Eureka Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Eureka, Kansas.
- Location
- 1020 N School Street, Eureka, Kansas 67045
- CMS Provider Number
- 175287
- Inspections on file
- 17
- Latest survey
- November 5, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Eureka Nursing Center during CMS and state inspections, most recent first.
A long-term care facility failed to protect residents from abuse, as evidenced by a resident-to-resident sexual abuse incident and inadequate investigation of employee-to-resident abuse allegations. A resident with a history of hypersexual behavior inappropriately touched another resident, and the facility's response was insufficient. Additionally, another resident was found with multiple bruises, but the facility did not conduct a thorough investigation or report the findings, placing residents at risk for further harm.
A resident with a history of hypersexual behaviors in a LTC facility grabbed another resident's breast without consent. Despite the resident's known history of inappropriate actions, the facility failed to implement adequate interventions or update the care plan to prevent such incidents. Staff interviews revealed a lack of awareness and documentation regarding the resident's behaviors, highlighting deficiencies in the facility's abuse prevention policies.
A resident with multiple medical conditions, including a right above-knee amputation, experienced two unsafe transfers at the facility. In the first incident, a shower chair's wheel broke, causing the resident to fall and fracture his tibia. In the second incident, the resident was transferred into an electric wheelchair with exposed metal, resulting in a laceration that required sutures. The facility failed to update the care plan to include a CAM boot and did not maintain the shower chair properly.
The facility failed to maintain sanitary conditions in food storage and preparation, potentially risking foodborne illnesses. Observations revealed undated food items, an open garbage can near food prep areas, and kitchen equipment with scratches and debris. Dietary staff confirmed these issues, and the facility lacked a food storage policy.
The facility did not maintain the required RN coverage for at least eight continuous hours on 29 days between August 2023 and January 2024, as confirmed by the Payroll Based Journal and Daily Staff Postings. With a census of 48 residents, this lack of coverage placed residents at risk for unsupervised nursing care. Administrative Staff A confirmed the absence of RN coverage on the specified days.
The facility failed to submit accurate staffing data to CMS, missing 24-hour Licensed Nurse coverage on 16 dates. This was confirmed by Administrative Staff A, who admitted inaccuracies in the Payroll Base Journal (PBJ) data for specific weekends in April, May, and June 2023.
The facility failed to provide a clean and sanitary environment for residents in the special care unit due to a persistent urine odor, despite multiple interventions. Additionally, two residents had cracked and worn fall mats, making sanitation difficult and reducing their effectiveness. The facility lacked policies for urine odor elimination and fall mat maintenance.
The facility failed to accurately complete the MDS for three residents, resulting in uncommunicated care needs. Errors included misdocumenting antiplatelet medication as anticoagulant for two residents and failing to document contractures for another. These discrepancies were confirmed by the Administrative Nurse, who noted the lack of a facility policy for MDS completion.
A facility failed to develop a comprehensive person-centered care plan for a resident with Alzheimer's, anxiety, and dementia within the required timeframe. The resident, with a BIMS score indicating moderately impaired cognition, did not have a care plan completed within 21 days of admission, contrary to the facility's policy. Observations noted the resident's anxiety and lack of documented interventions, highlighting unmet needs.
A resident with multiple health conditions, including a right above-knee amputation, was not provided with a revised care plan to include the use of a CAM boot as ordered by a physician. This oversight led to a laceration on the resident's leg during a transfer without the boot, due to contact with exposed metal on the wheelchair. The facility's policy required care plan updates for changes in condition, which was not followed.
A facility failed to apply sheepskin padding to a resident's wheelchair arm rests as required by the care plan, despite the resident's history of arthritis and a recent skin tear. Observations confirmed the absence of the padding, and staff verified it had never been applied. This oversight potentially increased the risk of further skin injuries.
A resident with a history of trauma, including childhood sexual abuse and domestic violence, did not receive trauma-informed and person-centered care. The care plan lacked interventions for past trauma, and staff were unaware of the resident's trauma history or PTSD training. The facility's policy on Trauma Informed Care was not followed, leading to inadequate care for the resident's mental and psychosocial well-being.
The facility was found to have a deficiency in maintaining a sanitary environment in the soiled utility room on the 400-hall. A trash can was observed without a liner and lid, contrary to the facility's standard practice. The Maintenance Director confirmed the requirement for liners and lids, but the facility lacked a policy on this matter.
