sustained by a resident with multiple medical conditions, including a stable burst fracture of two vertebrae, chronic respiratory failure, chronic lymphocytic leukemia in remission, pain, osteoarthritis, and dorsalgia. The resident, who had moderately impaired cognition and was dependent on staff for transfers, was found with two bruised areas and skin tears on her left lower leg after being assisted by CNAs for supper. The resident reported that her leg was bumped during a transfer, but the care plan did not provide specific staff direction for transfers and mobility, and there was no history of falls since admission. The incident report for the injury did not include a dated witness statement, and the facility was unable to provide a witness statement documenting what happened during the transfer, despite the resident's claim. The facility's policy required all injuries of unknown origin to be thoroughly investigated and documented, but the investigation was incomplete and not conducted in a timely manner. The interdisciplinary team reviewed the incident, but the required documentation and witness statements were missing or undated, resulting in a failure to meet the facility's own policy for investigating potential abuse, neglect, or exploitation.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO) regarding the hospital transfers of two residents, resulting in a deficiency related to required documentation and notification. For one resident with a history of Alzheimer's disease, hypertension, diabetes, and a recent femur fracture, the clinical record did not show evidence that the Ombudsman was notified when the resident was transferred to the hospital for treatment. The resident's care plan and progress notes documented the transfer and subsequent readmission, but the omission of notification was confirmed by facility staff, who stated the resident was mistakenly missed during the notification process. Another resident, also with Alzheimer's disease and additional diagnoses including chronic kidney disease and encephalopathy, was transferred to the hospital following a decline in condition, including confusion, weakness, and respiratory symptoms. The resident's niece was notified of the transfer, and the resident was later readmitted to the facility. However, the clinical record lacked documentation that the LTCO was notified of the discharge to the hospital. Facility staff confirmed that this resident was not included in the monthly report sent to the Ombudsman office, as required by facility policy. Facility policy states that residents or their representatives must be notified in writing of impending transfers or discharges, and a copy of this notice must be sent to the Office of the State Long-Term Care Ombudsman at the same time. In both cases, the required notification to the Ombudsman was not completed, as confirmed by staff interviews and review of the clinical records.
Failure to Provide Consistent Bathing Assistance to Residents
Penalty
Summary
The facility failed to provide consistent bathing services to two residents who required assistance with activities of daily living, specifically bathing. One resident with diagnoses including Parkinson's disease, hypertension, anxiety, and depression, and who had intact cognition but required supervision with bathing, did not receive a bath or shower for multiple extended periods as documented in the facility's records. Although some refusals were recorded in the electronic medical record, there were numerous days with no documentation of bathing or refusal, and observations noted the resident with uncombed hair and unresponsiveness to questions. Another resident, diagnosed with a displaced femur fracture, Alzheimer's disease, hypertension, and diabetes, and who required partial to substantial staff assistance for bathing, also experienced significant gaps in receiving showers. Facility records showed long intervals without showers, with only a few refusals documented. Observations found this resident with greasy, uncombed hair, unshaven, and wearing soiled socks, and the resident was unable to recall if staff offered different bathing choices. Interviews with staff indicated that when residents refused bathing, alternative days or times were offered, and refusals were documented and reported to nursing staff. The facility's policy required staff to observe residents' skin condition, notify supervisors of refusals, and report according to policy and professional standards. Despite these procedures, the documentation and observations revealed that the facility did not consistently ensure that residents received the necessary assistance with bathing, as required by their care plans and facility policy.
Failure to Provide Range of Motion Services for Resident with Hemiplegia
Penalty
Summary
The facility failed to provide appropriate range of motion (ROM) services to a resident with hemiplegia and hemiparesis following a stroke, resulting in a partially contracted right hand. The resident's medical record documented the need for assistance with activities of daily living due to hemiplegia and generalized weakness, but the care plan lacked specific interventions to prevent contractures. Although the care plan instructed staff to monitor and report signs of immobility, it did not include any restorative or splint/brace therapy interventions. The resident reported not receiving ROM exercises or restorative services for his right hand, and his splint was out of reach, requiring staff assistance to apply it. Interviews with facility staff revealed that there was no active restorative program, and restorative aides were not available. Nursing staff were unaware of the resident's need for the hand splint, and the care plan did not address contracture prevention. The therapy consultant confirmed the resident's hand did not open fully and that he was educated on splint use, but the facility did not ensure consistent application or ROM services. The facility's own policy required restorative nursing care as needed, but this was not provided to the resident.
Failure to Provide Bowel Management Interventions for a Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate interventions for bowel management for one resident with a history of constipation. The resident had diagnoses including dementia, anxiety, hypertension, and constipation, and was noted to have moderately impaired cognition but remained independent in activities of daily living. The care plan directed staff to administer medications as ordered, monitor for side effects of constipation, report changes in bowel patterns to the physician, and document daily bowel movement patterns. Standing orders and physician orders were in place for the administration of stool softeners and laxatives, with instructions to notify the physician if there was no result after specific interventions. Despite these directives, the resident's bowel monitoring record showed an eight-day period without a documented bowel movement, and the medication administration record lacked evidence that interventions were provided during this time. There was also no documentation of a bowel assessment for the period in question. Staff interviews confirmed that there were procedures for reporting and initiating standing orders after three days without a bowel movement, but the records did not reflect that these actions were taken for the resident during the identified period. The facility's policy required assessment and intervention for bowel dysfunction, but these were not documented as completed.
