Elmhaven East
Inspection history, citations, penalties and survey trends for this long-term care facility in Parsons, Kansas.
- Location
- 1400 S 15th Street, Parsons, Kansas 67357
- CMS Provider Number
- 175415
- Inspections on file
- 24
- Latest survey
- June 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Elmhaven East during CMS and state inspections, most recent first.
The facility did not ensure RN coverage for at least eight consecutive hours on multiple occasions, as confirmed by staff postings and administrative interview. The facility also lacked a policy to guarantee this required RN coverage, affecting a census of 30 residents.
The facility did not complete the required Care Area Assessments (CAAs) as part of the comprehensive Minimum Data Set (MDS) process for several residents. Review of electronic medical records showed that, although comprehensive and quarterly MDS assessments were conducted, the triggered CAAs were not completed as required by the Resident Assessment Instrument (RAI).
A resident dependent on staff for mobility and toileting was left uncovered during peri-care, with the privacy curtain not drawn. Another staff member entered the room and spoke with the door open, making the resident visible from the hallway. Staff and administrative interviews confirmed this violated facility policy on resident dignity and privacy.
A resident with multiple serious health conditions and intact cognition was admitted to hospice care and expressed a wish to remain DNR. However, the facility failed to ensure the DNR directive was signed by the resident or representative, and inconsistencies were found in the resident's code status across records. Staff acknowledged the missing signature and the lack of a clear policy for advanced directives.
A resident with CHF on a diuretic experienced multiple significant daily weight gains, but nursing staff did not notify the physician as required by care plan and physician orders. Interviews confirmed that staff were expected to notify the physician for such changes, but no documentation of notification was found, and the facility lacked a policy for provider notification of weight changes in these cases.
A resident with multiple mental health and neurological diagnoses did not receive a required quarterly MDS assessment within the mandated timeframe. The resident, who was routinely administered antidepressant and anticonvulsant medications and exhibited moderate cognitive decline, was observed to be frequently sleeping and unresponsive. Staff confirmed the expectation for timely and accurate MDS completion, but the assessment was not performed as required.
A resident with neurogenic bladder and a Foley catheter did not have catheter care addressed in the baseline care plan upon admission. Staff observed the resident with dark red urine in the catheter bag, and administrative nurses confirmed that catheter care should have been included in the initial care plan, as required by facility policy.
A resident with a history of CVA and one-sided impairment required substantial assistance for transfers, as documented in her care plan. Staff did not consistently document the assistance needed, and during observation, two CNAs provided total assist with a gait belt, with the resident unable to bear weight and her feet not flat on the floor as required. Staff interviews confirmed inconsistency in the resident's weight-bearing ability, and the facility's ADL policy was unavailable.
Several residents with conditions such as multiple sclerosis and cerebrovascular accident did not receive restorative care or proper positioning as outlined in their care plans. Staff failed to perform or document required range of motion exercises, and one resident was observed with unsupported feet while seated in a Geri-chair. Facility policies for restorative nursing and wheelchair positioning were not followed, and staff interviews confirmed the deficiencies in care.
A resident receiving continuous oxygen therapy was repeatedly observed with oxygen tubing dragging on the floor and tangled around the wheelchair axle. Multiple staff members acknowledged that the tubing should have been secured in a pouch on the wheelchair, but the facility's policy did not address proper storage or management of oxygen equipment to prevent contamination.
A review of staffing records revealed that actual hours worked by nursing personnel were not documented on daily staffing sheets, contrary to facility policy. An administrative nurse reported being unaware of the requirement to include actual hours worked in daily postings.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for at least eight consecutive hours per day as required, with documented lapses on multiple dates. Review of the facility's Daily Staff Posting from 05/01/24 through 07/30/24 showed that on nine specific dates, there was no evidence of the required RN coverage. During an interview, the administrative nurse was unable to verify RN presence for the required hours on those dates. Additionally, the facility did not provide a policy ensuring RN coverage for at least eight consecutive hours every 24 hours. The facility had a reported census of 30 residents at the time of the deficiency.
