Clearwater Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Clearwater, Kansas.
- Location
- 620 E Wood Street, Clearwater, Kansas 67026
- CMS Provider Number
- 175454
- Inspections on file
- 23
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Clearwater Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia and poor communication abilities, who was dependent on staff for hygiene, had a long-standing, well-maintained beard that was an important part of his identity. The care plan did not address his grooming or beard preferences, and staff shaved off his beard due to food in it without obtaining input from his representative. Family members later reported they did not recognize him without the beard and felt his dignity and identity were stripped. Staff interviews showed uncertainty about who should obtain and document resident grooming preferences at admission, and social services acknowledged a grievance had been filed about shaving the resident without contacting the representative, while administrative staff confirmed that such preferences should be incorporated into the care plan, particularly for residents with confusion.
A resident with dementia and severe cognitive impairment, known to wander and exhibit physical behavioral symptoms, repeatedly entered other residents’ rooms uninvited, sometimes wearing only a brief and not leaving when asked. Other residents reported having to tell the resident to leave, physically push the resident out in a wheelchair, keep a bed in a high position to prevent the resident from getting in, and waking to the resident touching a foot. Staff, including CNAs, LNs, a CMA, and Social Services, acknowledged the resident’s frequent wandering and described redirecting, offering snacks and fluids, and brief one-on-one engagement, but the resident remained constantly on the go and did not stay at activities. Despite a care plan and a dementia protocol calling for identification of support needs and adjustment of interventions, the facility failed to provide effective supervision and behavioral management to prevent ongoing intrusive wandering into other residents’ rooms.
A resident with MRSA, osteomyelitis, DM, renal failure, CHF, and sepsis-related wound infection was discharged on IV Daptomycin and Piperacillin-Tazobactam with specific dosing frequencies. After an ID clinic visit, new orders increased the frequency and extended the duration of both IV antibiotics, and staff were directed to use the revised regimen. However, the EMAR was never updated, and the resident continued to receive the original, less frequent dosing until hospitalization, with no physician notification of the discrepancy. An ID provider later documented that the corrected frequencies had not been given and also found the PICC dressing unchanged and the clave connector exposed, while facility policy required medications and treatments to follow safe and effective order writing principles.
A resident with a history of cerebral infarction was injured during transport in a facility van when a CMA failed to use the safety belt, instead using a gait belt to secure the resident's wheelchair. The resident slid forward out of the wheelchair onto the floor of the van after the CMA had to brake suddenly, resulting in multiple injuries. The CMA had been misinformed about the seatbelt's functionality and had not reported the issue to the administration.
The facility failed to protect residents from abuse, particularly resident-to-resident abuse, involving a resident with a history of aggressive behavior. This resident continued to hit others on multiple occasions, and the facility's care plan lacked specific interventions to prevent such altercations. Another resident exhibited aggressive and inappropriate sexual behaviors, which were not adequately addressed or reported. The facility's failure to follow its abuse investigation and reporting policies resulted in a deficiency that placed residents at risk for continued abuse.
The facility failed to report incidents of resident-to-resident abuse to the State Agency or law enforcement. A resident with a history of aggression physically assaulted two other residents, and another resident with a history of sexual behaviors and aggression was involved in two incidents of abuse. Despite staff notifying management, these incidents were not reported as required, placing residents in immediate jeopardy.
The facility failed to investigate and address multiple incidents of resident-to-resident abuse involving residents with aggressive behaviors and cognitive impairments. Despite having care plans, the facility did not implement effective interventions or report incidents as required, leading to continued altercations and placing residents at risk.
The facility failed to maintain safe hot water temperatures, with levels reaching hazardous degrees in resident rooms and a beauty shop, posing burn risks. Additionally, the facility did not adequately document or implement effective fall prevention measures for residents at high risk, leading to repeated falls and major injuries, including hip fractures, for two cognitively impaired residents.
The facility failed to implement necessary interventions to prevent pressure injuries for three residents, leading to the development of preventable, facility-acquired stage 3 pressure injuries. One resident with cognitive impairment and a history of femur fractures did not have appropriate interventions in place, resulting in pressure injuries on the buttocks. Another resident developed a stage 3 pressure ulcer on the heel due to a lack of preventive measures in the care plan. A third resident, admitted with an unstageable pressure ulcer, also developed stage 3 pressure injuries due to inadequate care planning and intervention.
The facility failed to provide a homelike environment due to inadequate room temperature control and compromised privacy. Residents were unable to control their room temperatures, with thermostats shared among multiple rooms. A resident's door was held open with a gait belt, affecting privacy. Maintenance staff confirmed these issues, and the facility lacked a policy for room temperatures.
The facility failed to provide adequate staffing, lacking 8-hour RN coverage for 29 days and 24-hour LN coverage for 127 days in 2023. Residents reported delays in staff response to call lights, with some waiting over 45 minutes for assistance. The survey team observed residents calling out for help and noted constant call light sounds without visual indicators. Direct care staff expressed concerns about low staffing levels. The deficiency resulted in multiple citations, including Immediate Jeopardy (IJ) and substandard quality of care.
The facility failed to maintain the required 8-hour RN coverage daily, as observed during a survey where residents reported staffing issues. The 2023 PBJ data showed multiple dates without RN coverage, especially on weekends, leading to citations for Immediate Jeopardy and substandard care. Observations revealed residents calling for help and staff being difficult to locate, with staff confirming low staffing concerns.
The facility failed to serve food that was palatable and at the appropriate temperature. A resident reported receiving cold meals, and a sample meal tray confirmed that vegetables were served below the required temperature. Both the survey team and Dietary Staff O found the vegetables unpalatable. The facility also lacked a policy for ensuring food palatability.
The facility failed to maintain sanitary conditions in food storage and preparation, risking foodborne illness. Issues included undated and uncovered food items in the main refrigerator and walk-in freezer. Dietary staff confirmed the need for proper labeling and covering of food items, but the facility lacked specific policies on these practices.
The facility failed to ensure the dumpster lid was closed at all times, as observed during a survey. Dietary staff were unaware of their responsibility to keep the lid closed, and the facility lacked a policy to enforce this requirement. Administrative Nurse B acknowledged the expectation for the lid to be closed, but no policy was in place.
