Bonner Springs Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bonner Springs, Kansas.
- Location
- 520 E Morse Street, Bonner Springs, Kansas 66012
- CMS Provider Number
- 175401
- Inspections on file
- 23
- Latest survey
- May 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Bonner Springs Nursing & Rehab Center during CMS and state inspections, most recent first.
A resident with multiple health conditions and high risk for pressure ulcers did not receive appropriate preventative interventions, such as pressure-relieving devices or a turning program, and developed a Stage 3 pressure ulcer on the heel. After the ulcer developed, the resident was not consistently provided with protective boots, and the Registered Dietitian was not notified to provide nutritional recommendations for wound healing. Staff interviews and observations confirmed gaps in care planning and implementation.
The facility did not submit accurate nurse staffing data through the PBJ system, with reports showing multiple dates without licensed nurse coverage despite payroll records and staff interviews confirming that a nurse was present at all times. Administrative staff managed scheduling, but PBJ submissions were handled by the corporate team, leading to discrepancies between actual staffing and reported data.
The facility did not maintain a QA&A Committee that met at least quarterly with all required members present, as only one meeting's attendance roster was available and key members, such as the Medical Director, were not consistently in attendance. This failure was identified through review of meeting records and staff interviews.
The facility did not implement the required antibiotic stewardship program, as evidenced by incomplete infection control surveillance logs that lacked organism identification, antibiotic duration, and infection details for multiple months. An administrative nurse identified that the previous infection preventionist had not completed the necessary monthly logs, resulting in a failure to monitor and trend antibiotic use as outlined in facility policy.
A resident with multiple comorbidities and high risk for pressure ulcers did not have a comprehensive care plan addressing skin breakdown prevention. The care plan lacked specific interventions, and staff did not consistently implement or communicate pressure ulcer prevention measures, resulting in the development and progression of a stage 3 pressure ulcer. Dietary staff were also unaware of the resident's wound, and no additional nutritional support was provided.
A resident with a history of stroke, hemiplegia, and anxiety continued to receive Seroquel, an antipsychotic, without an allowable diagnosis or documented clinical rationale, after the Consultant Pharmacist recommended physician review. The physician did not respond to the pharmacist's recommendation, and the facility did not ensure the required documentation or consideration of a gradual dose reduction, as outlined in facility policy.
Two residents received antihypertensive medications despite physician orders to hold these drugs when vital signs were outside specified parameters. Medication administration records and staff interviews confirmed that medications were given when heart rates or blood pressures were below the ordered thresholds, and staff did not consistently notify licensed nurses when this occurred. This failure to follow physician orders resulted in the administration of unnecessary medications.
A resident with multiple chronic conditions and severely impaired cognition was administered blood pressure medications by a CMA despite a heart rate below the physician-ordered threshold for holding the medication. The CMA was unaware of the heart rate parameter and did not notify a nurse, resulting in a medication administration error.
Two residents receiving hospice care did not have complete or coordinated care plans, as required by facility policy. The care plans lacked essential information such as hospice contact details, the scope of hospice services (including supplies, equipment, and medications), visit schedules, and clear communication processes between the facility and hospice provider. Nursing staff acknowledged these omissions, and the absence of this information placed the residents at risk of not receiving necessary care.
Two residents in a facility engaged in an altercation in the dining room, resulting in one resident throwing a ceramic mug and causing a broken nose to the other. The incident occurred due to inadequate supervision, as staff were either absent or distracted, failing to prevent the escalation. Both residents have histories of behavioral issues, and the facility's policies on monitoring and abuse prevention were not effectively followed.
The facility did not have a qualified director of food and nutrition services, risking residents' dietary and nutritional needs. Social Services X, without a Certified Dietary Manager (CDM) qualification, temporarily covered kitchen duties due to the absence of the full-time cook. Administrative Staff A and B were overseeing the kitchen while seeking a CDM. The facility's policy required a CDM-certified manager, but the position had been vacant for months.
The facility failed to provide sufficient staff with appropriate skills in the food and nutrition service, leading to unrecorded temperature logs and resident complaints about food quality and availability. Residents reported issues with overcooked and stale food, and the facility lacked a dedicated cook for the evening shift, relying on administrative and social services staff to cover kitchen duties.
