Colonial Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Overland Park, Kansas.
- Location
- 12500 W 137th St, Overland Park, Kansas 66221
- CMS Provider Number
- 175560
- Inspections on file
- 16
- Latest survey
- December 10, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Colonial Village during CMS and state inspections, most recent first.
A resident with a history of insomnia, progressive supranuclear palsy, dementia, and dysphagia experienced significant unplanned weight loss due to the facility's failure to implement adequate nutritional interventions. Despite being at risk for nutritional impairment, the resident's weight decreased from 163.8 lbs. to 150 lbs. over a few months. The facility did not involve the RD or provide necessary supplements in a timely manner, leading to continued weight loss and risk of malnourishment.
The facility did not complete the required yearly performance evaluation for a CNA hired in June 2023, as revealed by a review of performance evaluation records. Administrative Nurse D confirmed the absence of the evaluation, which is required by the facility's policy to identify employee strengths and training needs. This oversight placed residents at risk for inadequate care.
The facility failed to follow sanitary dietary standards for food storage, risking food-borne illnesses. An inspection revealed undated and unlabeled food items in the kitchen and kitchenettes, including milk, whipping cream, a spinach and beef sandwich, dessert pastries, and an expired Arginaid drink. Dietary staff confirmed that all opened food products should be labeled and dated, and personal or undated items should not be stored in the kitchenettes.
The facility failed to follow infection control standards related to hand hygiene and disinfecting shared equipment. Observations showed CNAs and an LN not performing hand hygiene between glove changes and not disinfecting equipment between resident uses. Staff interviews confirmed the expectations for hand hygiene and equipment disinfection, which were not met, placing residents at risk for infectious diseases.
A resident with cognitive impairment and multiple medical conditions was transferred to a hospital without the facility providing the required written notification of transfer to the resident or their representative. The facility's records lacked documentation of this notification, and staff confirmed the absence of the necessary paperwork.
A facility failed to provide a bed hold notice to a resident with dysphagia, cognitive-communication disorder, dementia, and acute kidney failure when transferred to a hospital. The resident's medical record lacked evidence of the notice, and administrative staff confirmed the requirement but could not locate it. This oversight placed the resident at risk for impaired right to return to the same room.
Two residents at risk for pressure ulcers had their low air-loss mattresses set at incorrect weights, with one resident's mattress set significantly higher than her actual weight. Staff did not adjust the settings, and the care plan lacked guidance on appropriate settings. Additionally, a resident's heel protectors were not used, and proper hand hygiene was not followed during wound care, increasing the risk of skin breakdown.
A facility failed to ensure a resident had a physician-ordered indication for an indwelling catheter and did not provide adequate catheter care. The resident, with muscle weakness and hypertension, had a Foley catheter without a documented indication. During care, CNAs did not perform hand hygiene between glove changes, violating the facility's hand hygiene policy. This placed the resident at risk of catheter-related complications and UTIs.
A facility failed to ensure a resident's PRN psychotropic medication had a 14-day stop date or specified duration, as required. The resident, diagnosed with anxiety disorder and dementia, had multiple PRN Lorazepam orders without the necessary documentation. Staff interviews confirmed the expectation for a stop date, and the facility's policy required PRN psychotropic medications to be used for the shortest duration with proper documentation.
A facility failed to ensure collaboration with hospice services for a resident with severe cognitive impairment and Alzheimer's disease. The resident's care plan lacked documentation of hospice contact information, equipment, medications, and services, placing the resident at risk for delayed services. Staff confirmed that necessary hospice information was not integrated into the care plan, contrary to the facility's hospice policy.
Failure to Implement Nutritional Interventions for Resident
Penalty
Summary
The facility failed to provide adequate nutritional interventions for a resident, identified as R25, who experienced significant unplanned weight loss. R25, who had a medical history including insomnia, progressive supranuclear palsy, dementia, and dysphagia, was admitted with a weight of 163.8 lbs. and was noted to be at risk for nutritional impairment. Despite being on a regular diet with regular texture and thin liquids, R25 experienced a gradual weight loss, dropping to 150 lbs. within a few months, which was a 13.06% decrease from his usual body weight of 185-190 lbs. The facility's records indicated that R25's weight loss was not addressed with appropriate nutritional interventions. Although R25 was added to a supplemental nutrition program for weight gain, there was no evidence of nutritional supplements being administered until much later. The facility's care plan for R25 included monitoring for dysphagia and providing supplements, but these interventions were not effectively implemented. The resident's weight continued to decline, and it was noted that he had difficulties feeding himself and resisted assistance from staff and his representative. The facility's policy required that residents at risk for significant weight loss be care planned based on nutritional impairments, with interventions implemented to prevent further weight loss. However, the facility did not involve the Registered Dietician (RD) when initial weight loss was noted, and the necessary interventions were not put in place in a timely manner. This oversight resulted in R25's continued weight loss and placed him at risk for malnourishment-related complications.
