Azria Health Wichita
Inspection history, citations, penalties and survey trends for this long-term care facility in Wichita, Kansas.
- Location
- 7057 West Village Circle, Wichita, Kansas 67205
- CMS Provider Number
- 175563
- Inspections on file
- 23
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Azria Health Wichita during CMS and state inspections, most recent first.
Surveyors found widespread failures in food labeling, sealing, and storage, along with poor sanitation and hand hygiene practices in the main kitchen and dining kitchenettes. Multiple opened, undated, and unsealed dry, refrigerated, and frozen food items were observed, as well as a nonfunctioning, rusted ice machine. Kitchenette areas contained trash, food debris, dirty and damaged cabinets, calcium buildup and rust on beverage and ice machines, and dirty refrigerators holding open, unlabeled food containers with utensils left inside. Dietary staff were seen handling food, utensils, and meal tickets with the same gloves, removing gloves without hand hygiene, and resuming food service tasks without washing hands. A resident’s hot meal tray sat out for an extended period and was later found to be below appropriate hot-holding temperatures before being discarded. Staff interviews confirmed dietary aides were responsible for cleaning these areas and that weekend cleaning coverage was lacking, despite facility policy requiring clean, properly labeled and dated food storage.
Surveyors identified multiple infection control failures involving two residents, including improper management of an indwelling urinary catheter and poor handling of oxygen tubing. One resident on EBP with a catheter had the drainage bag repeatedly placed on or dragging along the floor, at times positioned above bladder level, while CNAs provided peri-care, brief changes, dressing, and mechanical lift transfers without performing hand hygiene, changing gloves after soiled contact, or wearing gowns. Another resident’s oxygen tubing was repeatedly observed wrapped around a wheelchair handle instead of stored in a bag. Staff interviews showed CNAs lacked awareness of required glove changes, hand hygiene during care, and appropriate PPE and storage practices, despite nursing leadership stating expectations consistent with facility catheter care and hand hygiene policies.
A resident with anxiety, depressive disorder, and drug-induced dyskinesia, and with intact cognition per BIMS, was receiving multiple psychotropic medications, including an antidepressant, antianxiety, antipsychotic, and trazodone, without documented informed consent regarding risks and benefits. The care plan directed staff to educate the resident and family on psychotropic medication risks, benefits, and side effects, and assessments identified the medications as high risk with fall-related risk factors, yet the clinical record contained no consent documentation. Nursing staff reported being unaware of the psychotropic medication policy, and an administrative nurse stated that psychotropic evaluations and family notifications were usually done in-house, but in this case no psychotropic consent was obtained or documented because an outside provider managed the psychiatric medications.
Surveyors determined that the facility failed to provide required written notification of transfers for three residents who were sent to the hospital for issues including vomiting with pain, evaluation and treatment ordered by a provider, and hallucinations reported by family. In each case, documentation showed that the residents were transferred via EMS or at a family member’s request, but the EMR contained no evidence that written transfer notices were given to the residents or their representatives. Staff reported that they sent bed-hold information with the transfer packet and notified families by phone, but they were not aware of the requirement for written transfer notification, despite a facility policy stating that facility-initiated discharges require resident or representative notification and documentation.
A resident with intact cognition, depressive disorder, and an antidepressant order requiring monitoring for constipation went six consecutive days without a documented bowel movement, assessment, or treatment. Despite physician orders to follow the bowel routine protocol and PRN orders for prune juice, Milk of Magnesia, and Fleet enemas, staff did not initiate the constipation management steps outlined in the facility policy after three days without a BM. EMR review showed no constipation interventions or progress note assessments during this period, even though nurses reported they receive alerts after three days without a BM and are expected to assess, document, and follow the standing bowel protocol.
A resident with highly impaired hearing and a cognitive communication deficit did not receive adequate hearing-related care. Although standing orders and MAR entries showed intermittent Debrox use for cerumen impaction, there was no documentation of effectiveness assessments and no evidence of continued treatments in subsequent months. The resident reported difficulty hearing due to wax buildup and stated that hearing aids were not working and had not been cleaned recently. Staff interviews described expectations to verify hearing aid function, clean ears, and report problems to nursing leadership, and facility policy required assistance with hearing services and device maintenance, but the resident’s care plan lacked specific hearing interventions and the documented care did not align with these expectations.
A resident receiving IV ertapenem via a midline catheter had an undated dressing with dried blood visible under and through the soft cloth border and a loose bottom seal that remained unchanged over multiple days, with no documentation that staff assessed or addressed the soiled dressing. Physician orders and the care plan specified scheduled dressing changes but no PRN changes, and nursing documentation lacked evidence of dressing assessment despite twice-daily monitoring orders for IV-related complications. During IV medication administration, an LN performed hand hygiene and donned gloves but then repeatedly reached into pockets, handled the IV line, and touched her hair without changing gloves before connecting the IV tubing to the hub, while acknowledging the soiled, loose dressing and absence of a PRN order to change it, contrary to administrative expectations for daily IV site and dressing assessment and aseptic practice.
A resident with HTN and CHF, moderate cognitive impairment, and dependence for ADLs had physician orders for daily amlodipine and isosorbide mononitrate with specific BP and pulse hold parameters. MAR review over several months showed both antihypertensives were repeatedly administered when vital signs were outside the ordered parameters. The consultant pharmacist’s monthly medication regimen reviews did not identify or report these irregularities, despite facility expectations and written pharmacy service procedures that the consultant pharmacist oversee medication administration processes and report when medications are given contrary to physician‑ordered parameters.
A resident with HTN and CHF, moderate cognitive impairment, and dependence for ADLs had physician orders for daily isosorbide mononitrate and amlodipine with specific BP and pulse hold parameters. Over several months, MAR reviews showed both antihypertensives were repeatedly administered when BP and/or pulse readings were outside the ordered ranges, despite the care plan directing staff to follow medication orders and obtain and act on vital signs, and despite staff and consultant statements that medications should be held when parameters were not met. The facility’s policy required adherence to physician orders and notification of the DON and physician if orders could not be followed, but the documented medication administration did not align with these requirements.
