Center At Waterfront Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Wichita, Kansas.
- Location
- 1541 North Lindberg Circle, Wichita, Kansas 67206
- CMS Provider Number
- 175564
- Inspections on file
- 18
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Center At Waterfront Llc during CMS and state inspections, most recent first.
A cognitively impaired resident with moderate elopement risk left the facility unsupervised after staff failed to implement care plan interventions addressing elopement, and the incident was only discovered when the resident's representative was alerted by a community member. Staff interviews and records confirmed that the resident's risk was known but not addressed in the care plan prior to the event.
The facility failed to maintain sanitary conditions in food preparation areas, with issues such as food debris in the refrigerator, stained shelf covers, and deeply grooved cutting boards. Dietary staff confirmed these concerns needed attention, and the cleaning schedule was not being adequately followed.
The facility failed to maintain a sanitary kitchen environment, with food debris and dirt observed around the kitchen floor perimeter, beneath equipment, and in floor drains. Dietary staff acknowledged the need for cleaning, but the facility lacked a specific policy for kitchen floor cleaning.
The facility failed to notify the State Ombudsman of the transfer or discharge of four residents, including those with acute kidney failure, pancytopenia, peripheral vascular disease, and metabolic encephalopathy. Administrative staff were unaware of the requirement, and the facility lacked a policy for such notifications.
The facility failed to develop comprehensive assessments by not completing the Care Area Assessments (CAAs) for further investigation and development of the comprehensive care plan for seven residents. These residents had various medical conditions and required specific care plans that were not adequately addressed, leaving them without proper care plans to address their complex medical needs.
A resident with Parkinson's disease could not access the mirror in his bathroom to shave, leading to unshaven facial hair despite his preference to be clean-shaven. Staff interviews and observations confirmed that the resident required assistance with shaving, but the facility failed to provide reasonable accommodations to his physical environment, resulting in inadequate grooming care.
The facility failed to notify a resident with a Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of a Medicare covered Part A stay. The Social Service Designee responsible for completing the NOMNCs had quit six weeks prior, leading to the deficiency.
The facility failed to provide two residents and/or their representatives with a written notice specifying the duration and cost of the bed hold policy at the time of the residents' transfer to the hospital. Staff interviews revealed that bed holds were not completed for residents when they transferred to the hospital, and administrative staff were unaware of the need for such documentation.
The facility failed to develop baseline care plans within 48 hours of admission for three residents, including one with multiple diagnoses, one on antipsychotic medication, and one requiring dialysis. This led to deficiencies in their care, as confirmed by staff interviews and record reviews.
The facility failed to assist a resident with Parkinson's disease in shaving, despite his need for supervision and expressed preference to be clean-shaven. Observations and staff interviews confirmed that the resident had several days' growth of facial hair and had difficulty seeing the mirror to shave while seated in his wheelchair.
The facility failed to provide appropriate treatment for a resident with skin injuries and did not follow sanitary procedures during dressing changes. The resident, who had multiple diagnoses and was at risk for pressure ulcers, did not receive proper wound care, and the facility did not adhere to its policy for pressure ulcers. Observations revealed undated dressings, improper hand hygiene, and unsanitary bed linens, indicating significant deficiencies in treatment protocols and infection control.
A resident with a stage III pressure ulcer on the coccyx did not have the wound cleansed before a new dressing was applied. The resident was at high risk for pressure ulcers due to obesity, decreased mobility, and incontinence. Despite facility policies and staff expectations to cleanse wounds before dressing changes, the nurse did not follow this procedure, leading to a deficiency in care.
The facility failed to ensure proper communication with the dialysis facility for a resident with end-stage renal disease (ESRD). The baseline care plan lacked dialysis instructions, and the Dialysis Communication Form was incomplete, missing critical information. Staff confirmed that the form should be filled out and sent with the resident, but this protocol was not followed.
The facility failed to follow physician-ordered parameters for administering medications to two residents. One resident received Midodrine Hydrochloride outside the prescribed blood pressure parameters, and another resident did not receive the ordered sliding scale insulin for elevated blood glucose levels. These deficiencies were confirmed through interviews and record reviews.
