El Dorado Care And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in El Dorado, Kansas.
- Location
- 900 Country Club Lane, El Dorado, Kansas 67042
- CMS Provider Number
- 175324
- Inspections on file
- 19
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at El Dorado Care And Rehab during CMS and state inspections, most recent first.
Two residents experienced unmet nutritional needs when the facility failed to follow diet orders, monitor weight loss, and provide required meals. A resident with DM and a documented vegetarian diet order received regular diet meal tickets listing meat-based options, had poor intake of facility meals, and experienced a 16.3% weight loss in 19 days without timely documentation, provider notification, or initiation of nutritional interventions, despite policies requiring monitoring of impaired nutrition and unplanned weight loss. Another resident with ESRD on a therapeutic renal dialysis diet left very early for thrice-weekly dialysis and was not provided breakfast or alternative food to take, with EMR entries showing breakfast as not available or not applicable on dialysis days and staff confirming no meals or snacks were prepared, contrary to facility policies requiring at least three meals daily and coordination of nutritional management for dialysis care.
The facility failed to submit complete and accurate direct care staffing data to CMS via the PBJ system, resulting in reports that showed excessively low weekend staffing for multiple fiscal quarters. An administrative staff member acknowledged that a former business office manager had submitted the PBJ data incorrectly. This failure occurred despite a facility policy requiring uniform electronic submission of verifiable payroll data for all direct care staff, including agency and contract personnel, and specifying whether staff were employees or contracted workers.
Staff failed to follow the facility’s infection prevention and control policies, including Enhanced Barrier Precautions and hand hygiene, during care for multiple residents. CNAs performing peri-care and ostomy care used soiled gloves to open drawers, handle supplies, and apply barrier cream, did not change gloves appropriately, and did not perform hand hygiene after glove removal. Wound care consultants providing treatment to a resident’s foot wound used the same gloves to cleanse the wound and then handle clean dressings, the treatment cart, door handles, and the resident’s closet, and one consultant repeatedly removed and reapplied gloves to use a phone without hand hygiene. During wound care for a resident on EBP with a Foley catheter, colostomy, and hemodialysis port, several wound care staff wore gloves only and did not don required gowns, despite facility policy requiring gown and glove use for high-contact care of residents on EBP.
Surveyors observed that a resident’s Novolog insulin pen on a medication cart was in use without an open or discard date, and a treatment cart contained four expired stock medications (aspirin, vitamin D, calcium with vitamin D, and zinc). A CMA verified the medications were expired, and an LN acknowledged that staff were required to date insulin pens when opened. These findings showed that staff did not consistently label insulin pens or remove expired stock medications as required by the facility’s medication storage policy.
Surveyors identified multiple food service sanitation and hygiene deficiencies, including staff personal items and beverages placed on food prep counters next to unsealed and moldy bread products, missing temperature log entries for refrigeration units, and numerous undated, unsealed, or expired food items in the refrigerator, walk-in cooler, freezer, and dry storage. Food and canned goods were stored directly on the floor, and storage areas contained debris. Dietary staff entered the kitchen without hairnets, drank coffee in the kitchen near uncovered ready-to-serve food, used a single paper towel to wipe a thermometer between multiple food temperature checks, and reheated pureed food uncovered in the microwave, all contrary to facility policies on food safety, sanitation, and employee hygiene.
A resident repeatedly experienced his pants slipping down and exposing part of his buttocks while standing and walking in common areas, including the dining room and nurse’s station, requiring him to hold up his pants and leading another resident to comment on what she saw. Staff interviews indicated they were aware the clothing did not fit properly, and facility policy states residents must be treated with respect and dignity and that care should emphasize comfort and personal needs, including appropriate clothing.
A resident with chronic respiratory failure, tracheostomy, schizophrenia, and severely impaired cognition had an existing court-supported advance directive and DNR, documented in the EMR and signed by the guardian and a physician. During a mock survey, regional staff reportedly told facility staff the DNR was not valid because it was signed after guardianship paperwork, and the then-DON had the provider discontinue the DNR and change the resident’s status to full code. Subsequent provider orders and the care plan directed CPR and full-code measures, while notes and interviews showed staff confusion about the DNR’s validity and no follow-through by social services to assist the guardian in re-establishing the DNR, contrary to facility policy requiring that advance directives be respected and clearly documented.
A resident with chronic respiratory failure, schizophrenia, severe cognitive impairment, and total dependence for ADLs was observed with a red abrasion on the forehead that had not been documented in weekly skin assessments or progress notes. Staff had care plan instructions to inspect skin and report changes, but no documentation or investigation of the injury occurred until the next day, when an RN noted a purple abrasion of unknown origin and speculated the resident’s head may have contacted the wall after a room change. A CNA reported not noticing the abrasion, and an LN acknowledged being informed of the injury but failed to document it, assuming another nurse had done so, while administrative nursing staff were unaware of the injury.
A resident with anemia, CKD, DM, HTN, and major depressive disorder, who required extensive ADL assistance and used a wheelchair, was sent to the hospital after a critical Hgb result and provider direction to transfer. The record showed no written bed-hold notice or documentation of the facility’s bed-hold policy for this facility-initiated transfer, and staff confirmed that no such notice was given. The facility also lacked evidence that the State LTCO was notified of the resident’s transfer/discharge, and could not produce an Ombudsman notification policy, despite a written bed-hold policy requiring resident notification and filing of the bed-hold information in the medical record.
The facility failed to provide consistent bathing and grooming for several residents who required assistance with ADLs. One resident with cognitive impairment went extended periods without documented baths or showers despite a care plan requiring assisted bathing, and was observed with stained clothing and chin hair. Another resident with intact cognition, who preferred twice-weekly showers and staff-assisted shaving, lacked documentation of receiving the requested showers, appeared unshaven, and reported not getting showers while being told he had refused, with no refusal forms available. A third resident with severe cognitive impairment and total dependence for personal hygiene was repeatedly observed with facial hair and dirty, jagged fingernails despite care plans directing staff to assist with grooming. Staff interviews revealed inconsistent practices and confusion over who was responsible for shaving and nail care, contrary to facility policy requiring necessary services to maintain residents’ grooming and personal hygiene.