The facility failed to effectively manage its resources, resulting in multiple deficiencies affecting resident care and well-being. Issues included inadequate QAPI implementation, improper handling of abuse allegations, failure to maintain a homelike environment, and insufficient care planning. Additionally, the facility did not manage medications properly, maintain sanitary conditions, or report accurate staffing data, compromising resident safety and care quality.
The facility failed to submit accurate RN staffing information to CMS, missing RN coverage documentation for eight hours every 24 hours on 29 dates in 2023. The PBJ report was found inaccurate, and the facility lacked a policy for accurate PBJ completion.
The facility was cited for multiple deficiencies, including five Immediate Jeopardy citations, affecting all residents. Issues included hazardous hot water temperatures, failure to prevent and report abuse, inadequate care planning, and insufficient staffing. The facility also failed to maintain a clean environment, provide necessary treatments, and accurately report staffing information to CMS.
The facility failed to maintain an effective infection control program, as observed in two instances. A laundry aide left a clean linen cart unattended with the cover raised, indicating a lack of adherence to infection control protocols. Additionally, a licensed nurse and two CNAs did not implement enhanced barrier precautions during wound care for a resident with a chronic wound, despite acknowledging the necessity of such precautions. These actions demonstrate a failure to follow the facility's infection prevention policies.
The facility failed to ensure dignity in resident dining by serving meals in Styrofoam containers to seven residents who chose to eat in their rooms due to a lack of sufficient plates, cups, and flatware. The Dietary Manager cited supply chain issues, and the Administrative Nurse was unaware of the regulatory requirement for non-disposable flatware. The facility could not provide a policy on disposable flatware use.
The facility failed to accurately complete the MDS for several residents, leading to uncommunicated care needs. A resident's CAA lacked documentation for hospice services and high-risk medications, while another's did not include insulin use or dialysis care. A third resident's CAA failed to reflect their fall risk, and another's MDS did not capture antidepressant medications. These oversights risked the residents' well-being.
The facility failed to develop comprehensive care plans for residents, including those with diabetes, pressure ulcers, and hospice needs. Care plans lacked critical interventions for insulin use, dialysis, wound care, and end-of-life care, despite existing physician orders and staff awareness. This deficiency could negatively impact residents' well-being.
A resident with severe cognitive impairment and dementia exhibited increased behaviors, including hitting another resident, leading to one-on-one supervision. The facility failed to notify the resident's Durable Power of Attorney (DPOA) about these changes, contrary to its policy requiring prompt notification of the resident's representative.
A facility failed to recognize a significant change in a resident's condition and did not perform a comprehensive MDS assessment within the required 14-day period. The resident, with a history of diabetes, dementia, and fractures, required substantial assistance for all cares. However, the facility did not document the necessary level of assistance in the EHR or progress notes. Administrative staff confirmed the oversight, acknowledging that the assessment should have been a Significant Change comprehensive assessment.
The facility failed to update fall care plans for three residents, leading to repeated falls without appropriate interventions. Despite being identified as high risk for falls, the care plans lacked updates for incidents, placing residents at risk for impaired well-being. The facility's policy required intervention updates, but this was not followed, resulting in a deficiency in care planning.
A resident with cognitive impairment and specific medical conditions was not provided timely assistance with facial hair removal, despite facility policies emphasizing person-centered care. Observations and staff interviews revealed that the resident, who preferred to be clean-shaven, had untrimmed facial hair over several days, indicating a failure in adhering to scheduled care routines.
A facility failed to coordinate care for a resident receiving hospice services, resulting in a lack of guidance in the care plan. Despite the resident's severe cognitive impairment and multiple diagnoses, staff were unclear about hospice roles, and administrative nurses were unaware of the need for care coordination. The facility also lacked a hospice care policy.
A resident requiring hemodialysis three times a week did not have a comprehensive care plan addressing dialysis care and catheter management. The resident experienced unreliable transportation to dialysis, leading to shortened sessions, and staff failed to consistently check the dialysis port or document post-dialysis care. Facility staff acknowledged the care plan's deficiencies, which lacked essential instructions for dialysis and insulin administration.
A resident with PTSD and a history of trauma did not receive adequate behavioral health care in a facility. The resident's care plan lacked necessary interventions, and staff were unaware of the resident's PTSD diagnosis and how to approach them properly. This deficiency in care placed the resident at risk for impaired quality of life.
A facility failed to follow up on pharmacy recommendations for a resident's lorazepam prescription, which lacked a 14-day end date requirement. The resident, with multiple diagnoses including anxiety disorder and major depressive disorder, was prescribed lorazepam for anxiety. Despite the consulting pharmacist's review noting the absence of a 14-day requirement, the facility did not obtain a timely physician response. Observations revealed the resident exhibited behaviors controlled with medication, but the facility lacked a policy for pharmacy reviews.
The facility failed to manage psychotropic medications properly for two residents. One resident received PRN lorazepam without adhering to the 14-day federal requirement, lacking new orders or rationale for extended use. Another resident did not receive quarterly AIMS assessments while on antipsychotic medications, despite severe cognitive impairment and multiple diagnoses. These deficiencies indicate non-compliance with federal regulations, potentially affecting residents' well-being.
Failure to Honor Grooming Preferences and Dignity for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide care in a respectful and dignified manner to a dependent, cognitively impaired resident when staff shaved off his beard without consideration of his preferences or those of his representative. The resident had diagnoses including dementia with psychotic disturbances and failure to thrive, and his Baseline Care Plan documented poor communication and comprehension but did not address his grooming or beard-maintenance preferences. Upon admission, he required total assistance with hygiene after a bowel movement, indicating dependence on staff for personal care decisions. Progress notes show that the resident’s family later contacted the facility to express that they were upset because staff had shaved off his beard. The family reported that his beard was part of his identity, was well cared for, and that they and his grandchildren did not initially recognize him without it. They stated that the resident, due to dementia, would not recognize himself in the mirror and that they felt he had been stripped of his dignity and identity. The family reported being told by staff that the beard was shaved because there was food in it and that staff claimed they had tried to call but had the wrong number. Interviews with staff revealed uncertainty and gaps in practice regarding obtaining and documenting resident preferences, particularly for residents with dementia. A CNA and a licensed nurse both stated they did not recall the resident and were unclear about who was responsible for obtaining preference information at admission, though they acknowledged that such information should be collected from residents or representatives. The social services staff member stated she did not ask about shaving preferences and did not know if consent was required to shave a resident with a full beard, but acknowledged that preference information for ADLs should be obtained and that a grievance had been filed about shaving the resident without contacting the representative. Administrative staff confirmed that residents’ and representatives’ histories and preferences should be incorporated into the care plan, especially for confused residents, and acknowledged awareness of the grievance about the beard being shaved without having responded to the reporter as of the survey date.
