Eskridge Care And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Eskridge, Kansas.
- Location
- 505 N. Main Street, Eskridge, Kansas 66423
- CMS Provider Number
- 175455
- Inspections on file
- 19
- Latest survey
- April 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Eskridge Care And Rehab during CMS and state inspections, most recent first.
The facility failed to maintain proper food serving temperatures, placing residents at risk of unpalatable food and food-borne illness. A dietary staff member was unaware of the correct serving temperatures, leading to pureed turkey and corn being served at inadequate temperatures. The facility's food safety policy lacked specific holding/serving temperature guidelines.
The facility did not retain evidence of required QAA and QAPI members attending meetings at least quarterly, as they could not provide attendance sheets for the past year. This failure to document attendance, as required by the facility's policy, placed residents at risk of unidentified quality care services.
The facility failed to ensure the acting Infection Preventionist, Administrative Nurse D, was certified, as she temporarily assumed the role without the necessary qualifications. This deficiency placed residents at risk due to the lack of proper identification and treatment of infections, as the designated Infection Preventionist had not yet started.
The facility did not complete the required annual performance reviews for two CNAs who had been employed for over a year. This was confirmed by Administrative Nurse D, who noted that two of the five randomly selected staff members lacked these evaluations. The facility's policy requires nursing staff to demonstrate competency in skills necessary for resident care, and the absence of these evaluations placed residents at risk of impaired care.
The facility failed to provide two residents with the necessary CMS-approved forms related to their Medicare coverage. The residents did not receive the Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055, and the Notice of Medicare Non-Coverage (NOMNC) form 10123 lacked the Quality Improvement Organization (QIO) contact information. This placed the residents at risk of making uninformed decisions about their skilled services.
The facility failed to notify the LTCO of the discharges of two residents to an acute care hospital, contrary to its policy. One resident, with intact cognition and multiple mental health diagnoses, was hospitalized for two days, while another, with memory and decision-making impairments, was hospitalized for three weeks. The facility only sent a Continuation of Stay form to KDADS monthly and did not inform the LTCO, placing both residents at risk for uninformed decision-making.
A facility failed to assess and maintain urinary continence for a resident with a history of mental and movement disorders. The resident, initially documented as continent, later experienced occasional incontinence without a toileting program trial. Despite care plan instructions, the facility did not implement measures to address the incontinence, leading to multiple incidents over a 30-day period. Staff noted nocturnal incontinence and the resident's need for linen changes, but the facility did not assess causation factors, risking embarrassment and complications.
A resident with a history of mental health disorders experienced significant weight loss due to the facility's failure to address his food preferences. Despite being identified as a picky eater, the resident's care plan lacked specific food preferences, and he frequently refused meals. Staff interviews revealed a lack of communication and documentation regarding the resident's dietary needs, contributing to ongoing weight loss.
The facility failed to ensure the safety of bed rails for two residents, placing them at risk for accidents or injuries. Both residents required significant assistance with bed mobility and transfers, yet the facility did not adequately assess the stability and safety of the bed rails. Observations revealed unstable rails with large openings, and the facility did not conduct further assessments as required by their policy.
A facility failed to ensure the correct administration of a subcutaneous insulin injection, risking a resident receiving less than the ordered dose. An LN administered insulin using a Novolog pen but did not prime the needle with waste insulin as required by the facility's policy. The LN admitted to being nervous and forgetting this step.
The facility failed to label insulin flex pens for three residents with the date opened and discard date, as observed on two nurse medication carts. This oversight was confirmed by both a licensed nurse and an administrative nurse, violating the facility's medication storage policy and placing residents at risk for ineffective medication.
A resident with a known allergy to mushrooms was served a meal containing mushrooms, leading to a severe allergic reaction. Despite the resident's immediate notification to staff, the resident experienced anaphylaxis and required emergency medical intervention. The dietary staff failed to check the ingredient label, and the facility's policy on food allergies was not followed.
Failure to Maintain Proper Food Serving Temperatures
Penalty
Summary
The facility failed to store, prepare, and serve food at the required serving temperature, which placed residents at risk of unpalatable food and food-borne illness. During an observation, Dietary Staff (DS) CC was preparing to serve the noon meal, and DS BB checked the serving temperature, finding the pureed turkey at 110 degrees Fahrenheit and the pureed corn at 115 degrees Fahrenheit. DS CC was unaware of the correct holding/serving temperature for hot food. The surveyor informed the kitchen supervisor, Social Service Staff X, who instructed DS CC to reheat the food to the proper temperature of 160 degrees Fahrenheit before serving. The facility's Food Safety Requirements policy, dated 10/2024, did not specify the holding/serving temperature, contributing to the deficiency.
Failure to Document QAPI Meeting Attendance
Penalty
Summary
The facility failed to retain evidence that the required Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) members attended meetings at least quarterly. This deficiency was identified during a survey when the facility could not provide QAPI meeting attendance sheets for the past year. Administrative Staff A confirmed the absence of these records from 2024. According to the facility's QAPI Committee policy dated October 2024, the committee should include the Director of Nursing, the Medical Director or designee, the Infection Preventionist, and at least three other staff members, and should meet monthly while maintaining records of attendance. The lack of documentation placed the residents at risk of unidentified quality care services.