Failure to Complete Yearly Performance Evaluation for CNA
Penalty
Summary
The facility failed to complete the required yearly performance evaluation for one of the five Certified Nurse Aides (CNAs) reviewed, specifically CNA O, who was hired on June 21, 2023. This deficiency was identified during a review of the facility's performance evaluation and in-service records, which revealed that CNA O had not received a yearly performance evaluation. Administrative Nurse D confirmed the absence of the required evaluation for CNA O, despite the facility's policy mandating annual performance reviews for all CNA staff. The policy is intended to identify employee strengths and goals and determine training needs. The lack of a performance evaluation for CNA O placed the residents at risk for inadequate care.
Failure to Follow Sanitary Dietary Standards
Penalty
Summary
The facility failed to adhere to sanitary dietary standards concerning food storage, which posed a risk of food-borne illnesses to residents. During an inspection of the facility's kitchen, surveyors found an open but undated half-gallon carton of milk and a carton of heavy whipping cream in the walk-in refrigerator. Additionally, in the back hall kitchenette, there was an unlabeled plate of spinach and beef sandwich and an undated bag with dessert pastries. The main dining kitchenette drink station contained an open and undated bottle of whipping cream, and the refrigerator held an eight-fluid-ounce container of Arginaid with an expired date. Dietary Staff BB confirmed that all opened food products should be labeled and dated, and personal or undated items should not be placed in the kitchenettes. The facility's Storage Guidelines policy, revised on a specific date, mandates that all food and supplies be stored appropriately to ensure quality and safety, which was not followed in this instance.
Infection Control Deficiency in Hand Hygiene and Equipment Disinfection
Penalty
Summary
The facility failed to adhere to proper infection control standards, specifically in hand hygiene and disinfecting shared equipment between residents. During an observation, two CNAs were seen transferring a resident using a mechanical lift without performing hand hygiene between glove changes. The CNAs also failed to disinfect the lift after use. Another observation revealed a licensed nurse performing wound care on a resident without adhering to hand hygiene protocols between glove changes, and using the same gloves to handle wound care supplies. Interviews with staff confirmed that hand hygiene should be performed between glove changes and when transitioning from dirty to clean tasks. It was also noted that shared equipment should be disinfected between each resident use. The facility's policies on hand hygiene and cleaning of resident-care equipment were not followed, as evidenced by the observations and staff interviews. These practices placed residents at risk for complications related to infectious diseases.
Failure to Provide Written Notification of Transfer
Penalty
Summary
The facility failed to provide written notification of transfer to a resident, identified as R32, and/or their representative, specifying the location and reason for the facility-initiated transfer. This deficiency was identified during a review of R32's records, which showed that the resident was sent to an acute care facility due to changes in mental status and returned to the facility two days later. However, the Electronic Medical Records (EMR) lacked documentation of the required written notification of transfer. R32's medical history included diagnoses of dysphagia, cognitive-communication disorder, dementia, and acute kidney failure. The resident's Discharge Minimum Data Set (MDS) indicated a discharge to a short-term hospital with an anticipated return, and upon return, the Entry MDS noted moderate cognitive impairment requiring substantial assistance for daily activities. Despite these documented needs, the facility did not provide a policy related to transfers and discharges, and Administrative Staff A confirmed the absence of the required written notification for R32's hospitalization.
Failure to Provide Bed Hold Notice for Hospitalized Resident
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to a resident, identified as R32, and/or their representative when the resident was transferred to a hospital. The resident's medical records indicated diagnoses of dysphagia, cognitive-communication disorder, dementia, and acute kidney failure. The resident was discharged to a short-term hospital with an anticipated return to the facility, and subsequently returned from the hospital. However, the medical record lacked evidence of a bed hold notice being sent to the resident or their representative for the transfer. Upon review, the facility's administrative staff confirmed the requirement to send both a written notification of transfer and a bed hold notice, but they were unable to locate the notice for the resident's hospitalization. The facility's bed hold policy, revised in July 2024, mandates providing written notifications of bed hold and the facility's return policy to each resident or their representative. The failure to provide this notice placed the resident at risk for impaired right to return to the facility to the same room.
