Evergreen Community Of Johnson County
Inspection history, citations, penalties and survey trends for this long-term care facility in Olathe, Kansas.
- Location
- 11875 S Sunset Drive, Suite 100, Olathe, Kansas 66061
- CMS Provider Number
- 175355
- Inspections on file
- 19
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Evergreen Community Of Johnson County during CMS and state inspections, most recent first.
Surveyors identified a failure to follow sanitary food storage and labeling practices in the main kitchen and two kitchenettes serving 79 residents. Multiple opened and undated food items were found in the walk-in freezer, dry storage, and refrigerators, including fish fillets, pepperoni, tater tots, cauliflower, egg noodles, molded cheddar cheese, expired or spoiled produce, and undated choy noodles. In the kitchenettes, undated mixed fruit, prunes, and pretzels were observed, along with unlabeled and undated resident food items such as pizza and a plate with a hamburger and tater tots. Dietary staff acknowledged that facility policy required all opened and leftover foods to be stored in covered or sealed containers, clearly labeled and dated, and that dietary aides were responsible for checking for spoiled food and proper labeling, which did not occur as required.
A resident with multiple medical conditions, including dementia and dependence on staff for ADLs, received a significant portion of nutrition via PEG tube with detailed MD orders and a care plan for enteral feeding. Over several observations, surveyors noted that the resident’s enteral feeding bags, running on a pump at the ordered rate, were not labeled with the formula contents or the date and time they were started, despite facility policy and staff statements that night-shift nurses were responsible for labeling bags with date, time, rate, and formula.
The facility failed to utilize safe heat therapy practices, resulting in a second-degree burn on a resident's knee, and did not maintain functional fall-prevention alarms for another resident, placing them at risk for preventable falls and injuries.
The facility failed to follow sanitary dietary standards related to cleaning, food storage, equipment storage, and food preparation practices. Observations included improper storage of utensils, unclean kitchen equipment, and unlabeled food items. A dietary staff member was also observed not following proper hand hygiene and food handling procedures.
The facility failed to provide a resident with a wheelchair lap meal tray as care planned, and another resident's call light was out of reach while unsupervised. Both residents had significant medical conditions and required assistance, but staff did not follow the care plans, leading to impaired quality of life and care.
The facility failed to ensure that a resident received the required assistance with ADLs as directed in her care plan. The resident, who had multiple diagnoses and was dependent on two staff members for all ADLs, was left in the same position for extended periods without being repositioned or checked for incontinence. Staff interactions were minimal and did not include the necessary care actions, placing the resident at risk for complications.
The facility failed to ensure a resident was invited, encouraged, and assisted to attend activities she enjoyed, despite her care plan indicating her preferences for spiritual and music-related activities. Staff admitted to forgetting and not noticing the updated activity calendar, and the facility lacked a policy for activities.
The facility failed to ensure a physician-documented rationale for the extended use of as-needed psychotropic medication for two residents with severely impaired cognition, placing them at risk for unnecessary medication administration and potential harmful side effects. Staff interviews and record reviews confirmed the absence of required documentation for the extended use of lorazepam.
The facility failed to ensure collaboration with hospice services to identify hospice-supplied services, supplies, medication, and equipment for a resident with multiple medical diagnoses. The care plan lacked detailed hospice information, and the resident struggled to access his drink due to an ill-fitting lap tray. Staff interviews confirmed the absence of detailed hospice information in the care plans.