Inadequate Certification of Acting Infection Preventionist
Penalty
Summary
The facility failed to ensure that the staff member designated as the Infection Preventionist, responsible for the Infection Prevention and Control Program, completed the specialized training required for the role. At the time of the survey, Administrative Nurse D was acting as the Infection Preventionist but admitted to lacking the necessary certification. This situation arose because the designated Infection Preventionist was not yet in place, and Administrative Nurse D had assumed the responsibilities temporarily without the appropriate qualifications. The facility's policy, dated August 2024, outlined the responsibilities of the Infection Preventionist, which included assessing, implementing, developing, and monitoring the infection prevention and control program. The policy also required the Infection Preventionist to report compliance information to the Administrator and Quality Assurance and Assessment Committee, stay updated on infection control guidelines, and provide education and training. However, the facility's failure to ensure that the acting Infection Preventionist was certified placed residents at risk for inadequate identification and treatment of infections.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to conduct the required annual performance reviews for two Certified Nurse Aides (CNAs) who had been employed for over a year. This deficiency was identified during a review of the facility's nurse aide performance evaluations, which revealed that CNAs M and N did not have their annual reviews completed. On February 20, 2025, Administrative Nurse D confirmed that two of the five randomly selected staff members lacked these evaluations. The facility's Staff Competency policy, dated June 2024, mandates that nursing staff demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments and resulting plans of care. The absence of these evaluations placed residents at risk of receiving impaired care, as the facility did not ensure that nurse aide performance reviews were conducted in relation to the special needs of the resident population.
Failure to Provide Required Medicare Coverage Notices
Penalty
Summary
The facility failed to provide two residents, R9 and R111, with the necessary CMS-approved forms related to their Medicare coverage. Specifically, the facility did not provide the Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055, which is required to inform residents of potential liability for services not covered by Medicare. Additionally, the Notice of Medicare Non-Coverage (NOMNC) form 10123, which was given to the residents, lacked the Quality Improvement Organization (QIO) contact information necessary for residents to request an expedited review of Medicare decisions. The facility's policy, dated August 2024, mandates that residents be informed at least three days prior to the termination of Part A covered services, and that they receive the NOMNC form with QIO contact details. However, the administrative nurse confirmed that the QIO phone number was omitted from the forms provided to R9 and R111, and the CMS form 10055 was not used. This oversight placed the residents at risk of making uninformed decisions regarding their skilled services.
Failure to Notify LTCO of Resident Discharges
Penalty
Summary
The facility failed to notify the Long-Term Care Ombudsman (LTCO) of the discharges of two residents, R26 and R111, to an acute care hospital. R26, who had diagnoses including bipolar disorder, schizoaffective disorder, chronic tension-type headache, and PTSD, was hospitalized for two days. Despite having intact cognition and requiring staff setup for all activities of daily living, the facility did not provide proof of sending a notice to the LTCO regarding her discharge. Social Services Staff X confirmed that the facility only sent a Continuation of Stay form to the KDADS offices monthly and did not send information to the LTCO regarding hospitalizations, which was against the facility's Transfer or Discharge policy. Similarly, R111, who had diagnoses of schizoaffective disorder, diabetes mellitus, and COPD, was hospitalized for approximately three weeks. The resident had long-term memory problems, moderately impaired decision-making skills, and an acute mental status change, requiring staff assistance for all activities of daily living. Upon return from the hospital, there was no evidence that the facility notified the LTCO of her discharge. The facility's failure to send a notice to the LTCO for both residents placed them at risk for uninformed decision-making, as the facility's policy required such notifications.
Failure to Maintain Urinary Continence for a Resident
Penalty
Summary
The facility failed to assess and maintain urine continence for Resident 51, who had a history of schizoaffective disorder, bipolar type, autism, insomnia, extrapyramidal and movement disorder, constipation, and encopresis. The resident's Minimum Data Set (MDS) initially documented that they were always continent of urine and bowels, but later indicated occasional urinary incontinence without a trial of a toileting program. Despite the resident's care plan instructing staff to observe patterns of incontinence and initiate a toileting schedule if indicated, the facility did not implement these measures. Observations and interviews revealed that Resident 51 experienced incontinence 18 days during a 30-day period, with incidents of nocturnal incontinence noted. Staff reported that the resident sometimes needed to change clothes and requested linens. The facility's policy required ensuring continence unless the resident's clinical condition made it impossible, but the facility did not assess causation factors or maintain the resident's urinary continence, placing them at risk for embarrassment and complications.
