Diversicare Of Council Grove
Inspection history, citations, penalties and survey trends for this long-term care facility in Council Grove, Kansas.
- Location
- 400 Sunset Drive, Council Grove, Kansas 66846
- CMS Provider Number
- 175239
- Inspections on file
- 18
- Latest survey
- July 8, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Diversicare Of Council Grove during CMS and state inspections, most recent first.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as identified through surveyor observation and record review.
A strong urine odor and unsanitary conditions were observed in a common area, where a resident was found sitting in a saturated recliner with wet clothing. Staff delayed cleaning the chair, and the area remained stained and odorous for hours. Family and staff reported ongoing issues with cleanliness and odor, and the facility could not provide a policy for maintaining a clean, comfortable environment.
A resident with severe cognitive impairment and incontinence was left in a urine-soaked recliner that was not promptly or properly disinfected, as housekeeping used only hot water without chemicals. In a separate incident, a nurse performed wound care on another resident without following required hand hygiene protocols, including failing to wash hands between glove changes and after removing personal protective equipment. These actions did not align with the facility's infection control policies.
Multiple rooms were found to have significant fly infestations, with one resident's wound care revealing live maggots. Staff acknowledged ongoing fly issues, limited and ineffective mitigation efforts, and the absence of a pest management policy.
A resident with intact cognition and a skin infection received a dressing change from a nurse who did not close the door or privacy curtain, leaving the resident exposed to the hallway. Facility policy required privacy during such care, but this was not followed, as confirmed by both the nurse and an administrative nurse.
A resident with multiple medical and behavioral diagnoses was issued a 30-day involuntary discharge without sufficient evidence in the clinical record to justify the action. Documentation did not show that the resident's needs could not be met or that others were endangered, and there was a lack of documented behavioral interventions or incident reports. Staff interviews confirmed the absence of physical aggression toward other residents, and the care plan lacked discharge planning prior to the notice.
The facility failed to submit accurate staffing data to CMS for four quarters, inaccurately reporting weekend staffing due to the omission of a salaried nurse's hours. The facility lacked a policy for completing the PBJ, and data submission was handled by the corporate office.
The facility failed to update care plans for residents with scabies and catheter management issues. A resident with dementia and vision loss had a scabies infection not reflected in their care plan. Another resident with severe cognitive impairment had catheter management issues, with tubing often on the floor and no alternatives for securing the catheter. A third resident lacked a care plan update for a leg bag and dignity cover, despite expressing a preference for privacy. Lastly, a resident with muscular dystrophy and a scabies infestation did not have an updated care plan or notification to their representative.
A facility failed to accommodate a resident with muscular dystrophy by not following up on recommendations for a new electric wheelchair. Despite an occupational therapy evaluation recommending a new wheelchair to improve posture and independence, the facility did not act on these recommendations. The resident's representative reported multiple attempts to contact the facility administrator without response, and the facility lacked documentation of any follow-up or communication regarding the wheelchair needs.
A resident with muscular dystrophy and a BIMS score of 15 was diagnosed with scabies, but the LTC facility failed to notify the resident's chosen representative about the new treatment plan. Despite the facility's policy requiring such notification, the representative was not informed, and the care plan was not updated, as confirmed by record reviews and staff interviews.
Two residents with severe cognitive impairment were observed with their urinary catheters exposed in public areas of the facility, violating their right to dignity. One resident's leg bag was visible without a dignity cover, and another resident's catheter tubing was exposed and unanchored. Staff confirmed the lack of appropriate covers and anchoring devices, despite facility policies emphasizing dignity and respect.
A resident with severe cognitive impairment and multiple medical conditions was not provided safe transfer techniques by staff, leading to a deficiency. The resident, who required substantial assistance, was initially instructed to transfer herself without the use of a gait belt or locked wheelchair brakes, contrary to standard safety practices.
A facility failed to provide proper catheter care for a resident with severe cognitive impairment, allowing catheter tubing to lie on the floor and lacking an anchoring device. Additionally, the facility did not analyze a resident's voiding diary to create a personalized toileting plan, leading to a fall. Staff were unaware of the resident's toileting plan, and the facility's fall prevention policy was not followed.