The facility failed to monitor a resident for the use of antipsychotic medications. Despite the resident's diagnosis of dementia with psychotic disturbance and a policy requiring an AIMS assessment, no such assessment was completed when the medication was ordered. This oversight was confirmed by staff interviews and a review of the resident's medical record.
Failure to Provide Adequate Supervision and Elopement Interventions for Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with a history of weakness, insomnia, diabetes mellitus, and moderate cognitive impairment was admitted to the facility and identified as being at moderate risk for elopement based on multiple wandering risk assessments. The resident's care plan, however, did not include any interventions or instructions related to elopement risk prior to the incident, despite documentation of decreased safety awareness, impaired cognition, and a recent non-injury fall. The resident required staff supervision or assistance for ambulation and used a wheelchair for mobility. On the day of the incident, the resident left the second floor, traveled to the first floor, and exited the facility without staff knowledge. The facility became aware of the elopement only after the resident's representative, who had been contacted by a community member, called to alert staff that the resident was seen outside. Staff then conducted a search and located the resident outside the facility. The resident was found uninjured and returned to the building. At the time of the incident, the facility's care plan for the resident lacked any interventions addressing the known elopement risk, and staff had not provided adequate supervision to prevent the resident from leaving the premises. Interviews with facility staff confirmed that the resident was known to be at risk for elopement, and that observation rooms were used for residents requiring close monitoring. However, the care plan was not updated to reflect the resident's elopement risk until after the incident occurred. The facility's policy required individualized care plans for residents at risk of elopement and immediate response to door alarms, but these measures were not effectively implemented for this resident prior to the event.
Failure to Maintain Sanitary Conditions in Food Preparation Areas
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions, as observed during an initial tour of the kitchen. Specific issues included food debris on the bottom shelf of the reach-in refrigerator next to the coffee machine, a dark brown stain on a plastic shelf cover underneath the coffee and tea machine, and a build-up of food debris on shelves underneath the tray line and a worktable storing cereal boxes. Additionally, there was a large build-up of crumbs underneath the toaster, and four cutting boards were found to be deeply grooved. Dietary Staff BB confirmed these areas of concern needed attention. The Dietary Aide Daily Cleaning Schedule, which was undated, indicated that dietary aides were responsible for cleaning and sanitizing these areas every shift, but this was not being adequately performed.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff. During an initial tour and a follow-up visit to the kitchen, surveyors observed a large amount of food debris and ground-in dirt around the perimeter of the kitchen floor. Additionally, the floor beneath the steam table, cooks' line, and tray lines contained significant food debris. Three floor drains in the kitchen were also found to contain food debris and trash. Dietary staff confirmed these areas of concern needed attention. The facility's cleaning schedules indicated that floor drains should be cleaned on specific days and that cooks were responsible for sweeping and mopping the floors every shift. However, the facility lacked a policy related to the cleaning of kitchen floors.
Failure to Notify Ombudsman of Resident Transfers/Discharges
Penalty
Summary
The facility failed to notify the State Ombudsman of the transfer or discharge of four residents, as required by regulations. Resident 60, who had acute kidney failure, diabetes, and heart disease, was discharged to acute care without notification to the Ombudsman. Similarly, Resident 62, who had pancytopenia, fibromyalgia, and a malignant neoplasm of the breast, left the facility against medical advice without the required notification. Administrative Staff A confirmed the lack of notification and the absence of a policy for such notifications. Resident 18, who had peripheral vascular disease, osteomyelitis, and diabetes with a foot ulcer, was transferred to the hospital and returned without the Ombudsman being informed. Resident 44, diagnosed with metabolic encephalopathy and sepsis, was also transferred to an acute hospital without notification. Both Administrative Nurse D and Administrative Staff A were unaware of the requirement to inform the Ombudsman of hospital admissions. The facility lacked a policy for Ombudsman notification for resident discharges, leading to these deficiencies.
