Delmar Gardens Of Overland Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Overland Park, Kansas.
- Location
- 12100 W 109th Street, Overland Park, Kansas 66210
- CMS Provider Number
- 175182
- Inspections on file
- 21
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Delmar Gardens Of Overland Park during CMS and state inspections, most recent first.
The facility failed to designate a qualified and certified Infection Preventionist, placing all residents at risk for lack of identification, tracking/trending, and treatment of infections. An administrative nurse was in the process of becoming certified, and another nurse, who was not certified, was managing immunizations and antibiotic stewardship. The facility could not provide an Infection Preventionist policy.
The facility failed to provide evidence of the required prevention of abuse, neglect, and exploitation training for two of the five CNAs sampled. Administrative staff could not show the required 12 hours of yearly in-service education, and the staff responsible for education did not track hours properly. The facility did not have staff education records from the previous 12 months, and efforts to improve the process had only recently been implemented.
The facility failed to ensure that five CNAs had the required 12 hours of in-service education, and two CNAs lacked dementia care training. Administrative staff acknowledged the deficiencies and noted that the previous educator may have left with the 2023 education records. Despite efforts to improve the education process, the facility's disorganized records and lack of documentation placed residents at risk for inadequate care.
The facility failed to ensure food was appropriately labeled and dated during storage, and tableware was stored appropriately before meal service. Observations revealed opened and unlabeled food items in the freezer and refrigerator, and unsanitary handling of clean meal plates by dietary staff. Temperature logs for the dishwasher and food were also incomplete.
The facility failed to follow proper infection control standards, including disinfecting shared equipment and storing respiratory equipment. Observations revealed unbagged BiPAP masks and oxygen tubing, unsanitized mechanical lifts, and incorrect disinfectants used for a C-diff isolation room. Staff interviews confirmed these deficiencies, and the wrong isolation precautions were posted for a resident with C-diff.
The facility failed to consistently reconcile controlled drugs at the end of each work shift on one medication cart, placing 16 residents at risk for medication misappropriation. Observations and staff interviews revealed multiple instances where the narcotic reconciliation was not completed as required by the facility's policy.
The facility failed to complete the comprehensive MDS assessment Section V, CAA for multiple residents, lacking analysis and rationale for care planning decisions. Administrative Nurse D did not realize the need to document analysis data, leading to incomplete assessments and placing residents at risk.
The facility failed to address recurring issues reported by the Resident Council, including missing property, slow call light response, staff cell phone use, and lack of healthy snacks. Despite these concerns being documented over a year, no actions or outcomes were recorded, leading to resident frustration and decreased psychosocial well-being.
The facility failed to provide a system for residents to file grievances anonymously and did not maintain grievance logs for the required period. Residents were unaware of any means to file anonymous grievances, and the facility was missing grievance logs from several months. This deficiency placed residents at risk for decreased psychosocial well-being and unresolved grievances.
The facility failed to secure hazardous chemicals, use safe assistive techniques for a resident in a wheelchair, and ensure proper mechanical lift transfer techniques for two residents. Unsecured chemicals were accessible to cognitively impaired residents, and improper use of wheelchairs and lifts led to preventable injuries.
The facility failed to provide adequate respiratory care for a resident by not ensuring proper BiPAP settings and maintaining sanitary storage for the equipment. The resident's EMR lacked specific directions for BiPAP settings and routine disinfection. Staff interviews revealed a lack of clarity and responsibility for cleaning and storing the BiPAP equipment, increasing the risk of respiratory infection and complications.
The facility failed to manage and treat a resident's pain despite multiple reports of pain and a prescription for tramadol. The resident's care plan lacked direction for pain management, and staff did not document or provide any pain relief interventions. This resulted in unmanaged pain and placed the resident at risk for impaired mobility and diminished quality of life.
The facility failed to provide timely written notification to the LTCO and the resident or their representative for facility-initiated transfers involving two residents with cognitive impairments and significant medical needs. Both residents were transferred to a hospital without the required written documentation, leading to potential miscommunication and missed healthcare opportunities.
The facility failed to provide the required bed hold notifications to two residents and their family representatives when they were transferred to the hospital, placing them at risk for impaired ability to return to the facility or their same rooms.
A resident's right to private communications was compromised when a package addressed to her was opened and its contents removed before delivery. Despite the resident's cognitive intactness and multiple health conditions, the facility could not determine what happened to the package contents, and no concerns or resolutions were documented in the grievance logs.
The facility failed to issue the CMS SNF ABN form 10055 to two residents when their Medicare Part A episodes ended. Both residents remained in the facility for custodial care, and the facility could not provide evidence that the required forms were issued. Administrative Staff A was unaware of the requirement, and the facility lacked an Advance Beneficiary Notices policy.
The facility failed to provide dignified care for a resident by not placing a catheter urine collection bag inside a dignity bag and failed to ensure a dignified dining experience for another resident by standing while assisting with a meal. These actions were against the facility's expectations and policies, placing the residents at risk for impaired dignity and quality of life.
The facility failed to include a resident in the development and planning of his care plan, despite his multiple diagnoses and need for total assistance with ADLs. The resident expressed a desire to participate in care conferences, but the last documented conference was over a year ago, contrary to the facility's policy.
The facility failed to ensure a resident's call light remained within reach and did not honor another resident's bathing preferences, compromising their care and autonomy. Despite policies requiring call lights to be within reach and honoring residents' personal care preferences, staff did not adhere to these policies, resulting in impaired care for the residents.
A facility failed to complete a comprehensive Significant Change MDS assessment for a resident after the addition of hospice services. Despite the resident's diagnoses and the addition of hospice care, the necessary MDS was not completed within the required 14-day timeframe, placing the resident at risk for unidentified care needs.
The facility failed to complete an accurate MDS assessment for a resident's use of a trunk restraint. The resident's care plan and clinical records lacked evidence of a physician order for the restraint, and staff were unaware of any restraint orders. This deficiency placed the resident at risk for inappropriate care planning and unmet care needs.
The facility failed to identify a resident's required level of care assistance and her high-risk medication on her baseline care plan. The resident, admitted with dementia, a fractured femur, insomnia, and a history of falls, required partial to moderate assistance with ADLs. The care plan did not specify the level of assistance or address her antipsychotic medication, Seroquel. Additionally, the facility failed to complete a baseline care plan for another resident, placing both residents at risk for preventable falls and injuries.