Crushing of Extended-Release Medication Results in Significant Medication Error
Penalty
Summary
A certified medication aide crushed and administered an extended-release (ER) metoprolol tablet to a resident by mixing it with applesauce, despite the medication label indicating 'Do not crush.' The aide proceeded with this action even after being questioned about the appropriateness of crushing the ER medication, stating she would consult the nurse later. Review of the medication records revealed that the current physician order was not for ER metoprolol, but the medication card still reflected the ER formulation, leading to confusion. The administrative nurse confirmed that the medication administration did not align with the current physician order and that the pharmacy had not been notified of the order change in a timely manner, resulting in an incorrect Medication Administration Record (MAR). The facility's policy requires medications to be administered according to prescriber orders and verified for correct method of administration prior to delivery.
Failure to Update Care Plan for Resident Receiving Hospice Services
Penalty
Summary
The facility failed to ensure coordinated care and services between the facility and hospice for a resident who was admitted to hospice care. The resident had multiple diagnoses, including Alzheimer's disease, chronic kidney disease, encephalopathy, acute bronchitis, and congestive heart failure, and required significant staff assistance with activities of daily living (ADLs) due to severe cognitive impairment and functional limitations. Although the resident was admitted to hospice care and had a physician's order for hospice services, the facility did not update or create a facility care plan reflecting the resident's hospice status. The care plan in the electronic health record did not indicate that the resident was receiving hospice services, despite documentation from the hospice provider and orders from the primary care physician. The facility's policy required comprehensive, person-centered care plans to be developed and revised as residents' conditions changed, including when a resident was admitted to hospice. The lack of an updated care plan coordinating hospice and facility services placed the resident at risk for inadequate end-of-life care.
Failure to Accurately Report Direct Care Staffing Data via PBJ
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information through the Payroll-Based Journal (PBJ) system as required by CMS. During the review period, the PBJ report for two consecutive fiscal quarters indicated excessively low weekend staffing, despite the facility's own nursing staffing schedules showing adequate staff on duty. Administrative staff confirmed that daily schedule sheets, including updates, were sent to the regional office, and any changes were also communicated. The facility's policy required that direct staffing information be collected daily and reported electronically in a uniform format, but the submitted PBJ data did not accurately reflect the actual staffing levels provided, leading to the deficiency.
Failure to Provide Timely Pressure Ulcer Prevention and Care
Penalty
Summary
A resident with multiple comorbidities, including diabetes, immobility, and cognitive impairment, was admitted to the facility with existing pressure ulcers and was identified as being at risk for further skin breakdown. The resident required substantial to maximum assistance for mobility and personal care and was dependent on staff for transfers and repositioning. The care plan directed staff to use pressure-relieving devices and follow protocols for skin breakdown prevention, but it did not include specific interventions for repositioning or offloading until after the resident developed a new pressure ulcer on the left heel. Despite the resident's risk factors and care needs, documentation and staff interviews revealed uncertainty about whether pressure-relieving boots were in use prior to the development of the left heel ulcer. Staff could not confirm if turning and repositioning were consistently implemented or if these interventions were clearly communicated in the care plan. The resident developed a facility-acquired unstageable pressure ulcer on the left heel, which progressed in size and severity, eventually becoming necrotic and malodorous, and was later diagnosed as osteomyelitis by a hospital. The facility's records lacked evidence of timely care plan updates and did not provide a policy on pressure ulcer prevention. Staff interviews indicated gaps in communication and training regarding pressure ulcer prevention interventions. The care plan was not updated to include offloading and heel protectors until after the pressure ulcer had developed, and there was no documentation of a systematic approach to ensure at-risk residents received necessary preventive care.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent a cognitively impaired resident, identified as R1, from exiting the facility without staff knowledge. R1, who had a history of Alzheimer's disease, muscle weakness, and was at risk for elopement, was able to propel his wheelchair from the dining room to the smoker's room. Despite being identified as an elopement risk, R1 was left unsupervised in the smoker's room by CNA N, who was informed of R1's location by Housekeeping Staff U. CNA N left R1 in the room to attend to other duties, assuming R1 was not attempting to exit. At approximately 08:20 AM, Administrative Staff A found R1 in the parking lot, sitting in his wheelchair, expressing a desire to go home to see his family. The investigation revealed that the door alarm to the smoker's room was sounding, but staff could not hear it due to its low volume. This lack of audible alarm contributed to the staff's failure to respond promptly to R1's elopement. The facility's incident report confirmed that R1 exited through the smoker's room door, and the alarm was not heard by staff who were occupied in other areas of the facility. R1's care plan documented his risk for elopement and outlined strategies for intervention, including redirection and structured activities. However, these measures were not effectively implemented, leading to R1's unsupervised exit. The facility's Wandering and Elopement Policy aimed to identify and manage residents at risk, but the failure to ensure the alarm was audible and the lack of immediate staff response resulted in R1's elopement, placing him in immediate jeopardy.
Removal Plan
- All nursing staff were re-educated on wandering/elopement.
- R1 is one-on-one with staff until it is determined he is not exiting seeking.
- Maintenance fixed the smoke room door alarm, so it would alarm not only in the room and outside but at the alarm panel to alert staff.
- Maintenance staff and the manager on duty are checking all door alarms.
- Care plans of residents at risk for elopement were reviewed and new elopement risk evaluations were completed on all residents.
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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