Failure to Prevent and Manage Pressure Ulcer in High-Risk Resident
Penalty
Summary
A resident with multiple comorbidities, including schizophrenia, dementia, bipolar disorder, hypertension, acquired absence of toes, and peripheral vascular disease, was identified as being at high risk for pressure ulcers. Despite this, the resident did not have pressure-relieving devices for her bed or chair, was not on a turning or repositioning program, and her care plan lacked interventions to prevent skin breakdown. The Braden Scale assessments consistently documented a very high risk for developing pressure ulcers, and the Pressure Ulcer Care Area Assessment directed staff to observe and report any skin changes, but these preventative measures were not implemented. The resident developed a Stage 3 pressure ulcer on her right heel. Documentation showed that staff observed a fluid-filled blister, and a low-air-loss mattress was ordered after the ulcer developed. Physician orders were given for wound care and the use of heel protectors, but there was evidence that the resident was not consistently wearing the protective boots as required. Observations confirmed that the resident was found in bed and in the living room without the protective boots on, and staff interviews revealed a lack of awareness regarding the interventions in place before and after the ulcer developed. Additionally, after the development of the pressure ulcer, there was no documentation that the Registered Dietitian was notified or involved for nutritional recommendations to promote wound healing. The clinical record lacked evidence of a dietitian evaluation or recommendations during the period following the onset of the pressure ulcer. Dietary staff were unaware of the resident's skin breakdown, and the resident was not receiving any additional protein or supplements for wound healing. The facility's policy required routine preventative care, including proper positioning, use of pressure relief devices, and maintaining adequate nutrition, but these measures were not consistently implemented for this resident.
Failure to Accurately Report Nurse Staffing in PBJ Submissions
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. Review of PBJ reports for multiple fiscal quarters indicated that there were several dates recorded with no licensed nurse coverage. However, examination of the facility's licensed nurse payroll data for those dates showed that a licensed nurse was on duty 24 hours a day, seven days a week. Administrative staff confirmed that nurses were always scheduled for each 12-hour shift, including the use of agency staff when necessary. Interviews with administrative and nursing staff revealed that while scheduling was managed internally, the actual PBJ submission was handled by the corporate team. The facility's policy required accurate electronic reporting of staffing and census information, including agency and contract staff, to CMS. The failure to submit accurate PBJ data resulted in records that did not reflect the actual nurse staffing present in the facility.
QA&A Committee Lacked Required Quarterly Meetings and Attendance
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QA&A) Committee that met at least quarterly with the required members in attendance. During the survey, the facility was only able to provide an attendance roster for one meeting, and could not produce documentation for other required meetings. Administrative staff confirmed that while meetings were being held monthly, the Medical Director only attended quarterly, and there was no attendance sheet available for the most recent meeting. The facility's own QAPI policy indicated that the committee should meet monthly to review reports, evaluate data, and monitor QAPI-related activities, but the lack of documentation and inconsistent attendance by required members led to the deficiency.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement the core elements of antibiotic stewardship as part of its infection prevention and control program. Specifically, a review of the Infection Control Surveillance Log from January 2024 through March 2025 revealed missing documentation for several months, including the absence of organism identifications, duration of antibiotic prescriptions, and the specific infections treated for February, April, May, September, November, and December 2024. This lack of documentation meant that the facility was not adequately tracking or trending infections and antibiotic use as required by its own policies. An administrative nurse reported that upon assuming responsibility for the infection control program, she discovered that the previous infection preventionist had not been completing the monthly antibiotic stewardship surveillance logs. The facility's policies, dated October 2021, outlined the need for monitoring antibiotic use and conducting surveillance to identify infection trends and guide interventions. However, these procedures were not followed, resulting in incomplete records and a failure to ensure effective antibiotic stewardship for the residents.
Failure to Develop and Implement Comprehensive Pressure Ulcer Prevention Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan with specific interventions to prevent pressure ulcers for one resident. The resident had multiple diagnoses, including schizophrenia, dementia, bipolar disorder, hypertension, acquired absence of toes, and peripheral vascular disease, and was assessed as having severely impaired cognition and high risk for pressure ulcers. Despite these risk factors, the care plan did not include a care area or interventions for skin breakdown, and there was no turning or repositioning program in place. The resident required substantial assistance with activities of daily living and was dependent on staff for bed mobility and personal care. Clinical documentation showed that the resident developed a fluid-filled blister on the right heel, which progressed to an open, stage 3 pressure ulcer. Physician orders and wound clinic assessments directed the use of a low air-loss mattress, heel protectors, and specific wound care treatments. However, observations revealed that the resident was not consistently wearing protective boots while in bed, and staff were not always aware of or able to articulate the interventions in place to prevent or treat the pressure ulcer. Additionally, dietary staff were unaware of the resident's skin breakdown and no additional dietary interventions or supplements for wound healing were provided. Interviews with nursing and dietary staff confirmed gaps in communication and implementation of care interventions. The administrative nurse acknowledged the absence of a pressure ulcer care plan, and staff education on the importance of offloading and pressure relief was documented but not consistently followed. The facility's policy required the development of an individualized, comprehensive care plan within seven days of assessment, but this was not completed for the resident in question.