Failure to Maintain Sanitary Food Storage and Labeling Practices
Penalty
Summary
The deficiency involves failure to maintain sanitary dietary standards and proper food storage practices in the main kitchen and two kitchenettes serving 79 residents. During an initial kitchen tour, surveyors observed multiple opened, undated food items in the walk-in freezer, including a resealable bag with three fish fillets, an opened bag of pepperoni, an opened bag of tater tots placed in a resealable bag, and an opened bag of cauliflower florets, none of which were labeled or dated. In the dry food storage room, there was an opened and undated bag of egg noodles. In the walk-in refrigerator, surveyors found a metal bowl covered with plastic wrap containing several slices of molded cheddar cheese. In the walk-in produce refrigerator, they observed a bag of broccoli with a manufacturer “best if used by” date that had passed, three bags of coleslaw mix that were soft, mushy, and appeared spoiled, with one bag containing brown fluid, and multiple peppers (jalapeno, green, red, and yellow) that were moldy, soft, wilted, wrinkled, or had blackened, moldy spots. Additional observations in the main kitchen and kitchenettes showed further failures to follow food storage policies. In the kitchen’s main area, there was a plastic container of choy noodles that was not dated. In one kitchenette refrigerator, two plastic bins of mixed fruit were not labeled or dated, and in a kitchenette cabinet, an opened bag of prunes and an opened bag of pretzels were also not dated. In a resident refrigerator within a kitchenette, surveyors found a box of pizza and a plate with a hamburger and tater tots covered in plastic wrap, neither of which were dated or labeled with a resident’s name. Dietary staff later stated that all opened food items were expected to be labeled and dated, that opened bags should be placed in resealable plastic bags and labeled and dated, and that dietary aides were responsible for checking kitchenettes after each meal to look for spoiled food and ensure items were labeled and dated. The facility’s Food Storage policy required all leftover and stored foods to be in covered or sealed containers, clearly labeled and dated, and used within specified time frames or discarded, which was not followed in these instances.
Unlabeled Enteral Feeding Bags for Tube-Fed Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enteral feeding bags were labeled with the contents and the date and time the feeding was started, as required by facility policy. The resident had diagnoses including muscle weakness, difficulty in walking, hypertension, dementia, and anxiety, with a BIMS score of 15 indicating intact cognition. The MDS documented that the resident had bilateral lower body impairment, was dependent on staff for toileting and bathing, had a feeding tube, and received 51 percent of her calories through tube feedings. The care plan and physician orders specified detailed enteral feeding procedures, including elevating the head of bed, checking tube placement and residuals, flushing the PEG tube with specified amounts of water, and changing and labeling the feeding syringe daily with name and date. The facility’s policy for administering nutritional formulas through an enteral tube required staff to label the bag and tubing with the date and time. Surveyor observations on multiple mornings showed the resident in bed with the head of bed elevated and the enteral feeding running via pump at the ordered rate, but the feeding bags were not labeled with the contents or the date and time the feeding was started. On one observation, the enteral feeding bags were hung on the feeding pump without any markings, and on subsequent observation the pump was running at 70 ml/hr with the bags still unlabeled. Interviews with a licensed nurse and an administrative nurse confirmed that night-shift nurses were responsible for hanging and labeling the bags with the date, time, rate, and formula, and that the bags should be marked on the back with the date and contents. Despite these stated responsibilities and the written policy, the resident’s feeding bags remained unlabeled during the surveyor’s observations, constituting the identified deficiency.
Failure to Ensure Safe Heat Therapy and Maintain Fall-Prevention Alarms
Penalty
Summary
The facility failed to utilize safe heat therapy practices for a resident, resulting in a second-degree burn on the resident's right knee. The resident had a history of epilepsy, seizures, osteoarthritis, muscle weakness, and Alzheimer's disease. During a therapy session, the resident complained of knee pain, and the consultant applied a moist heating pack without a protective cover, using multiple layers of towels instead. This led to a blister and a second-degree burn on the resident's knee. The consultant reported the injury to nursing services, the resident's medical practitioner, and the resident's representative. The facility's investigation revealed that the correct protective covers were available, but the consultant did not ask staff where they were located. The facility's policy required the use of appropriate equipment and placement for heat therapy, which was not followed in this instance. The facility also failed to ensure a safe environment related to maintaining another resident's wheelchair and bed fall-prevention alarm. This resident had a history of dementia, anxiety disorder, cognitive-communication deficit, muscle weakness, and required assistance with personal care. The resident's care plan included the use of pressure sensor pads for the bed and wheelchair to prevent falls. However, during an observation, the resident was seen attempting to transfer herself from her bed to her wheelchair without staff intervention. Tests revealed that the pressure sensor pads were not functioning correctly, and the alarms did not relay to the nurse's station. Staff acknowledged that the alarms should have been checked each shift to ensure functionality, but this was not done consistently. The facility's Fall Prevention and Management policy indicated that staff were to ensure environmental conditions remained safe for residents at risk and that equipment remained in working order. The failure to maintain the pressure sensor pads and ensure their functionality placed the resident at risk for preventable falls and injuries. The facility's inaction in maintaining the alarms and ensuring their proper function directly contributed to the deficiency.
