Edwardsville Care And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Edwardsville, Kansas.
- Location
- 751 Blake Street, Edwardsville, Kansas 66111
- CMS Provider Number
- 175245
- Inspections on file
- 26
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 2 (2 serious)
Citation history
Health deficiencies cited at Edwardsville Care And Rehab during CMS and state inspections, most recent first.
A resident with schizoaffective disorder, hallucinations, delusions, and documented wandering and rejection of care was care planned as moderate to high elopement risk with interventions including increased supervision, room placement away from exits, secure lodging, and use of a WanderGuard. Despite this, the resident accessed an unlocked smoking patio, used a dining room chair to climb a tall fence, and left the premises during cold weather, walking about 1.8 miles to a truck stop and remaining away for hours. Staff did not complete required safety rounds on night and day shifts, were unaware of the resident’s absence for roughly nine hours, and some staff either did not see the resident all night or did not enter the room when the curtain was closed. The resident eventually returned and rang the front doorbell to be let back in, at which point staff assessed the resident and confirmed no injuries, and surveyors cited the failure to supervise and identify the elopement as immediate jeopardy.
A resident with paranoid schizophrenia, anxiety disorder, and cancer, who was care planned to be calmly redirected and reassured when escalating, became involved in a yelling incident with a dietary staff member during snack service. Camera footage and staff interviews confirmed that the staff member yelled and screamed at the resident in front of others, called the resident an expletive, and moved toward the resident until a CMA intervened and removed the resident from the situation. The resident reported she had only asked for more food, stated that being yelled at by staff was common, and said she did not feel safe when this occurred. The facility’s investigation acknowledged the staff member’s behavior as unacceptable but did not include written witness statements or documented psychosocial follow-up in the EMR, and social services staff either were unaware of the incident details or only performed undocumented, generalized verbal check-ins.
A resident with cognitive impairments and at risk for elopement exited the facility without staff knowledge, remaining outside in freezing temperatures for 45 minutes. The facility failed to ensure the WanderGuard system was functioning, and the exit door alarm did not sound due to a power interruption. The resident's care plan was not updated with new interventions after the incident, and the facility's investigation lacked witness statements.
The facility failed to employ a full-time certified dietary manager for its 94 residents, as required by its Food Service Staffing Policy. The Dietary Manager overseeing meal preparation was not certified, having completed the necessary classes but not yet taken the certification test. This deficiency was confirmed through observations and interviews, placing residents at risk of inadequate nutrition.
The facility's kitchen failed to meet professional standards for food service safety, with issues such as ice buildup in a freezer, uncovered and unlabeled food, missing Formica, and inadequate temperature monitoring. These deficiencies were verified by staff and placed 94 residents at risk for foodborne illness.
The facility failed to provide four residents with the required bed hold policy notice upon their transfer to the hospital. This oversight involved residents with various medical conditions, including cerebral atherosclerosis, schizoaffective disorder, COPD, and respiratory failure. The facility's policy mandates informing residents and their representatives of the bed hold policy, but this was not done, placing the residents at risk of not being able to return to their original rooms.
The facility failed to label and discard outdated insulin flex pens and expired stock medications, risking residents' safety. Observations revealed unlabeled and expired insulin pens for several residents and expired Vitamin D3 tablets. Nurses confirmed the requirement to date and discard outdated medications, as per facility policy, which was not followed.
The facility failed to assess and document the eligibility of several residents for the PCV20 pneumococcal vaccine, as per CDC guidelines. A review of EMRs showed no documented vaccinations or refusals for certain residents, despite physician orders. Interviews revealed staff were unaware of vaccine requirements, leading to a deficiency in following CDC recommendations and facility policy, placing residents at risk.
The facility failed to provide written notification of facility-initiated transfers for two residents with respiratory conditions. Both residents were transferred to the hospital without receiving the required notices, and the Ombudsman was not informed due to a misunderstanding about coverage. The facility lacked a policy for notice of transfer/discharge, contributing to the deficiency.
A resident with complex medical conditions was admitted to hospice care, but the facility failed to complete the required Significant Change MDS. Despite receiving hospice services, the resident's care plan lacked updates for end-of-life care, as the significant change MDS was overlooked, placing the resident at risk for inappropriate care.
The facility failed to follow smoking safety protocols for two residents. One resident, with multiple diagnoses, was observed smoking without a required apron, contrary to their care plan. Another resident, with nicotine dependence, was not assessed for smoking safety for 18 months, despite needing supervision and an apron. These lapses in policy adherence placed both residents at risk for smoking-related injuries.