A resident with COPD and CHF received unsanitary respiratory care when a CMA failed to replace oxygen tubing and nebulizer components that fell on the floor. The CMA did not perform hand hygiene or wear gloves, contrary to facility policies. The resident, with severe cognitive impairment, required continuous oxygen and nebulizer treatments, highlighting the need for proper sanitary practices.
Two residents with constipation diagnoses did not receive necessary PRN medications for bowel movements, leading to prolonged periods without bowel movements. Despite having physician orders for laxatives, the facility lacked a standardized bowel protocol, resulting in inconsistent administration of medications. Staff interviews revealed uncertainty about bowel management procedures, contributing to the deficiency.
The facility did not maintain accurate daily staffing information for its 43 residents. Over a 90-day period, the actual hours worked by staff were not recorded on the Daily Staffing Sheets, which were posted each morning without updates. Administrative Nurse D confirmed the omission, and the facility lacked a policy for completing these sheets.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and objectives of the resident. The report does not specify the exact nature of the treatment or care that was not provided, nor does it detail the resident’s medical history or condition at the time of the deficiency.
Failure to Maintain Clean and Homelike Environment in Common Area
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment in the common living area, as evidenced by multiple observations of strong urine odors and unsanitary conditions. Upon entering the facility, a strong odor of urine was detected, particularly in the A-Hall unit. A resident was observed sitting in a recliner with visibly wet pants and a saturated chair, both emitting a strong urine smell. Certified Nurse Aides used a sit-to-stand lift to assist the resident, confirming the saturation of both the resident and the recliner. Despite requests to housekeeping, the chair remained uncleaned for an extended period, and when it was eventually shampooed, it remained wet and stained hours later. Family members and staff corroborated the presence of persistent urine odors and noted a decline in cleanliness over the past several months. Staff reported using odor-masking sprays to address the smell. The facility was unable to provide a policy related to maintaining a clean, safe, and comfortable home-like environment for residents.
Infection Control Deficiencies: Inadequate Hand Hygiene and Improper Cleaning of Soiled Furniture
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by inadequate hand hygiene during wound care and improper cleaning of soiled furniture. One resident with severe cognitive impairment, a history of urinary tract infections, and total incontinence was observed sitting in a fabric recliner that was saturated with urine. Certified Nurse Aides transferred the resident to be cleaned and changed but did not immediately clean or disinfect the soiled chair. Housekeeping later cleaned the chair using only hot water in a shampooer, without any disinfectant chemicals, and the chair remained visibly stained and wet for several hours. Staff interviews revealed inconsistent understanding and application of cleaning protocols, with some staff believing hot water alone was sufficient and others stating that soiled cloth chairs should be discarded or disinfected with germicidal wipes. Additionally, a licensed nurse was observed performing wound care on another resident without following proper hand hygiene protocols. The nurse donned gloves and a gown without performing hand hygiene, removed and cleaned wounds, and changed gloves multiple times without washing hands between glove changes or before applying clean dressings. The nurse also removed personal protective equipment in the incorrect order and failed to perform hand hygiene at required points during the procedure. The nurse later acknowledged these lapses and described the correct procedures, which were not followed during the observed care. Facility policies required maintaining a safe, sanitary, and comfortable environment to prevent and manage the transmission of infections. However, observations and staff interviews demonstrated that these policies were not consistently implemented, resulting in practices that could contribute to the spread of infection among residents.
Failure to Implement Effective Pest Control Measures
Penalty
Summary
The facility failed to ensure effective pest control, as evidenced by multiple observations of a significant fly infestation in the rooms of two residents. On several occasions throughout the day, large numbers of flies were observed in these rooms, with one room displaying a fly paper strip as the only visible mitigation effort, while the other room showed no evidence of any fly control measures. During wound care for one resident, live maggots were found in a lower leg wound. Facility staff acknowledged ongoing concerns about flies, identified certain rooms as problem areas, and noted that fly paper strips had been ineffective. Although fly bags had been ordered and received, they had not yet been installed. The facility was unable to provide a policy related to pest management.