Failure to Ensure Physician Response to Pharmacist's Antipsychotic Medication Recommendation
Penalty
Summary
The facility failed to ensure that the attending physician responded to the Consultant Pharmacist's (CP) recommendation regarding the use of an antipsychotic medication for a resident. The CP identified that the resident was receiving Seroquel, an antipsychotic, without an allowable diagnosis to support its use and requested a clinical rationale from the physician. Despite this recommendation, the physician did not provide a response or documentation addressing the CP's concern. The resident's medical record showed ongoing administration of Seroquel for mood management, with no evidence of a gradual dose reduction being considered or implemented since admission. The resident involved had a history of cerebral infarction, hemiplegia, anxiety, and symptoms involving emotional state, but maintained intact cognition and independence in functional abilities. The care plan directed staff to administer medications as ordered and monitor for side effects and behaviors. The facility's policy required timely physician response to CP recommendations, including documentation of review and actions taken, but this process was not followed in this case, resulting in the continued use of an antipsychotic without appropriate clinical justification.
Failure to Hold Blood Pressure Medications per Physician Orders
Penalty
Summary
The facility failed to ensure that blood pressure medications were held according to physician-ordered parameters for two residents. For one resident with multiple diagnoses including traumatic brain injury, dementia, diabetes, and hypertension, physician orders specified that certain antihypertensive medications should be withheld if the systolic blood pressure or heart rate fell below set thresholds. Despite these orders, medication administration records showed that the resident received losartan, amlodipine, and Coreg on multiple occasions when the heart rate was below the specified parameters. Observation confirmed that a Certified Medication Aide administered these medications without recognizing the need to hold them due to a low heart rate. Another resident with diagnoses including heart failure, anxiety, and diabetes had a physician order for metoprolol to be held if the systolic blood pressure was below a certain level or if the pulse was under a set rate. Medication administration records indicated that this resident received metoprolol on several occasions when the systolic blood pressure was below the ordered threshold. Staff interviews revealed that Certified Medication Aides were expected to notify licensed nurses when vital signs were out of range, but this process was not consistently followed. The facility's own medication therapy policy required that medication regimens be consistent with physician orders and supported by appropriate care processes. However, the failure to adhere to physician-ordered parameters for holding medications resulted in the administration of unnecessary drugs, as defined by the facility's policy and federal regulations.
Medication Administration Error Due to Failure to Hold Antihypertensives for Low Heart Rate
Penalty
Summary
A resident with multiple diagnoses, including traumatic brain injury, dementia, depression, diabetes mellitus type two, and hypertension, was dependent on staff for all activities of daily living and received several daily medications, including diuretics, antidepressants, and insulin. The resident's care plan and physician's orders required staff to monitor blood pressure and heart rate, and to hold specific blood pressure medications if the systolic blood pressure was below 110 mmHg or the heart rate was below 60 or 65 beats per minute, depending on the medication. On the day of the incident, a Certified Medication Aide (CMA) measured the resident's heart rate at 55 beats per minute but proceeded to administer all prescribed blood pressure medications, failing to recognize that the heart rate was below the physician-ordered parameters for holding the medication. The CMA stated that they were only aware of the blood pressure parameter and not the heart rate requirement. The Licensed Nurse later confirmed that CMAs were expected to notify a nurse when vital signs were out of range, as some orders required physician notification. The administrative nurse also stated that staff were expected to follow physician orders and hold medications when vital signs were out of parameters. The facility did not provide a policy for medication errors when requested.