A resident with dementia, prior CVA, and ear malformation causing hearing impairment was care planned and ordered to use a right-ear hearing aid during the day, with staff responsible for ensuring its availability, function, and placement. Despite this, the resident was repeatedly observed without a hearing aid, and multiple CNAs and a CMA reported they had never seen one or were unaware of a care plan for its use. Activity and social services staff reported the hearing aid had stopped working months earlier, attempts to reach the DPOA about repair were unsuccessful, and no audiology visit was known to have occurred, while an RN later indicated a replacement hearing aid had been purchased and left charging at the nurse’s desk. The facility did not provide a policy governing hearing aid management.
A resident with Alzheimer’s disease, muscle weakness, and moderately impaired cognition, assessed as high risk for falls and dependent for transfers and toileting, experienced multiple falls in the dining room when staff did not consistently follow the fall-prevention care plan. The plan required non-slip footwear, not leaving the resident unattended in the dining room after meals, keeping the resident in a wheelchair rather than a dining chair, using an antithrust cushion with Dycem, and removing the Hoyer sling from the wheelchair after transfers. Fall investigations documented that the resident was found on the dining room floor on several occasions, including after not being offered toileting post-meal and when the lift sling had not been removed. Observations showed the resident being transported with the sling still under her and sling straps looped on wheelchair handles, while staff acknowledged the resident’s impulsivity and history of falls, demonstrating inadequate supervision and failure to implement care-planned interventions.
A resident with GERD, major depressive disorder, and protein calorie malnutrition, who was cognitively intact and independent with oral hygiene, developed tooth pain and a dental abscess that was treated only with antibiotics. Facility assessments documented tooth pain and abscessed teeth, but the care plan did not address broken or decayed teeth or specify dental services. Observation later revealed the resident had missing teeth, one decayed and split tooth, and another broken at the lower jaw. An administrative nurse acknowledged she had not assessed the resident’s mouth until the survey, confirmed the presence of two broken teeth, and verified the resident was not enrolled in the facility’s dental services and had received no dental care since admission, contrary to the facility’s routine dental care policy.
A resident did not receive timely or complete meals when dietary meal tickets failed to print and staff were unaware the meals were missing. On one morning, the resident waited in a wheelchair in her room well past normal breakfast time before receiving a tray with only cream of wheat and toast, without requested items such as eggs, orange juice, sugar, butter, or jelly. The previous evening’s supper had also been delayed for the same reason. Facility policy required that residents be provided palatable, attractive food at a safe, appetizing temperature and that food be prepared and served in compliance with safe food handling practices.
An administrative staff member misappropriated funds from three residents by writing checks on their personal accounts, forging signatures, and depositing the checks into her own bank account without proper written authorization. One affected resident had dementia with moderately impaired cognition and required assistance with most ADLs, and there was no documented authorization in the EHR for the facility to manage this resident’s funds. The staff member claimed the transactions were part of a Medicaid spend-down and that cash was placed in a facility safe or intended to be kept for the resident’s future use, but the checks were flagged by the bank’s fraud department, prompting the resident’s representative to confront the staff member. Subsequent review identified additional forged checks for two other residents, all in violation of facility policies prohibiting misappropriation and requiring written consent for management of resident funds.
A resident with paraplegia and other medical issues experienced a delay in surgery due to the facility's failure to obtain preoperative orders. The resident's surgery to close a PEG tube site was canceled and rescheduled because nursing staff did not receive or follow up on the necessary orders. Interviews revealed a lack of communication and follow-up, and the facility lacked a policy to ensure all components of planned procedures were in place.
Two residents requiring tracheostomy care in an LTC facility were found to have improperly stored suction tubing, with ends uncapped and placed directly in drawers with other supplies. This practice violated the facility's policy for maintaining sterile conditions, posing a risk of infection. Staff acknowledged the tubing should have been capped and stored properly to prevent contamination.
A resident with heart failure received Metoprolol outside prescribed parameters on multiple occasions without physician notification. The resident also refused the medication several times, with no documentation of physician notification or education on risks and benefits. Staff interviews confirmed the need to follow physician orders, but the facility lacked a policy for handling such situations.
The facility failed to prevent foodborne illness by not adhering to food safety and sanitation policies. Observations revealed uncovered condiment bottles, a dirty handwashing sink, a splattered air fryer, and an improperly drained ice machine. Staff confirmed these issues, indicating non-compliance with facility policies.
A facility failed to ensure proper infection control during incontinence care for a resident with a sacral pressure ulcer. The resident, with a history of diabetes, heart failure, and cerebral infarction, required substantial assistance and was incontinent. During care, a CNA improperly wiped from the rectum over the wound, contrary to infection control practices. The facility's policy required care that promotes healing, which was not followed, leading to a deficiency.
The facility failed to maintain safe patient care equipment for two residents. An over-the-toilet commode was found to be unstable, and commode grab bars were not securely fixed, posing a risk during use. The facility lacked a specific maintenance policy for these items, contributing to the deficiency.
The facility failed to ensure that three residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and/or the residents' choices, specifically related to skin treatments for ostomies. Dressings for suprapubic catheters and a gastrostomy tube were not changed as ordered by the physician, and the facility lacked policies to address these issues.
The facility failed to ensure that three residents received treatment and care in accordance with physician's orders related to skin treatments for ostomies and gastrostomy tubes. Dressings were not changed as ordered, and concerns were not adequately addressed by the administrative staff.