Failure to Provide Privacy During Personal Care
Penalty
Summary
A deficiency occurred when a licensed nurse entered a resident's room to perform a dressing change without providing privacy. The nurse did not close the door or pull the privacy curtain, leaving the resident visible from the hallway during the procedure. The resident involved had a diagnosis of local skin infection and an unspecified adult personality disorder, with documentation indicating intact cognition. The facility's policy required staff to inform residents about care and ensure privacy by shutting the door and pulling the curtain, but this was not followed during the observed event. Both the nurse and an administrative nurse confirmed that privacy should have been provided during personal care.
Involuntary Discharge Without Sufficient Documentation or Interventions
Penalty
Summary
The facility initiated a 30-day involuntary discharge for a resident with multiple complex diagnoses, including schizoaffective disorder, diabetes mellitus type 2, heart failure, visual loss, personality and behavioral disorders, and alcohol abuse. The resident's clinical record documented behavioral symptoms such as verbal outbursts, accusations, and occasional refusal of care, but there was no evidence in the record to validate the reason for the involuntary discharge. Specifically, the clinical documentation did not show that the resident's needs could not be met at the facility or that the resident had placed other residents in danger, which are required justifications for involuntary discharge. Throughout the review period, progress notes described the resident as having episodes of yelling, cursing, and making accusations against staff and other residents, as well as some physical actions like throwing a shoe and rolling a wheelchair into staff. However, the records consistently lacked documentation of interventions attempted to address these behaviors, and there were no investigative or incident reports regarding alleged inappropriate behaviors toward other residents. Staff interviews confirmed that while the resident was verbally aggressive and irritable, there were no known physical altercations with other residents, and all aggressive behaviors were primarily directed at staff. One administrative staff member reported a threat made by the resident toward another resident, but this was not recognized or reported as resident-to-resident abuse, and no incident report was filed. The care plan for the resident did not include discharge planning interventions prior to the issuance of the involuntary discharge notice. Additionally, the facility was unable to provide a policy related to involuntary discharge. The lack of documentation supporting the necessity of the involuntary discharge, absence of evidence that the resident's needs could not be met, and failure to document or attempt behavioral interventions led to the deficiency. The facility's actions did not demonstrate that the transfer or discharge met the resident's needs or preferences, nor that the resident was prepared for a safe transfer or discharge.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for four consecutive quarters. The deficiency was identified through observation, interview, and record review, revealing that the facility did not accurately report weekend staffing on the Payroll Base Journal (PBJ). Despite the facility's daily staffing sheets indicating that weekend staffing was the same as weekdays, the PBJ data showed excessively low weekend staffing. This discrepancy was partly due to the omission of hours worked by a salaried employee, Administrative Nurse D, whose hours were not recorded on the facility timesheet. The facility lacked a policy regarding the completion of the PBJ, and the responsibility for submitting the data to CMS was delegated to the corporate office.
Failure to Update Care Plans for Residents with Scabies and Catheter Management Issues
Penalty
Summary
The facility failed to review and revise care plans for four residents, leading to deficiencies in addressing their medical needs. Resident 8, diagnosed with dementia and vision loss, exhibited symptoms of scabies, but the care plan was not updated to reflect this condition or the treatment prescribed by the physician. Despite two rounds of treatment with Permethrin cream, the care plan remained unchanged, contrary to the facility's policy requiring updates based on resident status. Resident 19, with severe cognitive impairment and an indwelling urinary catheter, had issues with catheter management. Observations revealed the catheter tubing frequently lay on the floor, and the resident often removed the anchoring device. The care plan did not include alternatives for securing the catheter or address the resident's behavior of removing the device, which was necessary to maintain catheter hygiene and proper positioning. Resident 41, also with severe cognitive impairment and an indwelling catheter, lacked a care plan update to include the use of a leg bag and a dignity cover. The resident expressed a preference for privacy regarding the visibility of the catheter bag, but the facility did not provide a dignity cover. Similarly, Resident 18, with muscular dystrophy and a scabies infestation, did not have an updated care plan to reflect the new diagnosis and treatment, nor was there documentation of notifying the resident's representative about the change in condition.