Failure to Complete Comprehensive Assessments and Care Plans
Penalty
Summary
The facility failed to develop comprehensive assessments by not completing the Care Area Assessments (CAAs) for further investigation and development of the comprehensive care plan for seven residents. These residents had various medical conditions and required specific care plans that were not adequately addressed. For instance, one resident with peripheral vascular disease, osteomyelitis, and diabetes mellitus with a foot ulcer did not have CAAs triggered for further investigation, despite requiring substantial assistance with daily activities and receiving multiple medications, including pain management and antibiotics. Observations confirmed the resident's need for a comprehensive care plan, which was not developed due to incomplete CAAs. Another resident with cellulitis and a skin tear, who was dependent on a wheelchair and required oxygen and CPAP at night, also did not have CAAs completed for further investigation. This resident had frequent pain and required specific wound care, which was documented but not followed up with a comprehensive care plan. The facility's failure to complete the CAAs left the resident without a proper care plan to address their complex medical needs. Additionally, a resident with acute and chronic respiratory failure and COPD, who required continuous oxygen therapy, did not have CAAs completed for further investigation. This resident exhibited shortness of breath and was on multiple medications, including antibiotics and antiplatelets. Despite these needs, the CAAs were not developed, leaving the resident without a comprehensive care plan. The facility's lack of a written policy for the completion of MDS or CAAs and reliance on the Resident Assessment Instrument (RAI) manual contributed to these deficiencies, as acknowledged by the administrative staff.
Failure to Provide Reasonable Accommodations for Resident's Grooming Needs
Penalty
Summary
The facility failed to provide reasonable accommodations to a resident with Parkinson's disease, who could not access the mirror in his bathroom to shave. The resident, who had normal cognitive function and required supervision or touching assistance for personal hygiene, was observed with unshaven facial hair on multiple occasions. Despite the resident's preference to be clean-shaven and his difficulty seeing the mirror due to its location, staff did not adequately assist him with shaving. Interviews with various staff members, including a licensed nurse and certified nurse aides, confirmed that the resident required assistance with shaving and had requested help, but the assistance provided was insufficient to meet his needs. The resident's care plan instructed staff to provide assistance with grooming, bathing, and personal hygiene, but the facility's failure to accommodate his physical environment prevented him from accessing the mirror. The facility's policy on ADL services required staff to provide assistance with ADLs every shift, including shaving, but this was not effectively implemented for the resident. The administrative nurse acknowledged that staff should provide grooming assistance per resident preferences, yet the resident continued to have several days' growth of facial hair, indicating a lapse in care and accommodation for his needs.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to notify one resident, R167, with a Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of a Medicare covered Part A stay. The deficiency was identified during a review of discharged Medicare A residents, where it was found that R167 did not receive the required NOMNC. Administrative Nurse D reported that the Social Service Designee (SSD), who was responsible for completing the NOMNCs, had quit about six weeks prior to the survey. The facility's policy, dated 06/20/23, mandates that the NOMNC must be delivered at least two calendar days before Medicare covered services end, and the beneficiary or their representative must sign and date the notice to acknowledge receipt and understanding of the termination decision. The failure to provide the NOMNC as required was a direct result of the SSD's departure and the facility's lack of a replacement to fulfill this responsibility.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
The facility failed to provide two residents and/or their representatives with a written notice specifying the duration and cost of the bed hold policy at the time of the residents' transfer to the hospital. Resident 44, who had a diagnosis of metabolic encephalopathy and was dependent on staff for assistance with ADLs, was transferred to an acute hospital with a diagnosis of sepsis. The resident's electronic medical record lacked a signed bed hold for this hospital admission. Interviews with Licensed Nurse I and Administrative Nurse D revealed that bed holds were not completed for residents when they transferred to the hospital. Administrative Staff A was unaware of the need for residents and/or their representatives to sign a bed hold when transferred to the hospital. The facility's policy, revised on 03/15/24, stated that notice of bed holds should be provided upon admission and at the time of transfer to the hospital, but this was not followed in the case of Resident 44. Similarly, Resident 18, who had an amputation on his left leg below the knee, was discharged to the hospital and returned four days later. The resident's electronic medical record also lacked evidence of written notification of the bed hold policy. Administrative Staff B reported that she should fill out a short online report about the bed hold and might talk to the family if available, but she did not get signatures for any bed holds. Administrative Nurse D confirmed that nurses did not complete bed holds for residents. Administrative Staff A was unaware of the bed holds not being completed and assumed that the facility would always have a bed available for returning residents. The facility's policy for bed holds was not adhered to in the case of Resident 18 as well.