Failure to Provide Ordered Vegetarian Diet, Address Significant Weight Loss, and Serve Breakfast on Dialysis Days
Penalty
Summary
The deficiency involves the facility’s failure to meet residents’ nutritional needs by not honoring a prescribed vegetarian diet and not responding to significant weight loss for one resident, and by not providing breakfast meals on dialysis days for another resident. One resident with diabetes mellitus was admitted for IV antibiotic therapy after a recent UTI and was identified as at risk for dehydration and nutritional issues. Her baseline care plan and physician orders documented a vegetarian diet, regular texture, and thin liquids, and the care plan instructed staff to monitor and record meal intakes, obtain RD evaluation as needed, and complete weekly weights. Despite this, her MDS showed she did not receive a therapeutic diet, and her meal tickets were printed as a regular diet with meat-based options such as chicken, cheeseburger, hot dog, and sloppy joe, and no vegetarian menu was available. Dietary staff acknowledged they did not have a vegetarian meal ticket for her and had not yet ordered soy burgers, and staff reported difficulty providing her vegetarian diet due to lack of appropriate choices. The same resident’s intake of facility-provided meals was documented as poor, less than 50% of meals, and she was described as very particular about what she ate, with her husband frequently bringing in outside food of unknown amounts. Weights documented in the EMR showed 156.2 lbs on admission and again on a later date, followed by a drop to 132.8 lbs and then a calculated weight of 128.4 lbs when the wheelchair weight was subtracted, representing a significant weight loss of 16.3% in 19 days. The EMR lacked a progress note addressing the weight loss on the date it was first recorded, and nursing documentation showed that when the provider was in the facility shortly after the low weight was obtained, staff updated the provider about low blood pressure but not about the weight loss. The provider was not documented as being notified of the weight loss until several days later, and there was no evidence of re-weighing, appetite stimulant orders, or nutritional supplements being initiated despite existing orders allowing the RD or interdisciplinary team to start supplements. Administrative and dietary staff later reported they were unaware of the weight loss at the time and had not reviewed the resident’s weights. The deficiency also includes failure to provide breakfast meals to another resident with ESRD and moderate protein-calorie malnutrition who received dialysis three times per week. This resident had a therapeutic renal dialysis diet ordered and required set-up assistance for eating, with documentation that his meal intakes were generally good and adequate to meet estimated needs. His EMR showed multiple breakfast meal entries on dialysis days marked as “not available” or “not applicable,” and staff interviews revealed that he left very early for dialysis and was not provided breakfast or a snack to take with him. The resident reported he did not eat breakfast before dialysis because none was provided, and he did not receive a snack at the dialysis center. CNAs and an LN confirmed that no actual breakfast meal was prepared for him on dialysis mornings, the kitchen was closed at the time he woke up, and no alternative food or drinks were offered to take with him. The facility’s own policies on dialysis care and frequency of meals required communication about nutritional management and provision of at least three meals daily at regular times or according to resident needs and care plan, but these were not followed for this resident on dialysis days. The facility’s Nutrition (Impaired)/Unplanned Weight Loss clinical protocol required monitoring and documenting weight and dietary intake in a way that allowed ready comparison over time, defining current nutritional status through interdisciplinary assessment, and using supplementation strategies such as food fortification and increased portions for residents with impaired nutrition or risk factors. For the resident with significant weight loss and a vegetarian diet order, the record and interviews showed that although poor intake and vegetarian preference were known, the facility did not adjust menus to provide appropriate vegetarian options, did not consistently document or act on poor intake, and did not promptly assess or intervene when substantial weight loss occurred. For the resident on dialysis, the facility’s Dialysis, Care for a Resident policy required communication about nutritional and fluid management, and the Frequency of Meals policy required at least three meals or their equivalent daily, but staff acknowledged that no breakfast meal or equivalent was prepared or offered on dialysis mornings, and refusals were not documented in the EMR or care plan.
Inaccurate PBJ Submission Resulting in Underreported Weekend Staffing
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS through the Payroll Based Journal (PBJ) system as required, resulting in reported staffing levels that did not reflect actual staffing. CMS PBJ reports for Fiscal Year 2026 Quarter 1 and Fiscal Year 2025 Quarter 3 showed excessively low weekend staffing, indicating that the data submitted did not accurately capture direct care staff hours. During an interview, an administrative staff member acknowledged awareness of a problem and reported that the previous Business Office Manager had submitted the PBJ information incorrectly. The facility’s own PBJ F851 policy required submission of payroll data in a uniform CMS-specified format for all direct care staff, including community, agency, and contract staff, and required that the data distinguish between employees and contracted or agency staff, but this policy was not followed, leading to incomplete and inaccurate staffing information being reported.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, including Enhanced Barrier Precautions (EBP) and hand hygiene, during resident care. Surveyors observed two CNAs providing perineal care to a resident when one CNA used the same soiled gloved hand that had been used for peri-care to open a drawer, remove barrier cream, and apply it to the resident’s buttocks. The same CNA then removed her gloves and applied a new pair without performing hand hygiene. The second CNA did not change gloves after cleansing a small, soft bowel movement and continued assisting the resident with clothing, then removed her soiled gloves, did not perform hand hygiene, touched the doorknob, exited and re-entered the room, and applied new gloves. In interviews, both CNAs stated they did not realize they were required to wash their hands after removing soiled gloves and did not realize they had used soiled gloved hands to open drawers and apply barrier cream. In a separate observation, one of the same CNAs provided ostomy care to another resident by removing the ileostomy bag and wafer, cleansing around the stoma, and then using the same soiled gloves to open a box of ostomy supplies, remove a new bag/wafer, and apply it to the resident’s abdomen. The CNA then opened a drawer with gloved hands to obtain wipes and barrier cream, applied new gloves, opened the bathroom and closet doors, removed a brief, cleansed the resident’s buttocks, and applied barrier cream. Afterward, the CNA removed her gloves and assisted the resident with her brief without performing hand hygiene. The assisting CNA also removed her gloves, failed to perform hand hygiene, applied new gloves, and opened the closet door to remove the resident’s clothes. In interviews, both CNAs acknowledged they did not realize they had to wash their hands when removing gloves during care and that they had used soiled gloved hands to open drawers and closets and to handle supplies. Additional deficiencies were observed during wound care for another resident and during wound care for a resident on EBP. A wound care consultant removed soiled dressings from a resident’s right foot and great toe, removed her gloves, and then applied new gloves without hand hygiene. Another consultant cleansed the open wound using a 4x4 gauze without flipping it, kept the same gloves on, and then handled clean dressings, the treatment cart, and door handles with those gloves. The primary consultant intermittently removed one glove to use her phone for wound measurements and photographs, reapplied gloves without hand hygiene, and continued wound care. The second consultant continued to wear the same gloves used to clean the wound while opening drawers on the treatment cart, entering the resident’s closet to obtain dressings, and wiping down the treatment cart. In a separate observation, multiple wound care consultants provided wound care to a resident on EBP who had a Foley catheter, colostomy, and hemodialysis port, but none wore gowns as required; all wore gloves only. Interviews with the wound care consultants and the facility’s infection preventionist confirmed that gowns and gloves were required for residents on EBP and that staff were expected to perform hand hygiene after glove removal and avoid touching clean items or residents with soiled gloves, consistent with the facility’s EBP and hand hygiene policies.
