Excel Healthcare And Rehab Topeka
Inspection history, citations, penalties and survey trends for this long-term care facility in Topeka, Kansas.
- Location
- 2515 Sw Wanamaker Road, Topeka, Kansas 66614
- CMS Provider Number
- 175172
- Inspections on file
- 33
- Latest survey
- January 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Excel Healthcare And Rehab Topeka during CMS and state inspections, most recent first.
A resident with cognitive impairment and aphasia experienced a fracture of unknown origin, which the facility failed to identify and investigate as potential abuse or neglect. Despite the resident's severe cognitive impairment and history of falls, the facility did not implement protective measures or update the care plan to reflect the resident's need for increased assistance. Staff interviews revealed a lack of awareness and action regarding the resident's condition, placing the resident in immediate jeopardy.
The facility failed to provide a safe environment and adequate supervision, resulting in multiple incidents of falls and injuries. A resident with a history of falls was found on the floor after her bed was left in a high position, leading to a fracture. Another resident with dysphagia was left in a flat position during meals, risking aspiration. Additionally, a resident was transported without proper use of wheelchair foot pedals, and another's call light was not within reach. The facility also failed to investigate and respond to a resident's increased need for assistance.
A resident with a history of mental health disorders did not receive her prescribed antipsychotic medication, Invega Sustenna, as scheduled, leading to increased hallucinations and psychosocial distress. The medication was missed on two occasions, and the facility failed to notify the physician, resulting in additional psychotropic medications being prescribed. The facility's medication error policy was not adhered to, contributing to the resident's decline.
The facility failed to conduct a thorough assessment to determine necessary resources for resident care, lacking specific staffing levels and contingency plans. The assessment did not specify the number of RNs, LPNs, CMAs, and CNAs needed for each unit or shifts, affecting all 88 residents.
The facility's ineffective QAA program led to multiple deficiencies, including inadequate resident care and safety measures. Residents faced risks due to unaddressed potential abuse, incomplete care assessments, inconsistent activities, and medication management issues. Staff competency and training were also lacking, impacting the quality of care provided.
The facility failed to ensure agency staff received required communication training, impacting care quality for 88 residents. The facility could not provide training records for several CNAs from an agency, and the Administrative Nurse noted difficulties in obtaining these records. The facility's policy requires all staff to be certified and educated in key competencies, but the lack of training for agency staff was a deficiency, risking impaired care and decreased quality of life.
The facility failed to ensure agency staff received required training on resident rights, impacting care quality. Training records for CNAs from a contracted agency were unavailable, and Administrative Nurse D noted difficulties in obtaining these records. The facility's policy requires all staff to be certified and educated on key competencies, but this was not ensured for agency staff, risking impaired care and decreased quality of life.
The facility failed to ensure agency staff received required infection control training, placing residents at risk. The facility could not provide training records for several CNAs, and Administrative Nurse D noted difficulties in obtaining these from the contracted agency. The facility's policy required all staff to be certified and educated in infection control, but this was not ensured for agency staff.
The facility failed to maintain a surety bond that adequately covered the resident trust funds, placing 52 residents at risk for financial loss. The Trust Account statement showed a balance of $32,310.15, but the surety bond only covered $30,000.00. Administrative staff were unaware of this discrepancy, violating the facility's policy requiring a protective bond to cover deposited amounts.
The facility failed to provide adequate ADL assistance and hygiene care for several residents, including one who struggled to eat due to improper positioning and lack of assistance, another who did not receive consistent bathing, and others who experienced deficiencies in personal hygiene and toileting assistance. These failures placed residents at risk for impaired nutrition, decreased quality of life, and unmet care needs.
The facility failed to provide consistent weekend activities based on resident preferences, risking decreased psychosocial well-being. Scheduled activities often did not occur due to staffing issues, leading residents to self-organize activities. Activity Staff Z attempted to cover weekends, but without additional support, the facility's policy for ongoing individualized and group activities was not consistently met.
The facility failed to ensure proper storage of medications and biologicals, with unlocked medication and treatment carts found in the North Unit. Unsecured prescription medications, diabetic supplies, and medicated ointments were observed, along with a medicine cup labeled with a resident's name left unsupervised. This non-compliance with the facility's policy on medication storage posed risks for medication errors and diversions.
The facility failed to adhere to infection control protocols, as a resident's ventilator mask was improperly stored, a nurse neglected hand hygiene during wound care, and a sit-to-stand lift was not sanitized after use. Staff interviews revealed gaps in understanding and implementing infection control procedures, despite existing policies.
A resident with impaired cognition and functional limitations was not provided a dignified dining experience when a CNA stood over them while assisting with meals, contrary to the facility's policy. Staff interviews confirmed the expectation to sit at eye level with residents during meal assistance, highlighting a failure to adhere to dignity standards.
The facility failed to ensure a resident could functionally activate his call light for assistance, despite his severe cognitive impairment and medical conditions. Additionally, another resident was pushed in a wheelchair without foot pedals, contrary to her care plan, which required their use due to her history of stroke and severe cognitive impairment. These deficiencies placed both residents at risk for unmet care needs.
A facility failed to honor a resident's right to self-determination by not allowing a resident with a smoking agreement to continue smoking after a policy change. The resident, with COPD and intact cognition, was offered nicotine replacement or relocation assistance. Despite expressing a desire to quit smoking and remain, the resident was transferred before a grandfather provision was implemented. Another resident was also not allowed to choose bathing times, impacting autonomy.
A resident's medical record was left unsecured and visible on a laptop screen on an unattended medication cart. An agency CMA, unfamiliar with the facility's procedures, failed to lock the laptop screen. The facility's policy requires PHI to be protected from unauthorized exposure, and staff are expected to secure medication carts and screens when unattended.
A resident with severe cognitive impairment and osteoporosis experienced a fracture of unknown origin, which the facility failed to report as potential abuse or neglect. Despite the resident's history of falls and decline in function, the facility did not recognize the fracture as an injury of unknown origin requiring investigation. Staff interviews revealed a lack of consensus on reporting requirements, leading to a deficiency in handling potential abuse or neglect cases.
A facility failed to provide a complete written notification of transfer for a resident with severe cognitive impairment and multiple medical conditions. The transfer form lacked the reason and location of the transfer, contrary to the facility's policy. This oversight was confirmed by administrative staff.
The facility failed to complete the Care Area Assessment (CAA) analysis for two residents, which is essential for developing individualized care plans. The CAAs for various health concerns were not completed with the necessary analysis, as confirmed by observations and interviews. This placed the residents at risk for impaired care and decreased quality of life due to unidentified care needs.