Failure to Adequately Supervise and Manage Intrusive Wandering in a Dementia Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, treatment, and services for a resident with dementia who exhibited intrusive wandering behaviors into other residents’ rooms. The resident had diagnoses of dementia, Alzheimer’s disease, hypertension, and unspecified protein-calorie malnutrition, with a Quarterly MDS documenting severe cognitive impairment, physical behavioral symptoms toward others, and frequent wandering. The resident’s care plan identified a potential for physical aggression related to dementia, triggers such as abrupt approaches, and interventions including redirection, distraction, offering snacks, and documenting behaviors and interventions. Despite this, the resident’s behavior log and care planning adjustments in response to ongoing intrusive wandering and room entries were not described, and the resident continued to enter other residents’ rooms uninvited and sometimes partially clothed. Multiple residents reported specific incidents of this resident entering their rooms and not leaving when asked. One resident reported that the wandering resident entered her room wearing only a diaper and had to be told to leave. Another resident stated that the wandering resident came into her room in a wheelchair, requiring her to get out of bed and physically push the resident out. A further resident reported keeping her bed in a high position so the wandering resident could not get into it, and another incident where she awoke to the resident touching her foot. Staff, including CNAs, LNs, a CMA, and Social Services, acknowledged that the resident wandered into other rooms and described efforts to redirect, offer snacks and fluids, and engage the resident in activities, but the resident did not consistently stay at activities and remained “on the go.” The facility’s dementia clinical protocol required the IDT to identify the resident’s level of support, review changing needs, and adjust interventions as needed, but the ongoing intrusive wandering and repeated room entries showed that the resident’s behaviors continued despite these general redirection efforts, leading to the cited deficiency in supervision and behavioral management.
Failure to Implement Revised IV Antibiotic Orders and Notify Physician of Medication Errors
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received IV antibiotics as ordered and to notify the physician of the resulting medication errors. The resident had multiple serious diagnoses, including wound infection, osteomyelitis, DM, renal failure, CHF, MRSA in a right heel wound, and sepsis likely due to a necrotic right heel wound with palpable bone and cellulitis. Hospital discharge instructions and an Infectious Disease (ID) Outpatient Antibiotic Order dated 02/17/26 initially directed Daptomycin 750 mg IV every 48 hours and Piperacillin-Tazobactam 4.5 g IV twice daily until 03/14/26, with further antibiotic orders to come from the ID clinic after the first appointment. At an ID clinic visit on 02/28/26, the provider issued a Final Report ID Outpatient Antibiotic Order, which changed the frequency and duration of both antibiotics: Daptomycin 750 mg IV every 24 hours until 03/17/26 and Piperacillin-Tazobactam 4.5 g IV every eight hours until 03/17/26. The facility was directed to use this new order. However, the resident’s EMAR for February and March 2026 continued to show the original orders—Daptomycin 750 mg IV every 48 hours and Piperacillin-Tazobactam 4.5 g IV twice daily—starting 02/18/26, and these orders were not discontinued until 03/05/26 after the resident went to the hospital. The orders were not updated to reflect the increased frequency specified by the ID provider. On 03/05/26, during a follow-up ID office visit, the provider documented that the resident had not received the corrected medication frequency for either antibiotic. The provider also noted that the PICC line dressing, which was to be changed weekly and as needed, was loose and had not been changed since 02/17/26, and that the PICC line clave connector had been exposed for an unknown amount of time. The physician was notified, the PICC line was removed, and the resident was sent to the hospital for worsening wounds and concern for blood infection. Subsequent observation on 03/23/26 showed a nurse administering IV medication via the PICC lumen, but the underlying deficiency centered on the facility’s failure to update and implement the revised ID antibiotic orders and to notify the physician of the medication errors.
Resident Injured Due to Improper Securing in Facility Van
Penalty
Summary
The facility failed to ensure a resident remained free from accidents during transportation in the facility van. A Certified Medication Aide (CMA) did not utilize the safety belt for the resident before transporting her in the van. The resident, who had a history of cerebral infarction and required assistance with mobility, was not secured properly in her wheelchair with the van's safety belt. Instead, the CMA used a gait belt to loop around the armrests of the wheelchair. During the transport, the CMA had to slam on the brakes to avoid an accident, causing the resident to slide forward out of her wheelchair onto the floor of the van, resulting in multiple injuries including skin tears and a laceration. The resident involved had been admitted to the facility with diagnoses including cerebral infarction, abnormality of gait and balance, lack of coordination, weakness, and unsteadiness of feet. She required partial to moderate assistance with transfers and ambulated independently with a cane and self-propelled with a walker. At the time of the incident, the resident was alert and oriented, but presented with left-sided weakness to her upper and lower extremities. The failure to secure the resident properly in the van led to her sustaining injuries during the transport. The CMA reported that she had been informed by another staff member that the seatbelt in the facility van was not functioning properly, and she had not been trained on its use. However, an inspection of the van revealed that the seatbelt was working as intended. The CMA did not report the alleged malfunction of the seatbelt to the administration, and the incident occurred when she entered a busy highway and had to brake suddenly. The lack of proper safety measures during the transport directly contributed to the resident's injuries.
Removal Plan
- The facility suspended CMA R. She was terminated.
- The facility suspended CNA M. She self-terminated.
- The facility van was immediately taken out of service until the van could be inspected.
- The facility van was inspected, and it was discovered that the passenger safety belt was not in despair but rather working as was intended.
- All staff members were trained in lock out/tag out for equipment that was out of order.
- All staff members were trained on when to report equipment that was not functional and how to use the work order system to alert the administration.
- Staff members who transported residents for passenger pick up were educated on van safety and asked to demonstrate how to use the safety equipment in the van.