The facility failed to develop comprehensive care plans for three residents, leading to uncommunicated care needs and impaired care. One resident's care plan lacked documentation for bowel incontinence and specific mattress settings, another resident's plan did not include personal preferences for facial hair trimming, and a third resident's plan omitted critical interventions for leg wraps and insulin administration.
The facility failed to update the care plans of three residents to include critical information about their medications and medical devices. One resident's care plan did not include her diuretic medication, another's lacked information about her anticoagulant, and a third's did not mention her left-hand splint. Staff confirmed that these omissions were against facility policy, which requires care plans to reflect all medications and medical devices.
The facility failed to provide necessary assistance with personal hygiene for a resident who required partial to moderate assistance. Despite having intact cognition, the resident's care plan lacked specific directions for facial hair trimming, leading to long chin hairs being observed. Staff were unsure of the resident's preferences, and the facility lacked a policy on personal hygiene.
The facility failed to maintain a resident's physical function and comfort by not following occupational therapy recommendations for positioning, and did not apply a protective sleeve for another resident as per the care plan, leading to increased risk of impairment and skin injury.
The facility failed to ensure proper pressure ulcer prevention measures for two residents. One resident's low air-loss mattress pump was set incorrectly, causing pain and increased risk of skin breakdown. Another resident did not have pressure-relieving boots in place as required by their care plan, increasing the risk of pressure ulcers.
A facility failed to ensure a resident's left-hand splint was applied as directed, risking further decline in ROM and mobility. The resident, with diagnoses of cerebral infarction and contracture, was observed without the splint, and staff admitted to forgetting to apply it despite physician orders and care plan requirements.
The facility failed to ensure that the Consultant Pharmacist identified and reported medications lacking an indication for use for two residents. The EMRs for both residents documented several medications without a diagnosis or indication for use, and the CP's monthly medication reviews did not address these issues. Additionally, one resident had instances of blood sugar levels below the physician-ordered parameters without physician notification. This failure placed the residents at risk of unnecessary medication administration and possible adverse reactions.
The facility failed to ensure that the drug regimens for two residents included indications for use, leading to the administration of unnecessary medications. Additionally, the facility did not notify the physician when one resident's blood sugar levels fell below the ordered parameters. This oversight placed the residents at risk of unnecessary medication administration and potential adverse side effects.
A facility failed to ensure a resident's psychotropic medications had an indication for use, leading to unnecessary medication administration. The resident, with diagnoses including dementia and diabetes, received medications without documented indications, and the facility's records lacked a drug regimen review. Staff acknowledged the need for medication indications, but the facility could not provide a related policy.
A resident expressed frustration about the lack of diabetic-friendly food options and high carbohydrate content in meals. Despite the care plan allowing meal choices, the facility did not offer sufficient low-sugar options, leading to dissatisfaction and complaints. Observations and interviews confirmed the lack of specific special diets like low-carb or low-sugar, placing the resident at risk for impaired autonomy and decreased quality of life.
The facility failed to ensure that two residents were offered and educated regarding the Prevnar 20 (PCV20) pneumococcal vaccination or assessed by the physician to determine if contraindicated as recommended by the CDC. The facility's policy stated that residents would be assessed for the need for the pneumococcal vaccination upon admission, but this was not adhered to, as evidenced by the lack of documentation and assessment for the PCV20 vaccination for the two residents.
Lack of Certified Infection Preventionist
Penalty
Summary
The facility failed to designate a staff member with the required qualification and certification as the Infection Preventionist responsible for the Infection Prevention and Control Program. During the entrance conference, administrative staff reported that the facility did not have a certified Infection Preventionist, and an administrative nurse was in the process of becoming certified. On the specified date, the administrative nurse was unavailable for an interview, and another administrative nurse stated she was not certified but had been tracking immunizations and managing antibiotic stewardship. The facility was unable to provide an Infection Preventionist policy. This deficiency placed all residents at risk for lack of identification, tracking/trending, and treatment of infections.
Failure to Provide Required Abuse, Neglect, and Exploitation Training
Penalty
Summary
The facility failed to provide evidence of the required prevention of abuse, neglect, and exploitation training for two of the five CNAs that were sampled. Specifically, the employee records for CNA PP and CNA QQ lacked documentation of this mandatory training. The facility's administrative staff could not show the required 12 hours of yearly in-service education for these CNAs, and the staff responsible for providing education did not track hours properly. Additionally, the facility did not have the staff education records from the previous 12 months, which further complicated the situation. Administrative Staff A and B acknowledged the gaps in the education records and mentioned that a new educator had been hired to improve the education process and tracking. However, the new system had only been in place since February 2024, and the facility had conducted a skills fair that included the required training. Despite these efforts, the facility could not provide evidence that CNA PP and CNA QQ had completed the necessary training. CNA PP worked only one day a week and had reportedly done his education at another facility, while CNA QQ had not returned the book from the skills fair, and it had not been graded, resulting in the education hours not being recorded.