The facility failed to coordinate hospice care for two residents, leading to a lack of appropriate end-of-life care. One resident, with cerebral atherosclerosis and schizoaffective disorder, was admitted to hospice but lacked a coordinated care plan. Another resident, with multiple mental health and physical conditions, also lacked hospice care interventions in their plan despite being admitted to hospice. The facility's hospice policy required coordination, but this was not implemented, placing both residents at risk.
Failure to Supervise Elopement-Risk Resident and Identify Prolonged Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards, resulting in an elopement. A resident with a diagnosis of schizoaffective disorder, hallucinations, delusions, rejection of care, and wandering behaviors was assessed as having intact cognition with a BIMS score of 15 and was care planned as being at moderate to high risk for elopement. The resident’s care plan included interventions such as increased supervision during exit-seeking behaviors, placement in a room away from exits, lodging in a secure unit, medication review, psychiatric services as needed, and use of a WanderGuard with placement and function checks. The WanderGuard was intended to limit the resident’s ability to enter the backyard without staff present. Despite these identified risks and planned interventions, the resident was able to access the smoking patio and leave the facility without staff knowledge or supervision. At approximately 2:45 AM, the resident used a dining room chair placed on the smoking patio to climb over the tall fence surrounding the patio and exit the premises. The door to the patio remained unlocked, and although the WanderGuard alarmed at the door and indicated the need for staff assistance, the resident still gained access to the patio and then climbed the fence. The facility’s cameras later showed the resident using the chair to scale the fence. Staff statements indicated that the last known observations of the resident occurred between approximately 9:00 PM and 2:00 AM, with no indications of unrest reported at those times. After leaving the facility, the resident walked approximately 1.8 miles to a truck stop, remained there for several hours, and then walked back to the facility, returning around 11:45 AM. During this time, outdoor temperatures ranged from 29.9°F to 45.3°F. Staff were unaware of the resident’s absence for about nine hours due to a failure to complete resident safety rounds on both the night and day shifts. Multiple staff members, including CNAs, a CMA, and an LN, reported not completing rounds or not entering the resident’s room, with one nurse noting that the resident’s curtain was pulled and she did not verify his presence. The resident ultimately rang the front doorbell to re-enter the facility, at which point staff assessed him and confirmed he had no injuries. The surveyors determined that the failure to complete rounds and adequately supervise the resident, combined with the environmental setup that allowed use of a movable chair to climb the fence, resulted in an elopement that constituted immediate jeopardy.
Removal Plan
- Update R1's care plan.
- Place a WanderGuard on R1.
- Conduct education on elopement and rounds with staff.
- Give written warnings to staff for failure to complete rounds.
- Complete magnetic lock checks on the doors.
- Complete an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting.
- Complete an elopement drill.
Verbal Abuse of Resident by Dietary Staff During Snack Service
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a staff member. The resident had diagnoses including paranoid schizophrenia, anxiety disorder, shortness of breath, and malignant neoplasm of the breast, with a BIMS score indicating intact cognition. Care plan interventions directed staff to allow the resident to voice needs and concerns, avoid arguing with delusions, redirect the resident to a quiet area if escalating, offer reassurance, and interact in ways that built rapport and monitored for precursors to socially inappropriate behaviors. Despite these interventions, during a snack pass the resident became involved in a yelling and screaming incident with a dietary staff member in the dining room. According to the facility’s investigation and staff interviews, the dietary staff member was seen and heard on camera yelling and screaming at the resident in front of other residents, shouting profanities and using vulgar and offensive references. A CMA reported hearing the dietary staff member call the resident an expletive and described the staff member attempting to get in the resident’s face, prompting the CMA to step between them and remove the resident from the hostile environment. The CMA stated the resident was not getting into anyone’s face or going after staff and that the resident had only asked for more food when the dietary staff member yelled at her. Administrative staff confirmed that camera audio captured the dietary staff member calling the resident an expletive and that staff had to intervene. The resident later stated she remembered the incident, recalled that she was only asking for more food when she was yelled at, and reported that being yelled at by staff was nothing new or out of the ordinary, stating she was yelled at all the time and did not feel safe when this occurred. The facility’s investigation documented that the resident admitted she shouted back at the staff member and that staff intervened and helped calm her down and support her. The investigation noted that the staff member’s behavior, as seen on camera, was not accepted by the facility. The facility’s abuse prevention policy defined abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and included verbal abuse. The surveyors determined that the facility failed to ensure the resident remained free from verbal abuse, and this failure placed the resident in immediate jeopardy. The investigation and record review also showed gaps in follow-up related to the incident. The facility’s investigation did not include any staff witness statements, despite identification of a direct witness. The resident’s EMR lacked evidence of any follow-up psychosocial assessments or documented staff interviews with the resident related to the incident. One social services staff member stated she was not aware of the details of the incident and had not completed any psychosocial follow-up. Another social services staff member reported speaking with the resident the next day and performing generalized verbal check-ins but did not document these interactions and did not conduct or record a formal psychosocial assessment related to the event. Administrative staff stated there was no additional staff education completed after the incident because the involved staff member was terminated and other staff had prior ANE training.