Failure to Accommodate Resident's Wheelchair Needs
Penalty
Summary
The facility failed to reasonably accommodate the needs of Resident 18, who has muscular dystrophy, contractures, and is paraplegic, by not following up on recommendations for a new electric wheelchair. The resident's current wheelchair was donated years ago and was no longer suitable, as it contributed to poor positioning and increased the risk of contractures. Despite an occupational therapy evaluation in March 2023 recommending a new wheelchair to maximize the resident's posture and independence, the facility did not act on these recommendations. The resident's medical records from March 2023 to August 2024 lacked documentation of any follow-up on the wheelchair assessment and recommendations. The resident's representative reported multiple attempts to contact the facility administrator regarding the wheelchair, but received no response. The facility's administrative staff confirmed that the recommendations were forwarded to the corporate office, but there was no documentation of any decision or communication with the resident's representative. The resident expressed concerns about the deteriorating condition of his current wheelchair and the lack of communication from the facility. The therapy consultant reiterated the need for a new wheelchair to prevent further decline in the resident's condition. The facility did not have a policy in place to address reasonable accommodation of identified needs for residents, leading to a failure in meeting the resident's needs for a suitable wheelchair.
Failure to Notify Resident's Representative of New Treatment
Penalty
Summary
The facility failed to notify a resident's chosen representative when the resident required a new form of treatment for a newly diagnosed scabies infestation. The resident, who was cognitively intact with a BIMS score of 15, had a history of muscular dystrophy, contractures, immobility syndrome, and anxiety disorder. Despite the resident's clear preference for family involvement in care discussions, the facility did not inform the representative about the change in condition or the new treatment order for Permethrin cream to address the scabies infestation. The deficiency was identified through a review of the resident's records, which showed a lack of documentation indicating that the representative was notified of the condition change and treatment plan. Observations confirmed the resident was receiving treatment for scabies, and interviews with staff and the resident further revealed the oversight. The facility's policy required notification of the resident's representative in such cases, but this protocol was not followed, and the resident's care plan was not updated to reflect the new treatment.
Failure to Maintain Resident Dignity with Urinary Catheter Management
Penalty
Summary
The facility failed to maintain the dignity of two residents by not adequately covering their indwelling urinary catheters while they were in public areas. Resident 41, who has severe cognitive impairment and requires substantial assistance with toileting, was observed multiple times in the dining room and common areas with his urinary catheter leg bag visible to others. The facility did not provide a dignity cover for the leg bag, despite the resident expressing a preference for it to be concealed. Staff members confirmed the absence of appropriate covers for the leg bags, and the facility's policy emphasized the importance of treating residents with dignity and respect. Resident 19, who also has severe cognitive impairment and multiple medical conditions, was observed in the dining room with her urinary catheter tubing exposed and lying on the floor. The resident, who uses a wheelchair and requires assistance for transfers, did not have a lap robe to cover her exposed thighs, and the catheter tubing was not anchored properly. Staff noted that the resident often removed the anchoring device, but no alternative solutions were in place to ensure her dignity was maintained in public areas. The facility's failure to provide dignity covers and proper anchoring for urinary catheters resulted in the residents being exposed in common areas, contrary to the facility's policy on resident rights. The observations and interviews with staff highlighted a lack of resources and procedures to protect the residents' dignity, as required by the facility's own guidelines.
Failure to Ensure Safe Transfer Techniques for Resident at Risk for Falls
Penalty
Summary
The facility failed to ensure safe transfer techniques for a resident, identified as R19, who was at risk for falls due to severe cognitive impairment and multiple medical conditions, including a cerebral vascular accident, osteoarthritis, chronic obstructive pulmonary disease, and neurogenic bladder. The resident required substantial to maximal assistance for transfers and had a history of falls. Despite these needs, a Certified Nurse Aide (CNA) instructed the resident to transfer herself from her wheelchair to her bed without initially locking the wheelchair brakes or using a gait belt, which are standard safety practices. During the observed transfer, the resident struggled to stand and pivot into bed, requiring eventual assistance from the CNA who then used a gait belt. Additionally, the resident's water cup was placed on the floor, out of reach, which could have led to overreaching and potential falls. The facility's policy on falls prevention required staff to identify interventions to prevent falls, but these were not adequately implemented in this instance, leading to a deficiency in providing safe transfer techniques for the resident.