Deficiency in CNA In-Service Education
Penalty
Summary
The facility failed to ensure that five of the five CNA staff reviewed had the required 12 hours of in-service education, and two of the five CNA staff had the required in-service education for dementia care. This deficiency was identified through a review of the facility's in-service records, which revealed that several CNAs had not met the required training hours. Specifically, CNA LL had eight hours, CNA OO had six hours, CNA PP had zero hours and lacked dementia education, CNA QQ had zero hours and lacked dementia education, and CNA RR had six hours of in-service education in the past 12 months. The facility's records were disorganized, with binders lacking clear tracking of education hours and topics, and administrative staff were unable to provide the required documentation for the previous 12 months of education. Administrative staff acknowledged the deficiencies, stating that the previous educator may have left with the education records for 2023 and that the facility had recently hired a new educator to improve the education process and tracking. Despite efforts to implement a new system and conduct a skills fair, the facility failed to ensure that all CNAs received the necessary training. This placed residents at risk for inadequate care, particularly in areas such as dementia care and abuse prevention.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure food was appropriately labeled and dated during storage, and tableware was stored appropriately before meal service. During an initial tour of the main kitchen, it was observed that the walk-in freezer contained several opened bags of food items, such as tater tots, breaded chicken breasts, donuts, and mixed vegetables, none of which were labeled or dated. Additionally, the walk-in refrigerator had two opened bags of whipped cream without open dates. The temperature logs for the dishwasher and food temperatures for meals lacked evidence of being assessed on specific dates in March 2024. During meal service preparation, dietary staff were observed handling clean meal plates and bowls in an unsanitary manner. The plates and bowls were placed face up on the serving table, and dietary staff donned clean gloves without performing hand hygiene first. One dietary staff member scooped food onto a clean plate, which was then taken by another staff member to serve to a resident. The facility's policies on food storage and utensil handling were not followed, and there was no policy regarding food service during mealtimes. This placed residents at risk of foodborne illnesses and cross-contamination.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control standards were followed, particularly in the disinfecting of shared equipment and the sanitary storage of respiratory equipment. Observations revealed that a resident's BiPAP mask was laid on the floor and another resident's oxygen tubing was coiled on a wheelchair seat without being stored in a plastic bag. Additionally, a BiPAP mask was found unbagged on top of the BiPAP machine. Staff did not sanitize a mechanical lift after use, and the incorrect disinfectant was used to clean a C-diff isolation room. Furthermore, the wrong type of isolation precautions was posted for a resident with a C-diff infection, using enhanced barrier isolation instead of contact isolation as required by the facility's policy. Interviews with staff confirmed these deficiencies. Certified Nurse Aides and Licensed Nurses acknowledged that shared equipment should be disinfected between uses and respiratory equipment should be stored in plastic bags when not in use. They also confirmed that the correct isolation precautions should be posted on a resident's door. The facility's Isolation Precautions policy specified the use of contact precautions for residents with C-diff, but this was not followed, placing residents at risk for complications related to infectious diseases.
Failure to Reconcile Controlled Drugs Consistently
Penalty
Summary
The facility failed to provide a consistent reconciliation of controlled drugs at the end of each work shift on one medication cart, placing 16 residents with controlled substances at risk for misappropriation of medications. Observations revealed that the Controlled Drug Record flow sheet on the lower-level Hall B medication cart lacked evidence of narcotic reconciliation for multiple night, evening, and day shifts. Specifically, the reconciliation was not completed for night shifts on 02/01/24, 02/09/24, 02/10/24, 02/11/24, 02/23/24, 02/29/24, 03/01/24, 03/03/24, 03/09/24, and 03/10/24, for evening shifts on 02/23/24, 02/29/24, 03/01/24, and 03/03/24, and for day shifts on 03/01/24 and 03/03/24. This resulted in 16 instances of non-compliance out of a possible 126 work shifts. Interviews with staff confirmed that nurses were expected to count narcotics with another nurse at each shift change. Both the nurse coming on duty and the nurse going off duty were responsible for ensuring the narcotic count was correct. Despite this expectation, the facility's Medication and Controlled Substance policy, revised in 02/2023, was not consistently followed. The policy stated that controlled medications should be counted at the end of each shift, and any discrepancies should be reported to a supervisor and the pharmacy immediately. The failure to adhere to this policy placed residents at risk for medication misappropriation.
Incomplete MDS Assessments
Penalty
Summary
The facility failed to fully complete the comprehensive Minimum Data Set (MDS) assessment Section V, Care Area Assessment Summary (CAA) for multiple residents, including R1, R3, R16, R17, R30, R31, R50, R52, R67, R80, R81, and R286. This failure included not providing an analysis and rationale for care planning decisions, which is essential for developing an individualized comprehensive plan of care. The deficiency was identified through record reviews and interviews, revealing that the assessments were not completed as required, placing these residents at risk for not accurately reflecting their needs. Administrative Nurse D admitted to not realizing that there was a separate page to document the analysis data needed for the care plan. She stated that after signing the page, it would take her back to the original page, allowing her to validate and finalize the section without completing the necessary worksheets. The Resident Assessment Instrument Manual version 3.0 emphasizes the importance of the CAA process in providing a framework for reviewing triggered areas and clarifying a resident's functional status and related causes of impairments. The facility did not provide a policy for Minimum Data Set Completion upon request.
Recurring Resident Council Concerns Unresolved
Penalty
Summary
The facility failed to adequately address and resolve recurring issues reported by the Resident Council, which placed the residents at risk for decreased psychosocial well-being and impaired quality of life. The Resident Council Minutes from March 2023 through March 2024 documented recurring concerns such as missing property and clothing, slow call light response, staff cell phone use, lack of healthy snacks, specialized diets, and unresolved grievances. Despite these recurring issues being reported month after month, the minutes consistently lacked documentation of actions taken or outcomes for these concerns. Specific instances included the March 2023 minutes noting issues with call lights not being answered in the evening and missed showers, with no actions or outcomes documented. The May 2023 minutes again highlighted slow call light response and missing property, but similarly lacked any documented actions or outcomes. This pattern continued through subsequent months, with ongoing concerns about call light response times, staff using cell phones and earbuds during shifts, missing clothing, and the need for more healthy snacks and specialized diet options. The facility's failure to address these issues was further confirmed through interviews with staff, who indicated that concerns were reported but not resolved in a timely manner. On March 12, 2024, the Resident Council expressed frustration with the ongoing unresolved issues, including missing clothing, diabetic snacks, healthy snack choices, staff cell phone use, and long call light wait times in the evening. Interviews with laundry and dietary staff revealed attempts to address some concerns, such as providing a variety of snacks and ensuring laundry was returned to the correct rooms, but these efforts were insufficient to resolve the recurring issues. The facility did not provide a policy related to the Resident Council when requested, further indicating a lack of adequate response to the council's concerns.
Failure to Implement Anonymous Grievance System and Maintain Records
Penalty
Summary
The facility failed to implement a system to allow residents and/or their representatives to file grievances anonymously. During an inspection, it was observed that there were no designated grievance drop boxes or systems available in areas accessible to residents and visitors. The Resident Council members were unaware of any means to file anonymous grievances and reported that grievance forms had to be obtained from the front desk and handed to staff. Social Services staff confirmed that while a drop box existed, it was not clear if residents could use it anonymously. Additionally, the facility was missing grievance logs from November 2023 through February 2024, and administrative staff were unable to locate these records due to recent staffing changes. The facility's grievance policy, revised in June 2021, indicated that residents had the right to file grievances in writing, verbally, or anonymously, and that all grievances would be documented and retained for three years. However, the facility failed to adhere to this policy, as evidenced by the missing grievance logs and the lack of an anonymous grievance filing system. This deficiency placed residents at risk for decreased psychosocial well-being and unresolved grievances.