Two residents receiving end-of-life and hospice-related care did not have hospice services fully integrated into their person-centered care plans. For one resident, the EMR contained only a hospice referral order without an admission order, and both residents’ care plans lacked the hospice provider’s contact information, a description of hospice services, and details on hospice-supplied medications, equipment, and supplies, as well as the frequency of hospice staff visits. A CNA reported relying on nurses to verbally identify hospice residents and visit days, while an LN stated that hospice plans of care were kept in separate hospice binders rather than incorporated into the EMR care plans. An administrative nurse confirmed that hospice information was not entered into the EMR until after the hospice episode ended, despite facility policy calling for an individualized, interdisciplinary plan based on comprehensive assessment and hospice appropriateness.
The facility failed to follow its policy for posting daily nurse staffing information by not including the actual hours worked by nursing staff on the publicly posted staffing sheets. On multiple observed occasions and in prior records, the sheets lacked required details about actual time worked for each category and type of nursing staff, despite the facility’s policy specifying that this information, along with census and staffing categories, must be recorded and posted. Administrative staff and a CMA responsible for staffing confirmed that the posted sheets did not contain the actual hours worked.
A resident's hydrocodone medication was misappropriated by an LPN, who removed a card of 45 tablets from the facility. The resident, dependent on staff for daily living and pain management due to paraplegia and lupus, was aware of the missing medication but reported receiving her pain relief as needed. The LPN confessed to taking the medication and attempted to replace it with fewer tablets, violating facility policy on medication management.
The facility failed to provide sanitary food preparation and storage, with issues such as unsealed and undated food items, expired orange juice, and improper hair restraint observed in the kitchen. The facility's food storage policy was not followed, and no policy for hair-restraint use was provided.
The facility failed to maintain and dispose of garbage and refuse properly, leading to medical waste littering the outside dumpster area and the dumpster lid being left open. Staff were unaware of their responsibilities regarding the cleanliness and closure of the dumpster area. The facility could not provide a policy on garbage and refuse handling and disposal.
The facility failed to ensure a safe environment for 11 confused and self-mobile residents by storing hazardous chemicals within reach and using a gait belt to secure a door in the open position, posing fire and safety hazards. Staff confirmed that these practices were against safety protocols.
The facility failed to ensure certified nursing staff had appropriate competencies, compromising resident safety and well-being. Issues included improper catheter care for a resident, delays in call light responses for two residents, and lack of Enhanced Barrier Precautions. These deficiencies placed residents at risk for infection and decreased quality of care.
The facility failed to ensure medications were securely stored, leading to a potential risk for accidental ingestion by confused and mobile residents. Specifically, two residents' rooms were found with unsecured medications, despite the lack of self-administration assessments or physician's orders. Staff confirmed that medications should not be stored in resident rooms without appropriate assessments and orders, highlighting a deficiency in the facility's adherence to its medication storage policy.
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature. Test trays from two satellite kitchens revealed that some foods were served below the required temperature and were unpalatable. The facility could not provide a policy related to food palatability and service temperatures.
The facility failed to provide a sanitary environment, proper PPE use, and appropriate catheter care, leading to potential cross-contamination and infection risks for residents with catheters, wounds, and PEG tubes. Staff were unaware of Enhanced Barrier Precautions requirements, and necessary PPE supplies were not readily available.
The facility failed to maintain the dignity of three residents: one was spoken to in a demeaning manner, another had an uncovered urinary catheter bag, and a third was exposed during incontinence care with open window blinds. These actions violated the facility's dignity policy.
A resident with multiple health issues, including rheumatoid arthritis and mobility problems, struggled to reach and use the call light due to its improper placement. Despite staff protocols to ensure call lights are within reach, the resident's needs were not accommodated, and no policy was provided to address reasonable accommodations.
The facility failed to track and resolve a grievance filed by a resident regarding a nurse's behavior. The resident, who was cognitively intact, reported that a nurse refused to clean a resident lying in their waste. Despite reporting this grievance, the facility did not follow up, document the grievance, or provide a written decision or summary of findings, contrary to their grievance policy.
The facility failed to develop comprehensive, individualized care plans for two residents, one requiring grab bars for bed mobility and another needing oxygen. The care plans lacked necessary documentation and guidance, placing the residents at risk for uncommunicated care needs and potential health complications.
The facility failed to decrease the risk of UTIs for two residents by not adhering to proper hand hygiene and Enhanced Barrier Precautions during catheter care. Observations revealed improper storage of catheter bags, failure to perform hand hygiene, and reuse of washcloths and wipes, which are against the facility's policies. Additionally, one resident did not have a securement device for the catheter tubing, despite the facility having the necessary supplies in stock.
The facility failed to properly clean and store nebulizer equipment for two residents and did not label oxygen tubing for another resident, leading to potential respiratory complications and infection risks. The facility's policies for respiratory equipment maintenance were not followed, as confirmed by staff interviews and observations.
The facility failed to assess a resident for safety and risk of entrapment from bed rail use and did not obtain informed documented consent prior to the installation of the siderails. The resident had diagnoses of generalized muscle weakness, reduced mobility, incomplete paraplegia, and muscle wasting with atrophy. Despite using grab bars for bed mobility, no prior safety assessment or informed consent was documented.
