Diversicare Of Chanute
Inspection history, citations, penalties and survey trends for this long-term care facility in Chanute, Kansas.
- Location
- 530 W 14th Street, Chanute, Kansas 66720
- CMS Provider Number
- 175214
- Inspections on file
- 23
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Diversicare Of Chanute during CMS and state inspections, most recent first.
A hospice resident with a history of stroke, depression, anxiety, psychosis, insomnia, and impaired mobility had an established psychotropic regimen including clonazepam, lorazepam (Ativan), and Seroquel to manage terminal agitation and behavioral symptoms. After admission to hospice, an administrative nurse insisted the resident could not receive both clonazepam and Ativan, pressured staff to contact the PCP, and clonazepam was abruptly discontinued without hospice being notified, despite the PCP’s original plan to taper it gradually. Following this change, documentation showed the resident became increasingly agitated, paranoid, confused, and tearful, refused care and medications, attempted unsafe activities such as trying to leave his room and facility, and sustained an unwitnessed fall with a skin tear and low back discomfort, requiring more frequent narcotic pain medication. The resident’s DPOA and hospice staff reported that the resident’s behaviors and anxiety worsened after clonazepam was stopped and that they felt pressured by facility leadership to alter the medication regimen that had previously kept the resident more comfortable.
Surveyors observed that food and drink served to residents was not palatable, attractive, or at a safe and appetizing temperature, resulting in a deficiency related to meal quality and service standards.
Several residents reported not receiving their mail on weekends due to the absence of staff responsible for mail delivery on Saturdays. Staff interviews confirmed that mail was only checked and delivered Monday through Friday, with no clear process for weekend delivery, resulting in delayed access to mail for residents.
A resident with lymphedema and cellulitis had maggots found in his leg dressings due to the facility's failure to maintain clean and dry dressings. Despite the resident's concerns, staff did not change the soiled dressings for several days, and there was no protocol for handling such situations. Observations showed unsanitary conditions in the resident's room and improper hygiene practices by staff during wound care.
A resident with a history of muscle weakness and incontinence did not receive the prescribed wound care treatment due to staff failing to apply Dermafoam as ordered by the physician. Instead, an ointment was used, and the staff was unaware of the correct treatment protocol. The facility lacked a policy for following physician orders, leading to a deficiency in care.
A resident with a fractured right fibula and on medications contributing to constipation did not have a bowel movement for five days. The facility failed to monitor and address this issue, as the care plan lacked information on bowel function, and no medication for constipation was administered. Despite the resident's complaints and the facility's process for bowel monitoring, the physician was not notified, leading to a deficiency in care.
A resident with lymphedema and cellulitis received improper wound care, with staff failing to maintain a clean environment and perform appropriate hand hygiene. Dressings were not clean or intact, and supplies were placed on unclean surfaces. The facility's policies for hand hygiene and clean dressing changes were not followed, leading to an unsanitary environment.
A resident at the facility was found to have maggots on their skin during a wound clinic visit, indicating a failure in the facility's pest control program. Observations revealed flies in the resident's room and soaked bandages, with staff interviews highlighting a lack of awareness and communication regarding the pest issue. The facility's pest control policy was not effectively implemented, leading to this deficiency.
The facility failed to administer the physician-ordered amount of oxygen to a resident with COPD and ensure another resident with respiratory failure received oxygen as prescribed. Observations and staff interviews revealed deviations from prescribed oxygen levels and issues with empty oxygen bottles, highlighting a significant lapse in following physician orders.
A resident with atrial fibrillation and dependence on renal dialysis did not receive a physician-ordered anticoagulant medication for 22 days after a fistula placement procedure. The facility failed to document and administer the medication, and did not notify the cardiologist about the procedure. The administrative nurse was unaware of the error until 23 days later, and the facility lacked a policy for following physician orders.