A facility failed to create a comprehensive care plan for a resident using a Trilogy ventilator, despite the resident's chronic respiratory conditions. The care plan lacked specific instructions for the ventilator's care and application, and the resident was unsure about the mask's cleaning schedule. Staff interviews revealed that the necessary respiratory care details were missing, placing the resident at risk for impaired care.
A facility failed to update a resident's care plan with revised interventions for a Stage 1 pressure wound. Despite the resident's complex medical history and risk for pressure ulcers, the care plan lacked specific directions for managing the condition. Orders for treatments like zinc oxide cream and a low-air loss mattress were not reflected in the care plan, and there was a lack of documentation on wound assessment and measurement. Administrative nurses acknowledged the oversight but could not explain why the care plan was not updated.
A resident with aphasia and other medical conditions did not receive supportive care to maintain her quality of life due to the facility's failure to use communication cards as per her care plan. Despite a physician's order, staff did not utilize the picture sheets, leading to ineffective communication. Staff interviews revealed a lack of awareness about the requirement to use these tools, placing the resident at risk for decreased quality of life and impaired dignity.
The facility failed to provide ongoing wound assessment for a resident's pressure injury and did not ensure another resident's offloading boots were applied, placing both residents at risk for delayed healing and increased risk for pressure ulcers. The first resident, with a history of diabetes and other conditions, had a Stage 1 pressure ulcer that was not properly assessed or measured. The second resident, at moderate risk for pressure ulcers, was observed without offloading boots, contrary to the care plan.
A resident with chronic respiratory conditions had their Trilogy ventilator mask improperly stored directly on a refrigerator without a protective bag, contrary to facility policy. Staff interviews confirmed the expectation for sanitary storage, and the care plan lacked specific instructions for mask care, increasing the risk of respiratory infections.
A facility failed to monitor a resident's dialysis access site daily, as required by the care plan and facility policy, placing the resident at risk of adverse outcomes. The resident, with a history of cognitive impairment and diabetes, was only checked on dialysis days, contrary to the policy requiring daily monitoring and documentation.
A facility failed to ensure nursing staff demonstrated appropriate competencies, leading to a medication error for a resident. The staff incorrectly transcribed a hospital discharge order for IV daptomycin, documenting a 500 mg dose instead of the correct 650 mg. This error was not identified until several administrations had occurred, placing the resident at risk for medication errors and potential adverse side effects.
A resident with multiple diagnoses, including anxiety, did not receive her prescribed antianxiety medication, Buspar, in a timely manner due to a delay in delivery. The medication was not administered multiple times over several days, and staff interviews revealed confusion about the cause, with one nurse citing insurance issues. The facility's Pharmacy Services policy was not followed, leading to this deficiency.
A facility failed to ensure a Consultant Pharmacist identified and reported irregularities in medication administration for a resident with multiple diagnoses, including schizoaffective disorder and anxiety. The resident's antipsychotic and antianxiety medications were not administered as ordered, and the Monthly Medication Review lacked evidence of these irregularities being reported. This placed the resident at risk for unnecessary medication use and adverse side effects.
The facility failed to ensure proper documentation and informed consent for psychotropic medications for several residents, leading to deficiencies in medication management. One resident received an antidepressant without documented rationale or consent, while another was given antipsychotic medication without informed consent or evidence of gradual dose reduction. A third resident also lacked informed consent for antipsychotic medications. Staff were unclear about documentation requirements, and the facility lacked an unnecessary medication policy.
The facility failed to include the resident census on its daily posted nurse staffing sheets, as required by their policy. Inspections revealed that the sheets displayed staffing information but lacked the census. A Licensed Nurse confirmed that the sheets should include both the number of residents and staffing for the day. An Administrative Nurse stated that staffing records are maintained for 18 months and should include daily staffing requirements and census. The facility's policy mandates that staffing hours be maintained for 18 months and be available upon request.
The facility failed to ensure the director of food and nutrition services had the required qualifications of a certified dietary manager (CDM). Dietary Staff BB had completed the course but had not yet obtained certification, and the dietician was only present twice a week. This placed residents at risk for unmet dietary and nutritional needs.
The facility failed to provide sufficient dietary staff, resulting in delayed meal service and potentially impaired nutrition for residents. On one occasion, only one dietary staff member was present due to absences, causing breakfast to be served late. During lunch, residents waited without drinks, and meal trays were distributed past the scheduled time. The facility's policy requires adequate staffing for timely meal preparation and service, which was not met.
The facility failed to meet professional standards for food service safety, risking foodborne illness and cross-contamination. Observations included a dirty kitchen, unlabeled food, improper dishwashing temperature logs, and structural issues. Staff were seen not following hygiene protocols, and the facility lacked a food service policy.
The facility failed to ensure agency CNAs received required communication training, risking impaired care and decreased quality of life for residents. Training records for CNAs lacked documentation of communication training, and there was uncertainty about who was responsible for verifying this training. The facility's policy required in-service training, including communication, but this was not ensured for all staff.
The facility failed to ensure agency CNAs received required training on resident rights, as evidenced by missing documentation in their credentialing files. Administrative Nurse D was unsure who was responsible for verifying training completion. This oversight contravenes the facility's Staff Competency policy, which mandates regular in-service training, including resident rights, placing residents at risk for impaired care and decreased quality of life.
The facility failed to ensure all direct care staff received required training on abuse, neglect, and exploitation (ANE), placing residents at risk. A review revealed that two agency CNAs lacked evidence of completed ANE training. Administrative Nurse D was unsure who was responsible for verifying agency staff training, and the facility's policy required regular in-service training, including ANE, which was not completed for all staff.
The facility failed to ensure agency direct care staff received required infection control training, as evidenced by missing documentation in the credentialing files of two CNAs. Administrative Nurse D was unsure who was responsible for verifying training completion, and the facility's policy required regular in-service training, including infection control. This deficiency placed residents at risk for impaired care and decreased quality of life.
The facility failed to ensure call lights were within reach for several residents, including those with significant medical conditions, leading to risks of injury and delayed care. Additionally, a resident with severe cognitive impairment was pushed in a wheelchair without foot pedals, compromising safety. These deficiencies highlight lapses in adhering to care policies and ensuring resident safety.
The facility failed to address recurring grievances from the Resident Council, including staff cell phone usage, delayed personal care, and dining area cleanliness. Despite repeated concerns documented from December 2023 to May 2024, management responses were vague, and no concrete resolutions were achieved. Observations confirmed issues with cleanliness, impacting residents' quality of life.