Improper Food Storage, Sanitation, and Hand Hygiene in Dietary Services
Penalty
Summary
The deficiency involves failure to properly label, seal, and store food items and to maintain clean food service areas in the main kitchen and satellite kitchenettes. During an initial tour of the main kitchen, surveyors observed multiple opened, undated, and unsealed dry goods in the dry storage area, including cream of wheat, macaroni noodles, rainbow sprinkles, and hamburger buns. In the walk-in refrigerator and kitchen serving area refrigerator, there were opened, undated, and unsealed items such as shredded cheese, fish, sliced cheese, an onion, lettuce, and chicken base. The kitchen freezer contained several opened, undated, and unsealed bags and boxes of frozen foods, including chicken strips, potato wedges, beef patties, chicken nuggets, and corn dogs, with some corn dogs showing frost buildup. The ice machine in the kitchen was not working and had visible rust at the hinges. In the dining kitchenette areas, surveyors observed trash present, clean towels stored directly on the floor of a cabinet, and multiple food and beverage items that were open, unlabeled, undated, or stored in dirty refrigerators. These included an open water bottle, an open bottle of soda, and undated food containers such as a green dessert and rice casserole, some with utensils left inside the food. The juice machines and ice/water dispensers in different dining areas had visible calcium buildup, juice splatter on surrounding surfaces, rust on drip racks, and black particles floating in ice. Cabinets, drawers, and areas under sinks and around trash compartments contained food crumbs, coffee grounds, dried spills, discoloration from leaks, peeling laminate with exposed wood, and black debris of unknown substance. On subsequent days, these areas remained visibly soiled and largely unchanged from prior observations, with additional trash noted. Surveyors also observed improper hand hygiene and glove use by dietary staff during food plating and service. A dietary aide in a kitchenette plated food while wearing the same pair of gloves to handle utensils, meal tickets, and bread, then removed gloves without performing hand hygiene, donned new gloves, and continued handling food and clean plates without washing hands. Another dietary staff member handled covered food containers, set them up on the steam table, removed gloves without hand hygiene, made a phone call, then resumed uncovering food and placing serving utensils without washing hands or wearing gloves, and later donned clean gloves and began serving food without prior hand hygiene. Additionally, a resident’s meal tray with oatmeal, eggs, bacon, and toast remained on a service table for an extended period, and when temperatures were checked, all items were below appropriate hot-holding temperatures before the tray was discarded. Staff interviews confirmed that dietary aides were responsible for cleaning kitchenettes and dining service stations and that there was no one assigned to clean on weekends, contributing to the observed unclean conditions, despite a facility policy requiring clean food storage areas and proper labeling and dating of stored foods.
Inadequate Infection Control for Catheter Care, Hand Hygiene, and Oxygen Tubing
Penalty
Summary
The deficiency involves failures in infection prevention and control practices related to hand hygiene, use of PPE under Enhanced Barrier Precautions (EBP), management of indwelling urinary catheters, and handling of respiratory equipment. One resident with an indwelling urinary catheter was on EBP, as indicated by a sign on the door and a PPE bin that contained no gowns. Surveyors observed the resident in bed with the catheter drainage bag attached to the bed, and later in the dining room with the catheter bag hanging outside the dignity bag and touching the floor. When the resident was assisted back to her room, the catheter bag continued to drag on the floor as the wheelchair was pushed. During morning care, a CNA placed the catheter bag on the floor while draining urine from the tubing into the bag, then temporarily hung the bag above the level of the bladder on the footboard before another CNA repositioned it below bladder level. Throughout peri-care, brief change, dressing, and use of a mechanical lift, the CNAs did not perform hand hygiene, did not change gloves after contact with soiled areas, and did not wear gowns despite the resident being on EBP and having an indwelling catheter. Another resident using oxygen had her oxygen tubing wrapped around the handle of her wheelchair while she was in bed with oxygen in use, and this condition persisted on subsequent observation. A CNA reported that when assisting residents with oxygen, she typically wound the tubing and laid it on a surface and was unaware of any bag or sanitary container for storing the tubing. Staff interviews revealed gaps in knowledge and practice expectations: one CNA stated she did not know gloves had to be changed and hand hygiene performed during care after touching something dirty, and she was unsure about gown use for a resident with a catheter. The licensed nurse and administrative nurse both stated their expectations that catheter bags remain below bladder level, never touch the floor, that staff perform hand hygiene and change gloves after contact with contaminated areas, and that oxygen tubing be kept in a bag when not in use, consistent with facility policies on catheter care and hand hygiene.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to inform a cognitively intact resident or her representative about the risks and benefits of multiple psychotropic medications, including an antianxiety, antidepressant, and antipsychotic. The resident’s EMR documented diagnoses of anxiety, depressive disorder, and drug-induced dyskinesia, and her MDS showed a BIMS score of 15, indicating intact cognition. The MDS and Psychotropic Drug Use CAA documented that she received high-risk psychotropic medications, including two antidepressants and an antianxiety medication, with identified risk factors such as falls and injuries related to falls. Her care plan documented use of an antidepressant for depression, an antianxiety medication for anxiety with a directive to educate the resident and family on risks, benefits, and side effects, and an antipsychotic medication. Physician’s orders showed active prescriptions for Lexapro 10 mg daily for depression, haloperidol 1 mg daily for dyskinesia, trazodone 75 mg at bedtime for dyskinesias, and Klonopin 0.5 mg twice daily for anxiety. However, the clinical record lacked evidence of informed consent for any of these medications. During interviews, a licensed nurse stated she was unaware of the policy when a resident received psychotropic medication. An administrative nurse reported that she or another nurse completed psychotropic evaluations and notified families when new psychotropic medications were prescribed, and that a PA typically documented psychiatric medication management, but the PA did not see this resident because she used an outside provider. The administrative nurse further stated that the facility did not obtain a psychotropic consent for this resident because the off-site provider would obtain it, and no psychotropic consent documentation was present in the facility record despite a policy addressing antipsychotic medication use.
Failure to Provide Written Transfer Notifications for Hospitalized Residents
Penalty
Summary
Surveyors found that the facility failed to provide required written notification of transfers for three residents who were sent to the hospital. One resident experienced vomiting of a reddish-brown substance and reported right shoulder pain; the nurse obtained provider orders to send the resident to the ER via EMS, but the electronic medical record contained no evidence that written notification of the transfer was provided to the resident or representative. A second resident was sent to the ER for evaluation and treatment based on a verbal provider order documented in the progress notes, yet the electronic medical record similarly lacked documentation that written notification of the transfer was given to the resident or representative. A third resident was documented as hallucinating and talking to people who were not present, and the resident’s daughter requested that the resident be taken to the hospital; the resident was transferred, but the electronic medical record again lacked evidence of written notification of the transfer to the resident or representative. During interviews, social services staff stated that a bed-hold notice was sent with residents upon transfer and that families were notified by phone, but acknowledged they were not aware that written notification of transfers to the hospital was required. Administrative staff also stated they had not heard of the written notification requirement for hospital transfers and inquired about the applicable regulation. The facility’s transfer or discharge policy indicated that facility-initiated discharges require resident or representative notification, orientation, and documentation.