Failure to Secure Hazardous Chemicals and Ensure Safe Transfer Techniques
Penalty
Summary
The facility failed to ensure an environment free from accident hazards when staff did not secure chemicals in a safe, locked area, making them accessible to thirteen cognitively impaired, independently mobile residents. During a walkthrough, unsecured cleaning products were found in an unlocked janitor closet and spa rooms, all of which contained hazardous chemicals. Staff interviews confirmed that cleaning products should be locked and out of reach of residents, aligning with the facility's Chemical Storage policy. This oversight placed residents at risk for preventable accidents and injuries. The facility also failed to use safe assistive techniques for Resident 61, who had a history of falls and required assistance with transfers and mobility. Observations revealed that staff pushed Resident 61 in a wheelchair without foot pedals, causing her feet to drag on the ground. Staff interviews confirmed that residents' feet should be propped up on foot pedals during transport to prevent injuries. The facility's Fall Risk/Prevention policy indicated that staff should ensure safe practices and appropriate usage of transfer equipment, which was not followed in this case. Additionally, the facility failed to ensure safe mechanical lift transfer techniques for Residents 17 and 30. Both residents were struck in the head by the Hoyer lift bar during transfers, indicating improper use of the lift. The facility's investigation revealed that staff involved in these incidents had not received proper training or competency assessments for mechanical lift use. Staff interviews and documentation confirmed that lift training was provided, but not all staff had completed it. This failure to ensure proper training and adherence to safe transfer techniques placed the residents at risk for preventable injuries.
Inadequate Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide adequate respiratory care and services for a resident (R12) by not ensuring proper orders to clarify BiPAP settings and failing to maintain sanitary storage for R12's respiratory equipment. R12, who had diagnoses including acute and chronic respiratory failure, obstructive sleep apnea, and Covid-19, required total assistance with activities of daily living and had intact cognition. The resident's electronic medical record (EMR) lacked specific directions regarding BiPAP settings and evidence of routine disinfection of the BiPAP equipment. Observations revealed that R12's BiPAP mask was not stored in a sanitary container and was left on top of the machine, increasing the risk of respiratory infection and complications. Interviews with staff indicated a lack of clarity and responsibility regarding the cleaning and storage of R12's BiPAP equipment. A Certified Nursing Assistant (CNA) was unaware of who was responsible for cleaning the BiPAP, and a Licensed Nurse (LN) confirmed there were no orders or documentation for cleaning or storing the BiPAP mask. The Administrative Nurse acknowledged that there should be clear directions for staff on how to provide care using the BiPAP, including cleaning and storage procedures. This deficiency in respiratory care placed R12 at an increased risk for respiratory infection and complications.
Failure to Manage and Treat Resident's Pain
Penalty
Summary
The facility failed to recognize, evaluate, manage, and treat the underlying cause of pain for Resident 286, who had diagnoses of hemiplegia and hemiparesis following a stroke. Despite the resident's documented pain levels ranging from two to four out of ten on multiple occasions, there was no evidence that the prescribed pain medication, tramadol, was administered, offered, or refused during the review period. Additionally, the resident's care plan lacked direction regarding pain management and did not indicate the resident's tolerable or acceptable level of pain. On several occasions, the resident reported pain to staff, but no interventions were documented or provided. For instance, on one occasion, the resident informed a Certified Nurse Aide (CNA) about his pain, and although the CNA notified the nurse, no staff returned to address the pain. The resident continued to experience significant pain, rating it as high as eight out of ten, and stated that he had not received any pain relief. The Licensed Nurse (LN) acknowledged the lack of pain management and noted that the resident did not have an alternative pain relief option such as acetaminophen. Interviews with administrative staff revealed that they were unaware of the resident's pain complaints and expected staff to assess and document any pain interventions. The facility did not provide a policy related to pain management, and the failure to address the resident's pain resulted in unmanaged pain, placing the resident at risk for impaired mobility and diminished quality of life.
Failure to Provide Written Notification for Facility-Initiated Transfers
Penalty
Summary
The facility failed to provide timely written notification to the State Long-term Care Ombudsman (LTCO) and the resident or their representative for facility-initiated transfers involving two residents. Resident 43, who had a history of cerebral vascular incident (CVA), hypertension, hemiplegia, and hemiparesis, was transferred to an acute hospital due to hypernatremia. The facility did not provide written notification of this transfer to the resident, their representative, or the LTCO. The resident's spouse was notified of the transfer via phone, but no written documentation was provided as required by the facility's policy. Similarly, Resident 16, who had diagnoses of senile degeneration of the brain, dementia, diabetes mellitus, and hypertension, was transferred to a hospital. The facility did not provide written notification of this transfer to the resident's legal representative or the LTCO. The resident's representative was notified by phone, but again, no written documentation was provided. Both residents had documented cognitive impairments and required significant assistance with activities of daily living (ADLs). The facility's policy, revised in September 2022, mandates that written notice of transfer or discharge be provided to the resident and their representative, including the reason for transfer, effective date, right to appeal, and information on how to obtain an appeal form. The failure to adhere to this policy resulted in a risk of miscommunication between the facility and the residents' families, potentially leading to missed opportunities for healthcare services for the affected residents.
Failure to Provide Bed Hold Notifications
Penalty
Summary
The facility failed to provide the required bed hold notifications to two residents, R43 and R16, and their family representatives when they were transferred to the hospital. R43, who had a history of cerebral vascular incident (CVA), hypertension, hemiplegia, and hemiparesis, was transferred to the hospital due to hypernatremia. Despite the transfer, the facility did not provide evidence of a bed hold notification to R43's representative. Administrative staff confirmed that a bed hold notification had not been signed upon R43's discharge to the hospital, and the facility lacked a policy regarding bed holds. Similarly, R16, who had diagnoses of senile degeneration of the brain, dementia, diabetes mellitus, and hypertension, was transferred to the hospital. The facility also failed to provide evidence of a bed hold notification to R16's legal representative. Administrative staff confirmed that a bed hold notification had not been signed upon R16's discharge to the hospital, and the facility was unable to provide a policy related to bed hold notification. The lack of proper bed hold notifications for both residents placed them at risk for impaired ability to return to the facility or their same rooms. The facility's failure to adhere to the required bed hold notification process was identified through observations, record reviews, and interviews with administrative staff, highlighting a significant deficiency in the facility's discharge and transfer procedures.