Failure to Follow Hospice-Directed Psychotropic Regimen Resulting in Agitation and Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure a hospice resident received necessary care and his personalized, physician‑ordered medication regimen to manage terminal agitation and promote comfort. The resident had a history of cerebral infarction, depression, anxiety, psychosis, insomnia, impaired balance, lower extremity impairment with a prosthesis, and functional dependence in multiple ADLs. Care Area Assessments identified risks for further ADL decline, falls, incontinence, skin breakdown, pain, increased falls, impaired balance, and worsening depression and anxiety. The resident’s care plan documented he was on hospice for end‑of‑life care related to a terminal cerebral infarction and that staff were to coordinate care with hospice, notify hospice of any change in condition or medication changes, and provide medications as ordered while monitoring for effectiveness and side effects. The resident’s EMR showed he was receiving clonazepam 0.5 mg twice daily for anxiety related to altered mental status and Seroquel for dementia with distressing psychotic features. A provider order then added scheduled lorazepam (Ativan) 0.5 mg three times daily for agitation and irritability and admitted the resident to hospice. On hospice admission, most medications were discontinued, but clonazepam, lorazepam, Seroquel, Tylenol, Lantus, and PRN Tramadol were continued. Shortly afterward, an administrative nurse questioned why the resident had both scheduled Ativan and clonazepam, asserted the resident could not be on both, and required that the primary care provider be called to choose one or the other. A subsequent provider order discontinued clonazepam and continued lorazepam and Seroquel. Hospice was not informed of the discontinuation, and hospice staff later confirmed they had not received an order to stop clonazepam and only learned from facility staff that it had been stopped. Following the abrupt discontinuation of clonazepam, documentation showed the resident became increasingly agitated, confused, and distressed. Nursing notes described the resident becoming upset, refusing medications, expressing paranoid thoughts that staff were trying to poison him, picking up a folding table, threatening to throw it through a door, and requiring repeated staff interventions before eventually taking medications. Additional notes recorded the resident yelling for help, attempting to put on his prosthetic leg to “get some things out of the truck,” refusing care, being visibly upset and tearful, expressing confusion about his location and his daughter’s whereabouts, and having delusions about the Air Force being in the facility. The resident experienced an unwitnessed fall while trying to go downstairs, resulting in a skin tear and apparent discomfort, and he required increased use of narcotic pain medication after clonazepam was stopped. Hospice and the primary care provider later noted that the resident’s agitation and confusion increased around the time clonazepam was discontinued and that the original plan had been to taper clonazepam gradually while adjusting lorazepam, rather than stopping clonazepam abruptly. Interviews further documented that the administrative nurse told hospice and the resident’s DPOA that the resident could not be on both clonazepam and Ativan and indicated that if the DPOA did not agree, the resident could be taken home or the facility’s medical director would be used to discontinue medications. The DPOA reported feeling harassed, bullied, and pressured to have one of the medications discontinued, despite believing the combined regimen of lower‑dose Seroquel, clonazepam, and Ativan best controlled the resident’s behaviors and anxiety. The primary care provider confirmed she had intended to wean clonazepam over one to two weeks while adjusting Ativan but felt pressured by the situation at the facility to discontinue one of the medications sooner than planned. Facility administration later stated that the administrative nurse did not have authority to dictate what medications residents were allowed to take and that it would have been more appropriate to clarify concerns with the prescriber rather than stating the resident could not have the medication. The facility’s psychotropic medication policy stated that psychotropics are to be used only when a practitioner determines they are appropriate for a diagnosed condition and beneficial to the resident, with monitoring and documentation of response, underscoring that the resident’s ordered hospice comfort regimen was not followed as intended.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. Surveyors observed that the food and beverages did not meet these standards during their review. The deficiency was identified based on direct observation of the meals served to residents, noting issues with the quality, presentation, and temperature of the food and drink.
Failure to Ensure Timely Delivery of Resident Mail on Weekends
Penalty
Summary
The facility failed to provide residents with reasonable access to receive their mail, specifically on Saturdays. Multiple residents reported that while they received mail Monday through Friday, mail was not delivered to them on Saturdays because the staff responsible for mail delivery did not work weekends. One resident noted that he received mail at his nearby house on Saturdays and expected the same at the facility. Staff interviews confirmed that the mail was checked and delivered only on weekdays, and there was confusion among staff regarding who was responsible for mail delivery on weekends. Activity staff and administrative staff both stated they did not work on Saturdays, and mail accumulated over the weekend was delivered on Mondays. Facility policy affirms residents' rights to send and receive mail, but the policy did not address timely delivery of mail received on Saturdays. Observations and staff interviews indicated that no system was in place to ensure mail was delivered to residents on Saturdays, resulting in delayed access to their correspondence. The deficiency was identified through direct observation, resident interviews, and staff statements, all confirming the lack of weekend mail delivery.