The facility failed to maintain a clean and homelike environment, with surveyors observing dirty dining areas, strong urine odors, and sticky residues in resident rooms. Staffing issues were noted, but the facility did not adhere to its policy, placing residents at risk of infection and decreased well-being.
The facility failed to update care plans for several residents, including those with smoking habits, name preferences, and personal hygiene needs. This oversight led to uncommunicated care needs and potential risks, as staff did not document necessary interventions or preferences in the care plans.
The facility failed to maintain a safe environment and follow care plans for several residents, leading to potential hazards and risks of falls. A resident with severe cognitive impairment had a bed rail with a significant gap, and another resident was not assessed for safe use of an electric recliner. Additionally, care-planned fall interventions were not implemented for two residents, including missing visual cues and incorrect bed positioning.
The facility failed to properly label and store medications, with two opened insulin pens found undated in a medication cart and another cart left unlocked and unattended. This non-compliance with the facility's Medication Storage policy placed residents at risk for adverse outcomes or ineffective medication regimens.
A long-term care facility failed to follow infection control standards, including enhanced barrier precautions, hand hygiene, and proper storage of medical equipment. Observations included soiled incontinence products on the floor, oxygen masks on contaminated surfaces, and improper handling of a glucometer and urinary catheter drainage bag. Staff did not adhere to the facility's infection control policy, placing residents at risk for infectious diseases.
The facility failed to provide dignified care for two residents, one of whom was repeatedly left uncovered, compromising privacy, while another was addressed with informal terms not approved in her care plan. These actions did not align with the facility's policies on resident dignity.
The facility did not issue the required CMS Form 10055 Advance Beneficiary Notice of Non-coverage (ABN) to two residents who remained for custodial care after their Medicare Part A coverage ended. Social Services staff were unaware of the form's purpose, and the facility's policy designated a contact for Medicare information, but the forms were not provided, risking uninformed treatment decisions and unexpected costs.
A resident with multiple medical conditions experienced intentional rough treatment by a CNA during incontinence care, causing severe pain and nearly resulting in a fall. Despite the facility's abuse prevention program and training, the incident was reported by another resident, leading to the CNA's suspension and termination.
A resident with multiple medical conditions, including MS and Parkinson's, experienced unauthorized charges on her debit card after entrusting it to two CNAs for vending machine purchases. The facility failed to protect her from misappropriation, leading to fraudulent transactions totaling $577.50.
A resident with diagnoses of CHF, kidney failure, and HTN did not have a comprehensive care plan addressing ADLs and enteral feeding. Despite documented needs and ongoing skilled therapy, the care plan lacked specific interventions, which was noted during a survey. A nurse acknowledged the oversight, and the administrative nurse confirmed the care plan should have included these areas, as per facility policy.
Failure to Investigate Fracture of Unknown Origin
Penalty
Summary
The facility failed to ensure that a resident, who was cognitively impaired and had a diagnosis of aphasia, received the necessary protective oversight to prevent potential abuse and/or neglect. The resident experienced a fracture of unknown origin, which was not identified or investigated as a potential abuse or neglect situation. The resident had a history of wandering behaviors and was noted to have a non-injury fall, after which multiple assessments reported no apparent injury. However, later observations revealed the resident limping with a swollen knee, leading to an X-ray that initially showed no remarkable findings. It was only after the resident's pain intensified that a hip X-ray was conducted, revealing a fracture. The facility's staff failed to initiate an investigation to determine the cause of the fracture, which was a serious injury of unknown origin. Despite the resident's severe cognitive impairment and inability to communicate effectively, the facility did not implement protective measures to prevent ongoing abuse while an investigation was conducted. The resident's care plan documented various diagnoses, including dementia, osteoporosis, and a history of falls, but the facility did not adequately address these risks or update the care plan to reflect the resident's need for increased assistance. Interviews with facility staff revealed a lack of awareness and action regarding the resident's condition and the potential for abuse or neglect. The facility's abuse policy required thorough investigation of all allegations, but the staff did not suspect abuse or neglect and did not report the incident to the appropriate authorities. The facility's failure to identify and investigate the fracture as a potential abuse or neglect situation placed the resident in immediate jeopardy.
Removal Plan
- R65 is being monitored every shift using the appropriate pain scale.
- Staff conducted an immediate observation of R65 for identification of any current injuries as appropriate, and ongoing monitoring of R65 and other residents at risk, including conducting unannounced management visits.
- The Administrator will notify any alleged violations to the appropriate agency or law enforcement authority.
- An immediate assessment would be conducted on any resident with cognitive deficit issues if any signs of pain, discomfort, or alteration in the skin such as bruising, or discoloration are identified.
- If any of the above is identified, then a formal investigation will be initiated by the DON/ and or designee.
- Conduct interviews with cognitively intact residents to ensure residents are free of abuse, neglect, and exploitation.
- The facility enhanced its internal incident reporting and escalation program, by creating a real-time notification system for staff, visitors, or residents to utilize.
- Enhanced reporting program includes a focus for falls, abuse, and unusual occurrences/injuries of unknown source.
- Upon completion of the incident report, automated notification will be provided to facility leadership including but not limited to the Administrator and DON.
- The facility created an informational flyer displaying the internal incident reporting program and provides a QR code that can be scanned for immediate reporting/escalation.
Failure to Ensure Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure a safe environment for several residents, leading to multiple incidents of falls and injuries. One resident, who had a history of falls and a recent orthopedic surgery, was found on the floor after her bed was left in a high position by her family. Despite having a care plan that required her bed to be in the lowest position and a fall mat in place, these interventions were not followed, resulting in a fall that caused a fracture. The staff were unaware that the family had left, and thus did not check on the resident to ensure her safety. Another resident with severe cognitive impairment and dysphagia was left in a flat position during meals, which is against the facility's protocol for residents with swallowing difficulties. This resident was unable to use the call light independently and was found struggling to eat and coughing, indicating a risk of aspiration. The staff failed to supervise the resident during meals and did not ensure he was positioned correctly, which could have prevented the incident. Additionally, the facility did not ensure the proper use of wheelchair foot pedals for a resident with severe cognitive impairment and mobility issues. The resident was transported with her feet dangling, which posed a risk of injury. Furthermore, another resident's call light was not within reach, and her bed was not in the lowest position, contrary to her care plan. The facility also failed to investigate and respond to another resident's increased need for assistance, as evidenced by uninvestigated falls and a lack of appropriate interventions to prevent further incidents.