- All staff were educated that passenger safety was the responsibility of both the driver and transportation companion.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident abuse, involving a resident with a history of aggressive behavior. This resident, identified as R22, had a history of hitting other residents and continued to do so on multiple occasions. Despite having severely impaired cognition and requiring assistance with daily activities, R22 was independent with ambulation and exhibited physical behavioral symptoms directed toward others. The facility's care plan for R22 lacked specific interventions to prevent resident-to-resident altercations, and staff failed to appropriately identify and respond to these incidents, placing residents in immediate jeopardy for continued abuse. Another resident, R16, also exhibited problematic behaviors, including physical aggression and inappropriate sexual conduct. R16 had a history of intermittent explosive disorder, bipolar disorder, and dementia, which contributed to his aggressive and inappropriate behaviors. Despite these known issues, the facility did not adequately address or report incidents involving R16, such as when he hit another resident or engaged in inappropriate sexual behavior in public areas. The facility's failure to report these incidents to the appropriate authorities and to implement effective interventions further contributed to the deficiency. The facility's policies for abuse investigation and reporting were not followed, as evidenced by the lack of documentation and reporting of incidents involving both R22 and R16. Staff interviews revealed a lack of awareness and appropriate response to the incidents, and the facility's internal investigations were insufficient. The facility's failure to ensure staff identified and responded appropriately to all allegations of abuse, including resident-to-resident abuse, resulted in a deficiency that placed residents at risk for continued abuse.
Removal Plan
- Staff in-serviced on the facility's Abuse Neglect and Exploitation policy and procedure and would be completed. Staff will not be allowed to work until signatures received.
- Inter-Disciplinary Team was in-serviced for ANE reporting.
- Staff placed R22 on a one on one and would remain a one on one until deemed no longer a threat or discharged from the facility.
- Referrals would be sent to Behavior Units for temporary placement.
- Hospice and Medical Director to complete a medication review.
- Quality Assurance Performance Improvement meeting.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure the timely reporting of alleged abuse to the State Agency or local law enforcement, as required. This deficiency was identified through observations, interviews, and record reviews, revealing that the facility did not report two incidents of resident-to-resident abuse involving a resident with a history of hitting others. On two separate occasions, this resident physically assaulted other residents, yet these incidents were not reported to the appropriate authorities, placing residents in immediate jeopardy for continued abuse. The first incident involved a resident with severely impaired cognition and a history of physical behavioral symptoms. This resident punched another resident in the jaw and later raised a fist to another resident, making contact with their face. Despite staff notifying management of these incidents, they were not reported to the state agency or law enforcement. The facility's policy required all allegations of abuse to be promptly reported and thoroughly investigated, but this was not adhered to in these cases. Another resident with a history of sexual behaviors and physical aggression was involved in two incidents of abuse. This resident hit an unknown resident after a minor altercation and later grabbed the breast of another resident. Again, these incidents were not reported to the state agency, as required by the facility's policy. The failure to report these incidents highlights a significant deficiency in the facility's handling of abuse allegations, leaving residents vulnerable to further harm.
Removal Plan
- Staff in-serviced on the facility's Abuse Neglect and Exploitation policy and procedure. Staff will not be allowed to work until signatures received.
- Inter-Disciplinary Team was in-serviced for ANE reporting.
- Staff placed R22 on a one-on-one and would remain a one-on-one until deemed no longer a threat or discharged from the facility.
- Referrals would be sent to Behavior Units for temporary placement.
- Hospice and Medical Director to complete a medication review.
- Quality Assurance Performance Improvement (QAPI) meeting.
Failure to Investigate and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate and address multiple incidents of resident-to-resident abuse, particularly involving a resident with a history of aggressive behavior. This resident, diagnosed with vascular dementia and major depressive disorder, exhibited severely impaired cognition and required significant assistance with daily activities. Despite these needs, the resident was involved in several altercations, including hitting other residents and causing physical harm. The facility's care plan for this resident lacked specific interventions to prevent such altercations, and there was insufficient documentation and investigation into these incidents. Another resident with a history of sexual behaviors and physical aggression also engaged in inappropriate conduct, including hitting another resident and making unwanted physical contact. The facility did not thoroughly investigate these incidents, allowing the behavior to continue. The care plan for this resident also lacked interventions to manage these behaviors effectively, and there was a failure to report these incidents to the appropriate authorities as required by the facility's policy. Interviews with staff revealed a lack of awareness and reporting of these incidents, indicating a breakdown in communication and adherence to the facility's abuse investigation and reporting policies. The facility's policy required all allegations of abuse to be promptly reported and thoroughly investigated, but this was not consistently followed, placing residents at risk of further harm.
Removal Plan
- Staff in-serviced on the facility's Abuse Neglect and Exploitation policy and procedure. Staff will not be allowed to work until signatures received.
- Inter-Disciplinary Team was in-serviced for ANE reporting.
- Staff placed R22 on a one on one and would remain a one on one until deemed no longer a threat or discharged from the facility.
- Referrals would be sent to Behavior Units for temporary placement.
- Hospice and Medical Director to complete a medication review.
- Quality Assurance Performance Improvement (QAPI) meeting.
Deficiencies in Hot Water Safety and Fall Prevention
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, specifically regarding hot water temperatures in resident rooms and a beauty shop. During an annual survey, it was observed that the hot water in four resident rooms and a beauty shop measured at hazardous levels ranging from 138 to 157 degrees Fahrenheit. This posed a significant risk of burns and injury to residents, particularly affecting six residents, two of whom were cognitively impaired and independently mobile. The facility's maintenance staff was unaware of the elevated temperatures, and it was discovered that a small hot water tank had been inadvertently adjusted to a higher setting, which had not been monitored for at least three months. Additionally, the facility failed to adequately document and implement effective interventions for fall prevention for residents at high risk of falls. One resident, identified as having severe cognitive impairment and a history of falls, experienced multiple falls resulting in major injuries, including fractures of both hips. The facility's fall reports lacked thorough investigations, identification of causal factors, and immediate or permanent interventions to prevent future falls. Despite being identified as high risk for falls, the resident continued to fall repeatedly without appropriate measures being taken to mitigate the risk. Another resident, also identified as having severe cognitive impairment and a high risk for falls, experienced multiple falls over a two-month period. The facility's care plan for this resident lacked corresponding interventions for each fall, and the fall assessments were incomplete or lacked necessary details. The facility's failure to provide necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for these residents resulted in a deficient practice for quality of life and placed the residents at risk for further injury and delayed healing.