Failure to Maintain Clean Dressings and Proper Hygiene
Penalty
Summary
The facility failed to ensure that a resident, who was diagnosed with lymphedema, venous insufficiency, and cellulitis, had clean and dry dressings on his lower extremities. On a scheduled appointment, it was discovered that the resident's dressings were soaked with urine and fluid, and maggots were found on his right lower extremity. The dressings had not been changed since they were applied four days prior, despite the resident voicing concerns about the condition of his wraps to a licensed nurse the night before his appointment. The facility lacked additional orders to guide staff on actions to take if the dressings became soiled, wet, or loose. The resident's care plan and physician orders required that his lymphedema wraps be kept clean, dry, and intact, with outpatient therapy scheduled to change the dressings on specific days. However, the facility staff failed to monitor and address the condition of the wraps adequately. Documentation indicated that the wraps were not clean, dry, or intact on several occasions, yet no action was taken to rectify the situation or notify the physician for further instructions. The resident's condition was further compromised by the lack of a clear protocol for staff to follow when the dressings were not maintained as required. Observations revealed that the resident's room was unsanitary, with soiled dressings and gauze on the floor, and flies present, contributing to a foul odor. Staff members were observed handling the resident's dressings and performing wound care without adhering to proper hygiene protocols, such as changing gloves and performing hand hygiene. The facility's failure to maintain the resident's dressings and follow appropriate hygiene practices placed the resident at risk for further skin impairment and the presence of maggots in the wound areas.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to provide appropriate wound treatment for a resident, identified as R4, who had a medical history of muscle weakness, edema, and frequent incontinence leading to moisture-associated skin damage (MASD). Despite physician orders to apply Dermafoam to R4's bilateral upper back thigh wounds, the facility staff did not follow these orders. On a specific date, a Licensed Nurse (LN) applied Dermaseptin ointment instead of the prescribed foam dressing, indicating a failure to adhere to the treatment plan. The LN admitted to never having applied foam to those wounds before and was unaware of the correct treatment protocol. Further investigation revealed that the facility lacked a policy regarding adherence to physician orders, contributing to the oversight. Administrative staff confirmed that the Dermafoam should have been in place at all times and not treated as a PRN dressing. Additionally, another LN who worked the night shift was unaware of the treatment required for R4's thigh wounds, highlighting a communication gap among the staff. The resident, R4, reported that the foam dressing had been off since the previous night, and she was unsure if the nursing staff was aware of this. This series of actions and inactions led to the deficiency in providing the necessary wound care as per the physician's orders.
Failure to Monitor and Address Constipation in Resident
Penalty
Summary
The facility failed to monitor and address the bowel functioning of Resident 3, who had a medical history of a fractured right fibula and required assistance with personal care. Despite receiving medications such as Ultram and Bumex, which can contribute to constipation, there was no documentation of bowel movements for five days from June 20 to June 24, 2024. The facility's records, including the Baseline Care Plan and Care Plan, lacked information regarding bowel function, and there was no medication administered for constipation during this period. The facility's process for bowel monitoring involved CNAs reporting bowel movements daily, with alerts generated if a resident had not had a bowel movement in three days. However, this process was not effectively followed for Resident 3. Interviews with staff revealed that the facility had standing physician orders for constipation that could be activated if needed, but these were not utilized for Resident 3. The Licensed Nurse and Administrative Nurse were unaware of any actions taken to address the lack of bowel movements, and the physician was not notified as required by the facility's policy. Resident 3 expressed experiencing significant constipation and stated that at home, she took Miralax to manage her condition. Despite complaints of constipation reported by the CNA to the Licensed Nurse, no action was taken to address the issue, resulting in a deficiency in the facility's care for Resident 3.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper handling of a resident's wound care. The resident, who had a medical history of lymphedema, venous insufficiency, and cellulitis, was observed with dressings that were not clean, dry, or intact. The resident's room was unsanitary, with dressings and gauze on the floor, and flies present, contributing to a foul odor. The staff did not follow proper procedures for maintaining a clean environment, as evidenced by the presence of a tied-up plastic bag and a pile of wraps and gauze on the floor. During the dressing change, the licensed nurse (LN) failed to perform appropriate hand hygiene and did not use a clean dressing change procedure. The LN used the same contaminated gloves to clean the resident's legs after removing soiled dressings and did not perform hand hygiene before applying new gloves. Additionally, the LN placed treatment supplies directly on surfaces without a barrier and used a trash can to prop the resident's foot during the dressing change, which is against the facility's policy. The LN also failed to address the leaking dressings promptly and did not have an order for what to do if the wraps were not clean, dry, or intact. The facility's policies for hand hygiene and clean dressing changes were not followed, as the LN did not wash hands after removing gloves, did not use a barrier for dressing supplies, and did not dispose of dressings that touched unclean surfaces. The administrative nurse confirmed that hand hygiene should be performed during dressing changes, and a barrier should be used for dressing supplies. The failure to adhere to these policies resulted in an unsafe and unsanitary environment, increasing the risk of infection transmission.