Failure to Administer Antipsychotic Medication Leads to Resident Distress
Penalty
Summary
The facility failed to ensure that a resident, identified as R69, remained free from significant medication errors. R69, who had a history of schizoaffective disorder, bipolar disorder, and other mental health conditions, was prescribed Invega Sustenna, an antipsychotic medication, to be administered intramuscularly every 21 days. However, the medication was not administered as scheduled on 08/22/24, and there was no evidence that the physician was notified of this missed dose. This oversight led to a significant gap in the administration of the medication, with the next dose not being given until 09/14/24, 44 days after the previous administration. As a result of the missed medication, R69 experienced increased auditory and visual hallucinations, which caused significant psychosocial distress. The resident's condition deteriorated, leading to additional psychotropic medications being prescribed, including trazodone and buspirone, to manage the exacerbated symptoms. The facility's records indicated that R69 had multiple episodes of yelling and screaming due to hallucinations, and she began to self-isolate, requiring more assistance with activities of daily living. The facility's failure to administer the medication as ordered and to notify the physician of the missed doses contributed to the resident's decline. The report highlights that the facility's medication error policy was not followed, as there was a lack of verification of orders and monitoring of high-risk medications. The pharmacy's miscommunication regarding the medication schedule further compounded the issue, leading to a delay in the delivery and administration of the necessary antipsychotic medication.
Inadequate Facility-Wide Assessment for Staffing and Contingency Planning
Penalty
Summary
The facility failed to conduct a thorough facility-wide assessment to determine the necessary resources for competent resident care during both day-to-day operations and emergencies. The assessment provided by the Administrative Nurse was incomplete, lacking specific staffing levels for each unit, including the number of RNs, LPNs, CMAs, and CNAs needed based on patient acuity and census. Additionally, the assessment did not specify staffing requirements for different shifts, such as evenings and weekends. The facility's contingency plans for events that could impact resident care, but do not require activation of the emergency plan, were also inadequately detailed. Interviews with facility staff revealed that the assessment was recently updated, but it still failed to meet the necessary requirements. The facility's policy, revised in December 2023, mandates an annual review and update of the facility assessment to identify the resources needed to meet resident care needs, including specific staffing needs. However, the facility did not adhere to this policy, affecting all 88 residents residing in the facility.
Deficiencies in QAA Program and Resident Care
Penalty
Summary
The facility failed to maintain an effective Quality Assessment and Assurance (QAA) program, leading to several deficiencies that placed residents at risk. One resident was unable to activate a call light for assistance, and another was pushed in a wheelchair without foot pedals, increasing the risk of preventable accidents and injuries. Additionally, the facility did not have a surety bond covering resident trust funds, putting 52 residents at risk of financial complications. A serious injury of unknown origin for a resident was not identified as potential abuse or neglect, and the facility failed to report it to the State Agency or initiate an investigation, leaving the resident vulnerable to ongoing mistreatment. The facility also failed to provide necessary care and services, such as completing the Comprehensive Minimum Data Set for two residents, which could impair their care and quality of life. Residents did not receive consistent activities on weekends, leading to potential boredom and isolation. There were lapses in wound care and medication management, including a failure to apply offloading boots and ensure proper medication administration, which could delay healing and cause adverse effects. Furthermore, the facility did not ensure appropriate storage of medications, increasing the risk of errors and diversions. Staff competency was also an issue, as evidenced by incorrect medication transcription and administration, and a lack of required training for staff providing care. This placed residents at risk for impaired care and decreased quality of life. The facility's QAPI policy aimed to develop and maintain a data-driven program focused on care outcomes, but it failed to identify and address quality deficiencies effectively, leaving residents at risk for inadequate care.
Deficiency in Communication Training for Agency Staff
Penalty
Summary
The facility, with a census of 88 residents, failed to ensure that agency staff received the required communication training, which is essential for providing quality care. On a specific date, the facility was unable to provide proof of training records for several Certified Nurse's Aides (CNAs) employed through an agency. The Administrative Nurse acknowledged the difficulty in obtaining these records from the contracted nursing agency, stating that while the facility trained its own employees, it was the agency's responsibility to ensure their staff had the appropriate training. The facility's policy, revised in August 2022, mandates that all staff be appropriately certified and educated to meet competencies in areas such as abuse prevention, infection control, resident rights, dementia care, communication, and mental health services. The lack of communication training for agency staff was identified as a deficiency, placing residents at risk for impaired care and decreased quality of life.
Deficiency in Agency Staff Training on Resident Rights
Penalty
Summary
The facility, with a census of 88 residents, failed to ensure that agency staff received the required training on resident rights, which is essential for providing proper care. During a review on 11/20/24, the facility could not provide proof of training records for agency staff, specifically for Certified Nurse's Aides (CNA) MM, NN, OO, PP, and QQ. Administrative Nurse D acknowledged the difficulty in obtaining training records from the contracted nursing agency and stated that while the facility trained its employees, it was the agency's responsibility to ensure their staff had the appropriate training. The facility's policy, revised in August 2022, mandates that all staff be appropriately certified and educated on competencies related to abuse prevention, infection control, resident rights, dementia care, communication, and mental health services. The failure to complete the required resident rights training for agency staff placed residents at risk for impaired care and decreased quality of life.
Deficiency in Infection Control Training for Agency Staff
Penalty
Summary
The facility, with a census of 88 residents, failed to ensure that agency staff received the required infection control training, which placed residents at risk for impaired care and decreased quality of life. During a survey, the facility was unable to provide proof of training or in-service records for agency CNAs MM, NN, OO, PP, and QQ. Administrative Nurse D acknowledged the difficulty in obtaining training records from the contracted nursing agency and stated that while the facility trained its employees, it was the agency's responsibility to ensure contracted staff had appropriate training. The facility's policy, revised in August 2022, indicated that all staff should be appropriately certified and educated to ensure competencies in areas such as infection control. However, the facility did not ensure the completion of the required infection control training for agency staff providing care.
Inadequate Surety Bond for Resident Trust Funds
Penalty
Summary
The facility failed to maintain a surety bond that adequately covered the resident trust funds, which placed 52 residents at risk for financial loss. The facility's Trust Account statement showed a balance of $32,310.15, with 52 residents having active accounts managed by the facility. However, the surety bond in place only covered $30,000.00, which was insufficient to cover the total amount of resident funds. Administrative Staff B and A were unaware that the bond did not cover the full amount of the resident fund accounts. The facility's Resident Funds policy required a protective bond to cover the amounts deposited, but this was not adhered to, resulting in the deficiency.