Failure to Develop Baseline Care Plans
Penalty
Summary
The facility failed to develop baseline care plans for three residents within 48 hours of their admission, as required by their policy. Resident 20, who had diagnoses including aftercare for knee joint prosthesis extraction, diabetes, chronic kidney disease, and atrial fibrillation, was admitted to the facility but did not have a baseline care plan in place. This was confirmed by an interview with Administrative Nurse D. Similarly, Resident 221, who had Alzheimer's disease and was prescribed antipsychotic medication, did not have the use of this medication included in their care plan. Interviews with staff confirmed that antipsychotic medications should be included in care plans, but this was not done for Resident 221. Additionally, Resident 214, who had end-stage renal disease and required dialysis, did not have dialysis care instructions included in their baseline care plan. The resident's electronic medical record showed a physician's order for dialysis, but the baseline care plan lacked necessary details. A Dialysis Communication Form was also incomplete, missing critical information such as the resident's physician's name, contact person, and medication details. Interviews with staff confirmed that dialysis care should be included in care plans, but this was not done for Resident 214. The facility's failure to develop and implement baseline care plans within 48 hours of admission for these residents led to deficiencies in their care.
Failure to Assist Resident with Shaving
Penalty
Summary
The facility failed to provide necessary assistance with facial shaving to Resident 29, who has Parkinson's disease and requires supervision or touching assistance for personal hygiene. Despite the resident's normal cognitive function and expressed preference to be clean-shaven, observations revealed that he had several days' growth of facial hair. The resident stated he had difficulty seeing the mirror to shave due to its location in the bathroom, which he could not access while seated in his wheelchair. Interviews with staff, including a licensed nurse and certified nurse aides, confirmed that Resident 29 required assistance with shaving and had requested help. However, the facility did not ensure that this assistance was consistently provided, as evidenced by the resident's unshaven appearance over multiple days. The facility's policy on ADL services, which mandates assistance with grooming every shift as appropriate, was not followed in this case, leading to the deficiency in care for Resident 29.
Failure to Provide Appropriate and Sanitary Wound Care
Penalty
Summary
The facility failed to ensure that Resident 3 received appropriate treatment for an unidentified skin injury and sanitary dressing change. The resident, who had diagnoses including atrial fibrillation, lymphedema, and muscle weakness, was assessed with normal cognitive function and was dependent on staff for bed mobility. The resident had a skin tear, moisture-associated skin damage (MASD), and was at risk for pressure ulcers. Despite these conditions, the facility did not develop a Pressure Ulcer Care Area Assessment (CAA) and failed to follow the care plan instructions to monitor and assist the resident with turning and repositioning. Observations revealed that the resident's coccyx wound was not properly dressed, and the bed linens were not sanitary, which could contribute to the spread of infection. Additionally, the dressing on the resident's right posterior thigh was undated and contained serosanguineous drainage, indicating a lack of proper wound care documentation and treatment. On multiple occasions, the facility staff did not follow sanitary procedures during dressing changes. For instance, an administrative nurse did not sanitize her hands between glove changes while providing wound care. The resident's right thigh wound with drainage and an open area to the buttock were not properly assessed or treated until observed by surveyors. The facility's policy for pressure ulcers, which mandates treatment and care in accordance with professional standards, was not adhered to. Interviews with staff confirmed that the posterior thigh wound had not been assessed until the day of the survey, and the dressing should have been dated and documented. This failure to provide appropriate and sanitary wound care highlights significant deficiencies in the facility's treatment protocols and infection control practices.
Failure to Clean Pressure Ulcer Before Dressing Application
Penalty
Summary
The facility failed to appropriately clean the pressure ulcer (PU) of Resident 5 before applying a new dressing. Resident 5 had a stage III PU on his coccyx, which was documented to have yellow adherent slough over approximately 90% of the wound bed and a small amount of serosanguineous exudate. On 03/14/24, Administrative Nurse F changed the dressing without cleansing the wound, as the physician's order dated 02/06/24 did not include instructions for wound cleansing. This oversight was confirmed by Administrative Nurse F, who admitted to not seeking clarification of the order. The resident's medical record indicated that he was at high risk for PUs due to obesity, decreased mobility, and bowel and bladder incontinence. He was dependent on staff for all activities of daily living and had a pressure-relieving mattress and cushion. Despite these measures, the wound deteriorated, which Consultant GG attributed to the resident's overall decline in health rather than the lack of wound cleansing. However, the facility policy and other staff members, including Licensed Nurse H and Administrative Nurse D, stated that wounds should be cleansed with normal saline or wound cleanser before applying a new dressing, highlighting a failure to follow professional standards of practice.