Failure to Monitor and Treat Constipation per Bowel Protocol
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to monitor and respond to a resident’s lack of bowel movements in accordance with physician orders, the care plan, and the facility’s constipation management policy. The resident had diagnoses including anxiety, depressive disorder, and drug-induced dyskinesia, and MDS assessments showed intact cognition and that the resident was always continent of bowel without constipation. The care plan documented that the resident was on an antidepressant and directed staff to monitor for side effects, including constipation. Physician orders included following the facility’s bowel routine protocol and PRN orders for prune juice, Milk of Magnesia, and Fleet enemas for constipation. Review of the EMR task records showed that between 02/02/26 and 02/08/26, the resident went six consecutive days without a documented bowel movement or any constipation treatment or assessment. There were no progress notes documenting any assessment or intervention for constipation during this period, despite the facility’s constipation management policy directing that if no bowel movement occurred in three days, Milk of Magnesia should be given, followed by escalating interventions and provider notification if there were no results. Staff interviews confirmed that nurses were expected to monitor bowel movements, receive alerts when a resident went three days without a bowel movement, assess the resident, document the assessment, and follow the standing bowel protocol, which did not occur for this resident during the identified timeframe.
Failure to Provide Hearing Treatments and Maintain Hearing Devices
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary hearing treatments and maintain hearing devices for a resident with documented highly impaired hearing. The resident’s EHR showed a diagnosis of cognitive communication deficit and a need for assistance with personal care, while a recent MDS documented intact cognition, independence with footwear, and the need for varying levels of assistance with ADLs. The same MDS documented that the resident had highly impaired hearing. The resident’s care plan, including a revision dated 04/06/22 instructing staff to anticipate and meet the resident’s needs, lacked any interventions specifically addressing the resident’s impaired hearing as of 12/03/25. An audiology report dated 12/22/25 documented impacted cerumen, and the facility’s standing orders included Debrox ear drops and ear flushing for cerumen impaction. The resident’s EHR contained a standing order dated 12/23/25 for Debrox ear drops for wax buildup, and the December MAR showed Debrox was administered on multiple dates in December. However, there was no documentation in the progress notes that staff assessed the effectiveness of these Debrox treatments. The MARs for January and February lacked evidence of any Debrox treatments. During observation, the resident moved closer and tilted and turned his head when asked questions and reported difficulty hearing due to wax buildup. The resident also reported having hearing aids that did not work and that staff only cleaned them occasionally and not recently. A CNA stated she would check hearing aids and notify the nurse if they did not work, and an LN stated she would verify hearing aid function and notify the DON if there were issues, also stating the resident’s ears were cleaned regularly. An administrative nurse stated she expected daily verification that hearing aids were operational and that staff should notify leadership for repair or replacement and report hearing concerns to the provider. The facility’s policy on care of hearing-impaired residents required staff to assist with locating resources, scheduling appointments, arranging transportation, and assisting with care and maintenance of hearing devices, which was not reflected in the documented care and follow-through for this resident.
Failure to Maintain Clean, Intact Midline IV Dressing and Use Proper Aseptic Technique
Penalty
Summary
The deficiency involves the facility’s failure to provide IV care and services consistent with standards of practice for a resident with a midline IV catheter. The resident had diagnoses including UTI and hypertension and physician orders for daily IV ertapenem, heparin flushes, and twice-daily monitoring for signs and symptoms of infection, pain, redness, infiltration, bruising, embolism, phlebitis, fluid overload, and electrolyte imbalance. The care plan and physician orders directed that the midline dressing be changed on a set weekly schedule, but did not include any PRN order for dressing changes when soiled. Documentation in the MAR/TAR and progress notes showed staff recorded the ordered clinical monitoring but lacked evidence that staff assessed or documented the midline dressing’s cleanliness or integrity. During observation, the resident was noted in bed with a single-lumen midline IV in the right upper arm, and the dressing was undated with a large amount of dried blood collected under the dressing and seeping through the soft cloth border. The bottom seal of the dressing was loose, while the top was reinforced, and this condition remained unchanged on subsequent observation. There was no documentation that staff had assessed or addressed the soiled and loose dressing from the time it was first observed through later surveyor observations. When a nurse prepared to administer the resident’s IV antibiotic, she performed initial hand hygiene and donned gloves and a gown, but then placed her gloved hand into her pocket to retrieve supplies, wiped the IV hub with an alcohol wipe, allowed the hub to rest back on the resident’s arm, and continued to handle the IV line, touch her hair, and remove items from her pocket multiple times without changing gloves. She then connected the IV tubing to the hub while still wearing the same contaminated gloves. The nurse acknowledged the dressing was soiled and loose and that there was no date on it, and stated she believed a PRN order was needed to change a soiled dressing. Another nurse later confirmed the dressing was scheduled only for weekly changes, verified the presence of dried blood and the need for a change, and confirmed there was no PRN order. Administrative nursing staff stated their expectations that IV sites and dressings be assessed daily, that midline dressings be changed multiple times weekly and as needed, and that nurses document site and dressing condition during medication administration, but the facility’s written policy addressed only peripheral IV catheter and site selection and did not address care and monitoring of the site and dressing.