Deficiencies in ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance for activities of daily living (ADLs) for several residents, leading to deficiencies in care. One resident, identified as R57, was not properly assisted during meals, resulting in difficulty eating and potential risk for aspiration. Despite having severe cognitive impairment and a history of dysphagia, R57 was left in a flat position while eating, unable to reach water or activate the call light for help. This lack of assistance placed the resident at risk for impaired nutrition and a decline in ADL abilities. Another resident, R25, did not receive consistent bathing as per her care plan, which specified bathing on Mondays and Thursdays. Over a 51-day period, R25 only received five showers or baths, with several instances of being marked as unavailable without documentation to support this. The lack of consistent hygiene care was evident when R25 was observed with matted hair and feeling unwell, indicating a failure to maintain her personal hygiene and dignity. Additionally, R54 and R65 experienced deficiencies in personal hygiene and toileting assistance. R54 was observed with dirty fingernails over several days, despite the facility's policy to maintain cleanliness. R65, who had severe cognitive impairment and incontinence issues, did not receive the necessary staff assistance for toileting, leading to unmet care needs. These failures in providing essential ADL care placed the residents at risk for decreased quality of life and impaired dignity.
Inconsistent Weekend Activities for Residents
Penalty
Summary
The facility failed to provide directed, interactive activities based on resident preferences during weekends, which placed residents at risk for decreased psychosocial well-being, boredom, and isolation. The facility's activity calendars for September, October, and November 2024, indicated scheduled activities such as nail care, noodle ball, and social hour on Saturdays, and patio chit-chat, movies, and church service on Sundays. However, the Resident Council reported that these staff-led activities did not occur as scheduled every weekend due to an activities aide returning to school, leaving Activity Staff Z to cover weekends alone. As a result, some residents attempted to hold the groups themselves to maintain the activities. Licensed Nurse I confirmed that residents had started holding activity groups on weekends, with direct care staff occasionally assisting when possible. Activity Staff Z also stated that she tried to cover some weekends but had no one to cover when she was unavailable. The facility provided activity packets for residents to complete independently if no activities were available. Despite these efforts, the facility's Activities Evaluation policy, which mandates ongoing individualized and group activities to promote residents' goals, strengths, and social and emotional support, was not consistently met on weekends.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure the appropriate storage of medications and biologicals, as observed during a survey. On the North Unit, a medication cart was found unlocked and unsupervised in the 200 Hall, containing unsecured prescription medications, diabetic treatment supplies, and medicated ointments. Although the controlled substance drawer was locked, the rest of the cart was not secured until a Licensed Nurse intervened. Similarly, a treatment cart in the hallway alcove was found unlocked, containing medicated ointments and lotions with poison control warnings. This cart was also secured only after a Licensed Nurse was alerted to the situation. Additionally, a small medicine cup labeled with a resident's name was left unsupervised on top of a medication cart. A Certified Medication Aide later secured the pill, acknowledging it should not have been left unattended. The facility's policy mandates that all medications and biologicals be supervised and locked, accessible only to authorized personnel. The failure to adhere to this policy placed residents at risk for medication errors and potential diversions.
Infection Control Deficiencies in Equipment Handling and Hand Hygiene
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by several observations and interviews. A resident's ventilator mask was found resting directly on a refrigerator without being stored in a sanitary bag, and the resident was unsure of the cleaning frequency of the mask. Additionally, a nurse failed to perform adequate hand hygiene during wound care for another resident, neglecting to sanitize hands between glove changes. Furthermore, a sit-to-stand lift was not sanitized after use by a certified medication aide, despite facility policy requiring equipment to be cleaned between residents. Interviews with staff revealed inconsistencies in understanding and implementing infection control procedures. A certified nurse aide was unsure of the proper cleaning and storage methods for respiratory equipment, while a licensed nurse confirmed that all respiratory equipment should be bagged. An administrative nurse acknowledged the lapse in hand hygiene during wound care, attributing it to being in the moment and nervous. The facility's infection prevention and control policy mandates training for all personnel, yet these deficiencies indicate a failure to adhere to established protocols, placing residents at risk for infectious diseases.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for a resident, identified as R27, who required assistance with meals due to impaired cognition and functional limitations. During an observation, a Certified Nurse Aide (CNA) was seen standing over R27 while assisting him with breakfast, rather than sitting beside him at eye level, as expected by the facility's dignity policy. This action was contrary to the facility's policy, which mandates that residents be treated with dignity and respect at all times, including during meal assistance. R27's medical records indicated diagnoses of altered mental status, major depressive disorder, aphasia, and muscle weakness, with a documented need for supervision or touch assistance during meals. Interviews with staff, including a CNA, a Licensed Nurse, and an Administrative Nurse, confirmed the expectation that staff should be seated next to residents while assisting them with meals. The failure to adhere to this practice placed R27 at risk for impaired dignity, as it did not promote the resident's sense of well-being and self-esteem as outlined in the facility's dignity policy.
Failure to Accommodate Resident Needs for Call Light and Wheelchair Foot Pedals
Penalty
Summary
The facility failed to ensure that Resident 57 had a call light he could functionally activate for staff assistance. Resident 57, who had severe cognitive impairment and multiple medical conditions including insomnia, congestive heart failure, and polyneuropathy, was unable to use his push-button call light after returning from an acute medical facility. Despite the care plan indicating the need for a soft-touch call light, Resident 57 was observed struggling to activate his call light while in bed, leading to a delay in receiving assistance. Staff acknowledged the issue but did not provide an immediate solution, leaving Resident 57 at risk for unmet care needs. Additionally, the facility failed to ensure that Resident 66 had foot pedals on her wheelchair while being pushed by staff. Resident 66, who had severe cognitive impairment and a history of stroke affecting her right side, was observed being pushed without foot pedals, requiring her to lift her feet. This practice was against the care plan, which specified that foot pedals should be used when staff assisted her. Staff interviews confirmed the expectation that foot pedals should be used, yet this was not adhered to, placing Resident 66 at risk for impaired care. The facility's policies and procedures were not followed in both cases, as the call system policy required alternate means of communication for residents unable to use the standard call system, and staff were expected to ensure foot pedals were used when pushing residents in wheelchairs. These deficiencies highlight a failure to accommodate the needs and preferences of the residents, leading to potential risks for preventable accidents and injuries.