Failure to Prevent and Respond to Abuse in LTC Facility
Penalty
Summary
The facility failed to protect residents from abuse, specifically in the case of a resident-to-resident sexual abuse incident. Resident 2, who had a history of hypersexual behaviors, grabbed Resident 1's breast without consent. Despite Resident 2's documented history of inappropriate sexual behavior towards staff, the facility did not have adequate interventions in place to prevent such incidents. The care plan for Resident 2 lacked specific interventions related to sexual abuse, and the facility's response to the incident was insufficient, as it did not include a thorough investigation or appropriate updates to the care plan. Additionally, the facility failed to investigate and report potential employee-to-resident abuse involving Resident 10, who was found with multiple bruises of unknown origin. Despite the presence of bruises documented during skin assessments, the facility did not conduct a thorough investigation or report the findings to the state agency or local police. The lack of investigation into the bruises and the failure to identify them as potential abuse placed Resident 10 at risk for further harm. The facility's inaction in both cases demonstrates a failure to ensure the safety and well-being of its residents. The lack of appropriate interventions, failure to update care plans, and inadequate response to allegations of abuse highlight significant deficiencies in the facility's handling of abuse prevention and response.
Removal Plan
- R2 was placed on a one on one and would remain a one on one until alternative living arrangements can be made and/or medication can be implemented to decrease sexual urges.
- To ensure the psychosocial well-being of R1, a follow-up interview was conducted. During the interview conducted by Administrative Nurse B and Administrative Nurse C, R1 denied being afraid of R2 or that she was fearful of living across the hall from him. R1 reported she felt safe living at facility and had no complaints.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse, specifically when a resident with a history of hypersexual behaviors, including groping and making inappropriate comments, grabbed another resident's breast without consent. This incident occurred despite the resident's known history of such behaviors, which included previous inappropriate actions towards staff and other residents. The facility did not have adequate interventions in place to prevent this behavior, and the care plan for the resident lacked any documentation or interventions related to the sexual abuse incident. The resident involved in the incident had a diagnosis of vascular dementia and was noted to have intact cognition with a BIMS score of 14. Despite this, the resident exhibited impulsivity and behaviors that could lead to unsafe situations. The care plan included instructions for staff to provide redirection and reorientation, but it did not address the specific risk of sexual abuse towards other residents. The facility's records showed multiple instances of inappropriate behavior by the resident, yet there was no comprehensive plan to address these behaviors or protect other residents. Interviews with staff revealed that there was a lack of awareness and documentation regarding the resident's inappropriate behaviors towards other residents. Some staff members were unaware of the incident, and others confirmed that the care plan did not include interventions for sexual abuse. The facility's policy on abuse, neglect, and exploitation was not effectively implemented, as evidenced by the failure to update the care plan and take appropriate measures to prevent further incidents.
Removal Plan
- R2 was placed on a one on one and would remain a one on one until alternative living arrangements can be made and/or medication can be implemented to decrease sexual urges.
- To ensure the psychosocial well-being of R1, a follow-up interview was conducted. During the interview conducted by Administrative Nurse B and Administrative Nurse C, R1 denied being afraid of R2 or that she was fearful of living across the hall from him. R1 reported she felt safe living at facility and had no complaints.
Resident Safety Compromised During Transfers
Penalty
Summary
The facility failed to ensure the safety of a resident during two separate transfer incidents. The first incident occurred when staff used a shower chair to transport the resident, resulting in the chair's wheel breaking and the resident falling forward, sustaining a fractured tibia. The resident's medical history included chronic obstructive pulmonary disease, diabetes, polyneuropathy, and a right above-knee amputation, which made him dependent on staff for transfers and increased his risk for difficult transfers. In the second incident, the facility staff did not ensure a safe transfer of the resident into his electric wheelchair, which had exposed metal, while using a mechanical lift. This resulted in a laceration on the resident's anterior lower leg that required sutures. The resident's care plan was not updated to include the use of a controlled ankle movement boot, which was ordered by a physician for protection after the removal of a cast. The facility's policies and procedures were not adequately followed, as evidenced by the lack of maintenance documentation for the shower chair prior to the incident and the failure to apply the CAM boot before transferring the resident. Interviews with staff revealed that the resident's wheelchair lacked proper padding, contributing to the injury during the transfer. The facility's policy for resident showers and accident prevention was not effectively implemented, leading to these safety deficiencies.