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a resident having maggots identified on their skin. On a visit to a wound clinic, two maggots were discovered on the resident's right lower extremity by Consultant Staff GG while removing urine and fluid-soaked dressings. The dressings had been in place since 06/13/24, and the maggots were found on 06/17/24. The facility's progress notes did not document the presence of maggots upon the resident's return from the clinic. Observations on 06/24/24 revealed flies in the resident's room, a foul odor, and soaked bandages, indicating a lack of effective pest control measures. Interviews with staff revealed a lack of awareness and communication regarding the pest issue. Housekeeping Staff U noted flies in the resident's room but did not take action due to a lack of resources. Maintenance Staff V was unaware of any fly issues or maggots and stated that concerns should be communicated through the TELS system. Administrative Staff A was not informed of the maggot issue until the surveyor's arrival. The facility's pest control policy, dated 09/01/14, was not effectively implemented, as evidenced by the presence of flies and maggots in the resident's environment.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to administer the physician-ordered amount of oxygen to Resident 5 (R5) and ensure Resident 1 (R1) received oxygen as prescribed. R5, diagnosed with chronic obstructive pulmonary disease (COPD), had a physician order for oxygen at three liters per minute via nasal cannula. However, observations on multiple occasions showed the oxygen concentrator set between 3.5 to 4.0 liters. Licensed Nurse H admitted to increasing the oxygen flow without verifying the current physician order, which was still set at three liters per minute. This discrepancy was confirmed by Administrative Nurse D, who emphasized the importance of following physician orders for oxygen administration. Resident 1 (R1), diagnosed with acute respiratory failure with hypoxia and heart failure, had a physician order for oxygen at two liters per minute via nasal cannula as needed to maintain oxygen saturation above 90 percent. However, during a physician visit, R1's oxygen tank was found empty, resulting in an oxygen saturation level of 80 percent. Observations and interviews revealed that R1 frequently experienced issues with empty oxygen bottles, both in the facility and during transportation to appointments. Staff members, including a Certified Medication Aide and Maintenance Staff, confirmed that R1 often returned from dialysis with an empty or improperly set oxygen bottle. Administrative Staff A and Nurse G acknowledged the issue and noted that the facility's policy required ensuring residents had enough oxygen before leaving the building. The facility's policy on oxygen guidelines, dated 01/01/22, stated that oxygen should be provided according to a physician's order, including the dose and rate of administration. The facility failed to adhere to this policy for both R5 and R1, resulting in deviations from the prescribed oxygen levels. This failure was corroborated by multiple staff members and documented observations, highlighting a significant lapse in following physician orders and ensuring proper oxygen administration for residents with respiratory needs.
Failure to Administer Physician-Ordered Medication
Penalty
Summary
The facility failed to start a physician-ordered medication for a resident (R1) with diagnoses of atrial fibrillation and dependence on renal dialysis, resulting in 22 days without the ordered medication. The resident was supposed to start taking apixaban (Eliquis), an anticoagulant, after a fistula placement procedure. However, the facility did not document or administer the medication until 23 days after the initial order. The Medication Administration Record (MAR) for February and March 2024 lacked instructions for administering apixaban until March 15, 2024, and the medication was only administered starting March 16, 2024. The facility also failed to notify the cardiologist about the fistula placement and the need to restart the medication. Interviews and record reviews revealed that the facility's administrative nurse was unaware of the medication error until March 18, 2024. The facility lacked a policy for following physician orders, and the process for handling new orders upon a resident's return from an appointment was not followed. The charge nurse and medical records staff were responsible for ensuring new orders were noted and brought to the morning meeting, but this did not occur in R1's case. The family member of R1 also reported multiple calls questioning whether the medication had been restarted, indicating a communication breakdown within the facility.
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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