Removal Plan
- Staff in-serviced on facility Physical Environment - Water Temps Policy and Procedure. Staff would not be allowed to work until signatures were received.
- The facility drained the hot water tank at the end of the 200 hall.
- The facility checked the temperature of all rooms after the tank was drained and all were below 120 degrees.
- The facility ordered a new temperature gauge for the hot water tank.
- The facility will check the water temperatures daily for rooms 209, 210, 211, 212, and then resume weekly temperature checks per policy.
- We will have a QAPI meeting to review.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to implement necessary interventions to prevent pressure injuries for three residents, leading to the development of preventable, facility-acquired stage 3 pressure injuries. Resident 30, who had a history of femur fractures, diabetes, and cognitive impairment, was identified as at risk for pressure injuries but did not have appropriate interventions such as pressure-reducing devices or a turning/repositioning program in place. Despite being identified at risk, the resident's care plan lacked updates and interventions to prevent pressure injuries, resulting in the development of stage 3 pressure injuries on the buttocks. Resident 3, who had intact cognition but required maximal assistance with activities of daily living, developed a stage 3 pressure ulcer on the right heel after admission to the facility. The care plan for this resident did not include documentation or interventions related to pressure ulcer prevention, despite the resident's risk factors such as incontinence and dependence on staff for transfers. The facility's failure to update the care plan and implement preventive measures contributed to the development of the pressure ulcer. Resident 26, who had intact cognition and was admitted with an unstageable pressure ulcer, was also at risk for pressure injuries. However, the care plan lacked documentation related to pressure ulcer prevention or interventions for wound healing. Despite being identified at risk, the resident's care plan was not updated to include necessary interventions, leading to the development of stage 3 pressure injuries on the buttocks. The facility's policy on pressure injuries lacked guidance on actual care, contributing to the deficiencies in care planning and intervention implementation.
Deficiency in Room Temperature Control and Privacy
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, specifically regarding room temperature control and privacy. During an environmental tour, it was observed that four residents had blankets over their vents, indicating an inability to control the temperature in their rooms. One resident reported that the thermostat controlling his room's temperature was located in a neighboring room, making it too warm for him. Additionally, a resident's room door was held open with a gait belt tied to the doorknob and a dresser drawer handle, compromising privacy. Maintenance staff confirmed that thermostats were shared among every third resident room, affecting multiple residents' ability to control their room temperatures. They acknowledged that this setup was not conducive to a homelike environment and confirmed the issue with the blocked door, which could prevent privacy. The facility lacked a policy for resident room temperatures, contributing to the deficiency in maintaining a comfortable and homelike environment for all residents.
Inadequate Staffing Leads to Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of its residents, as evidenced by the lack of 8-hour Registered Nurse (RN) coverage for 29 days and 24-hour Licensed Nurse (LN) coverage for 127 days in 2023. This deficiency affected all residents, as reported during the annual survey that began on May 28, 2024. Residents reported significant delays in staff response to call lights, with some waiting over 45 minutes for assistance. The survey team observed numerous instances of residents calling out for help and noted the constant sound of call lights in the hallways without visual indicators of which rooms were activated. Direct care staff also reported concerns about low staffing levels. The facility's reported PBJ data highlighted specific infraction dates for both RN and LN coverage, with a notable number of infractions occurring on weekends. The lack of staffing was directly linked to the number of citations found on the current recertification survey, including four Immediate Jeopardy (IJ) citations, harm, and substandard quality of care. During the survey, Administrative Nurse B acknowledged the staffing issues and reported that the working schedules were updated and reported to the state, although the surveyor did not have access to the current quarter's report at that time. The deficiency in staffing had the potential to negatively affect all residents, placing them at risk for decreased quality of life, treatment, and care.
Failure to Ensure 8-Hour RN Coverage
Penalty
Summary
The facility failed to ensure the required 8-hour Registered Nurse (RN) coverage each day, which is necessary to meet the needs of the residents. This deficiency was identified during an annual survey that began on May 28, 2024, where several residents reported issues related to a lack of staff. The facility's 2023 Payroll-Based Journal (PBJ) data revealed multiple dates across several months where the required RN coverage was not met, particularly on weekends. This lack of staffing was directly linked to the number of citations found during the current recertification survey, including five Immediate Jeopardy (IJ) citations, harm, and substandard quality of care. Observations during the recertification survey from May 28 to June 3, 2024, revealed numerous instances of residents calling out for assistance and the constant sound of call lights in the hallways, with no visual indication of which room was activated. Surveyors observed residents asking for help and waiting for staff assistance, with staff being difficult to locate as they were busy between rooms. Interviews with direct care staff confirmed concerns about low staffing levels. Administrative Nurse B reported that the working schedules were updated and reported to the state, but acknowledged that there was one day in May 2024 without the required 8-hour RN coverage.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at the appropriate temperature to its residents. During an interview, a resident reported that meals delivered to his room were consistently cold. A sample meal tray was requested by the survey team, and upon delivery, the vegetables on the tray were found to be at 122 degrees Fahrenheit, below the required serving temperature of 135 degrees Fahrenheit. The survey team and Dietary Staff O both tasted the vegetables and confirmed they were not palatable due to the inadequate temperature. Additionally, the facility lacked a policy for ensuring food palatability.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to maintain sanitary conditions in food preparation and storage, which could potentially lead to foodborne illness among residents. During an inspection of the kitchen, several issues were identified, including multiple opened containers of sour cream, salad dressings, and cheese-pimento salad in the main refrigerator that lacked open dates. Additionally, spoiled lettuce and a half-spoiled onion were found, both undated, along with an unidentified meat product without a label or date. Uncovered blocks of butter and cheese slices were also noted, as well as an uncovered box of uncooked cookies in the walk-in freezer, all lacking open dates. Dietary Staff O confirmed that opened items should be labeled with an open date and a use/discard by date, typically seven days for most foods and 30 days for salad dressings and other multi-use packages. It was also noted that items in the refrigerator and freezer should be covered to prevent spoilage. The facility did not provide a policy regarding the dating of foods or the storage of staff items in resident refrigerators. The only documentation provided was a Refrigerator & Freezer Storage Chart from the US FDA, which did not address the specific storage issues observed.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse by not ensuring the dumpster lid was always closed. During an observation on 05/28/24 at 08:20 AM, it was noted that the lid of the dumpster used for garbage and refuse was open. Dietary staff O was unaware that maintaining the dumpster lid in a closed position was part of the kitchen staff's responsibilities. On 06/06/24 at 01:50 PM, Administrative Nurse B acknowledged the expectation for the dumpster lid to be closed at all times and was aware of the regulatory requirement. However, the facility lacked a policy to ensure the dumpster lid remained closed.