Failure to Ensure Resident's Right to Private Communications
Penalty
Summary
The facility failed to ensure a resident's right to private communications when a package addressed to the resident was opened and its contents removed before being delivered to the resident. The resident, who has diagnoses including lymphedema, cardiomyopathy, congestive heart failure, and type 2 diabetes mellitus, is cognitively intact with a BIMS score of 14. The resident reported the incident to her daughter and the facility's administrative staff, who confirmed that the package had been opened but could not determine what happened to the contents. The facility's grievance logs for January and February 2024 showed no concerns related to the opened package and no resolution was documented. On the morning of March 12, 2024, the resident was observed in her room with her legs wrapped in an ace wrap, looking at her mail. She mentioned that the package had arrived sometime before the current month and had been opened before she received it. The facility's policy on resident rights includes the right to be treated with dignity and respect and to have safeguards against any kind of harsh or abusive treatment. The facility's failure to ensure the resident's right to private communications by allowing the package to be opened and its contents removed placed the resident at risk for impaired privacy and decreased autonomy.
Failure to Issue SNF ABN Forms
Penalty
Summary
The facility failed to issue the CMS Skilled Nursing Facility Advance Beneficiary Notification (SNF ABN) form 10055 to two residents, R12 and R18, when their Medicare Part A episodes ended. R12's Medicare Part A episode began on 12/13/23 and ended on 01/05/24, and R18's episode began on 01/02/24 and ended on 01/23/24. Both residents remained in the facility for custodial care after their Medicare Part A coverage ended. The facility was unable to provide evidence that the SNF ABN 10055 forms were issued to these residents. Administrative Staff A admitted to being unaware of the requirement to use form 10055 with an estimated cost for continued services. The facility also lacked an Advance Beneficiary Notices policy, which contributed to the failure to provide the necessary information for residents to make informed choices and appeal non-coverage decisions.
Failure to Provide Dignified Care and Dining Experience
Penalty
Summary
The facility failed to provide care in a respectful and dignified manner for two residents. For one resident, staff did not place the catheter urine collection bag inside a dignity bag, leaving it visible from the hallway. This was observed on multiple occasions, and staff members entered and exited the room without addressing the issue. Interviews with staff confirmed that the catheter bags should be placed inside dignity bags, but this was not done for the resident in question. The facility did not provide a policy related to dignity, which contributed to the oversight and placed the resident at risk for impaired dignity and quality of life. For another resident, staff failed to provide a dignified dining experience. The resident, who had moderately impaired cognition and required assistance with eating, was assisted by a staff member who stood beside her while feeding her. This practice was against the facility's expectations, which required staff to sit next to residents and engage them during meals. Observations and interviews confirmed that staff should be seated at eye level with residents during mealtimes. The facility's undated Resident Rights policy emphasized the importance of treating residents with dignity and respect, but this was not upheld in the observed dining situation, placing the resident at risk for weight loss and impaired dignity.
Failure to Include Resident in Care Plan Development
Penalty
Summary
The facility failed to include Resident 12 in the development and planning of his care plan, which placed him at risk of impaired care and autonomy. Resident 12's Electronic Medical Record (EMR) documented multiple diagnoses, including acute and chronic respiratory failure, obstructive sleep apnea, depressive disorder, anxiety, seasonal allergic rhinitis, morbid obesity, and Covid-19. The Quarterly Minimum Data Set (MDS) indicated that Resident 12 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 14 and required total assistance with activities of daily living (ADLs). Despite these needs, the facility did not document any recent care conferences involving Resident 12, with the last recorded care conference occurring on 11/29/22. On 03/12/24, Resident 12 expressed that he had not participated in a care conference for a long time and desired to be involved. The Administrative Nurse confirmed that care plans were updated only when there were changes with the resident, but there was no documentation of ongoing care conferences. The facility's Care Plan Conference policy, revised in 05/21, mandates identifying resident needs and establishing goals to ensure optimal levels of activity and independence. The lack of inclusion of Resident 12 in his care planning process was a clear deviation from this policy, leading to the identified deficiency.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to ensure a resident's call light remained within reach, which left the resident vulnerable to impaired care and decreased autonomy. The resident, who had multiple medical diagnoses including depression, heart disease, and cognitive communication deficit, was observed on multiple occasions with his call light on the floor underneath his bed. Despite the facility's policy requiring call lights to be within reach, staff did not adhere to this policy, resulting in the resident having to yell for help and experiencing pain due to pressure injuries before staff responded to his needs. Additionally, the facility failed to honor another resident's preferences related to his bathing schedule. The resident, who had diagnoses including acute and chronic respiratory failure, obstructive sleep apnea, and morbid obesity, did not receive his scheduled showers. Despite the resident's requests for a shower on unscheduled days, staff did not accommodate his preferences, leaving him without a shower for an extended period. The facility's policy on resident rights emphasizes the importance of treating residents with dignity and respect, which includes honoring their preferences for personal care. These deficiencies highlight the facility's failure to reasonably accommodate the needs and preferences of its residents, as evidenced by the improper placement of call lights and the failure to adhere to residents' bathing schedules. These actions and inactions compromised the residents' care and autonomy, contrary to the facility's policies and standards of care.