Failure to Label Insulin Pen and Remove Expired Stock Medications
Penalty
Summary
Surveyors found that the facility failed to properly label and store medications and biologicals as required by facility policy and professional standards. During observation of the 100–200 hall medication cart at 8:05 AM, an insulin pen (Novolog) for Resident 41 was found without an open date or discard date. In a separate observation of the treatment cart at 8:15 AM, four bottles of stock medications were found to be expired: aspirin 325 mg (expired 01/26), vitamin D tablets (expired 03/26), calcium 600 mg with vitamin D 5 mcg (expired 07/25), and zinc 50 mg tablets (expired 01/26). A certified medication aide confirmed that the stock medications were expired, and a licensed nurse confirmed the insulin pen was undated and stated that staff were supposed to date insulin pens when opened. The facility’s Medication Storage policy, dated 03/2026, stated that all drugs and biologicals would be stored in a safe, secure, and orderly manner and that discontinued, outdated, or deteriorated drugs or biologicals would not be used and would be returned to the pharmacy or destroyed per state regulations. These observations and staff confirmations demonstrated that the facility did not ensure insulin pens were dated when opened and did not remove expired stock medications from use, contrary to its own policy and accepted standards for medication storage and labeling.
Food Service Sanitation and Hygiene Deficiencies in Dietary Department
Penalty
Summary
The deficiency involves failure to prepare and serve food under sanitary conditions and in accordance with professional standards. Surveyors observed staff personal items, including a purse and a drink tumbler with a straw, placed on a kitchen prep counter next to undated and unsealed hamburger and hot dog rolls, one bag of which contained rolls with fuzzy green mold. On the same counter, there were unsealed and undated bags of potato chips. Temperature logs for the kitchen refrigerator, walk-in cooler, and walk-in freezer had missing entries on multiple dates, despite expectations that temperatures be recorded at least daily or three times a day. In the kitchen refrigerator, surveyors found wilted lettuce in an unsealed bag, undated opened beef base, undated mustard and relish, unsealed and undated deli meats, and opened honey-thickened liquids dated beyond the manufacturer’s seven-day discard timeframe, along with undated cottage cheese and salsa. In dry storage, surveyors identified a dented can of cheese sauce in the front rotation of canned items, a box of gravy mixes and large cans of apple pie filling stored directly on the floor, and multiple unsealed dry products including rice cereal, spaghetti, and lasagna noodles. In the walk-in cooler, temperature logs again lacked entries for several days, and food items such as celery, wilted lettuce, a bowl of batter covered with foil but not labeled, unsealed sausage patties, a large container of egg salad dated beyond seven days, a loosely covered pastry, and an unlabeled container of meat in brown fluid were observed. In the walk-in freezer, boxes and bags of meat were stored directly on the floor, the internal thermometer was found on the floor, and the cooler and freezer floors contained significant debris that appeared to be old food crumbs. These conditions were inconsistent with facility policies requiring food to be stored off the floor, properly labeled, dated, sealed, and discarded when outdated, wilted, or moldy, and requiring clean storage areas. Additional deficiencies were observed in staff hygiene and food handling practices. One dietary staff member drank coffee in the kitchen and placed the cup on a counter next to an uncovered, ready-to-serve cake, and reported that he routinely drank coffee while working in the kitchen. The same staff member used a single paper towel to wipe a thermometer between multiple food temperature checks and later reported this was his usual practice, despite expectations to properly sanitize the thermometer after each use. He also reheated pureed food in the microwave uncovered, contrary to facility expectations. Another dietary staff member entered the kitchen multiple times without a hairnet before being instructed to put one on, and later acknowledged she should have applied it before entering. These practices conflicted with facility policies on employee hygiene, hair restraint use, prohibition of eating and drinking in food preparation areas, and proper sanitation of equipment and utensils.
Failure to Maintain Resident Dignity When Clothing Did Not Fit Properly
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident dignity by allowing a male resident’s pants to repeatedly fall and expose his buttocks in common areas without effective intervention. On one observed occasion during meal service at 11:55 AM, the resident stood up from the dining table and, as he began to walk, his pants fell below his abdomen, exposing the top of his buttocks. The resident had to grab the waistband of his pants to hold them up, and another elderly female resident verbally remarked that she had seen his buttocks. On another observed occasion at 12:10 PM, the same resident was at the nurse’s station on the phone when his plaid pajama pants slipped below his abdomen, exposing approximately a quarter of his buttocks. As he walked to the dining room, he continued to pull up his pants in an attempt to keep them from falling. During an interview on 06/08/26 at 11:00 AM, a licensed nurse stated that the resident had not experienced weight loss and she did not know why his clothes were not fitting correctly. The facility’s policy on Respect and Dignity, Right to Personal Property, Including Searches and Illegal Substances, dated 06/25, states that residents have the right to be treated with respect and dignity and that staff shall provide person-centered care emphasizing residents’ comfort, independence, and personal needs and preferences, including accommodation of personal clothing unless it infringes on others’ rights or safety. The repeated exposure of the resident’s buttocks in public areas, observed by other residents, occurred despite this policy and constituted a failure to promote and protect the resident’s dignity.