Facility Administration and Resource Management Deficiencies
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, leading to multiple deficiencies that compromised the quality of care and well-being of its residents. The administration did not implement an effective Quality Assessment and Performance Improvement (QAPI) program, as evidenced by numerous deficient practices and substandard quality of care. Specific issues included the use of Styrofoam containers for meal trays, failure to inform a resident's representative about behavioral changes, and inability to maintain a clean, comfortable, and homelike environment due to lack of temperature control in residents' rooms. The facility also failed to address allegations of abuse appropriately, including resident-to-resident abuse, and did not report these incidents to the State Agency or local law enforcement as required. Investigations into these allegations were inadequate, and the facility did not provide sufficient supervision or care-planned interventions to prevent further incidents. Additionally, the facility did not recognize significant changes in residents' physical conditions, failing to perform timely Comprehensive Minimum Data Set (MDS) assessments, and did not develop comprehensive person-centered care plans for several residents. Further deficiencies included the failure to provide necessary care and services to prevent falls and pressure ulcers, inadequate coordination with hospice services, and improper medication management. The facility also did not maintain sanitary conditions in food preparation and disposal, failed to report accurate staffing information to CMS, and did not uphold effective infection control practices. These failures collectively placed residents at risk for decreased quality of care, treatment, and overall well-being.
Inaccurate RN Staffing Reporting to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) as required. Specifically, the facility did not accurately report Registered Nurse (RN) coverage for eight hours every 24 hours on 29 different dates between January 1, 2023, and September 30, 2023. This deficiency was identified through a review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal year quarters 2, 3, and 4 of 2023. The report revealed multiple instances where RN coverage was not documented as required, indicating a failure to meet the CMS specifications for staffing information submission. During an interview on June 3, 2024, Administrative Nurse B stated that the facility had an RN on duty on all days except for May 4, 2024, suggesting that the PBJ report was inaccurate. Additionally, the facility lacked a policy for the accurate completion of the PBJ report, contributing to the submission of incomplete and inaccurate staffing data. This oversight in reporting and policy implementation led to the deficiency noted by the surveyors.
Multiple Deficiencies and Immediate Jeopardy Citations in LTC Facility
Penalty
Summary
The facility was found to have multiple deficiencies during the current survey, including five Immediate Jeopardy citations, which indicated substandard quality of care. These deficiencies were not identified by the facility's Quality Assurance and Performance Improvement (QAPI) program, affecting all 43 residents. The surveyors discovered issues such as hazardous hot water temperatures, failure to prevent and report resident-to-resident abuse, and inadequate investigation and protection against further abuse. These findings were consistent with previous surveys, indicating a failure to maintain corrective measures in known areas of concern. The survey also revealed that the facility failed to treat residents with dignity and respect, as evidenced by the use of Styrofoam containers for meal trays and the lack of temperature control in residents' rooms. There were also failures in communication with residents' representatives regarding behavioral changes and the need for one-to-one observation. Additionally, the facility did not maintain a clean and homelike environment, and there were significant lapses in the reporting and investigation of abuse allegations. Further deficiencies included the failure to perform timely and accurate assessments, develop comprehensive care plans, and provide necessary treatments to prevent pressure ulcers and falls. The facility also lacked adequate staffing, with significant gaps in RN and LN coverage, and failed to follow up on pharmacy recommendations. Issues with food service, infection control, and accurate reporting of staffing information to CMS were also noted. Overall, the facility's administration failed to identify and address these quality deficiencies, placing residents at risk for decreased quality of care and well-being.
Infection Control Deficiencies in Laundry and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection control program due to two main deficiencies. Firstly, the laundry services did not adhere to proper infection control protocols. On one occasion, a laundry aide was observed pushing a laundry cart with the cover down, delivering laundry items to a resident's room, and leaving the cart unattended in the hallway with the cover raised. The aide was unsure if linen carts were required to be covered when unattended, indicating a lack of training or awareness of the facility's infection control policies. Secondly, the facility did not implement enhanced barrier precautions (EBP) during wound care for a resident with a chronic wound. A licensed nurse, assisted by two certified nurse aides, provided wound care without using the necessary EBP, which includes targeted gown and glove use during high-contact care activities. The nurse acknowledged that EBP should have been in place for residents with vectors of infection, such as chronic wounds. This oversight was confirmed by an administrative nurse, highlighting a failure to follow the facility's policy on infection prevention and control.
Failure to Ensure Dignity in Resident Dining
Penalty
Summary
The facility, with a census of 43 residents, failed to ensure dignity in resident dining by serving meals in Styrofoam containers to seven residents who chose to eat in their rooms. This was due to a lack of sufficient plates, cups, and flatware. Observations on May 30, 2024, revealed that dietary staff delivered meals in Styrofoam containers to each hall, and CNAs then delivered these trays to the residents. The Dietary Manager acknowledged the use of Styrofoam containers prior to her hire and cited an unknown supply chain issue with the supplier, which hindered the acquisition of adequate tableware and silverware for all residents. The Administrative Nurse stated that only residents under isolation precautions or those taking meals to-go should be served with disposable containers and flatware. However, she was unaware of the regulatory requirement for serving residents with non-disposable flatware and utensils. The facility was unable to provide a policy related to the use of disposable flatware and utensils when requested. This oversight resulted in a failure to uphold the dignity of residents during dining, as meals were served in disposable containers due to insufficient supplies.