Failure to Complete Significant Change MDS After Addition of Hospice Services
Penalty
Summary
The facility failed to complete a comprehensive Significant Change Minimum Data Set (MDS) assessment for a resident (R24) after the addition of hospice services. Despite the resident's diagnoses of depressive disorder, dementia, anxiety, weakness, and hypertension, the facility did not conduct a Brief Interview of Mental Status (BIMS) as required. The resident's records showed that hospice services were added, but the facility did not complete the necessary Significant Change MDS within the required 14-day timeframe. This oversight was confirmed through observations, record reviews, and interviews with staff, including an administrative nurse who acknowledged the delay in starting the significant change MDS. The resident's care plan was revised to document the addition of hospice care, but the facility's failure to complete the Significant Change MDS meant that the resident's recent physical decline and new care needs were not properly assessed. The facility did not provide an MDS policy, and the lack of a comprehensive assessment placed the resident at risk for unidentified care needs. The RAI Manual mandates that a Significant Change MDS must be completed no later than 14 days after a resident is admitted to hospice services, a requirement the facility did not meet.
Inaccurate MDS Assessment for Restraint Use
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for a resident's status regarding the use of a restraint. The resident's Electronic Medical Record (EMR) documented diagnoses of cognitive communication deficiency, difficulty walking, and hypertension. The Annual MDS and Quarterly MDS assessments indicated that the resident was independent with walking and used a trunk restraint less than daily, despite the resident's care plan and clinical records lacking any evidence of a physician order for a trunk restraint. Additionally, the facility's staff, including a Certified Nurse Aide (CNA) and a Licensed Nurse (LN), were unaware of any residents with a restraint order, and the Administrative Nurse confirmed that no residents had a current restraint order, indicating an error in the MDS documentation. The facility's Restraint Management Policy emphasized promoting a restraint-free environment and required a physician's written order for any restraint use, along with regular assessments and care planning. However, the facility failed to adhere to this policy, as evidenced by the inaccurate MDS documentation for the resident's use of a trunk restraint. This deficiency placed the resident at risk for inappropriate care planning and unmet care needs, as the resident's care plan did not include directions for a trunk restraint, and there was no facility assessment or physician order for such a restraint.
Failure to Identify Care Assistance and High-Risk Medication in Baseline Care Plans
Penalty
Summary
The facility failed to identify a resident's required level of care assistance and her high-risk medication on her baseline care plan. The resident, who was admitted with diagnoses of dementia, a fractured femur, insomnia, and a history of falls, had a severe cognitive impairment and required partial to moderate assistance with various activities of daily living (ADLs). Despite these needs, the care plan did not specify the level of assistance required for her ADLs or address her antipsychotic medication, Seroquel, which was prescribed for delusion, agitation, and behaviors. This oversight was confirmed through observations, record reviews, and interviews with staff, who acknowledged that the care plan should have included these details to ensure proper care and monitoring. Additionally, the facility failed to complete a baseline care plan for another resident, further indicating a lapse in the facility's adherence to its care plan policy. The policy mandates that care plans reflect each resident's care levels, assistance needs, treatment goals, medications, and associated risks. The lack of detailed care plans placed both residents at risk for preventable falls and injuries due to uncommunicated care needs. Interviews with staff members, including a CNA and a licensed nurse, highlighted the importance of including high-risk medications and specific assistance levels in the care plans to ensure resident safety and proper care.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to uncommunicated care needs and impaired care. Resident 80, who had multiple medical diagnoses including depression, heart disease, and cognitive communication deficit, required substantial assistance with activities of daily living (ADLs) and was at risk for pressure ulcers. However, the care plan lacked documentation related to his bowel incontinence, Foley catheter, and specific settings for his low-air-loss mattress. Observations revealed that his call light was inaccessible, and staff were unaware of his specific needs, leading to delayed pain management for his pressure injuries. Resident 30, who had a history of traumatic brain injury and major depressive disorder, required partial to moderate assistance with personal hygiene. The care plan did not include her preference for facial hair trimming, which led to her having long chin hairs and feeling neglected. Staff were unaware of her personal preferences, indicating a lack of communication and documentation in her care plan. Resident 81, diagnosed with lymphedema, cardiomyopathy, and type 2 diabetes, had specific physician orders for leg wraps and insulin administration. However, her care plan did not include these critical interventions, leading to potential risks in her care. The facility's failure to complete the Care Area Assessments (CAAs) and accurately reflect each resident's needs and preferences in their care plans resulted in uncommunicated care needs and impaired care for the residents involved.
Failure to Update Care Plans with Critical Medication and Device Information
Penalty
Summary
The facility failed to revise the care plans of three residents to include critical information about their medications and medical devices. Resident 61's care plan did not include her spironolactone medication, which is a diuretic. Despite the medication being ordered and documented in her Electronic Medical Records (EMR), the care plan only mentioned her antidepressant medication, Lexapro. This omission was confirmed through observations and interviews with staff, who acknowledged that high-risk medications should be included in care plans for monitoring purposes. The facility's policy also indicated that care plans should reflect all medications and associated risks, which was not adhered to in this case. Resident 24's care plan similarly lacked information about her anticoagulant medication, Eliquis. Although her EMR documented the physician's order for Eliquis, the care plan did not provide any direction for staff to monitor for side effects of this high-risk medication. Interviews with staff confirmed that the care plan should have included this information to ensure proper monitoring. The facility's policy on interdisciplinary care planning also emphasized the need for care plans to identify residents' needs and establish goals, which was not followed in this instance. Resident 52's care plan did not include the application of her left-hand splint, which was ordered to be worn 24/7 with specific care instructions. Observations revealed that the resident was not wearing the splint as ordered, and staff admitted that the care plan should have included this information. The facility's policy on care planning indicated that all medical devices and their care should be documented in the care plan, which was not done for Resident 52. This failure placed the resident at risk of worsening contractures and further loss of independence with activities of daily living (ADLs).
Failure to Assist Resident with Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene for a resident (R30), who had diagnoses including weakness, a history of traumatic brain injury, hypertension, chronic pain, myalgia, and major depressive disorder. Despite having intact cognition as indicated by a BIMS score of 15, R30 required partial to moderate assistance with personal hygiene. The care plan documented that nursing staff would assist R30 with bathing twice a week and as needed, but it lacked specific directions regarding R30's preference for facial hair trimming. During an observation, R30 was noted to have very long chin hairs and stated she had forgotten to ask staff to trim them during her last few baths. Interviews with staff revealed that they were unsure of R30's preferences for facial hair trimming and that such preferences should be included in the care plan. The facility was unable to provide a policy related to personal hygiene, and staff interviews confirmed that assistance with personal hygiene, including trimming facial hair and nails, should be offered during bathing. The lack of specific instructions in the care plan and the absence of a facility policy on personal hygiene led to the failure to assist R30 with trimming her facial hair. This deficiency placed R30 at risk for poor hygiene, decreased self-esteem, and impaired dignity.