Inadequate Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure that pressure-reducing interventions were correctly implemented for two residents, R7 and R16, who were at risk for pressure ulcers. For R7, the low air-loss mattress was consistently set at an inappropriate weight of 500 to 550 pounds, despite R7 weighing only 111 pounds. This setting was not adjusted by the staff, as they only ensured the mattress was functioning, and the care plan lacked guidance on the appropriate settings for the mattress. The administrative nurse confirmed that the higher weight settings added more pressure to the resident's body, which could lead to skin breakdown. R16, who had a history of muscle weakness and hemiparesis, was also at risk for pressure ulcers. The low air-loss mattress for R16 was set at 300 pounds, which was not aligned with her actual weight of 197.6 pounds. Observations revealed that R16's heel protectors were not in use, and her heels were resting directly on the bed. Additionally, during wound care, the licensed nurse failed to perform proper hand hygiene between glove changes, potentially compromising the resident's skin integrity. The facility's policy required that pressure-reducing devices be set according to the resident's weight and care needs, but this was not adhered to. The facility's Prevention of Pressure Injuries policy outlined the need for appropriate interventions based on risk factors and care needs, including the correct setting of pressure redistribution surfaces. However, the facility did not ensure that the low air-loss mattresses were set correctly for R7 and R16, placing them at risk for complications related to skin breakdown and pressure ulcers. The staff's lack of adherence to the policy and failure to adjust the mattress settings contributed to the deficiency.
Inadequate Catheter Care and Lack of Physician Order Indication
Penalty
Summary
The facility failed to ensure that a resident had a physician-ordered indication for an indwelling catheter and did not provide adequate catheter care according to the standards of care. The resident, who had diagnoses of muscle weakness, need for assistance with personal care, and hypertension, had an intact cognition as indicated by a BIMS score of 14. The resident's care plan included specific instructions for catheter care, such as positioning the catheter drainage bag below the bladder level and monitoring for signs of discomfort during urination. However, the physician's order for the Foley catheter lacked an indication for its use. During an observation, two CNAs were seen providing catheter care to the resident. The CNAs failed to perform hand hygiene between glove changes, which is a critical step in preventing the spread of infections. The facility's hand hygiene policy emphasizes the importance of hand hygiene in preventing healthcare-associated infections. Interviews with the CNAs and nursing staff revealed that they were aware of the hand hygiene protocols, yet they did not adhere to them during the observed care. This failure to follow proper hand hygiene practices and the lack of a documented indication for the catheter placed the resident at risk of catheter-related complications and urinary tract infections.
Failure to Ensure PRN Psychotropic Medication Stop Date
Penalty
Summary
The facility failed to ensure that a resident's as-needed (PRN) psychotropic medication had a 14-day stop date or a specified duration with supporting physician documentation. This deficiency was identified during a review of the resident's electronic medical record, which revealed multiple PRN orders for Lorazepam without the required stop date or specified duration. The orders were for Lorazepam oral concentrate and tablets to be administered for moderate insomnia, moderate anxiety, and severe agitation, all dated the same day, but lacking the necessary documentation to comply with regulatory requirements. The resident involved had diagnoses of muscle weakness, anxiety disorder, and dementia, and was observed asleep in a specialized wheelchair. Interviews with facility staff, including a licensed nurse and an administrative nurse, confirmed the expectation that PRN psychotropic medications should have a 14-day stop date. The facility's policy on medication monitoring also stipulated that PRN psychotropic medications should be used for the shortest duration required, with appropriate documentation. The absence of a stop date or specified duration for the PRN Lorazepam orders placed the resident at risk for unnecessary medication administration and potential adverse side effects.
Lack of Coordination with Hospice Services for Resident
Penalty
Summary
The facility failed to ensure collaboration between the nursing home and hospice services for a resident with severe cognitive impairment and multiple medical diagnoses, including Alzheimer's disease. The resident was dependent on staff for various activities of daily living and was at risk for pressure ulcers. Despite being admitted to hospice services, the resident's care plan lacked documentation related to hospice contact information, equipment, medications, services, and scheduled visits from hospice staff. This omission placed the resident at risk for delayed services and uncommunicated care needs. Observations and interviews revealed that the hospice contact and service information were stored in a separate hospice binder, not integrated into the resident's care plan or Kardex. Staff members, including a CNA and a licensed nurse, confirmed that the care plan did not contain necessary hospice information, and the administrative nurse acknowledged that care plans should include such details. The facility's hospice policy emphasized the need for coordination and communication between the facility and hospice services, which was not effectively implemented in this case.
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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