Inaccurate MDS Completion Leads to Uncommunicated Care Needs
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for several residents, leading to uncommunicated care needs. For Resident 1, the Care Area Assessment (CAA) lacked documentation related to hospice services and psychotropic drug use, despite the resident being on hospice care and receiving high-risk medications. The administrative nurse admitted to not spending much time on the development of the CAA, which should have been used to generate the care plan process. This oversight placed the resident at risk for uncommunicated care needs. Resident 32's CAA did not include documentation related to insulin use or dialysis, despite the resident having diabetes mellitus type 2 and end-stage renal disease requiring dialysis. The care plan also lacked documentation related to the care of the resident's implanted dialysis catheter. The administrative nurse acknowledged that the CAAs lacked crucial information regarding the resident's condition, which could negatively impact the resident's well-being. Resident 30's CAA failed to accurately reflect the resident's status related to falls, despite the resident having a history of repeated falls and fractures. The care plan did not address the actual falls that occurred, and the facility's fall reports lacked documentation of injuries sustained during some falls. Additionally, Resident 39's MDS did not capture the resident's antidepressant medications, which were crucial for managing the resident's PTSD and dementia. The administrative nurse confirmed that the medications should have been documented on the MDS, highlighting a failure to communicate the resident's needs effectively.
Deficient Care Plans in LTC Facility
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for several residents, leading to potential negative impacts on their physical, mental, and psychosocial well-being. For instance, one resident with diagnoses of diabetes mellitus type 2, anemia, stage four chronic kidney disease, and end-stage renal disease did not have a care plan that included interventions related to insulin use or dialysis. Despite having physician's orders for dialysis and insulin administration, the care plan lacked documentation of these critical treatments, which were confirmed by administrative staff as needing to be added. Another resident with a diagnosis of diabetes mellitus type 2 and an unstageable pressure ulcer on admission did not have a care plan addressing pressure ulcer prevention or wound care. Although physician's orders were in place for wound treatment, the care plan did not reflect these interventions. Staff interviews revealed that the resident was non-compliant with turning and getting out of bed, which could exacerbate the pressure ulcer, yet these issues were not addressed in the care plan. Additionally, a resident receiving hospice care for cachexia did not have a care plan that included interventions related to hospice or end-of-life care. The resident's care plan was missing crucial information despite receiving multiple medications, including those with black box warnings. The facility's interdisciplinary team policy required comprehensive care plans within seven days of the MDS completion, but this was not adhered to, resulting in incomplete care plans for residents with complex medical needs.
Failure to Notify Resident's Representative of Behavioral Changes
Penalty
Summary
The facility failed to ensure the right of a resident's representative to be informed of changes in the resident's condition. The resident, who had a diagnosis of dementia with severe cognitive impairment, exhibited an increase in behaviors, including hitting another resident. As a result, the staff placed the resident on one-to-one observation. However, the facility did not notify the resident's Durable Power of Attorney (DPOA) about these behavioral changes or the implementation of one-on-one supervision. The facility's policy requires prompt notification of the resident's representative in the event of changes in the resident's medical or mental condition. Despite this policy, the resident's DPOA was not informed of the incident or the subsequent actions taken by the staff. Interviews with the facility's staff, including a Licensed Nurse and an Administrative Nurse, confirmed the expectation to notify the DPOA immediately in such situations, highlighting the facility's failure to adhere to its own notification policy.
Failure to Conduct Comprehensive MDS Assessment After Significant Change
Penalty
Summary
The facility failed to recognize a significant change in a resident's physical condition and did not perform a comprehensive Minimum Data Set (MDS) assessment within the required 14-day period. The resident, identified as R30, had a history of diabetes mellitus type 2, metabolic encephalopathy, dementia, repeated falls, and fractures in both femurs. The resident's condition required substantial or maximal assistance from staff for all cares, yet the facility did not document the level of assistance needed in the progress notes or the electronic health record (EHR) during the 14-day look-back period. The most recent comprehensive MDS assessment was dated several months prior, and the subsequent assessment failed to capture the significant change in the resident's care needs. The facility's failure to conduct a comprehensive MDS assessment following the resident's significant change in condition was confirmed by Administrative Nurse E, who acknowledged that the assessment should have been a Significant Change comprehensive assessment. Additionally, the facility's policy indicated reliance on the Resident Assessment Instrument (RAI) manual for MDS development, yet the necessary assessment was not completed. This oversight had the potential to lead to uncommunicated needs and placed the resident at risk of further deterioration in physical, mental, and psychosocial well-being.
Failure to Revise Fall Care Plans for Residents
Penalty
Summary
The facility failed to revise the fall care plans for three residents, placing them at risk for impaired physical and emotional well-being due to uncommunicated care needs. Resident 16 had a history of falls and was identified as a high risk for falls on multiple occasions. Despite this, the care plan lacked updated interventions for falls that occurred on specific dates. The facility's policy required staff to identify interventions based on evaluations and current data, but this was not followed, leading to repeated falls without appropriate care plan updates. Resident 30 also experienced multiple falls, some resulting in injuries such as fractures, yet the care plan was not revised to include updated interventions for these incidents. The resident was assessed as a high risk for falls, and the facility's fall reports documented several falls with varying degrees of injury. However, the care plan did not reflect these incidents, and the facility failed to implement necessary interventions to prevent further falls. Similarly, Resident 24 had multiple falls within a short period, but the care plan lacked corresponding interventions. The resident was identified as a high risk for falls, and the facility's policy required staff to monitor and document responses to interventions. Despite this, the care plan was not updated to address the falls, and the facility did not take appropriate action to prevent future incidents. The failure to revise care plans for these residents highlights a deficiency in the facility's care planning process.