Removal Plan
- Conduct interviews with each resident to identify if any residents were having adverse outcomes due to staff yelling and shouting profanities and/or any other incidents that may have gone unreported.
- Educate all staff that shouting profanities, calling residents vulgar names, or acting in any other excessive, obtuse, obscene, or nonsensical way would not be permitted at the facility.
- Complete Abuse, Neglect, and Exploitation training with staff, with an emphasis on their duty to report.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and appropriate interventions to prevent the elopement of a cognitively impaired resident, identified as at risk for elopement. The resident, who had diagnoses including schizoaffective disorder and diabetes, exited the facility without staff knowledge and remained outside in freezing temperatures for approximately 45 minutes. The resident's care plan had identified them as at risk for elopement and included interventions such as the use of a WanderGuard, which was not functioning properly due to a power interruption at the exit door. The resident's care plan directed staff to assess for elopement risk and ensure the WanderGuard was checked every shift. However, the exit door used by the resident was not equipped with a WanderGuard alert system, and the facility's investigation revealed that loose wiring caused a power interruption, preventing the alarm from sounding. The facility's policy required monitoring of at-risk residents, but the resident was able to leave the facility unimpeded, indicating a failure in supervision and monitoring. The facility's investigation lacked witness statements regarding the elopement, and the nurse's notes did not document a health assessment of the resident upon their return. The facility's policy stated that new wandering behavior or attempted elopement should be documented, and the care plan updated, but there was no documentation of new interventions implemented after the incident. This deficiency placed the resident in immediate jeopardy for potentially life-threatening injury due to exposure to freezing temperatures.
Removal Plan
- Staff conducted a headcount ensuring the safety of all residents in the facility.
- Camera footage was reviewed, identified the malfunction, and effected immediate repairs on the faulty exit door.
- Audited all doors and windows to ensure no similar situations existed. Reported the issue to the stated agency, physician et al.
- Conducted all staff in-service How to check Doors for Lock function.
- Conducted an Ad Hoc QAPI meeting with the Executive Director, Director of Nursing, and Medical Director.
Lack of Certified Dietary Manager
Penalty
Summary
The facility failed to employ a full-time certified dietary manager for its 94 residents, which was a requirement according to their Food Service Staffing Policy. The policy stipulated that if the facility dietitian was not full-time, another qualified nutritional professional should be employed as the Dietary Manager. This individual must meet specific qualifications, such as being a certified dietary manager or having a similar certification in food service management and safety. However, the Dietary Manager (DM) BB, who was overseeing meal preparation, did not possess the necessary certification. Although DM BB had completed the required classes, she had not yet scheduled a date to take the certification test. The deficiency was identified through observations and interviews conducted by the surveyors. On one occasion, DM BB was observed overseeing the preparation of a noon meal, which included meatloaf, Capri vegetables, a dinner roll, and strawberry cake. During an interview, DM BB confirmed that she was not a certified dietary manager. This was further verified by Administrative Staff A, who acknowledged that DM BB lacked the necessary certification. The absence of a certified dietary manager placed the residents at risk of not receiving adequate nutrition, as the facility did not comply with its own staffing policy requirements.