Failure to Ensure Proper Communication for Dialysis Care
Penalty
Summary
The facility failed to ensure an appropriate system for ongoing communication with the dialysis facility regarding dialysis care and services for Resident 214, who had a diagnosis of end-stage renal disease (ESRD). The baseline care plan for the resident, dated 03/06/24, lacked staff instructions regarding dialysis. Additionally, a physician's order indicated that the resident would receive dialysis at a local dialysis center on Tuesdays and Saturdays, but the Dialysis Communication Form dated 03/12/24 was incomplete. The form lacked critical information such as the name of the resident's physician, the contact person at the facility, the facility phone number, face sheet, medication list, vital signs, medications received before dialysis, and medications sent with the resident to the dialysis center. No other Dialysis Communication Form was made available for review. Licensed Nurse I confirmed that a dialysis communication form needed to be sent with the resident each time he went to dialysis, with the appropriate sections filled out. Administrative Nurse D stated that it was the expectation for the staff to complete the pre-dialysis information on the form and send it with the resident to the dialysis center. The facility policy for Dialysis Protocol, dated 04/28/20, also required that the dialysis communication sheet be given to the dialysis center with the facility and resident information. The facility failed to adhere to these protocols, resulting in a lack of proper communication with the dialysis facility regarding the resident's care and services.
Failure to Follow Physician-Ordered Medication Parameters
Penalty
Summary
The facility failed to ensure staff followed physician-ordered parameters for administering medications to two residents, R29 and R18. For R29, who has Parkinson's disease and is at risk for fluid imbalance, the physician ordered Midodrine Hydrochloride to be administered three times a day for hypotension, with instructions to hold the medication if the standing systolic blood pressure exceeded 120 mmHg. However, staff administered the medication outside of these parameters on seven occasions, with blood pressure readings ranging from 122/87 to 166/88. This failure was confirmed by Administrative Nurse D during an interview on 03/18/24, who acknowledged that the staff did not adhere to the physician's instructions for holding the medication based on blood pressure readings. For R18, who has diagnoses including peripheral vascular disease, osteomyelitis, and insulin-dependent diabetes mellitus, the physician ordered a sliding scale insulin regimen to manage blood glucose levels. Despite this, staff failed to administer the ordered sliding scale insulin on multiple occasions when the resident's blood glucose levels were elevated, with readings ranging from 257 to 340. This was verified by Licensed Nurse K and Administrative Nurse D, who confirmed that the insulin was not administered as ordered and that there were no entries on the Treatment Administration Record (TAR) or nurse progress notes to indicate that the insulin had been given. The facility's failure to follow physician-ordered parameters for medication administration for both residents resulted in deficiencies in care. The facility's policy on physician orders, revised on 08/20/22, instructed staff to administer medications as per the written orders of licensed and authorized prescribers. However, the staff's non-compliance with these orders led to the identified deficiencies, as confirmed by the interviews and record reviews conducted during the survey.
Failure to Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to monitor Resident 35 for the use of antipsychotic medications. The resident, diagnosed with dementia with psychotic disturbance, had a BIMS score indicating moderately impaired cognition and was receiving Seroquel for forgetfulness and possible dementia. Despite the facility's policy requiring an AIMS assessment for residents on antipsychotic medications, no such assessment was completed for Resident 35 when the medication was ordered. This oversight was confirmed by both a Licensed Nurse and an Administrative Nurse during interviews. The facility's policy, revised recently, mandates that residents on antipsychotic medications be evaluated for tardive dyskinesia at least every three months and upon starting the medication in-house. However, the resident's electronic medical record lacked any documentation of an AIMS assessment. This failure to adhere to the policy resulted in inadequate monitoring of the resident's condition and the potential side effects of the antipsychotic medication.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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