Failure to Complete Required Care Area Assessments in MDS
Penalty
Summary
The facility failed to complete the comprehensive Minimum Data Set (MDS) assessments for several residents as required. Specifically, for six residents, the comprehensive MDS assessments did not include the completion of the triggered Care Area Assessments (CAAs), as mandated by the Resident Assessment Instrument (RAI). Record reviews showed that for each of these residents, both quarterly and comprehensive MDS assessments were present in the electronic medical records, but the required CAAs were missing. This deficiency was identified through review of the residents' electronic medical records and confirmed by staff interviews.
Failure to Maintain Resident Dignity and Privacy During Care
Penalty
Summary
Staff failed to maintain a resident's dignity and privacy during morning care. A resident with multiple sclerosis, who was cognitively intact but dependent on staff for bed mobility and toileting, was observed lying uncovered on her bed while staff provided peri-care. During this time, the privacy curtain was not drawn around the bed. Another staff member knocked, was told care was in progress, but still entered the room and spoke to the staff with the door open, leaving the resident visible to others in the hallway. Interviews with staff and administrative personnel confirmed that facility expectations and policy require staff not to enter a resident's room during care and to maintain privacy. The facility's policy on promoting and maintaining resident dignity specifically states that residents' rights to privacy and dignity must be protected during care. The actions observed were inconsistent with these expectations and policies.
Failure to Verify and Document Resident's DNR Directive
Penalty
Summary
The facility failed to verify and properly document a resident's advanced directives, specifically regarding a Do-Not-Resuscitate (DNR) order. The resident, who had diagnoses including Parkinson's disease, atherosclerotic heart disease, epilepsy, heart failure, and hypertension, was documented as having intact cognition and had recently started hospice care with a terminal diagnosis. The care plan indicated the resident wished to remain a DNR, but a review of the electronic health record (EHR) revealed inconsistencies: the hospice certificate listed the resident as full code, while the EHR home screen and physician orders listed the resident as DNR. The DNR directive in the EHR was signed by the physician but not by the resident or their representative, as required. Interviews with the resident confirmed her wish to be a DNR, and staff acknowledged the missing resident signature on the DNR directive. Staff also indicated that, in the event of discrepancies between DNR and full code orders, the most recent advanced directive should be honored. However, the facility did not provide a policy for advanced directives, and the lack of a resident signature on the DNR directive represented a failure to ensure the resident's wishes were properly documented and verified.
Failure to Notify Physician of Significant Weight Gain in Resident with CHF
Penalty
Summary
The facility failed to notify the physician when a resident with a diagnosis of congestive heart failure (CHF) and on a diuretic experienced significant weight gains within 24-hour periods. The resident's care plan and physician orders required daily weight monitoring due to the use of a diuretic, and the facility's records showed multiple instances where the resident gained between four and seven pounds in a single day. Despite these notable weight increases, there was no documentation that the physician was notified on any of these occasions. Interviews with nursing staff revealed that the expectation was for the nurse on duty to notify the physician of significant weight changes, particularly if there was a three-pound or greater gain in a day, even if specific parameters were not outlined in the physician's order. However, the facility did not have a policy in place regarding provider notification for weight changes in residents with CHF on diuretics. Observations of the resident showed swelling in the legs and episodes of shortness of breath, but there was no evidence that these changes prompted physician notification as required.
Failure to Complete Timely MDS Assessment for Resident with Complex Needs
Penalty
Summary
The facility failed to complete the required Minimum Data Set (MDS) assessment for a resident within the mandated timeframe. Specifically, the quarterly MDS due on 03/18/25 was not completed for a resident with multiple complex diagnoses, including schizoaffective disorder, panic disorder, seizure disorder, PTSD, anxiety, insomnia, and depressive disorder. Previous MDS assessments documented moderate cognitive decline and no depression, with the resident routinely receiving antidepressant and anticonvulsant medications. The resident's care plan included monitoring for side effects of these medications, which have Black Box Warnings, and interventions to support mental health. Observations showed the resident was frequently sleeping and unresponsive to verbal stimuli, and staff reported that she slept a lot. The administrative nurse confirmed the expectation that MDS and Care Area Assessments (CAAs) should be completed accurately and on time. The Resident Assessment Instrument (RAI) guidelines require quarterly assessments every 92 days, which was not met in this case, resulting in a failure to ensure an accurate and timely assessment for the resident.