Failure to Provide Timely ADL Assistance for Facial Hair Removal
Penalty
Summary
The facility failed to provide appropriate and timely assistance with Activities of Daily Living (ADLs) for a resident, specifically regarding the removal of facial hair. The resident, identified as R17, had diagnoses including acute and subacute infective endocarditis and dysphagia following a cerebral infarction. The resident's Admission Minimum Data Set (MDS) indicated moderately impaired cognitive function, requiring assistance with daily care. Despite the care plan indicating the need for assistance with ADLs to prevent complications, there was no specific guidance on the frequency of facial hair removal. Observations over several days revealed that the resident had untrimmed facial hair, which he reported was bothersome and had not been shaved for a long time. Interviews with staff, including CNAs and a Licensed Nurse, indicated that the resident was supposed to be shaved during showers, which were scheduled twice weekly. However, there was a lack of documentation in the electronic medical records for facial shaves in April and May 2024. The facility's policy emphasized person-centered care, prioritizing individual preferences and needs, yet the resident's preference for being clean-shaven was not met. The deficiency was identified as a failure to provide the necessary care for the resident's facial hair removal, as per his preference and the facility's policy.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards by not coordinating resident care with hospice services. A resident with severe cognitive impairment and multiple diagnoses, including chronic atrial fibrillation, anxiety disorder, and diabetes mellitus, was receiving hospice care due to cachexia. Despite being admitted to hospice services, the resident's care plan lacked documentation and guidance related to hospice care. Observations and interviews revealed that staff, including a CNA and a licensed nurse, were aware of the hospice services but did not have a clear understanding of the hospice staff's role or the need for coordination between nursing and hospice care. Further interviews with administrative nurses highlighted a lack of awareness regarding the inclusion of hospice services in the care plan and the necessity of coordinating care between nursing and hospice services. The care plans were found to be lacking crucial information about the resident's condition and the plan for care. Additionally, the facility was unable to provide a policy regarding hospice care when requested, indicating a systemic issue in ensuring coordinated care for residents receiving hospice services.
Failure to Develop Comprehensive Dialysis Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as R32, who required hemodialysis three times a week. Despite having a diagnosis of diabetes mellitus type 2, anemia, stage four chronic kidney disease, and end-stage renal disease, the resident's care plan lacked specific instructions and interventions related to dialysis care and the management of the resident's implanted dialysis catheter. The Care Area Assessment and Care Plan did not document necessary details about insulin use or dialysis, which are critical for the resident's care. Observations and interviews revealed several deficiencies in the care provided to R32. The resident reported that the transportation service to dialysis appointments was unreliable, leading to shortened dialysis sessions. Additionally, the facility staff did not consistently check the dialysis port or obtain vital signs after dialysis sessions. The Dialysis Communication sheets, intended to facilitate communication between the Dialysis Center and the facility, were often incomplete, indicating a lack of proper documentation and follow-up on dialysis care. Interviews with facility staff confirmed the lack of a comprehensive care plan for R32. Certified Nurse Aide J and Licensed Nurse H acknowledged the presence of an implanted dialysis port and the need for monitoring, but the care plan did not reflect these requirements. Administrative Nurse E and Administrative Nurse B admitted that the care plan was missing essential information related to dialysis and insulin administration, which should have been documented according to the facility's policy. This oversight had the potential to lead to uncommunicated needs and negatively impact the resident's well-being.
Failure to Provide Adequate Behavioral Health Care for Resident with PTSD
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a history of personal trauma and a diagnosis of post-traumatic stress disorder (PTSD). The resident, identified as R39, had diagnoses including metabolic encephalopathy, PTSD, and dementia adjustment disorder. The resident's electronic health record (EHR) and care plan lacked guidance and interventions related to the PTSD diagnosis, despite the resident's history of military-related trauma and behaviors that put others at risk. Observations and interviews revealed that staff were unaware of the resident's PTSD diagnosis and how to appropriately approach the resident to prevent agitation or triggers. The care plan did not include instructions to avoid approaching the resident from behind, a crucial intervention noted in the trauma assessment. Staff, including a licensed nurse and a certified nurse aide, were not informed about the resident's condition or the necessary approaches to care, indicating a lack of communication and training. The facility's policy for Trauma Informed Care, which was intended to guide staff in providing appropriate care for individuals with trauma, was not effectively implemented. The policy included education about trauma and PTSD, but staff were not adequately trained or informed about the resident's specific needs. This deficiency in care placed the resident at risk for impaired quality of life due to untreated and ongoing mental health concerns.
Failure to Follow Pharmacy Recommendations for Lorazepam Prescription
Penalty
Summary
The facility failed to follow up on pharmacy recommendations in a timely manner for a resident regarding the administration of lorazepam, a medication used for severe agitation. The resident's electronic medical record revealed multiple diagnoses, including chronic atrial fibrillation, anxiety disorder, violent behavior, major depressive disorder, intermittent explosive disorder, delusional disorder, and personality disorder. The resident was prescribed lorazepam 1 mg every six hours as needed for anxiety, with no specified end date. The consulting pharmacist's monthly medication review noted the absence of a 14-day requirement end date for the lorazepam prescription, but the electronic medical record lacked a timely physician response to this recommendation. Observations and interviews conducted during the survey revealed that the resident exhibited behaviors such as vocal abuse and yelling obscenities, which were usually controlled with medication. Despite these behaviors, the facility did not have a policy for pharmacy reviews, and the administrative nurse confirmed the untimeliness of the physician's response to the pharmacy's recommendations. The deficiency was identified as the facility's failure to obtain a new prescription for lorazepam every 14 days, as recommended by the pharmacy, to minimize or prevent adverse consequences related to medication therapy.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure proper management of psychotropic medications for two residents, leading to deficiencies in medication administration and monitoring. For Resident 1, the facility did not adhere to the 14-day federal regulatory requirement for PRN lorazepam orders, as the medication was prescribed without an end date. Despite the resident's severe cognitive impairment and history of anxiety and violent behavior, the facility did not obtain new orders every 14 days or provide a rationale for extended use. Observations revealed the resident exhibited no signs of anxiety or distress, yet staff reported behaviors controlled by medication, indicating a lack of non-pharmacological interventions. For Resident 24, the facility failed to conduct quarterly AIMS assessments while the resident was on antipsychotic medications. The resident, with severe cognitive impairment and multiple diagnoses including dementia and major depressive disorder, was on routine antipsychotic medication. Although the care plan included monitoring for side effects and effectiveness, the facility did not complete AIMS assessments quarterly as required, with the last documented assessments occurring sporadically over the previous year. These deficiencies highlight the facility's failure to comply with federal regulations regarding psychotropic medication management, potentially affecting the residents' physical, mental, and psychosocial well-being. The lack of a policy for PRN anti-anxiety medication and incomplete monitoring of antipsychotic medication use contributed to these deficiencies.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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