Consultant Pharmacist Failed to Identify and Report Antihypertensives Given Outside Hold Parameters
Penalty
Summary
The deficiency involves the facility’s failure to ensure the consultant pharmacist identified and reported repeated administration of antihypertensive medications outside of physician‑ordered hold parameters for one resident. The resident had diagnoses of hypertension and congestive heart failure, a BIMS score of 12 indicating moderately impaired cognition, dependence on staff for ADLs, and was receiving an anticoagulant and a diuretic. Her care plan directed staff to administer medications as ordered, obtain vital signs at least daily per physician orders and as needed, and notify the physician of abnormal readings. Physician orders for isosorbide mononitrate 30 mg daily and amlodipine 10 mg daily for hypertension included explicit parameters to hold the medications if pulse was less than 50 BPM or greater than 120 BPM, or if BP was less than 120/40 or greater than 200/90 mm/Hg. Review of the resident’s MARs showed that both antihypertensive medications were administered multiple times when vital signs were outside the ordered parameters over several consecutive months. In November, amlodipine and isosorbide mononitrate were each given outside parameters on 6 of 30 opportunities. In December, each medication was given outside parameters on 12 of 30 opportunities. In January, each was given outside parameters on 15 of 30 opportunities. In February, each was given outside parameters on 5 of 24 opportunities. Despite this pattern, the consultant pharmacist’s Medication Regimen Reviews from January 2025 to the present did not identify or report that these medications were being administered contrary to the physician‑ordered hold parameters. Interviews confirmed that facility staff and administration expected medications to be held when BP or pulse readings were outside the ordered parameters and expected the consultant pharmacist to report when medications were given outside those parameters. A consultant stated she interpreted the physician parameters as directions to hold the medications when readings were below or above the ordered numbers and would expect the consultant pharmacist to identify and report when medications were not held appropriately. A CMA and a licensed nurse described processes for checking BP and pulse and holding medications or notifying a nurse when readings were low. The administrative nurse stated she expected anyone administering medications to hold them when readings were outside parameters and expected the consultant pharmacist to report such occurrences. The facility’s Pharmacy Services Overview documented that the consultant pharmacist oversees development of procedures related to medication administration and staff roles and responsibilities, but the consultant pharmacist’s reviews did not address the repeated administration of antihypertensives outside the ordered parameters for this resident.
Failure to Follow Hold Parameters for Antihypertensive Medications
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered parameters for administering antihypertensive medications to one resident. The resident had diagnoses of hypertension and congestive heart failure, a BIMS score of 12 indicating moderately impaired cognition, dependence on staff for ADLs, and was receiving an anticoagulant and a diuretic. The care plan directed staff to administer medications as ordered, obtain vital signs at least daily per physician orders and as needed, and notify the physician of any abnormal readings. Physician orders for isosorbide mononitrate 30 mg daily and amlodipine 10 mg daily included explicit parameters to hold the medications if pulse was less than 50 BPM or greater than 120 BPM, or if BP was less than 120/40 or greater than 200/90 mm/Hg. Review of the resident’s MARs showed that both antihypertensive medications were administered multiple times when BP and/or pulse readings were outside the ordered parameters over several months. In November, each medication was given outside parameters on 6 of 30 opportunities; in December, on 12 of 30 opportunities; in January, on 15 of 30 opportunities; and in February, on 5 of 24 opportunities. Staff interviews revealed that the consultant pharmacist interpreted the parameters as directions to hold the medications when readings were outside the ordered ranges, a CMA reported she would retake low readings and notify the nurse and hold the medication if still low, and an LN and administrative nurse both stated that medications should be held when BP or pulse readings were outside the ordered parameters. The facility’s medication and treatment orders policy required that physician orders be followed and that the DON/designee and physician be notified if orders could not be followed, but the documented MARs showed repeated administration of the antihypertensives contrary to those parameters.
Failure to Integrate Hospice Services Into Resident Care Plans
Penalty
Summary
Surveyors identified a deficiency in the facility’s coordination and documentation of hospice services for two residents receiving end-of-life care. For one resident, the EMR contained a physician’s order for a hospice referral dated 01/06/26 but lacked an order to admit the resident to hospice services. The resident’s care plan, dated 01/07/26, included general directions to adjust ADLs, encourage participation, consult with physicians and Social Services for hospice care, and work cooperatively with the hospice team to meet the resident’s needs and provide maximum comfort. However, the care plan did not specify the hospice provider’s contact information, the services hospice would provide, the supplies, equipment, and medications hospice would furnish, or the frequency of hospice staff visits. During observation on 02/23/26, the resident was seen in a high-back wheelchair in his room with a soft-touch call light nearby and a fall mat folded and leaning against the wall. For the second resident, the EMR showed a physician’s order dated 10/15/25, and the care plan revised on 02/02/26 indicated the resident was on end-of-life support, with directions to participate in activities as tolerated, assist with ADLs such as ambulation and mobility, and keep the resident as comfortable as possible. This care plan also lacked specific directions regarding the hospice provider’s services, including what supplies, equipment, and medications hospice would provide and how often hospice staff would visit. A CNA reported that nurses typically informed aides which residents were on hospice and which days the hospice aide would provide showers, but could not identify what supplies and equipment hospice provided. An LN stated that each hospice resident had a separate hospice book containing the hospice plan of care, including medications, supplies, equipment, and visit schedules, and did not believe this information needed to be in the resident’s person-centered plan. The Administrative Nurse confirmed that she expected this information to be in the resident’s plan of care, acknowledged that hospice orders for one resident were likely only in the hospice binder, and stated that hospice information was not entered into the EMR until after the resident died or the hospice episode ended, despite facility policy requiring an interdisciplinary, individualized plan based on comprehensive assessment and hospice appropriateness.
Failure to Post Required Actual Nursing Hours on Daily Staffing Sheets
Penalty
Summary
The facility failed to ensure that posted daily nurse staffing sheets included accurate and identifiable information, specifically the actual hours worked by nursing staff. On two separate observations in February, surveyors noted that the posted staffing sheets did not list the actual hours worked. Additionally, review of historical daily staffing sheets from two prior dates showed the same omission of actual hours worked. The posted sheets were required to reflect detailed staffing information, including the actual time worked during each shift for each category and type of nursing staff. Administrative staff reported that a certified medication aide functioning as the staffing coordinator provided staffing numbers to the receptionist, who then printed and posted the daily staffing sheets in the lobby. The staffing coordinator confirmed that the actual hours worked were not included on the posted sheets, and administrative staff later verified that the posted daily staffing sheets did not contain the required actual hours worked for resident care medical staff. The facility’s own policy, dated July 2016, required that the posted form include the facility name, date, resident census, 24-hour shift schedule, shift, type and category of nursing staff, the actual time worked during the shift for each category and type of nursing staff, and the total number of licensed and non-licensed nursing staff for the posted shift, which was not followed.