Failure to Address Resident's Food Preferences Leads to Weight Loss
Penalty
Summary
The facility failed to adequately address a resident's food preferences and dislikes, resulting in significant weight loss. The resident, who had a history of schizoaffective disorder, bipolar disorder, autism, and other conditions, experienced an 11.3% weight loss over six months. Despite being identified as a picky eater and having specific food preferences, the facility did not document these preferences in the resident's care plan or nutritional assessments. The resident's care plan mentioned the need to honor food preferences, but it lacked specific details about what those preferences were. The resident's weight fluctuated significantly, with a notable decrease from 176 lbs at admission to 153 lbs over the course of a year. The resident frequently refused meals, particularly breakfast, and expressed dissatisfaction with the food provided, preferring items like peanut butter and jelly sandwiches. Despite these preferences being known, the facility did not consistently provide meals that aligned with the resident's likes, contributing to the ongoing weight loss. Interviews with staff revealed a lack of communication and documentation regarding the resident's food preferences. Dietary staff admitted to not having discussed food preferences with the resident, and the resident himself reported not receiving many of the supplement drinks he liked. The facility's policy required nutritional assessments to include food preferences, but this was not adhered to, leading to the resident's continued weight loss and placing him at risk for further health decline.
Failure to Ensure Bed Rail Safety for Residents
Penalty
Summary
The facility failed to adequately assess the safety of bed rails for two residents, R7 and R1, which placed them at risk for accidents or injuries. R7, who had diagnoses of dementia, schizophrenia, and tremors, required substantial assistance with bed mobility and transfers. Despite the care plan documenting the use of grab bars for safety and mobility, the facility did not ensure the stability and safety of the bed rails. Observations revealed that the side rails on R7's bed were unstable and had large openings, which were not addressed in further assessments. Similarly, R1, diagnosed with Parkinson's disease, dementia, schizophrenia, and anxiety, also required significant assistance with bed mobility and transfers. The facility's failure to document the use of side rails in the MDS and to assess the safety of the rails placed R1 at risk. Observations showed that the side rail on R1's bed was unstable and had a large opening, similar to R7's situation. The facility did not conduct further assessments to ensure the safe use of the side rail. The facility's Bed Safety-Bed Rails policy required evaluations and assessments of bed rails upon admission, quarterly, and with any change in condition. However, the facility did not adhere to these guidelines, as evidenced by the lack of proper assessments and documentation for R7 and R1. This oversight in following the policy and ensuring the safety of bed rails contributed to the deficiency identified by the surveyors.
Failure to Properly Administer Insulin Injection
Penalty
Summary
The facility failed to ensure the correct administration of a subcutaneous insulin injection, which placed a resident at risk of receiving less than the ordered dose. During an observation, a Licensed Nurse (LN) administered insulin to a resident using a Novolog insulin pen dialed to five units. However, the LN did not prime the insulin needle with two units of waste insulin before administration, as she usually did. The LN admitted to being nervous and forgetting to perform this step. The facility's Insulin Administration policy required nursing staff to follow specific instructions for insulin delivery systems, but this was not adhered to during the incident.
Failure to Label Insulin Pens Properly
Penalty
Summary
The facility failed to properly label insulin flex pens for three residents, identified as R7, R12, and R23, with the date opened and the discard date. This oversight was observed on two nurse medication carts during a survey. Specifically, R7's Novolog flex pen, as well as R12's and R23's Basaglar flex pens, were not labeled with the necessary information. This deficiency was confirmed by both a licensed nurse and an administrative nurse, who acknowledged that the insulin pens should have been labeled with the date they were opened and their expiration date. The facility's policy on the storage of medication mandates that all drugs and biologicals be stored in a safe, secure, and orderly manner, and that outdated or deteriorated drugs should not be used. According to Medlineplus.gov, open and unrefrigerated Lantus, Novolog, and Basaglar insulin should be used within 28 days, after which they must be discarded. The failure to label the insulin flex pens appropriately placed the residents at risk for receiving ineffective medication.
Failure to Accommodate Resident's Food Allergy
Penalty
Summary
The facility failed to accommodate a resident's known food allergy to mushrooms, resulting in a severe allergic reaction. The resident, who had a documented allergy to mushrooms, was served a meal containing mushrooms. Despite the resident's immediate notification to staff about the allergy, the resident experienced symptoms of anaphylaxis, including itching, swelling of the tongue, and throat. The resident required administration of diphenhydramine and an epinephrine pen, followed by transfer to the Emergency Department for further evaluation and treatment. The resident's medical records, including the Physician Order Sheet and care plans, clearly documented the allergy to mushrooms. The dietary staff failed to check the ingredient label of the oriental vegetables served, which contained mushrooms. This oversight occurred despite the allergy being listed on the resident's tray card and care plan. The dietary staff admitted to not noticing the mushrooms in the meal and failing to offer an alternative meal. The facility's policy on food allergies and intolerance was not followed, leading to the resident's exposure to the allergen. The incident was reported by various staff members, and it was confirmed that the dietary staff did not check the ingredient label before serving the meal. The failure to adhere to the resident's dietary care plan and the facility's policy placed the resident in immediate jeopardy, resulting in a severe allergic reaction and emergency medical intervention.
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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