Failure to Honor a Resident’s Existing DNR and Advance Directive
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s existing do not resuscitate (DNR) order and advance directive. The resident had chronic respiratory failure, a tracheostomy, schizophrenia, severely impaired cognition, and required total assistance with all activities of daily living. The resident was nonverbal, rarely communicated, and was dependent on staff for all care. Court documentation under Kansas law authorized the guardian and conservator to consent on the resident’s behalf to the withholding of life-saving medical care, treatment, services, or procedures. The resident’s electronic medical record contained an uploaded DNR document signed by one physician, the guardian, and two witnesses, and the physician orders initially documented a DNR status from admission. Despite this, the resident’s DNR order was discontinued on a later date and replaced with a physician order for full code, all measures. The care plan was updated to instruct staff to initiate CPR when appropriate and continue until paramedics arrived. Provider notes showed conflicting documentation, with one note listing the code status as DNR and a later note documenting that the DON notified the provider that the resident required a DNR form in the chart. The provider then ordered the resident to be full code until two physicians could sign a form stating the resident was a DNR candidate and the durable power of attorney would work through the court process, and a progress note recorded that the code status was updated to full code pending completion of this process. Interviews and record reviews revealed confusion among staff regarding the validity of the DNR and the impact of guardianship paperwork. The social services designee reported that during a mock survey by regional staff, she was told the resident’s DNR was not valid because it was signed after the guardianship paperwork was in effect, and that the then-DON had the provider discontinue the DNR. She also stated she had not spoken with the guardian about a request for assistance in completing a DNR. The guardian reported that the resident used to be a DNR, that an audit required a change to full code, and that he did not understand why and had asked the facility for assistance. Administrative staff later reviewed the EMR, DNR, progress notes, orders, and guardianship paperwork and stated they had no prior knowledge of the guardian’s concern, even though facility policy required that advance directives be respected and prominently displayed in the medical record.
Failure to Identify and Document Forehead Abrasion of Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to identify, monitor, and respond to an injury of unknown origin on a resident’s forehead. The resident had chronic respiratory failure, schizophrenia, was nonverbal, rarely communicated, and was assessed as having severely impaired cognition, requiring total assistance for all ADLs and having no documented behaviors. The care plan directed staff to inspect the resident’s skin weekly and as needed, observing for redness, open areas, scratches, cuts, and bruises, and to report any changes to the nurse. Weekly skin notes for the period reviewed did not document any abrasion or bruise to the forehead. On the first day of the annual survey, the resident was observed in bed with a red abrasion on the right side of the forehead measuring approximately 0.5 cm by 2 cm. When asked if he had a fall, the resident shook his head side to side indicating no. The resident’s progress notes contained no evidence that staff had identified the forehead abrasion or investigated its origin until the following day, when a note documented a purple abrasion on the right forehead measuring 0.3 cm by 2.5 cm by 0 cm, with the resident unable to describe how it occurred. Staff reported no known event, and the note suggested the resident’s head may have hit the wall during cares after a recent room change that placed the bed against the wall, with a fall mat on the left side of the bed. A CNA who provided care reported she had not noticed the abrasion/redness and stated that any new skin issue should be reported to the nurse and that staff were required to write a statement for injuries such as bruises or skin tears. An LN reported being told by the night nurse that the resident had an abrasion but did not document it, assuming the night nurse had done so. An administrative nurse stated she was not aware of the abrasion and that the nurse should have reported, assessed, and completed risk management and a root cause analysis for the abrasion.
Failure to Provide Bed-Hold Notice and Ombudsman Notification for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notification of its bed-hold policy and to notify the State Long Term Care Ombudsman when a resident was transferred to the hospital. The resident had multiple diagnoses including anemia, chronic kidney disease Stage 3, DM, HTN, and major depressive disorder, and required substantial assistance with ADLs, used a wheelchair with setup assistance, and was identified as a fall risk. The resident’s care plan included monitoring for changes in mental status, lethargy, fatigue, tremors, seizures, breathing difficulties, and monitoring labs and electrolytes related to renal insufficiency. On one occasion, a critical hemoglobin value of 6.1 g/dl was reported by the lab, and the provider instructed staff to send the resident to the emergency room, after which the resident left the facility by ambulance and later returned from the hospital with end stage renal disease and anemia. Record review showed the resident’s clinical record lacked evidence of a bed-hold notice or bed-hold policy documentation related to this facility-initiated transfer to the hospital, and the facility was unable to provide such evidence upon request. The facility also could not provide evidence that the State LTCO was notified of the resident’s transfer/discharge to the hospital. During an interview, a social services staff member confirmed that there was no bed-hold notice for the resident’s hospital transfer and that the Ombudsman had not been notified. The facility’s own bed-hold policy required staff to inform residents upon admission and prior to transfer for hospitalization (including after emergency transfers, per state law) about the bed-hold policy and to file a copy of the resident’s bed-hold policy in the medical record, but this was not documented for the resident. The facility was also unable to provide an Ombudsman Notification policy upon request.
Failure to Provide Consistent Bathing and Grooming for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent bathing and grooming for multiple residents who required assistance with activities of daily living. One resident with Alzheimer’s disease, anxiety, and atrial fibrillation had a BIMS score indicating moderately impaired cognition and required staff assistance with showers and personal hygiene. Her care plan directed staff to assist with bathing using a shower chair. However, shower records showed she did not receive a bath or shower for extended periods in March and early April, with only a few refusals documented despite staff statements that she frequently refused. Observations noted stained clothing and multiple chin hairs, and interviews with CNAs and nursing staff revealed inconsistent documentation practices and uncertainty about what happened to shower sheets after they were completed. Another resident with benign prostatic hyperplasia, major depressive disorder, and polyneuropathy had intact cognition and required supervision with showers and personal hygiene. His care plan documented a preference for staff-assisted shaving and two showers per week on specific days. Monthly shower sheets and bathing records for February and March lacked documentation that he received the requested twice-weekly showers and did not show refusals. During observation, he was unshaven and reported not receiving showers as requested, stating staff told him he had refused, but he was unable to review any signed refusal documentation. Staff interviews indicated he did not typically refuse showers and suggested that the bath aide was sometimes reassigned to floor duties, which may have contributed to missed showers. A third resident with dementia and a history of cerebral infarction had severely impaired cognition, relied on staff to meet daily needs, and required total assistance for personal hygiene per MDS and care plan documentation. Care plans directed staff to assist with grooming and hygiene to the extent needed. On multiple observations over two days, this resident was noted to have several chin hairs approximately 0.25 inches long and fingernails with a brown substance underneath and jagged edges, with no change after morning care was provided. Interviews with CNAs and a nurse revealed inconsistent understanding of responsibilities for shaving and nail care, with some CNAs reporting they were taught not to shave residents and that nurses cut nails, while the administrative nurse stated CNAs were expected to file, clean, and trim fingernails (except for diabetic residents) and remove facial hair on shower days and as needed. These findings conflicted with the facility’s Quality of Life–Activities of Daily Living policy, which required necessary care and services to maintain residents’ grooming and personal hygiene.