Failure to Honor Resident Self-Determination in Smoking Policy Change
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not allowing a resident, who had a smoking agreement in place, to continue smoking after the facility changed its policy to prohibit smoking. The resident, identified as R80, had a diagnosis of chronic obstructive pulmonary disease (COPD) and was cognitively intact, as indicated by a BIMS score of 13. Despite having a care plan that included smoking rules and designated smoking areas, the facility issued a memorandum stating that it would become a non-smoking facility, effective 30 days from the notice. This change did not consider the resident's existing agreement and preference to continue smoking. The facility's administrative staff acknowledged that they did not initially consider a grandfather provision that would allow current residents who smoked to continue doing so. As a result, R80 was offered nicotine replacement therapy or assistance in relocating to another facility that permitted smoking. Although R80 initially agreed to transfer, she later expressed uncertainty about moving and stated she would quit smoking instead. However, the transfer proceeded, and R80 was discharged to a new facility before the grandfather provision was implemented. Additionally, the facility failed to allow another resident, R51, to choose his bathing times and preferences, further impacting resident autonomy. The facility's actions placed both residents at risk for decreased autonomy and impaired psychosocial well-being. The administrative oversight and lack of adherence to the grandfather provision contributed to the deficiency in promoting and facilitating resident self-determination.
Resident's Medical Record Left Unsecured
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's medical record, specifically Resident 34. On November 18, 2024, at 7:53 AM, a laptop displaying Resident 34's Medication Administration Record (MAR) was left unattended and visible on medication cart number eight. This incident occurred because a Certified Medication Aide (CMA), who was an agency staff member and had not worked a shift for a while, did not lock the laptop screen when away from the cart. The facility's policy, last revised in April 2014, mandates that Protected Health Information (PHI) should not be disclosed except as permitted by law and that all personnel must manage and protect such information to prevent unauthorized exposure. Administrative Nurse D confirmed that staff are expected to lock both the medication cart and laptop screen when unattended, and that resident information should never be left visible on a laptop screen.
Failure to Report Fracture of Unknown Origin as Potential Abuse or Neglect
Penalty
Summary
The facility failed to identify and report a fracture of unknown origin for a resident, referred to as R65, as potential abuse or neglect to the State Agency as required. R65 had a complex medical history, including severe cognitive impairment, dementia, osteoporosis, and a history of falls. Despite these conditions, the facility did not recognize the fracture as an injury of unknown origin that required reporting and investigation. This oversight placed R65 at risk for unidentified and ongoing abuse, neglect, or mistreatment. R65's medical records documented a series of incidents and observations that should have raised concerns. The resident had a history of falls and was noted to have a decline in cognitive and physical function, including increased behaviors related to dementia, such as playing with bowel movements and wandering. On one occasion, R65 was found with facial grimacing and limping, which led to the discovery of a fracture in the right femoral neck. Despite these signs, the facility did not report the fracture as a potential case of abuse or neglect. Interviews with facility staff revealed a lack of consensus on whether the incident required reporting. Administrative staff and nurses did not suspect abuse or neglect, and the facility's abuse coordinator did not report the incident to the State Agency. The facility's policy required all injuries of unknown origin to be reported and investigated, but this was not followed in R65's case. The failure to report and investigate the fracture as required by policy and regulation highlights a significant deficiency in the facility's handling of potential abuse or neglect cases.
Failure to Provide Complete Transfer Notification
Penalty
Summary
The facility failed to provide a written notification of transfer to a resident, identified as R57, and/or their representative, specifying the location and reason for the facility-initiated transfer. This deficiency was identified during a review of the resident's records, which showed that R57 was sent to an acute medical facility for an acute gastrointestinal disorder. Although a transfer form was completed, it lacked critical information such as the reason and location of the transfer. This oversight was confirmed by Administrative Staff A, who acknowledged that the notice should have included these details. R57's medical records indicated several diagnoses, including insomnia, congestive heart failure, polyneuropathy, muscle weakness, and dysphagia. The resident had a severe cognitive impairment, requiring extensive assistance for daily activities and was dependent on staff for mobility and transfers. The resident was also receiving hospice services. The facility's policy on transfer or discharge notices, revised in 2012, mandates that such notices include the reason, location, and information related to the return, which was not adhered to in this case.
Incomplete Care Area Assessments for Two Residents
Penalty
Summary
The facility failed to complete the Care Area Assessment (CAA) analysis of findings for two residents, which is a critical component of the Comprehensive Minimum Data Set (MDS). This deficiency was identified during a survey that included a sample of 26 residents out of a census of 88. Specifically, the CAAs for functional abilities, urinary incontinence, indwelling catheter, falls, nutritional status, dental care, pressure ulcer, and psychotropic medications for one resident, and psychotropic drug use, cognitive loss/dementia, urinary incontinence, indwelling catheter, falls, dental care, communication, and pressure ulcer injury for another resident, were not completed with the necessary analysis of findings. This lack of analysis is essential for building an individualized comprehensive care plan for each resident. The deficiency was confirmed through observations, record reviews, and interviews, including a statement from an administrative nurse who was unaware of the incomplete CAA assessments. The facility's policy, last revised in March 2022, mandates a comprehensive assessment of every resident's needs at intervals designated by OBRA and PPS requirements, which includes the completion of the MDS, the CAA process, and the development of a comprehensive care plan. The failure to complete these assessments as required placed the residents at risk for impaired care and decreased quality of life due to unidentified care needs.
Failure to Develop Comprehensive Care Plan for Resident with Trilogy Ventilator
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as R76, who required the use of a Trilogy ventilator for respiratory issues. The resident's electronic medical record documented diagnoses of chronic respiratory failure, emphysema, COPD, and hypoxia. Despite these conditions, the care plan did not include individualized, person-centered interventions for the Trilogy ventilator. Observations revealed that the Trilogy mask was not stored properly, and the resident was unsure about the cleaning or changing schedule for the mask. Interviews with staff indicated a lack of specific guidance in the care plan regarding the Trilogy mask's care and application. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timetables to meet residents' needs. However, the care plan for R76 lacked specific directions for the Trilogy ventilator, placing the resident at risk for impaired care due to uncommunicated care needs. Staff interviews highlighted that while access to care plans was available, the necessary respiratory care details were missing from R76's care plan, which was expected to be reviewed daily for any changes in care needs.
Failure to Update Care Plan for Stage 1 Pressure Wound
Penalty
Summary
The facility failed to update the care plan for Resident 15 with revised interventions related to her Stage 1 pressure wound. Despite having a comprehensive assessment and care plan in place, the care plan was not updated to reflect the new interventions necessary for the resident's current condition. This oversight was identified through observations, interviews, and record reviews, which revealed that the care plan lacked specific directions for managing the resident's Stage 1 pressure ulcer. Resident 15 had a complex medical history, including type 2 diabetes mellitus, cerebral infarction, congestive heart failure, dependence on renal dialysis, and venous insufficiency. She was at risk for pressure ulcers due to her decreased mobility and incontinence. The resident's care plan, last revised in May 2024, did not include updated interventions for her newly identified Stage 1 pressure ulcer, despite orders for specific treatments such as zinc oxide cream and a low-air loss mattress. The facility's failure to update the care plan was further highlighted by the lack of documentation regarding the assessment, measurement, and recording of the wound status. Interviews with administrative nurses revealed that the responsibility for updating the care plan lay with the charge nurse, MDS coordinator, or themselves, but they could not explain why the care plan had not been updated. This deficiency placed the resident at risk for delayed healing and increased risk for pressure ulcers due to uncommunicated care needs.