Food Service Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen. A white upright freezer had a significant ice buildup, and the middle section of a three-door refrigerator contained uncovered, undated, and unlabeled bowls of cantaloupe, which were discarded by dietary staff. The serving window had areas with missing Formica, and the wall under the dishwasher area had blackish streaks and a black substance on the caulking. Additionally, a piece of sheetrock was missing from the ceiling, covered with plastic, and the floor in front of the refrigerators had missing tiles. These conditions were verified by the Dietary Manager and Administrative Staff, who acknowledged the issues and provided explanations for some of the deficiencies. The facility's documentation revealed lapses in temperature monitoring for various refrigeration units, with several dates lacking recorded temperatures. The facility's policies required that food items be covered, labeled, and dated, and that refrigeration temperatures be monitored and documented. However, these procedures were not consistently followed, placing the 94 residents who received meals from the facility's kitchen at risk for foodborne illness. The facility's policies on supervision, maintenance services, and sanitation were not adequately implemented, contributing to the observed deficiencies.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide written information regarding the bed hold policy to four residents or their representatives when they were transferred to the hospital. This deficiency was identified through observations, record reviews, and interviews. The residents involved were not given the necessary documentation that would inform them of how long their bed would be held during their absence, which is a requirement according to the facility's policy. Resident 35, who had diagnoses including cerebral atherosclerosis, schizoaffective disorder, and dysphagia, was transferred to the hospital without receiving the bed hold policy notice. The resident's electronic health record and care plan did not document the provision of this notice. Similarly, Resident 19, with conditions such as schizoaffective disorder, hypertension, and COPD, was also transferred without receiving the bed hold notice. The facility's administrative staff confirmed the oversight in both cases. Resident 38, diagnosed with COPD, and Resident 72, with acute and chronic respiratory failure and asthma, were also transferred to the hospital without being provided the bed hold policy notice. The facility's policy requires that residents and their representatives be informed of the bed hold policy upon admission and prior to any transfer. However, in these instances, the facility did not adhere to its policy, placing the residents at risk of not being able to return to their original rooms upon discharge from the hospital.
Failure to Discard Outdated Medications
Penalty
Summary
The facility failed to properly label and discard outdated insulin flex pens and expired stock medications, which placed residents at risk for receiving ineffective medications. During an observation of the facility's A hall treatment cart, it was found that the insulin flex pens for three residents were not labeled with open or expired dates. Specifically, one resident's Novolog flex pen was not labeled, another resident's Basaglar flex pen was not labeled, and a third resident's Novolog flex pen was labeled with an expired date. Additionally, a bottle of Vitamin D3 with an expired date was found on the medication cart. Further observations in the A hall Medication Room revealed another resident's Ozempic flex pen was labeled with an expired date. Licensed Nurse I and Administrative Nurse D confirmed that the nurses were responsible for dating the flex pens when opened and discarding outdated insulin and stock medications. The facility's policy on the storage of medication mandates that all drugs and biologicals be stored safely and that discontinued, outdated, or deteriorated drugs be returned to the pharmacy or destroyed. The failure to adhere to these procedures resulted in the presence of outdated medications, posing a risk to the residents.
Failure to Assess and Document Pneumococcal Vaccination Eligibility
Penalty
Summary
The facility failed to assess and document the eligibility of several residents for pneumococcal vaccinations, specifically the PCV20 vaccine, as per the latest CDC guidelines. The review of the facility's Electronic Medical Records (EMR) revealed that residents, including R85, R16, R57, and R42, had no documented pneumococcal vaccinations or refusals, despite having physician orders directing staff to provide the vaccine according to facility protocol. This oversight indicates a lack of adherence to the facility's policy, which mandates that residents be assessed for vaccination eligibility within five working days of admission and be offered the vaccine unless contraindicated or previously vaccinated. Interviews with facility staff, including Administrative Nurses D and E, highlighted a lack of awareness and implementation of the CDC guidelines for the PCV20 vaccine. Nurse D was unaware of the vaccine requirements and eligibility criteria, while Nurse E confirmed that the facility had not assessed residents for eligibility for further pneumococcal vaccinations, relying instead on the PPSV23 vaccine. This deficiency in following the CDC recommendations and the facility's own policy placed residents at risk of acquiring and spreading pneumococcal disease.
Failure to Provide Written Notification of Transfers
Penalty
Summary
The facility failed to provide timely written notification of facility-initiated transfers to the residents or their representatives for two residents, R72 and R38. R72, who had a diagnosis of acute and chronic respiratory failure and asthma, was transferred to the hospital without receiving a written notice of the transfer. Despite having intact cognition, as indicated by a BIMS score of 15, R72 was not informed of the transfer, nor was the bed hold policy communicated to her or her representative. Administrative staff confirmed the lack of notification, and Social Services indicated that the Ombudsman was not notified due to a misunderstanding about coverage. Similarly, R38, diagnosed with COPD and receiving oxygen therapy, was transferred to the hospital due to abnormal vital signs without receiving a written notice of the transfer. The resident's clinical record lacked evidence of such notification, and administrative staff verified the omission. Social Services also confirmed the failure to notify the Ombudsman, citing the same misunderstanding about the need for notification. The facility did not provide a policy for notice of transfer/discharge, contributing to the deficiency.