Failure to Include Catheter Care in Baseline Care Plan
Penalty
Summary
The facility failed to address catheter care needs for a resident with a diagnosis of neuromuscular dysfunction of the bladder and neurogenic bladder, who was unable to bear weight and required assistance with activities of daily living. The resident's electronic medical record documented the presence of a Foley catheter with dependent drainage, initiated to manage her bladder condition and prevent skin breakdown. Despite this, the baseline care plan created upon admission did not include any documentation or instructions regarding the resident's catheter or its care, focusing only on wound assessment and pain management. Observations revealed the resident in bed with a catheter bag containing dark red urine, and staff interviews confirmed that the resident consistently had red, dark urine. Certified Medication Aides reported referencing the matrix for care information, and administrative nursing staff acknowledged that catheter care should have been included in the baseline care plan. The facility's policy required a baseline care plan to be developed and implemented within 48 hours of admission to address immediate care needs, which was not followed in this case.
Failure to Assess and Implement Proper Transfer Assistance for Resident with CVA
Penalty
Summary
The facility failed to recognize, assess, and implement appropriate interventions for a resident with a history of cerebrovascular accident (CVA) who required assistance with transfers. The resident's medical record indicated substantial to maximal assistance was needed for transfers due to impairments on one side of her body, and her care plan specified that her feet should be flat on the floor during transfers. However, staff documentation did not consistently reflect the level of assistance required, and there was no analysis of findings in the resident's Care Area Assessments (CAA). During observation, two CNAs transferred the resident using a gait belt and provided total assistance, as the resident was unable to bear weight on either leg and her feet were not flat on the floor, contrary to care plan instructions. Interviews with the CNAs revealed inconsistency in the resident's ability to bear weight, and the administrative nurse confirmed that residents should be able to bear weight during transfers. The facility's policy for activities of daily living (ADLs) was not available for review.
Failure to Provide Restorative Care and Proper Positioning for Residents with ROM Needs
Penalty
Summary
The facility failed to provide restorative care and proper positioning for multiple residents with documented needs for range of motion (ROM) and mobility support. One resident with multiple sclerosis, who was dependent on staff for transfers and wheelchair mobility and had limitations in lower extremity ROM, did not receive restorative care as outlined in her care plan. Observations showed her feet were left unsupported while seated in a Geri-chair at the dining table, contrary to facility policy and her care plan instructions. Staff interviews confirmed a lack of awareness regarding the need for foot support and acknowledged that restorative care had not been performed as required. Another resident with a history of cerebrovascular accident (CVA) and lower extremity ROM limitation was also not consistently provided with restorative care. Although her care plan specified daily active and passive ROM exercises, documentation revealed that restorative care was only provided sporadically over several months. Staff confirmed that the resident was not receiving the prescribed daily restorative care, and administrative staff acknowledged the deficiency in care delivery and documentation. A third resident with multiple sclerosis, who had no current ROM impairment but was prescribed upper extremity exercises with weights, did not receive the restorative care outlined in her care plan. The care area assessment for this resident triggered but lacked analysis, and staff interviews confirmed that restorative care was not being provided daily as required. Facility policies required maintenance and restorative services to maintain or improve residents' abilities, but these were not followed for the residents reviewed.
Failure to Prevent Oxygen Tubing Contamination
Penalty
Summary
Facility staff failed to implement proper infection control practices for a resident who was receiving continuous oxygen therapy. Multiple observations showed that the resident's oxygen tubing was repeatedly allowed to drag on the floor, become tangled around the wheelchair axle, and rest under the wheelchair in various locations throughout the facility, including the dining room and the resident's room. These observations occurred over two consecutive days and were witnessed by surveyors at different times. Interviews with facility staff, including a licensed nurse, administrative staff, and a CNA, confirmed that the oxygen tubing should not have been dragging on the floor and should have been secured in a designated pouch or pocket on the wheelchair. The facility's policy on oxygen administration did not address the proper storage and management of oxygen-delivering devices to prevent contamination or infection, contributing to the deficiency.
Failure to Post Actual Nursing Staff Hours Worked
Penalty
Summary
A review of the facility's Daily Staffing Sheets for the past 30 days showed that the actual hours worked by nursing personnel were not recorded on the daily staffing sheets. During an interview, an administrative nurse stated she was unaware that the daily staff postings were required to include the actual hours worked. The facility's policy, revised in July 2016, specifies that the actual time worked for each category of nursing personnel must be posted daily for each shift.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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