Failure to Coordinate and Document Hospice Services for Residents
Penalty
Summary
The facility failed to ensure proper communication and coordination between the hospice provider and facility staff for two residents receiving hospice services. For one resident with multiple diagnoses including epilepsy, bipolar disorder, depression, hypertension, atrial fibrillation, and morbid obesity, the care plan documented enrollment in hospice but lacked essential information such as the hospice contact number, details on supplies, equipment, and medications provided by hospice, as well as the schedule and nature of hospice staff visits. The care plan only directed staff to document advanced directive reviews and maintain these directives, without specifying the scope of hospice involvement or coordination. Another resident, diagnosed with hypertension, trigeminal neuralgia, and major depressive disorder, also experienced a lack of detailed hospice care planning. The care plan indicated hospice enrollment and directed staff to honor advance directives, but did not provide instructions regarding the services hospice would supply, the services the facility would continue to provide, or the process for communication and documentation between the facility and hospice provider. There were no directions for staff on when to notify hospice of significant changes in the resident's status, clinical complications, transfers, or death, nor was there information on the frequency or timing of hospice visits. Interviews with administrative nursing staff confirmed awareness of these omissions, acknowledging that care plans were incomplete and lacked required information about hospice services. The facility's own hospice policy required coordinated care plans and clear communication with hospice providers, but this was not reflected in the care plans reviewed for the two residents, placing them at risk of not receiving needed care.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident-to-resident abuse, resulting in an altercation between two residents in the dining room. Resident 1, who has a history of aggressive behavior and multiple mental health diagnoses, threw a ceramic mug at Resident 2, causing a broken nose. The incident occurred during a time when the dining room was unsupervised, as staff were either taking out trash or engaged in other tasks, leaving the residents without proper oversight. Resident 1's medical records indicate a history of dementia, mood disorders, and aggressive behavior, which required one-on-one monitoring and specific interventions to manage his behavior. Despite these documented needs, the facility's staff failed to maintain the necessary supervision, allowing the situation to escalate. Resident 2, who also has a history of being rowdy and mouthy, was involved in the altercation, which began with both residents throwing objects at each other. Interviews with staff revealed that there was a lack of adherence to the facility's policy requiring staff presence in the dining room during meals. Staff members were either absent or distracted, contributing to the failure to intervene before the altercation escalated. The facility's policies on abuse prevention and resident monitoring were not effectively implemented, leading to the incident and subsequent injury to Resident 2.
Lack of Qualified Food and Nutrition Services Director
Penalty
Summary
The facility failed to employ a director of food and nutrition services with the required qualifications, which placed residents at risk for unmet dietary and nutritional needs. The facility had a census of 31 residents and one main kitchen. Social Services X, who was not a Certified Dietary Manager (CDM), was temporarily covering the kitchen duties due to the absence of the full-time cook. Social Services X admitted to being unsure about the completion of food temperature logs and had an expired ServSafe certification. Administrative Staff B confirmed the absence of a CDM for a couple of months and stated that the administrator was also assisting in running the kitchen while they were in the process of hiring someone for the position. Administrative Staff A, who had been at the facility for about two and a half weeks, was actively seeking a CDM and had interviews scheduled. Both Administrative Staff A and B were splitting the responsibilities of overseeing the kitchen. The facility had a registered dietitian who visited once a month and was available as needed. The facility's policy required the food services manager to be CDM certified or enrolled in an accredited program, and in the absence of a manager, duties were to be assigned to other staff with input from the dietitian. However, the facility did not have a qualified director of food and nutrition services, leading to the deficiency.
Inadequate Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to provide sufficient support personnel to effectively carry out the functions of the food and nutrition service, which placed residents at risk for impaired nutrition and decreased quality of life. The facility, with a census of 31 residents, had one main kitchen but lacked adequate staffing. Observations and interviews revealed that the facility did not have enough staff with the appropriate skill sets, as evidenced by the absence of a cook on the evening shift and reliance on administrative staff and social services personnel to cover kitchen duties. This staffing shortage led to issues such as unrecorded refrigerator/freezer and food temperatures, which are critical for ensuring food safety. Residents expressed grievances about the quality and availability of food, indicating that the kitchen sometimes ran out of essential items like bread, sweeteners, and saltshakers. Complaints were also made about the food being overcooked, hard, or stale, making it difficult for some residents to eat. The Resident Council meeting minutes and individual resident interviews highlighted these concerns, with residents noting that the facility occasionally deviated from the posted menu and struggled to accommodate dietary preferences due to limited resources. Administrative staff acknowledged the staffing challenges, noting that the facility had only one full-time and one part-time cook for the day shift, with no dedicated cook for the evening shift. The facility's policy required a Certified Dietary Manager (CDM) or someone enrolled in an accredited CDM program to manage food services, but in the absence of such a manager, duties were assigned to other staff members with input from a dietitian. Despite efforts to follow recipes and maintain food safety standards, the lack of adequately trained and certified personnel contributed to the deficiency in food and nutrition services.
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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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