Failure to Complete Significant Change MDS for Hospice Resident
Penalty
Summary
The facility failed to complete the required Significant Change Minimum Data Set (MDS) for a resident who had been admitted to hospice care. The resident, identified as R81, had a complex medical history including schizoaffective disorder, anxiety disorder, major depressive disorder, and other physical ailments. Despite these conditions and the resident's admission to hospice care, the facility did not conduct a significant change MDS assessment, which is necessary to evaluate and adjust the care plan according to the resident's current needs. This oversight was acknowledged by the Administrative Nurse, who stated that the significant change MDS was overlooked and not completed. The resident's care plan, dated July 2024, did not include interventions for end-of-life or hospice care, despite a physician's order indicating hospice admission in October 2023. Observations and interviews revealed that hospice services were being provided, such as incontinence supplies and CNA visits, but the lack of a comprehensive assessment meant that the resident's care plan was not updated to reflect these changes. The facility's policy requires a comprehensive assessment when there is a significant change in a resident's condition, but this was not adhered to, placing the resident at risk for inappropriate care and unmet needs.
Failure to Follow Smoking Safety Protocols
Penalty
Summary
The facility failed to adhere to the care plan for a resident, identified as R6, who was at risk for smoking-related injuries. R6 had multiple diagnoses, including cerebral infarction, anxiety, paranoid schizophrenia, depression, and abnormal involuntary movements, which necessitated specific precautions while smoking. The care plan required staff to assist R6 to and from the designated smoking area, observe for unsafe smoking behaviors, and provide a smoking apron. However, observations revealed that R6 was smoking without a smoking apron, contrary to the care plan directives. Staff interviews confirmed that R6 should have been provided with a smoking apron, highlighting a lapse in following the established care plan. Another resident, identified as R53, was also not adequately assessed for safe smoking practices. R53 had a diagnosis of nicotine dependence and drug-induced subacute dyskinesia, with a documented need for staff supervision and a smoking apron. Despite this, R53's medical record lacked recent assessments of his smoking abilities or privileges, and he was observed smoking without a smoking apron. Staff interviews revealed that R53 had not been assessed for smoking safety for the past 18 months, contrary to the facility's policy requiring quarterly assessments. This oversight placed R53 at risk for accidents or injury while smoking. The facility's policies on accident prevention and smoking safety were not effectively implemented, as evidenced by the failure to provide necessary smoking aprons and conduct regular safety assessments for residents R6 and R53. The lack of adherence to these policies and care plans resulted in preventable risks for accidents and injuries related to smoking for these residents.
Failure to Coordinate Hospice Care for Residents
Penalty
Summary
The facility failed to ensure a coordinated plan of care for two residents, R35 and R81, who were receiving hospice services. For R35, the electronic health record indicated diagnoses of cerebral atherosclerosis, schizoaffective disorder, and dysphagia, with moderately impaired cognition. Despite being admitted to hospice care, R35's care plan lacked documentation of hospice services due to a terminal prognosis. Observations and interviews revealed that the facility did not have specific information on the care plan that coordinated with the hospice care plan for R35, placing her at risk for inappropriate end-of-life care. Similarly, R81's electronic medical record included diagnoses such as schizoaffective disorder, anxiety disorder, major depressive disorder, and drug-induced secondary Parkinsonism. The resident's care plan did not include end-of-life or hospice care interventions, despite a physician order indicating admission to hospice. Observations showed that R81 was receiving hospice services, but the facility's care plan lacked coordination with the hospice provider, as confirmed by staff interviews. This deficiency also placed R81 at risk for inappropriate end-of-life care. The facility's hospice policy and procedure required written identification of hospice services and coordination of the resident's person-centered care plan with the hospice provider. However, the facility failed to adhere to these procedures for both residents, as evidenced by the lack of coordinated care plans and documentation. The absence of a coordinated care plan between the facility and hospice provider for both residents was a significant deficiency, as it compromised the quality of end-of-life care provided to them.
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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