Failure to Follow Sanitary Dietary Standards
Penalty
Summary
The facility failed to follow sanitary dietary standards related to cleaning, food storage, equipment storage, and food preparation practices. During an initial walkthrough of the kitchen, surveyors observed two Crock-pot lids and a water pitcher lid stored with the food/beverage side upward, old crumbs and food particles covering the outside of the fryer and the side of the baking oven, and old pieces of food on the floor throughout the dry food storage room. Additionally, a dietary staff member was observed preparing a pureed meal without completing proper hand hygiene and using a scoop that was placed directly on a dirty food preparation area without a clean barrier. Inspections also revealed six opened and unlabeled quart containers of ice cream, an opened bag of tater tots in the dining room refrigerator, and an opened but undated bag of breaded chicken in the walk-in freezer. Dietary Staff BB confirmed that staff were expected to ensure clean hygienic food preparation, use clean utensils, and store cooking utensils and plates with the food or eating surface downward. The facility's Food Services and Nutrition policy indicated that all surfaces within the dining room and kitchen were to be cleaned and sanitized per professional standards, and that food would be labeled, dated, and stored in a manner that is safe and maintains nutritional value. The policy also required staff to complete hand hygiene between touching surfaces related to direct food preparation, handling, and serving, and to store kitchen and dining equipment in a manner that prevents soiling or contamination of clean items. The facility's failure to adhere to these standards placed residents at risk of food-borne illnesses and food safety concerns.
Failure to Provide Assistive Devices and Ensure Call Light Accessibility
Penalty
Summary
The facility failed to provide a resident with a wheelchair lap meal tray as care planned for his meals. The resident, who had diagnoses including Parkinson's disease, dementia, and left-sided paralysis, required the lap tray to independently eat his food. Despite the care plan indicating the need for the lap tray, observations showed that the tray was not used, and the resident struggled to reach his drink. Staff were unaware that the lap tray did not fit the resident's new Broda chair, and no action was taken to replace it, leading to the resident's impaired quality of life and care. Another resident's call light was found to be out of reach while she was unsupervised in her room. This resident had diagnoses including dementia, heart failure, and anxiety, and was dependent on staff for all activities of daily living. Despite the care plan indicating that the call light should be within reach, observations showed that the call light was placed in the middle of the bed, out of the resident's reach. Staff acknowledged that the call light should be within reach and that the resident was unable to push the button, requiring periodic checks. The facility's policies on assistive devices and call light monitoring were not followed, leading to deficiencies in the care provided to both residents. The failure to provide the necessary assistive devices and ensure the call light was within reach placed the residents at risk for impaired physical, mental, and psychosocial well-being.
Failure to Assist Resident with ADLs as Directed in Care Plan
Penalty
Summary
The facility failed to ensure that Resident 39 received the required assistance with activities of daily living (ADLs) as directed in her care plan. Resident 39, who had diagnoses including dementia, dysphagia, heart failure, hypertension, and anxiety, was documented as being dependent on two staff members for all toileting, positioning, transfers, and ADLs. Observations revealed that Resident 39 was left in the same position in her Broda chair for extended periods without being repositioned or checked for incontinence, contrary to the care plan instructions that required repositioning every two hours during the day and every four hours at night, as well as regular checks and changes for incontinence. Staff interactions with Resident 39 were minimal and did not include the necessary care actions as outlined in her care plan. On one occasion, Resident 39 was observed from 08:14 AM to 11:36 AM without being repositioned or checked for incontinence, despite the care plan's directives. Staff members were present in the room at various times but did not perform the required care tasks. Additionally, a Certified Nursing Aide (CNA) acknowledged knowing the care plan requirements but did not follow through with the necessary actions. Interviews with staff, including a Licensed Nurse and an Administrative Nurse, confirmed that the expectation was for CNAs to follow the care plan, but this was not adhered to in Resident 39's case. This failure placed Resident 39 at risk for complications such as skin breakdown, discomfort, and impaired psychosocial well-being.