Failure to Maintain Physical Function and Apply Protective Sleeve
Penalty
Summary
The facility failed to provide services to maintain Resident 31's highest practicable level of physical function and promote comfort. Resident 31, diagnosed with Parkinson's disease, dementia, and cognitive communication deficit, was dependent on staff for all activities of daily living (ADLs) and was on hospice. Despite recommendations from occupational therapy to use wedges and proper positioning to maintain alignment and comfort, observations revealed that Resident 31 was not positioned correctly in her Broda chair or bed. Staff failed to implement the recommended positioning aids, leading to Resident 31's deteriorated alignment and increased discomfort. Administrative and therapy staff confirmed that restorative services were not provided to Resident 31 while on hospice, contrary to facility policy that such services should continue regardless of hospice status. The facility also failed to implement the protective sleeve for Resident 67's right arm as per the order and care plan. Resident 67, diagnosed with cerebral infarction and hemiplegia, was at risk for skin breakdown and required a protective sleeve to prevent further skin injury. Observations on multiple occasions showed that Resident 67 did not have the protective sleeve on while in her wheelchair. Documentation inconsistencies and lack of a backup sleeve contributed to the failure to apply the sleeve. Staff interviews revealed confusion about documentation practices and the absence of a policy on non-pressure-related skin injury prevention. These deficiencies placed Resident 31 at risk for further impairment, pain, and contractures, and Resident 67 at risk for skin injury. The facility's failure to follow care plans and provide necessary restorative and protective services highlights significant lapses in care and adherence to established protocols.
Failure to Ensure Proper Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure a resident's low air-loss mattress pump was set to a tolerable comfort level and correct weight. The resident, who had multiple diagnoses including depression, heart disease, and muscle weakness, was at risk for pressure ulcers and had a deep tissue injury on his coccyx. Despite the resident's weight being 117 pounds, the mattress pump was set to 150 pounds, causing discomfort and pain. Staff did not adjust the mattress setting until the resident complained, and it was found that the setting was incorrect for his weight, leading to increased pain and risk of further skin breakdown. Another resident, who had a history of traumatic brain injury, hypertension, and chronic pain, was also at risk for pressure ulcers. The resident's care plan indicated the use of pressure-relieving boots while in bed, but the boots were found on the floor next to the resident's wheelchair. The resident acknowledged forgetting to remind staff to put the boots on, and staff confirmed that the boots should have been in place as per the care plan. This oversight placed the resident at increased risk for developing pressure ulcers. The facility's Pressure Ulcer Prevention policy, revised in May 2021, required interventions such as frequent repositioning, skin lotions, and special mattresses to prevent pressure ulcers. However, the facility failed to implement these measures effectively for the two residents, leading to deficiencies in their care and increased risk of complications related to skin breakdown and pressure ulcers.
Failure to Apply Left-Hand Splint as Directed
Penalty
Summary
The facility failed to ensure that a resident's left-hand splint was applied as directed, which was necessary to prevent an avoidable reduction of range of motion (ROM) and/or mobility. The resident, who had diagnoses of cerebral infarction, hemiparesis/hemiplegia, and contracture of the left hand, was observed without her left-hand splint on multiple occasions. The resident's care plan lacked specific directions for the left-hand splint, and staff admitted to forgetting to apply it, despite physician orders requiring the splint to be worn 24/7 with regular skin checks and repositioning. Certified Nurse Aide (CNA) and Licensed Nurse (LN) interviews confirmed that the resident should always wear the splint to prevent worsening of her contracture. The facility's policy on range of motion also indicated that an established plan should be followed, but this was not adhered to in the resident's case. The failure to apply the splint as ordered left the resident at risk for further decline in ROM and mobility.
Failure to Identify and Report Medications Lacking Indications
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported medications lacking an indication for use for two residents, R1 and R16. For R1, the electronic medical record (EMR) documented several medications, including medroxyprogesterone, Nuedexta, rosuvastatin, and tamsulosin, without a diagnosis or indication for use. Despite the facility's policy requiring monthly medication reviews, the CP's reviews from March 2023 to the present did not include any recommendations or reports regarding the lack of indications for R1's medications. Interviews with licensed nurses and administrative staff confirmed that medications should have a diagnosis listed, but they could not explain why some of R1's medications did not have this information. For R16, the EMR documented several medications, including insulin, amitriptyline, aspirin, famotidine, Lexapro, Lasix, losartan, metoprolol succinate, and raloxifene, without an indication for use. Additionally, the EMR revealed instances where R16's blood sugar levels were below the physician-ordered parameters, but there was no evidence that the physician was notified. The CP's monthly medication reviews from December 2023 through February 2024 did not identify or report these irregularities. Interviews with licensed nurses and administrative staff indicated that the CP should have noted these issues as irregularities, but this did not occur. The facility's policy on Pharmacist Consultant Duties and Responsibilities, last revised in May 2021, required the CP to monitor medication administration and review each resident's chart to identify and address any irregularities, including medications without indications and blood sugars outside ordered parameters. The failure to adhere to this policy placed both R1 and R16 at risk of unnecessary medication administration and possible adverse reactions.
Failure to Ensure Indications for Use in Medication Orders
Penalty
Summary
The facility failed to ensure that the drug regimens for two residents, R1 and R16, included indications for use, leading to the administration of unnecessary medications. For R1, the electronic medical record (EMR) documented several medications, including medroxyprogesterone, Nuedexta, rosuvastatin, and tamsulosin, without corresponding diagnoses or indications for use. Despite the care plan directing monthly pharmacy reviews and monitoring for adverse reactions, the facility did not provide a policy for unnecessary medications, and staff were unable to explain the lack of diagnoses for these medications. This oversight placed R1 at risk of unnecessary medication administration and potential adverse side effects. Similarly, R16's EMR documented multiple medications, including insulin, amitriptyline, aspirin, famotidine, Lexapro, Lasix, losartan, metoprolol succinate, and raloxifene, without indications for use. The facility also failed to notify the physician when R16's blood sugar levels fell below the ordered parameters on two occasions. The care plan indicated that the pharmacist would review medications monthly and provide recommendations, but the monthly medication reviews lacked evidence of identifying and reporting blood sugars outside the physician-ordered parameters and the lack of indications for medication administration. This placed R16 at risk of unnecessary medication administration and possible adverse reactions. Interviews with licensed nurses and administrative staff confirmed that all medications should have a diagnosis included on the Medication Administration Record and that physicians should be notified of blood sugars outside the ordered parameters. However, the facility was unable to provide a policy related to physician orders. The failure to ensure that physician-prescribed medications had indications for use and to notify physicians of abnormal blood sugar levels resulted in deficiencies that compromised the residents' safety and well-being.