Failure to Ensure Resident Access and Assistance With Prescribed Hearing Aid
Penalty
Summary
The facility failed to ensure that a dependent resident received staff assistance with the use of a prescribed hearing aid. The resident’s EMR documented dementia with severely impaired cognition, a history of cerebral infarction, and an ear malformation causing hearing impairment. A Significant Change MDS and subsequent Quarterly MDSs showed the resident wore a hearing aid and relied on staff to have needs met, with no change in hearing aid use. The resident’s care plan directed staff to ensure availability and functioning of adaptive communication equipment, including a right-ear hearing aid to be worn during the day, removed at night, and stored and charged at the nurses’ station. Physician orders allowed for specialist care, including an audiologist, as needed. Activity notes documented that the resident was hearing impaired and wore a right-ear hearing aid when available, and that the resident had limited communication. During multiple observations, the resident was seen in a wheelchair and in the dining room without a hearing aid in place. Multiple CNAs and a CMA reported they had never seen the resident with a hearing aid and did not know if the resident was care planned for one. The Activity Director and Administrative Nurse F gave conflicting information, with the Activity Director initially stating the resident did not have a hearing aid and staff had to speak loudly in the resident’s right ear, and later stating the hearing aid had stopped working and would not hold a charge. The Social Service Designee reported the hearing aid had broken months earlier, that attempts to contact the resident’s durable power of attorney about repair had been unsuccessful, that she was unsure about coverage or personal funds for repair, and that she did not think the resident ever had an audiology appointment. Administrative Nurse D stated she expected staff to ensure hearing aids were offered and placed as ordered and reported that an unnamed nurse had purchased a hearing aid for the resident, which had been at the nurse’s desk charging. The facility did not provide a policy for hearing aids.
Failure to Follow Fall-Prevention Care Plan and Supervise High-Risk Resident in Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe environment for a resident with a known high risk for falls, particularly in the dining room. The resident had diagnoses including Alzheimer’s disease, anxiety, atrial fibrillation, and muscle weakness, with a BIMS score of 8 indicating moderately impaired cognition. Assessments documented that the resident required partial staff assistance for eating and mobility, was dependent for transfers and toileting, did not ambulate, and had been identified as high risk for falls on multiple fall assessments. The care plan contained specific fall-prevention interventions, including ensuring non-slip footwear, use of a floor mat by the bed, not leaving the resident unattended in the dining room after meals, keeping the resident in the wheelchair rather than transferring to a dining chair for meals, use of an antithrust cushion with Dycem in the wheelchair, and removal of the Hoyer sling from the wheelchair after transfers. Despite these identified risks and documented interventions, the resident experienced multiple falls in the dining room. A fall on 12/21 was documented after the resident had been one-on-one all afternoon due to attempts to stand and walk and expressing a desire to go home; staff later found the resident on the dining room floor. A subsequent fall on 03/11 occurred when another resident called for help and staff found the resident seated on the floor in front of the wheelchair; the investigation identified that the sling from the mechanical lift had not been removed after transfer, and this was determined to be the root cause of that fall. Another fall on 03/28 occurred when the resident was found lying face down on the floor with the wheelchair at her feet, and documentation noted that the resident needed to go to the bathroom after a meal and had not been offered toileting. Observations and staff interviews further showed that the facility did not consistently follow the resident’s care plan interventions. On 04/06, the resident was observed being pushed to the dining room in a wheelchair with the sling still under her, contrary to the care plan directive to remove the sling after transfer. On 04/07, a CNA was observed leaving the sling partially under the resident in the wheelchair and looping the sling straps around the wheelchair handles after using the Hoyer lift. Staff, including a CNA and a licensed nurse, acknowledged that the resident was impulsive, had multiple falls, and required close observation. An administrative nurse stated that the resident should not have been left alone in the dining room because of her impulsivity and history of falls and that staff were expected to follow the care plan. The facility’s fall policy required review of the care plan and evaluation of the circumstances of falls to determine causes and implement appropriate interventions to prevent further falls, but the repeated falls and observed practices demonstrated that key care plan interventions were not consistently implemented.
Failure to Facilitate Necessary Dental Services for a Resident with Abscessed and Broken Teeth
Penalty
Summary
The facility failed to provide necessary routine and 24-hour emergency dental care for a resident who required dental services. The resident’s EMR documented diagnoses of GERD, major depressive disorder, and protein calorie malnutrition, with an admission MDS showing intact cognition and independence with oral hygiene. Initial assessments recorded that the resident did not have natural teeth or dentures and had recent weight loss, but lacked further dental documentation. A Dental Care CAA later recorded tooth pain on the right side and initiation of an antibiotic for a dental abscess. Nursing notes documented the resident’s report of a tooth abscess, mouth soreness, and pain, followed by an order for Clindamycin 300 mg four times daily for seven days and continued antibiotic treatment for abscessed teeth. Despite these documented dental issues and the facility’s Routine Dental Care policy requiring ongoing assessments, physician notification, and dental consultation as appropriate, the resident’s care plan contained no reference to broken or decayed teeth or to dental services to be provided. Observations showed the resident eating with missing teeth, one decayed and split tooth, and another broken off at the lower jaw. The Administrative Nurse confirmed she had not visualized the resident’s mouth or teeth until the survey date, verified the resident was edentulous except for two broken teeth, and acknowledged the resident was not on the facility’s dental services and had not received any dental care or services since admission, despite the facility’s policy outlining initial evaluation of dental needs, consultation with a dental consultant, and a daily oral hygiene plan of care.