Misappropriation of Resident's Pain Medication
Penalty
Summary
The facility failed to protect a resident from the misappropriation of medications, specifically hydrocodone, which is used for pain management. On a specified date, a Licensed Nurse removed a card containing 45 tablets of hydrocodone from the facility, which was intended for a resident diagnosed with paraplegia, lupus, and chronic back pain. The resident was dependent on staff for all activities of daily living and required opioid medication for pain relief. The resident was aware of the missing medication but reported receiving her pain medications as needed. The investigation revealed that a Licensed Nurse had worked on the unit during the time the medication went missing and later confessed to taking the card of hydrocodone. The nurse attempted to replace the missing medication with a new card containing fewer tablets. The facility's policy required immediate reporting of missing medications to initiate an investigation, which was not followed promptly. The incident placed the resident at risk for missed medication and uncontrolled pain.
Sanitary Food Preparation and Storage Deficiencies
Penalty
Summary
The facility failed to provide sanitary food preparation and storage of food, which could potentially lead to the spread of foodborne illness among residents. During an initial tour of the kitchen, several issues were observed, including a staff member with long hair not properly restrained, expired food items, and multiple instances of unsealed and undated food in both the refrigerator and freezer. Specifically, expired orange juice, unsealed hotdog buns, and various undated and unsealed food items such as potatoes, onions, mayonnaise, raw chicken, and assorted vegetables were found in different storage areas of the kitchen. Additionally, the facility's food storage policy was not adhered to, as it mandates that all foods should be labeled with the name and expiration date, and raw poultry should not be left uncovered or unsealed. The facility also failed to provide a policy for hair-restraint use in the kitchen areas when requested. These deficiencies were confirmed by Dietary Staff H, who acknowledged that all items in the refrigerators and freezers should be sealed and dated, and that all staff should have hair restraint devices on when in the kitchen areas.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain and dispose of garbage and refuse properly in a sanitary condition, which could prevent the harborage and feeding of pests. During an initial tour of the kitchen facilities, it was observed that the outside dumpster area was littered with medical waste, including soiled bandages and disposed gloves, and the dumpster lid was open. Dietary Staff H was unaware that kitchen staff were responsible for the cleanliness of the area around the dumpster or that the dumpster lid should remain closed. Administrative Nurse B stated that all staff taking trash to the dumpster should ensure the area is free of debris and the lid is closed. Housekeeping Supervisor J was also unaware of these requirements. The facility could not provide a policy related to garbage and refuse handling and disposal when requested. This deficiency had the potential to attract pests and posed an infection control concern.
Failure to Maintain a Safe Environment and Prevent Accident Hazards
Penalty
Summary
The facility failed to ensure the environment was free of accident hazards for 11 confused and self-mobile residents. Observations revealed that hazardous chemicals, such as an unidentified spray bottle, Fabuloso cleaning agent, and air-freshener, were stored in residents' rooms and bathrooms within reach. These chemicals had manufacturer labels indicating they should be kept out of reach of children. Additionally, a gait belt was used to secure a resident's door in the open position, which restricted door movement and posed a fire and safety hazard. Staff members, including a Licensed Nurse (LN) and Certified Nurse Aides (CNAs), confirmed that chemicals should not be stored in resident rooms and that door movement should not be restricted with any device due to safety concerns. The facility did not provide a policy related to the prevention of accident hazards when requested. The observations and interviews with staff indicated a failure to maintain a safe environment by keeping hazardous chemicals out of reach and improperly securing doors. This deficiency was identified through multiple observations over several days, highlighting a systemic issue in the facility's safety protocols and supervision of residents.
Deficiencies in Staff Competencies and Call Light Response Times
Penalty
Summary
The facility failed to ensure that certified nursing staff had the appropriate competencies and skill sets to provide nursing-related services, which compromised resident safety and well-being. For Resident 50, the staff did not follow proper catheter care procedures, including hand hygiene and the use of Enhanced Barrier Precautions. CNA C was observed not washing her hands before and after glove use and was unaware of the guidelines for proper catheter care and Enhanced Barrier Precautions. This placed Resident 50 at risk for infection and decreased quality of care. Resident 165 experienced delays in call light responses, with logs showing multiple instances where the call light remained unanswered for 15 to 30 minutes. This delay in response time was confirmed by both the resident and staff interviews. The facility failed to provide a policy regarding call lights, and the administrative nurse indicated that audits and investigations would be conducted if call light responses exceeded 10 minutes. However, the lack of timely response placed the resident at risk for decreased quality of care. Resident 25 also faced issues with catheter care. Staff failed to perform hand hygiene and did not use Enhanced Barrier Precautions during catheter care. Additionally, the resident did not have a securement device for the catheter, despite it being available in the facility's supply room. Both CNA D and LN M did not follow proper procedures for hand hygiene and catheter care, which was confirmed through interviews. This failure placed the resident at risk for infection and decreased quality of care. Similar issues were observed with Resident 11 and Resident 3, who also experienced delays in call light responses, further indicating a systemic issue with staff competencies and response times.