Deficiencies in Catheter Care and Toileting Plan
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident with severe cognitive impairment and multiple medical conditions, including a history of urinary tract infections. Observations revealed that the resident's urinary catheter tubing was frequently found lying directly on the floor, and the resident lacked an anchoring device for the catheter. Despite the resident's tendency to remove the anchoring device, staff did not ensure the tubing was kept off the floor, and the facility did not provide a skills checklist for catheter care. Another deficiency involved the facility's failure to analyze a three-day voiding diary for a resident with stress incontinence and severe cognitive impairment. The resident experienced frequent incontinence episodes, but the facility did not interpret the voiding pattern data to develop a personalized toileting plan. This lack of analysis contributed to the resident's fall while attempting to reach the bathroom independently. Interviews with staff revealed a lack of awareness regarding the resident's toileting plan, and the facility's fall prevention policy was not adequately followed. The facility did not evaluate a toileting schedule for the resident, which was a contributing factor to the resident's fall and the failure to address the resident's toileting needs effectively.
Unsanitary Respiratory Care for Resident with COPD and CHF
Penalty
Summary
The facility failed to provide sanitary respiratory care for a resident with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). The resident, who had severe cognitive impairment, required continuous oxygen via nasal cannula and nebulizer treatments with ipratropium-albuterol. During an observation, a Certified Medication Aide (CMA) was seen handling the resident's oxygen tubing and nebulizer components in an unsanitary manner. The oxygen tubing cannula was found lying on the floor, and the CMA attempted to clean it with a wet paper towel instead of replacing it. Additionally, the CMA did not perform hand hygiene or wear gloves while handling the nebulizer components, which were also dropped on the floor and inadequately rinsed before being returned to the storage container. The facility's policies on oxygen and nebulizer guidelines, which align with the Center for Disease Control Guidelines for Preventing Healthcare-Associated Pneumonia, were not followed. The Administrative Nurse confirmed that the standard practice would require replacing the oxygen cannula, tubing, and nebulizer components if they fell on the floor, and that staff should perform hand hygiene and wear gloves during such procedures. The failure to adhere to these guidelines resulted in unsanitary respiratory care for the resident, who had a compromised respiratory system.
Failure to Administer PRN Medications for Constipation
Penalty
Summary
The facility failed to ensure that two residents, R12 and R27, remained free from unnecessary medications related to the administration of PRN medications for bowel movements. Resident 12, who had a diagnosis of constipation and required extensive assistance for transfers and toileting, did not have a bowel movement for five days. Despite the care plan indicating the need for PRN bowel medication, the resident's Medication Administration Record showed no PRN medications available for constipation. Interviews revealed that the facility lacked a specific bowel protocol, and the resident confirmed experiencing constipation without receiving medication. Similarly, Resident 27, who also had a diagnosis of constipation and required substantial assistance for toileting, did not have a bowel movement for four days. The resident had physician orders for various laxatives, but reported inconsistent administration of these medications by the nursing staff. Interviews with staff indicated that while the computer system alerted nurses to residents who had not had a bowel movement in three days, there was no consistent protocol for addressing constipation, and the facility lacked a policy regarding bowel movements. The deficiency was further highlighted by the lack of a standardized bowel protocol and the absence of standing orders for bowel management. Both residents experienced prolonged periods without bowel movements, and the facility's failure to administer PRN medications as needed contributed to this issue. Staff interviews revealed uncertainty about the facility's bowel management procedures, indicating a systemic issue in addressing residents' constipation needs.
Failure to Maintain Accurate Daily Staffing Information
Penalty
Summary
The facility failed to display accurate and publicly accessible staffing information on a daily basis for its 43 residents. Upon review of the facility's Daily Staffing Sheets over the past 90 days, it was found that the actual hours worked by staff were not recorded on these sheets. The staffing sheets were completed and posted each morning without any updates or changes to reflect the actual hours worked. An interview with Administrative Nurse D confirmed that the facility did not include actual hours worked on the daily staffing sheets. Additionally, the facility lacked a policy for the completion of these daily staffing sheets, contributing to the deficiency in maintaining accurate staffing records.
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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