Failure to Provide Timely and Complete Meals Due to Missing Dietary Tickets
Penalty
Summary
The facility failed to meet residents' nutritional needs in accordance with established national guidelines when a resident did not receive timely and complete meals due to errors in the dietary ticketing and delivery process. On the morning of 04/06/26, the resident was observed sitting in a wheelchair in her room at 9:00 AM with her bedside table in front of her, waiting for her breakfast tray. At 9:30 AM, a nurse aide informed her that the kitchen had not yet delivered the food cart to the hall and that her tray would be delivered once it arrived. By 10:00 AM, the resident was still waiting for breakfast. When questioned at 10:05 AM, Administrative Nurses D and E acknowledged that the resident should have received breakfast before 10:00 AM. At 10:10 AM, the resident finally received a tray containing cream of wheat and one piece of toast, without sugar, butter, or jelly. The resident reported that she had requested eggs and orange juice but was told by staff that those items were unavailable and that what she received was all that was available. Administrative Nurse E verified that the kitchen had not printed a breakfast ticket for the resident, which resulted in her not receiving her meal on time. Dietary Staff BB later confirmed that the resident had not received her breakfast tray because the meal ticket did not print and also verified that the resident’s supper meal the previous evening had been delayed for the same reason. The facility’s Food Preparation and Service policy, dated 10/2025, states that residents are to be provided with food that is palatable, attractive, and at a safe and appetizing temperature, and that food service employees should prepare and serve food in a manner that complies with safe food handling practices.
Misappropriation of Resident Funds Through Unauthorized Checks and Forged Signatures
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of their personal funds when an administrative staff member wrote checks and forged signatures on resident accounts without proper authorization. One resident had dementia with moderately impaired cognition, required assistance with most ADLs, and had a documented diagnosis of dementia. This resident’s EHR did not contain any written authorization from the resident or the resident’s representative allowing the facility to manage personal funds, as required by facility policy. Despite this, an administrative staff member assumed responsibility for the resident’s finances and engaged in financial transactions on the resident’s behalf. According to the facility’s investigation notes and staff and representative statements, the resident’s representative was contacted by the bank’s fraud department about suspicious checks drawn on the resident’s account and deposited into the administrative staff member’s personal account. The administrative staff member stated she had written a large check in the past to apply toward the resident’s liability to the facility and later wrote two additional checks for several hundred and over one thousand dollars each, made out to the facility in care of herself. She reported that she deposited these checks into her personal bank account, then took cash to the facility and placed it in a safe, claiming it was part of a spend-down process to help the resident qualify for Medicaid and to provide the resident with money after Medicaid started. The resident’s representative reported that the administrative staff member admitted depositing the checks into her personal account and said she planned to keep the money in a closet and return it to the resident after Medicaid began. Further review by the facility revealed two additional instances in which the same administrative staff member forged signatures to cash checks belonging to two other residents, resulting in misappropriation of smaller amounts from their accounts. The facility’s policies on abuse prevention and management of residents’ personal funds stated that residents have the right to be free from misappropriation of property and that any management of resident funds by the facility must be authorized in writing and documented in the resident’s EHR. In these cases, checks were written, signatures were forged, and resident funds were deposited into a staff member’s personal account without appropriate written authorization or adherence to the facility’s stated procedures for handling resident funds.
Failure to Ensure Preoperative Orders Delays Resident's Surgery
Penalty
Summary
The facility failed to ensure that a resident received appropriate preparations for a scheduled surgery, which resulted in the surgery being delayed. The resident, who had paraplegia and other medical issues, was dependent on staff for activities of daily living. The resident was scheduled for surgery to close a PEG tube site, but the nursing staff did not receive or follow up on preoperative orders from the physician's office. This oversight led to the resident refusing to take his blood thinner, causing the surgery to be canceled and rescheduled for a later date. Interviews with facility staff revealed a lack of communication and follow-up regarding the preoperative orders. A CNA was aware of the need for transportation for the surgery but assumed the nursing staff had the necessary orders. Administrative nurses confirmed that the nursing staff did not prepare the resident for surgery due to not ensuring the receipt of preoperative orders. The facility lacked a policy to ensure that all components of planned operative procedures were in place, contributing to the delay in the resident's surgery and progress toward returning home.
Improper Storage of Suction Equipment Leads to Deficiency in Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, R27 and R3, who required tracheostomy care and tracheal suctioning. Both residents had severe cognitive impairments and were unable to communicate effectively. R27 had a history of spastic quadriplegia, cerebral palsy, chronic respiratory failure with hypoxia, and pneumonia, while R3 had chronic respiratory failure, COPD, and was a carrier of MRSA. The care plans for both residents directed staff to monitor for respiratory infections and ensure proper storage of suctioning equipment to prevent contamination. Observations revealed that the suction tubing for both residents was improperly stored, with the ends uncapped and placed directly on the bottom of drawers alongside other medical supplies. This practice was inconsistent with the facility's policy, which required sterile equipment to prevent infection. Licensed nurses and administrative staff acknowledged that the tubing should have been capped and stored properly to prevent contamination and cross-contamination. The facility's failure to adhere to professional standards of practice regarding the storage of suctioning equipment led to a deficiency in providing necessary respiratory care. The improper storage of suction tubing posed a risk of infection and cross-contamination, which was not in line with the facility's policy for maintaining sterile conditions during tracheostomy care and suctioning procedures.