Unsanitary Food Storage and Preparation Practices
Penalty
Summary
The facility failed to store, prepare, and serve food in a sanitary manner, which could potentially lead to foodborne illnesses among residents. During an observation, a sealed 10-pound bag of macaroni was found without an opened date in the dry goods pantry. Additionally, a half meat sandwich in a zip lock bag lacked a date, and a sealed zip lock bag contained four half-emptied squeeze bags of icing dated several months prior, with no expiration dates noted. Dietary Staff BB confirmed these concerns during an interview. Furthermore, an open garbage can full of garbage was observed near the food preparation station, which Dietary Staff B acknowledged should have been closed at all times. During an environmental tour, several unsanitary conditions were noted in the kitchen. The top oven had areas of bubbled burned food debris, and two large fry pans had multiple scratches on their cooking surfaces. A large white cutting board was found with multiple scratches and gouges on both sides, and two white rubber spatulas had cracks and chips on their outer surfaces. Dietary Staff BB confirmed these issues during an interview. The facility also failed to provide a policy on food storage, further contributing to the unsanitary conditions observed.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to maintain the required Registered Nurse (RN) coverage for at least eight continuous hours on 29 specific days between August 2023 and January 2024. This deficiency was identified through a review of the Payroll Based Journal (PBJ) and Daily Staff Postings, which confirmed the absence of RN coverage on the specified dates. The facility reported a census of 48 residents, and the lack of RN coverage placed these residents at risk for unsupervised nursing care and services. Administrative Staff A confirmed the absence of RN coverage on the days indicated in the PBJ report. The facility utilized the Facility Assessment to determine the required RN coverage but failed to ensure compliance with the eight-hour requirement.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) as required. Specifically, the facility did not accurately report 24-hour Licensed Nurse (LN) coverage for 16 specific dates between April 1, 2023, and March 31, 2024. This deficiency was identified through a review of the Payroll Base Journal (PBJ) Staffing Data Report for the fiscal year, Quarter 3 of 2023, which revealed gaps in LN coverage on several weekends in April, May, and June 2023. During an interview on July 11, 2024, Administrative Staff A acknowledged that the PBJ data was inaccurate regarding the 24-hour LN coverage for the specified dates. The facility relied on its Facility Assessment policy for completing the PBJ, but this did not ensure accurate reporting. The failure to provide complete and accurate staffing information in a uniform format as specified by CMS constitutes a deficiency in the facility's compliance with federal requirements.
Facility Fails to Maintain Sanitary Environment and Fall Mat Maintenance
Penalty
Summary
The facility failed to provide a clean, home-like, and sanitary environment for residents in the special care unit. During an environmental tour, a pervasive odor of urine was detected throughout the unit and extended into the main hallway. Maintenance Director U attributed the odor to a resident who urinated in random places, and despite multiple interventions by nursing staff since September 2022, the issue persisted. Administrative Nurse E confirmed that the odor compromised the sanitary and home-like environment for the 11 residents in the special care unit. The facility did not have a policy related to the elimination of urine odors. Additionally, the facility failed to maintain sanitary conditions for two residents who had cracked and worn fall mats in their rooms. During an initial tour, it was observed that one resident had a fall mat with multiple cracks and worn surfaces, while another resident had two fall mats with similar issues. Administrative Nurse E confirmed that the condition of the fall mats made sanitation difficult and reduced their effectiveness. The facility lacked a policy for fall mat maintenance, contributing to the unsanitary and unsafe environment for these residents.
Inaccurate MDS Documentation Leads to Uncommunicated Care Needs
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for three residents, leading to uncommunicated care needs. For one resident, the MDS inaccurately documented the use of antiplatelet medication as an anticoagulant, despite physician orders and medication administration records indicating the use of aspirin, an antiplatelet medication. This discrepancy was confirmed by the Administrative Nurse, who acknowledged it as a clerical error and noted the absence of a facility policy for MDS completion. Another resident's MDS also incorrectly documented the use of anticoagulant medication instead of antiplatelet medication. The resident's care plan and medication records showed the administration of aspirin, but there was no documentation of anticoagulant use. The Administrative Nurse confirmed this error, attributing it to clerical mistakes and the lack of a specific MDS completion policy. Additionally, the MDS for a third resident failed to document contractures as impairments, despite the resident having a right-hand contracture and using a hand splint and carrot splint. Observations noted inconsistencies in the application of these splints, and staff reported that care sheets lacked information about the splints. The Administrative Nurse confirmed the oversight in the MDS documentation, again highlighting the absence of a facility policy for MDS completion.