Failure to Secure Medications in Resident Rooms
Penalty
Summary
The facility failed to ensure that medications were securely stored, leading to a potential risk for accidental ingestion by confused and mobile residents. Specifically, Resident 25's room was found to have a bottle of generic antacid tablets on the bathroom counter, despite the resident not having a self-administration assessment or a physician's order for self-administration. The facility's policy prohibited medications in resident rooms unless these conditions were met, and staff confirmed the lack of necessary assessments and orders for Resident 25. Similarly, Resident 1's room was observed multiple times with various medications, including refresh eye drops, Ciclopirox drops, and Restasis drops, on the over-the-bed table. Like Resident 25, Resident 1 did not have a self-administration assessment or a physician's order for self-administration. Staff interviews confirmed that medications should not be stored in resident rooms without the appropriate assessments and orders, and the facility's policy lacked specific instructions related to self-administration of medications. The facility's failure to secure medications in the rooms of Residents 25 and 1 created a potential risk for accidental ingestion by confused and mobile residents. The observations and staff confirmations highlighted a deficiency in the facility's adherence to its medication storage policy, which required medications to be stored in a safe, secure, and orderly manner. The lack of self-administration assessments and physician's orders for these residents further underscored the facility's failure to provide a safe environment for its residents.
Failure to Provide Palatable and Safe Food
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature. During a survey, test trays were requested from two satellite kitchens. The noon meal tray from the west kitchen had all foods measured above the appropriate temperature of 135 degrees Fahrenheit, but the tater-tots tasted stale and freezer burnt. The meal tray from the east kitchen had tater-tots and popcorn shrimp measured below the required 135 degrees Fahrenheit, and both items were cool and unpalatable. Dietary staff confirmed that all hot foods should be served at a minimum of 135 degrees Fahrenheit. The facility was unable to provide a policy related to food palatability and food service temperatures when requested. This deficiency had the potential to lead to residents not eating appropriate portion sizes and causing foodborne illnesses due to improper serving temperature.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to provide a sanitary and safe environment to prevent cross-contamination and infection related to the appropriate use of personal protective equipment (PPE) and the safe and sanitary handling of glucometers. Licensed Nurse P did not perform hand hygiene before applying gloves, used a community glucometer without sanitizing it between residents, and failed to sanitize the medication cart and glucometer container. This led to potential cross-contamination and infection risks for multiple residents, including those with catheters, wounds, and percutaneous enteral gastrostomy tubes (PEG). Additionally, the facility did not have Enhanced Barrier Precautions (EBP) in place for residents requiring them, and staff were not aware of the need for EBP until after the surveyor's observation. The facility also failed to provide appropriate catheter care and hand hygiene for residents with urinary catheters. Certified Nurse Aide (CNA) C did not wash her hands before applying gloves and did not use a gown while providing catheter care. CNA C placed soiled wipes on top of clean wipes and did not wash her hands after removing gloves. Similarly, Licensed Nurse (LN) AA did not perform hand hygiene when changing gloves and used improper infection control techniques while providing catheter care. These actions increased the risk of urinary tract infections and other complications for residents with catheters. Furthermore, the facility did not implement Enhanced Barrier Precautions for residents with catheters, wounds, and PEG tubes until after the surveyor's observation. Staff were not aware of the need for EBP, and PPE supplies such as gowns and signage were not readily available. This lack of implementation and awareness among staff further contributed to the risk of cross-contamination and infection for residents requiring enhanced precautions during care activities.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of Resident 20 when a nurse spoke to her in a demeaning manner, stating 'That's not my job' when the resident was lying in her waste. Despite the resident reporting this grievance during a Resident Council Meeting, the facility did not document the complaint in the Grievance Log or follow up with the resident regarding an action plan to address the concern. The facility's dignity policy mandates that all residents be treated with respect and that their privacy be maintained during personal care, which was not upheld in this instance. Resident 50, who had a diagnosis of urinary retention and required an indwelling catheter, was observed without a privacy bag for the catheter collection bag on multiple occasions. This oversight was noted by both a Certified Nurse Aide and a Licensed Nurse, who confirmed that all residents with catheter bags should have a privacy bag to protect their dignity. The facility's policy explicitly states that urinary catheter bags should be covered to maintain resident dignity, which was not adhered to in this case. Resident 25, who had diagnoses including generalized muscle weakness and incomplete paraplegia, was subjected to incontinence and catheter care with the window blinds open, exposing her lower abdomen and genitals to a courtyard visible from the main entrance of the building. Both the Certified Nurse Aide and Licensed Nurse involved in the care confirmed that the window blinds should have been closed to protect the resident's privacy. The facility's dignity policy requires that residents' privacy be protected during personal care, which was not followed, leading to the resident feeling a negative psychosocial impact on her dignity.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light remained within reach, which is a deficiency in accommodating the resident's needs. The resident, who had diagnoses including diabetes mellitus type 2, generalized weakness, aphasia following a stroke, and rheumatoid arthritis, required substantial assistance for all activities of daily living except eating. Despite having intact cognition, the resident had difficulty grasping and pressing the call light due to deformities in his fingers and mobility issues with his left shoulder and arm. On multiple occasions, the resident was observed struggling to reach and use the call light, which was tied to the left upper grab bar on the bed, making it difficult for him to access it without repositioning himself in an unnatural and potentially harmful manner. Interviews with staff, including CNAs and a licensed nurse, confirmed that call lights should be placed within easy reach of residents, especially those with mobility problems. The staff acknowledged that they should notify the nurse on duty if a resident had difficulty using the call light so that appropriate adjustments could be made. Despite these protocols, the resident's need for an easier way to alert staff for assistance was not addressed, and the facility failed to provide a policy related to reasonable accommodations of individual needs when requested. This oversight resulted in the resident not receiving the appropriate call light equipment to accommodate his individual needs.
Failure to Track and Resolve Resident Grievance
Penalty
Summary
The facility failed to track grievances through to their conclusions and provide prompt efforts to resolve a grievance filed by a resident regarding the behavior of staff. Resident 20, who had a history of cognitive communication deficit, cerebral vascular accident, traumatic brain injury, repeated falls, and fractures, reported a grievance about a nurse's behavior. The resident, who was cognitively intact with a BIMS score of 13, expressed concerns about a nurse's refusal to clean a resident lying in their waste, stating, 'That is not my job.' Despite reporting this grievance in a Resident Council Meeting, the facility did not follow up with the resident or document the grievance in the Grievance Log. The Social Service Worker responsible for tracking grievances was unaware of Resident 20's complaint, and the Grievance Log lacked documentation of the concern. Administrative staff confirmed that the grievance was reported but not followed up on, and the facility did not provide a written grievance decision or a summary of the findings to the resident. The facility's policy on grievances, which requires prompt investigation and resolution, was not adhered to in this case. The facility's failure to track and resolve the grievance, provide written decisions, and offer a summary of the findings or corrective actions taken, highlights a significant deficiency in handling resident grievances. This lapse in procedure left Resident 20's concerns unaddressed and undocumented, contrary to the facility's stated grievance policy.