Failure to Facilitate Resident Participation in Enjoyed Activities
Penalty
Summary
The facility failed to provide Resident 39 the opportunity to participate in activities she enjoys, which placed her at risk for decreased psychosocial well-being. Resident 39 has multiple diagnoses, including dementia, dysplasia oropharyngeal phase, combined systolic and diastolic heart failure, hypertension, and anxiety. Her care plan indicated that she enjoyed spiritual and religious activities, as well as music, and should be invited to such events. However, on the day of observation, staff did not invite or assist her to attend Bible Study or a live music event, despite these activities being listed on the facility's activity calendar. Staff interviews revealed that the CNAs were aware of the activities each resident liked to attend but failed to take Resident 39 to the activities she enjoyed. One CNA admitted to forgetting to take her to the activities and not noticing the updated activity calendar. The Social Service staff responsible for activities on Resident 39's unit also failed to ensure she attended the live music event, despite the activity calendars being posted in multiple locations. The facility did not provide a policy for activities, further contributing to the oversight in Resident 39's care.
Lack of Physician-Documented Rationale for Extended Use of As-Needed Psychotropic Medication
Penalty
Summary
The facility failed to ensure a physician-documented rationale for the extended use of as-needed psychotropic medication for two residents, R29 and R40. R29, diagnosed with Alzheimer's disease, delusion, and anxiety, had severely impaired cognition and was receiving multiple psychotropic medications, including lorazepam. The facility's records lacked evidence of a physician-documented rationale for the extended duration of as-needed lorazepam, and staff were unable to provide this documentation upon request. Observations noted R29 asleep in a reclined position in a specialized wheelchair, and staff interviews confirmed that the physician reviewed and decided on medication durations but did not document the rationale for the extended use of lorazepam. Similarly, R40, diagnosed with Alzheimer's disease, anxiety, depression, and dementia, also had severely impaired cognition and was receiving multiple psychotropic medications, including lorazepam. The facility's records for R40 also lacked evidence of a physician-documented rationale for the extended duration of as-needed lorazepam. Staff interviews revealed that the physician reviewed monthly pharmacy reviews and made changes to medication durations but did not document the rationale for the extended use of lorazepam. Observations noted R40 lying in bed with eyes closed, and staff confirmed the absence of documented rationale for the extended use of lorazepam. The facility's policy on antipsychotic drug use required a comprehensive assessment and documentation of the necessity for such medications, including the consideration of non-pharmacologic interventions. However, the facility failed to adhere to this policy, resulting in the lack of documented physician rationale for the extended use of as-needed lorazepam for both residents. This deficiency placed the residents at risk for unnecessary medication administration and potential harmful side effects.
Failure to Ensure Collaboration with Hospice Services
Penalty
Summary
The facility failed to ensure collaboration between the nursing home and hospice services to identify hospice-supplied services, supplies, medication, and equipment for Resident 47. The resident had multiple medical diagnoses, including senile degeneration of the brain, Parkinson's disease, dysphagia, memory deficit, left-sided hemiplegia, left-sided hemiparesis, and dementia. The resident's care plan indicated he was on hospice services, but it lacked documentation related to the hospice equipment, medications, services, and scheduled visits from hospice staff. Observations revealed that the resident struggled to reach his drink due to the absence of a properly fitting lap tray for his new Broda chair, which was replaced by hospice. Staff interviews confirmed that the care plans did not include detailed hospice information other than the name of the hospice company. The facility's policy indicated that it would coordinate with the selected hospice agency to provide necessary end-of-life care services. However, the facility did not ensure this coordination, as evidenced by the lack of detailed hospice information in the care plans and the resident's difficulty in accessing his drink due to the ill-fitting lap tray. This deficient practice placed the resident at risk for delayed services and uncommunicated care needs.
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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