Failure to Monitor and Administer Heart Failure Medication Correctly
Penalty
Summary
The facility failed to ensure that medications were monitored and administered correctly for a resident with heart failure. The resident, who was cognitively intact but experienced a decline in cognition, was prescribed Metoprolol Succinate ER to manage heart failure. The physician's orders specified that the medication should be held if the resident's systolic blood pressure (SBP) was less than 110 or if the pulse was less than 60. However, the resident received the medication outside of these parameters on five occasions, and there was no documentation of physician notification for these instances. Additionally, the resident refused the medication on five separate occasions, yet there was no evidence of physician notification or documentation of education provided to the resident regarding the risks and benefits of taking the medication. Interviews with facility staff revealed that the resident frequently refused medication, often due to being agitated when woken up. The licensed nurse confirmed that the medication should be held and the physician notified if vital signs were outside the prescribed parameters. The administrative nurse reiterated that staff should follow physician orders and notify the physician when necessary. The facility lacked a policy to address the administration of medications according to physician orders and the notification of physicians regarding parameter outliers and resident refusal of medication.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that foods were stored, prepared, and distributed in a manner to prevent foodborne illness to the residents. During an observation, it was noted that the kitchen refrigerator contained six squirt bottles of condiments, such as salad dressings, which lacked coverings over the tips. Additionally, during an environmental tour of the kitchen, several areas of concern were identified: the kitchen handwashing sink had a black substance along the back edge caulking and brown/yellow discolorations on the sink back edges; the air fryer/convection oven had splatters of a black substance on the upper interior surface; and the ice machine drain was directly in the drain without a two-inch air gap. Dietary Staff BB confirmed these issues, and Maintenance Staff U confirmed the lack of a two-inch air gap for the ice machine drain. The facility's policies on food safety and sanitation were not adhered to, as foods stored in the refrigerators were not covered, labeled, and dated, and the food service area was not maintained in a clean and sanitary manner.
Infection Control Deficiency in Incontinence Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control during incontinence care for a resident with an open wound on her sacrum. The resident, who had a history of diabetes, heart failure, cerebral infarction, and a stage two pressure ulcer, required substantial assistance with activities of daily living and was incontinent of bowel and bladder. During an observation, a Certified Nurse Aide (CNA) and an Administrative Nurse provided incontinence care to the resident. The CNA used peri wipes to cleanse the rectal area of stool, and upon instruction, removed the soiled dressing from the sacral wound. However, the CNA then wiped the resident from the rectum over the wound, which was not in accordance with proper infection control practices. The facility's policy on wound care guidelines instructed staff to provide care that promotes healing, which was not adhered to in this instance. The Administrative Nurse acknowledged that staff should wipe incontinent residents from front to back and, in this case, should have wiped away from the wound to prevent contamination with stool. This failure to follow appropriate incontinence care procedures resulted in a deficiency in infection prevention and control for the resident with a sacral pressure ulcer.
Unsafe Patient Care Equipment
Penalty
Summary
The facility failed to maintain patient care equipment in safe operating conditions for two residents. During an observation, it was noted that the over-the-toilet commode used by one resident had four legs that wobbled when pressure was applied to the armrests, rendering it unstable. Additionally, the commode grab bars in another resident's bathroom were found to be unstable and moved when the resident attempted to sit or rise from the commode. An interview with administrative staff revealed that there was an expectation for staff to enter maintenance requests into their electronic system for such tasks. However, the facility lacked a policy specifically for the maintenance of commode grab bars and over-the-toilet commodes, leading to the failure to ensure these items were maintained in a safe condition to prevent accidents.
Failure to Change Dressings as Ordered
Penalty
Summary
The facility failed to ensure that three residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and/or the residents' choices, specifically related to skin treatments for ostomies. Resident 2, who had a suprapubic catheter, did not have their dressing changed as ordered by the physician. The dressing, dated 03/12/24, was not changed on 03/13/24 by the night shift nurse, who was an agency nurse. This failure was confirmed by multiple licensed nurses and the administrative nurse, who acknowledged that the night shift nurse was responsible for changing the dressing nightly. The facility lacked a policy to address changing dressings for suprapubic catheter insertion sites to prevent infections and maintain skin integrity. Resident 3, who also had a suprapubic catheter, experienced a similar issue. The dressing dated 03/12/24 was not changed on 03/13/24 by the night shift nurse. Licensed nurses confirmed that the night shift nurse should have changed the dressing as ordered by the physician to prevent infection and monitor the skin for breakdown. The facility again lacked a policy to address changing dressings for suprapubic catheter insertion sites. Resident 4, who had a gastrostomy tube, did not have their dressing changed as ordered by the physician. The dressing, dated 03/12/24, was not changed on 03/13/24 by the night shift nurse. Licensed nurses confirmed that the night shift nurse should have changed the dressing to prevent skin breakdown from leaking acidic stomach content. The facility lacked a policy to address changing dressings for gastrostomy insertion sites to prevent infections and maintain skin integrity. The facility failed to ensure that the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and/or the residents' choices, related to skin treatments for this resident that required gastrostomy insertion site dressing changes.
Failure to Follow Physician Orders for Dressing Changes
Penalty
Summary
The facility failed to ensure that three residents received treatment and care in accordance with physician's orders related to skin treatments for ostomies. Resident 2, who had a suprapubic catheter, did not have his dressing changed as ordered by the physician. The dressing dated 03/12/24 was still in place on 03/14/24, despite orders to change it nightly. Licensed Nurse H confirmed that the dressing should have been changed on 03/13/24 and reported that the night shift nurse, who was an agency nurse, did not follow the physician's orders. This issue was not uncommon, and concerns had been previously reported but not adequately addressed by the administrative staff. Resident 3, who also had a suprapubic catheter, experienced a similar issue. The dressing dated 03/12/24 was not changed as ordered by the physician. Licensed Nurse H confirmed that the dressing should have been changed on 03/13/24 and reported that the night shift nurse did not follow the physician's orders. This issue was also reported to the previous administrative nurse but was not followed up on, and the most recent administrative nurse was not aware of the concern. Resident 4, who had a gastrostomy tube, did not have his dressing changed as ordered by the physician. The dressing dated 03/12/24 was still in place on 03/14/24, despite orders to change it nightly. Licensed Nurse H confirmed that the dressing should have been changed to prevent skin breakdown from leaking acidic stomach content. The facility lacked a policy to address following physician orders related to changing dressings for suprapubic catheter and gastrostomy tube insertion sites, leading to a failure in providing the necessary treatment and care for the residents.
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Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
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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