Failure to Use Communication Cards for Resident with Aphasia
Penalty
Summary
The facility failed to ensure that a resident, identified as R66, received supportive care and services to maintain her quality of life. R66, who had aphasia and other medical conditions such as hemiparesis, hypertension, diabetes, and COPD, required communication cards to express her needs and feelings. Despite a care plan and physician's order directing the use of picture sheets for communication, staff did not utilize these tools during interactions with R66. Observations showed that R66 attempted to communicate by reaching out her hand, but staff did not use the communication sheets, which were found under containers on her bedside table. Interviews with staff revealed a lack of awareness and understanding of the requirement to use communication cards. A CNA and a licensed nurse both stated they were familiar with R66's usual requests and did not realize the importance of using the communication cards. The licensed nurse also misunderstood the purpose of signing off on the Treatment Administration Record, believing it was to ensure the availability of communication tools rather than their use. This oversight in following the care plan and physician's orders placed R66 at risk for decreased quality of life, isolation, and impaired dignity.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide ongoing wound assessment for a resident's pressure injury and did not ensure another resident's offloading boots were applied, placing both residents at risk for delayed healing and increased risk for pressure ulcers. The first resident, who had a history of type 2 diabetes mellitus, cerebral infarction, congestive heart failure, and venous insufficiency, was at risk for pressure ulcers due to decreased mobility and incontinence. Despite having a care plan that included a low-air loss mattress and regular skin assessments, the facility did not consistently document wound measurements or assess the status of a Stage 1 pressure ulcer weekly. The resident's medical records indicated the presence of open areas on her skin, including her left posterior thigh and buttocks, which were not properly assessed or measured by the staff. The facility's policy required comprehensive documentation of pressure sores, including their size and stage, but this was not adhered to. Interviews with administrative nurses revealed an expectation for weekly skin checks and proper documentation, which was not met in this case. For the second resident, who had diagnoses including lymphedema, diabetes mellitus, and cerebral infarction, the facility failed to apply offloading boots as ordered. Despite being at moderate risk for pressure ulcers, the resident was observed multiple times without the boots, and staff interviews confirmed a lack of adherence to the care plan. The facility's policy required the application of pressure-relieving devices, but this was not consistently implemented, increasing the resident's risk for pressure ulcers.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure the sanitary storage of a Trilogy ventilator mask for a resident with chronic respiratory conditions, including chronic respiratory failure, emphysema, COPD, and hypoxia. The resident's care plan included directives for oxygen therapy and monitoring but lacked specific instructions for the care and application of the Trilogy mask. Observations revealed that the resident's Trilogy mask was placed directly on a refrigerator without a protective bag, and the resident was unsure about the cleaning or changing frequency of the mask. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that respiratory equipment should be stored in a clean plastic bag when not in use. The facility's infection prevention policy for respiratory therapy tasks and equipment also emphasized the importance of reviewing care plans for special precautions. The failure to store the Trilogy mask in a sanitary manner increased the resident's risk of respiratory infections and complications.
Failure to Monitor Dialysis Access Site Daily
Penalty
Summary
The facility failed to monitor a resident's dialysis access site for complications at least daily, which placed the resident at risk of adverse outcomes and physical complications related to dialysis. The resident, identified as R25, had a history of cognitive impairment, depression, and diabetes mellitus, and was receiving dialysis services. The resident's care plan directed staff to check and change the dressing daily at the access site and document the condition and any complications. However, it was revealed that the access site was only checked on the days the resident had dialysis, contrary to the facility's policy that required daily monitoring and documentation. Observations and interviews indicated that the resident expressed feeling unwell and nauseated, and a licensed nurse confirmed that the access site was not checked daily. The facility's policy on the care of hemodialysis catheters required documentation of the catheter's location, condition of the dressing, and any observations post-dialysis every shift. The failure to adhere to this policy and the care plan directives resulted in a deficiency, as the resident's access site was not monitored for signs of infection, bleeding, or dressing status, increasing the risk of potential adverse outcomes.
Failure to Transcribe Correct Medication Dosage
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated the appropriate competencies and skill sets to provide nursing services to meet the needs of a resident, identified as R182, who was at risk for medication errors. The deficiency occurred when the staff failed to transcribe the correct dosage amount from the hospital discharge order to the Medication Administration Record (MAR) for the intravenous antibiotic daptomycin. The hospital discharge summary for R182 documented an order to continue IV daptomycin at a dosage of 650 mg every 24 hours. However, the MAR incorrectly documented the dosage as 500 mg, which was administered multiple times before the error was identified. On a specific date, a Licensed Nurse (LN) noticed the discrepancy between the MAR and the medication label while preparing to administer the medication. The LN, along with an Administrative Nurse, verified the correct dosage from the admission order and confirmed that the MAR had been incorrectly transcribed. The facility's policies required staff to demonstrate competency in medication management, including verifying orders and transcribing them accurately. The failure to adhere to these policies placed R182 at risk of unnecessary medication administration and potential adverse side effects.
Failure to Provide Timely Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to ensure a resident, identified as R69, received her prescribed antianxiety medication, Buspirone Hcl (Buspar), in a timely manner. R69 had a history of multiple diagnoses, including diabetes mellitus, epilepsy, schizoaffective disorder, bipolar disorder, depressive disorder, and anxiety, with intact cognition as indicated by a BIMS score of 15. The medication was ordered on 09/16/24, but the Medication Administration Record (MAR) showed it was not administered multiple times between 09/22/24 and 09/27/24. The medication was finally delivered and administered on 09/28/24 after the physician was notified. Interviews with facility staff revealed a lack of clarity regarding the reason for the delay in medication delivery. Administrative Nurse D was unaware of the reason, while Licensed Nurse I suggested that the delay was due to insurance issues, which led the facility to pay for a 30-day supply until the insurance concern was resolved. Administrative Nurse E could not recall the reason for the delay. The facility's Pharmacy Services policy required the consultant pharmacist to provide consultation on all aspects of pharmacy services, including ensuring timely medication administration, which was not adhered to in this case.