Deficient Care Plans for Bed Mobility and Oxygen Use
Penalty
Summary
The facility failed to develop a comprehensive, individualized person-centered care plan for two residents, leading to uncommunicated care needs. Resident 25, who had diagnoses including generalized muscle weakness, reduced mobility, and incomplete paraplegia, required the use of grab bars for bed mobility. Despite this need, the care plan, physician's orders, and electronic health records lacked documentation related to grab bar use. Interviews with staff confirmed that interventions performed by staff should be included in the care plan, but this was not done for Resident 25, placing the resident at risk for uncommunicated care needs. Resident 27, who had diagnoses of heart failure and chronic respiratory failure, required oxygen as part of her care. The care plan for Resident 27 did not address the use of oxygen or provide guidance on maintaining oxygen equipment to prevent infection. Observations revealed that the oxygen equipment, including tubing, cannula, and humidifier bottle, was not labeled with dates indicating when they were placed into service. Staff interviews confirmed that the care plan should provide guidance on the care and treatment of oxygen equipment, but this was not done for Resident 27, leading to potential risks of cross-contamination and infection. The facility's policy on comprehensive person-centered care plans stated that the care plan should describe the services to be furnished, including any specialized services. However, the facility failed to adhere to this policy for both residents, resulting in deficiencies in their care plans. This lack of documentation and guidance placed the residents at risk for uncommunicated care needs and potential health complications.
Failure to Adhere to Hand Hygiene and Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to provide necessary services to decrease the risk of urinary tract infections (UTIs) for two residents, R1 and R25, by not adhering to proper hand hygiene and Enhanced Barrier Precautions (EBP) during catheter care. For R1, observations revealed that the catheter bag was improperly stored on the floor and the catheter tubing contained dark amber urine with sediment. Licensed Nurse (LN) AA did not perform hand hygiene when changing gloves and used improper infection control techniques during catheter care, which was confirmed by the nurse during an interview. The facility's policy required aseptic techniques and proper hand hygiene, which were not followed in this case, increasing the risk of UTIs for R1. For R25, the facility also failed to adhere to proper hand hygiene and EBP during catheter care. Observations showed that LN M and Certified Nursing Aide (CNA) D did not perform hand hygiene when changing gloves and reused washcloths for multiple swipes, which is against the facility's policy. Additionally, R25 did not have a securement device for the catheter tubing, despite having a documented history of adverse reactions to adhesive devices. The facility's supply room had leg securement straps in stock, but they were not used for R25, as confirmed by staff interviews. This failure to follow proper procedures and provide necessary equipment increased the risk of UTIs for R25. Interviews with staff, including Administrative Nurse B, confirmed that the facility's policies for catheter care and EBP were not followed. The staff admitted to not using proper hand hygiene and reusing wipes and washcloths, which are infection control concerns. The facility's failure to adhere to its own policies and procedures for catheter care and EBP led to an increased risk of UTIs for both R1 and R25.
Deficiencies in Respiratory Care Practices
Penalty
Summary
The facility failed to properly clean and store nebulizer equipment for two residents, R28 and R11, and did not place a date label on the oxygen tubing for R27. For R28, the nebulizer was observed with an unknown clear liquid in the chamber, and the care plan lacked guidance related to the care of the nebulizer equipment. The facility's policy required nebulizer equipment to be rinsed, dried, and stored in a plastic bag, but this was not followed. Similarly, R11's nebulizer was found intact on a windowsill, and the care plan also lacked instructions for the care of the nebulizer equipment. The facility's policy for nebulizer care was not adhered to, as confirmed by staff interviews and observations. For R27, the facility failed to label the oxygen tubing, cannula, and humidifier bottle with the date of placement, which is necessary to ensure routine changes and prevent infection. The resident's room had an undated container of distilled water on the bedside commode, which should have been stored elsewhere to prevent cross-contamination. Staff interviews confirmed that oxygen equipment should be labeled and changed weekly, but this protocol was not followed. The facility lacked a policy to address the maintenance of oxygen equipment to prevent the spread of infection. These deficiencies in respiratory care practices placed the residents at risk of respiratory complications and potential infection. The facility's failure to adhere to its own policies and professional standards of care for respiratory equipment maintenance was evident in the observations and staff interviews documented in the report.
Failure to Assess Bed Rail Safety and Obtain Informed Consent
Penalty
Summary
The facility failed to assess Resident 25 for safety and risk of entrapment from bed rail use and did not obtain informed documented consent from the resident or resident representative prior to the installation of the siderails. Resident 25 had diagnoses of generalized muscle weakness, reduced mobility, incomplete paraplegia, and muscle wasting with atrophy. Despite having intact cognition and being dependent on staff for most cares, the resident's records, including the Minimum Data Set (MDS) and Care Area Assessments (CAA), lacked documentation related to grab bar use. Additionally, the physician's orders and Electronic Health Records (EHR) did not include a safety assessment for bed rail use. The resident revealed using grab bars for bed mobility and repositioning, but no prior safety assessment or informed consent was documented before the installation of the siderails. Interviews with staff confirmed the absence of a safety assessment and informed consent in the resident's records. A safety assessment and informed consent were only documented on 04/15/24, after the deficiency was identified. The facility's Bed Safety and Bed Rails policy required resident assessment for potential risks and informed consent about the benefits and hazards associated with bed rail use, which was not followed in this case. This failure placed Resident 25 at risk for uninformed decisions and potential injury due to bed rail use.
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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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