Lack of Indication for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident's psychotropic medications had an indication for use, leading to the administration of unnecessary medications. The resident, who had diagnoses including senile degeneration of the brain, dementia, diabetes mellitus, and hypertension, was documented to have moderately impaired cognition. The resident's Annual and Quarterly Minimum Data Sets (MDS) indicated that she received insulin, diuretic, and antidepressant medications without documented indications for their use. Additionally, the MDS lacked documentation of a drug regimen review during the observation period. The Psychotropic Drug Use Care Area Assessment (CAA) also lacked an analysis triggered by the annual MDS, and the resident's care plan did not address the need for medication indications. Observations and interviews revealed that the resident was assisted with meals by nursing staff, but the facility's records showed that the orders for the resident's psychotropic medications, including Amitriptyline and Lexapro, lacked indications for administration. Licensed nurses and administrative staff acknowledged that all medications should have a diagnosis included on the Medication Administration Record, and the facility was unable to provide a policy related to physician orders. This deficiency placed the resident at risk of unnecessary medication administration and possible adverse reactions.
Failure to Provide Diabetic-Friendly Food Options
Penalty
Summary
The facility failed to provide and serve food substitutions that accommodated a resident's preferences, specifically for a low-carbohydrate and diabetic-friendly diet. The resident, who was on a regular diet, expressed frustration multiple times about the lack of diabetic options and high carbohydrate content in meals. Despite the resident's care plan allowing her to make her own meal choices, the facility did not offer sufficient low-sugar or sugar-free options. Observations confirmed that only regular syrup was available, and the snack cart lacked low-sugar items. Interviews with dietary staff revealed that the facility did not offer specific special diets like low-carb or low-sugar, although some sugar-free snacks were available upon request. However, these were not consistently provided to the resident, leading to dissatisfaction and complaints during resident council meetings. The resident council minutes from various months in 2023 and 2024 documented repeated complaints about the lack of diabetic-friendly options and the hoarding of snacks by other residents and staff. The facility's policy on enhancing the dining experience emphasized providing nourishing and satisfying meals with as many choices as possible, but it failed to meet the specific dietary needs and preferences of the resident. This deficiency placed the resident at risk for impaired autonomy and decreased quality of life, as the facility did not adequately accommodate her dietary requirements and preferences.
Failure to Offer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that two residents were offered and educated regarding the Prevnar 20 (PCV20) pneumococcal vaccination or assessed by the physician to determine if contraindicated as recommended by the CDC. Specifically, one resident's immunization record documented previous pneumococcal vaccinations but lacked evidence of assessment or education regarding the PCV20. Another resident's immunization record lacked documentation of any pneumococcal vaccinations being received or offered since admission. The facility's policy, last revised in February 2024, stated that residents would be assessed for the need for the pneumococcal vaccination upon admission. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and assessment for the PCV20 vaccination for the two residents. This failure was confirmed by an administrative nurse who stated that the PCV20 was offered at admission and tracked in the Preventative Health tab, but the records did not reflect this practice.
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Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
The facility failed to coordinate hospice services within the care plans for two residents receiving hospice. Both residents had severe cognitive impairment and extensive ADL needs, and their MDS assessments documented hospice care. Their care plans included general directions about ADL assistance, pain monitoring, and consulting with hospice or the physician, but omitted key hospice-specific details such as hospice contact information, visit schedules, services to be provided, and what supplies, equipment, and medications hospice would furnish. Clinical record review and interviews with an administrative nurse confirmed that there was no documented coordination between hospice and facility care plans, contrary to the facility’s hospice policy requiring an interdisciplinary plan integrating hospice and facility services.
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 Coordinate Hospice Services in Resident Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain a coordinated hospice plan of care that integrated hospice services with facility services for two residents receiving hospice. For one resident with Alzheimer’s disease, CAD, and atrial fibrillation, the Significant Change MDS documented severely impaired cognition and extensive assistance needs for bed mobility and transfers, and indicated the resident was receiving hospice services. The resident’s care plan noted a terminal prognosis due to Alzheimer’s, directed staff to adjust ADL care, consult the physician for hospice care in the facility, and monitor and treat pain, but it did not include instructions on hospice services such as hospice staff visit schedules, supplies, medical equipment, or medications covered by hospice. The clinical record showed the resident had been admitted to hospice care months earlier, yet there was no documented evidence of coordination of care between hospice and the facility. For the second resident, diagnosed with PVD, DM, HTN, and atherosclerotic heart disease, the Significant Change MDS showed severe cognitive impairment with a BIMS score of two and dependence on staff for most ADLs, and documented that the resident received hospice services. The resident’s care plan recorded admission to hospice and directed staff to adjust ADL provision, encourage participation as desired, assess coping, respect wishes, and consult with the physician and hospice for continuing hospice care, as well as monitor for pain and notify the physician and hospice for breakthrough pain. However, the care plan lacked a hospice contact number, information on what supplies, equipment, and medications hospice would provide, and details on when hospice staff would be in the building and what care they would deliver. Observations and staff interviews confirmed these omissions. One resident was observed in bed receiving eye drops from a CMA, and during record review, the Administrative Nurse acknowledged that the facility care plan lacked specific information coordinating with the hospice care plan. For the second resident, the Administrative Nurse verified that the care plan did not contain information regarding hospice visits, phone numbers, or medical supplies provided by hospice, and stated that such information should be on the resident’s care plan. These findings were inconsistent with the facility’s Hospice Services policy, which required an interdisciplinary care plan integrating facility and hospice services, including coordination of services and supplies provided by the hospice provider.
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