Failure to Develop Timely Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as R47, within the required timeframe. R47 was admitted with diagnoses including Alzheimer's disease, anxiety, and dementia, and had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. Despite these conditions, the care plan was not completed within 21 days of admission, as required by the facility's policy. The policy mandates that a comprehensive care plan be developed within seven days after the completion of the comprehensive Minimum Data Set (MDS). Observations and interviews revealed that R47's care plan lacked staff interventions to provide person-centered care. The resident was noted to be anxious, wringing her hands, and moving around her room, indicating potential unmet needs. The facility's policy, dated 03/28/24, emphasizes the importance of developing a care plan that includes measurable objectives and timeframes to address the resident's medical, nursing, mental, and psychosocial needs. However, the facility did not adhere to this policy, resulting in a deficiency that could negatively impact the resident's well-being.
Failure to Update Care Plan for CAM Boot Use
Penalty
Summary
The facility failed to review and revise the care plan for a resident, identified as R30, to include the use of a controlled ankle movement (CAM) boot as ordered by the physician. The resident had a history of chronic obstructive pulmonary disease, diabetes, polyneuropathy, and a right above-knee amputation, and was dependent on staff for transfers and mobility. Despite a physician's order dated 05/23/24 for the CAM boot to be worn except during skin checks and range of motion exercises, the care plan was not updated to reflect this requirement. This oversight led to an incident where the resident sustained a laceration on his left lower extremity due to contact with an exposed piece of metal on his wheelchair during a transfer without the CAM boot being applied. Observations and interviews revealed that staff did not apply the CAM boot prior to transferring the resident, which was contrary to the physician's order and the facility's policy on accidents and supervision. The resident reported a previous incident where a shower chair wheel broke, resulting in a fall and a subsequent fracture, which required a cast and later a CAM boot. The facility's policy required changes in a resident's condition to be reflected in the care plan, but this was not done for R30, leading to inadequate protection during transfers and resulting in injury.
Failure to Apply Sheepskin Padding to Wheelchair Arm Rests
Penalty
Summary
The facility failed to apply sheepskin padding to the arm rests of Resident 34's wheelchair, as required by the care plan. Resident 34 had a history of arthritis and anxiety, with severely impaired cognition as indicated by a BIMS score of five on the Annual MDS. The care plan, dated July 4, 2024, specified the application of sheepskin padding due to a skin tear obtained on the same day. However, the physician orders dated July 10, 2024, did not document the need for sheepskin padding, and observations on July 10, 2024, confirmed the absence of sheepskin on the wheelchair arm rests. Certified Nurse Aide M verified the lack of sheepskin padding and stated she had never seen it on the resident's wheelchair. Administrative Nurse E expressed that the charge nurse responsible for the intervention should have ensured its completion according to the care plan. The facility's policy on accidents and supervision emphasized maintaining a hazard-free environment and implementing necessary interventions to prevent accidents. The failure to apply the sheepskin padding potentially increased the risk of additional skin injuries for Resident 34.
Failure to Implement Trauma-Informed Care for Resident
Penalty
Summary
The facility failed to develop and implement trauma-informed and person-centered care for a resident with a history of personal trauma. The resident, who had diagnoses including Alzheimer's disease, anxiety, and dementia, was found to have a history of childhood sexual abuse and domestic violence. Despite this, the resident's care plan lacked interventions to address past trauma, adjustment difficulties, or indications of distress. The care plan did not include strategies to assist the resident in reaching and maintaining their highest level of mental and psychosocial well-being. Observations and interviews revealed that the resident exhibited signs of anxiety, such as hand-wringing and restlessness, yet the care plan did not reflect any trauma-informed interventions. Staff members, including CNAs and administrative staff, were unaware of any training on PTSD or the resident's trauma history. The facility's policy on Trauma Informed Care emphasized the importance of culturally competent care that minimizes triggers and re-traumatization, but this was not reflected in the care provided to the resident.
Sanitary Environment Deficiency in Soiled Utility Room
Penalty
Summary
The facility failed to maintain a sanitary environment in the soiled utility room on the 400-hall, as observed during an environmental tour. A trash can in this room was found without a liner and a lid, which is against the facility's standard practice. The Maintenance Director confirmed that all trash containers should have liners and lids, and that trash and soiled linen containers are to be washed out at the end of every shift. However, the facility did not provide a policy related to the requirement for lids or coverings on trash cans, indicating a lapse in maintaining sanitary conditions.
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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