Failure to Identify and Report Medication Administration Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities in the administration of medications for a resident, referred to as R69. R69's medical history included diagnoses of diabetes mellitus, epilepsy, schizoaffective disorder, bipolar disorder, depressive disorder, and anxiety. The resident was prescribed antipsychotic and antianxiety medications, specifically Invega and Buspirone, which were not administered as ordered by the physician. The Medication Administration Record (MAR) documented that the Invega dose scheduled for 08/22/24 was not administered, and there was no evidence of rescheduling or physician notification. Additionally, the Buspirone was not administered multiple times in September 2024, as indicated by the MAR. The Monthly Medication Review (MMR) from August to October 2024 lacked evidence that the CP identified and reported these medication administration irregularities. Interviews with facility staff revealed that the CP was responsible for completing the MMR for all residents, but the CP did not address the issue with R69's medications. The facility's Pharmacy Services policy required the CP to provide consultation on all aspects of pharmacy services and collaborate with the facility and medical director, which was not adhered to in this case. This deficiency placed R69 at risk for unnecessary medication use, ineffective benefits, and possible adverse side effects.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure proper documentation and informed consent for the administration of psychotropic medications to several residents, leading to deficiencies in medication management. For one resident, identified as R66, the facility did not document a physician's rationale, risk versus benefits, or informed consent before starting an antidepressant medication. The resident's medical record showed no signs of depression, and there was no evidence of non-pharmacological interventions being attempted prior to medication administration. Additionally, the facility did not provide an unnecessary medication policy, which contributed to the oversight. Another resident, R25, was administered antipsychotic medication without documented physician rationale or informed consent. The resident's medical record indicated a lack of gradual dose reduction or documentation that such a reduction was clinically contraindicated. The facility's staff were unsure about the documentation requirements for starting medications and where to find records of non-pharmacological interventions, further highlighting the deficiency in medication management practices. Similarly, for resident R69, the facility failed to obtain informed consent for the use of antipsychotic medications. The resident's medical record lacked evidence of a signed consent form, and the facility was unable to provide it upon request. Staff members were unclear about the documentation needed for medication administration, and the facility did not have an unnecessary medication policy in place. These deficiencies placed the residents at risk for unnecessary medication side effects.
Failure to Include Resident Census on Daily Staffing Sheets
Penalty
Summary
The facility failed to include the resident census on its daily posted nurse staffing sheets, as required by their policy. During inspections on two separate days, the sheets displayed staffing information but lacked the census of residents. A Licensed Nurse confirmed that the sheets were completed by the night shift and should include both the number of residents and staffing for the day. An Administrative Nurse stated that staffing records are maintained for 18 months and should include daily staffing requirements and census. The facility's policy, revised in August 2022, mandates that staffing hours be maintained for 18 months and be available upon request. However, the daily posted nurse staffing hours consistently lacked the required census information.
Lack of Qualified Dietary Manager in Facility
Penalty
Summary
The facility, with a census of 93 residents, failed to ensure that the director of food and nutrition services possessed the required qualifications of a certified dietary manager (CDM). The facility's policy required that if a qualified dietician or other clinically qualified nutrition professional was not employed full-time, a designated person should serve as the director of food and nutrition services with specific qualifications. These qualifications included being a certified dietary manager, a certified food service manager, or having a similar national certification for food service management and safety. Additionally, the individual should have an associate's or higher degree in food service management or hospitality, with relevant coursework, or have two or more years of experience in a similar position in a nursing facility setting, along with completed coursework in food safety and management. During the survey, it was observed that Dietary Staff BB, who was responsible for the dietary services, had completed her course for a dietary manager but had not yet obtained her certification, as her test was still pending. Furthermore, the facility's dietician, who previously attended the facility daily, had moved to a corporate position and was now only present twice a week. This situation placed residents at risk for unmet dietary and nutritional needs due to the lack of a qualified individual overseeing the food and nutrition services as per the facility's policy.
Insufficient Dietary Staffing Leads to Delayed Meal Service
Penalty
Summary
The facility failed to ensure sufficient staffing in the Food and Nutrition Services department, leading to delayed meal service and potentially impaired nutrition for residents. On the morning of 05/20/24, only one dietary staff member was present in the kitchen due to the cook being sick and the dietary manager arriving later. Administrative Nurse D and other staff had to assist in meal preparation, indicating a lack of available dietary staff to cover absences. Breakfast service was delayed, with the first meal served at 09:03 AM, beyond the scheduled time of 08:00 AM to 09:00 AM. During lunch on the same day, approximately 12 residents in the north dining room were left without drinks for an extended period, as dietary staff were delayed in bringing the drink cart. The meal service was further delayed, with food trays not being distributed until 01:21 PM, past the scheduled lunch time of Noon to 01:00 PM. The facility's policy requires sufficient staff to ensure timely meal preparation and service, which was not met, placing residents at risk of delayed meal service and potentially impaired nutrition.
Food Service Safety Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, placing residents at risk of foodborne illness and cross-contamination. During an initial kitchen tour, surveyors observed a dirty kitchen floor with food debris, unwashed dishes from the previous day, and unlabeled and undated food items in the walk-in refrigerator. The walk-in freezer condenser was iced over, and the dishwashing temperature logs lacked evidence of proper monitoring on several occasions. Additionally, clean plates were improperly stored face up, and a staff member was seen serving a resident while touching the drinking surface of a cup. Further observations revealed that a dietary staff member did not wear a beard net in the food prep area, and there were structural issues such as holes in the walls and missing trim pieces. The dishwashing area had a leaking water tank with rusted containment, and the walk-in cooler door was not properly latched, leading to ice formation. Undated food items were found in the refrigerator, and a staff member failed to perform hand hygiene before food preparation. The facility did not provide a policy related to food service, preparation, and storage when requested.
Lack of Communication Training for Agency Staff
Penalty
Summary
The facility failed to ensure that agency direct care staff received the required communication training, which placed residents at risk for impaired care and decreased quality of life. During a review of the training records for agency CNAs, it was found that CNA NN, CNA QQ, and CNA RR did not have documented evidence of completed communication training. Although CNA NN's file included training in abuse, neglect, and exploitation, resident rights, dementia, and infection control, it lacked documentation for communication training. Similarly, CNA QQ and CNA RR's files also lacked evidence of communication training. Administrative Nurse D indicated uncertainty about who was responsible for verifying the completion of communication training for agency staff. While human resources or scheduling staff were responsible for ensuring agency staff had the correct qualifications, there was no clear process for verifying communication training. The facility's Staff Competency policy required all nurse aide personnel to participate in regularly scheduled in-service training, including effective communication. However, the facility did not ensure that this requirement was met for all staff providing care, leading to the deficiency.
Deficiency in Resident Rights Training for Agency Staff
Penalty
Summary
The facility, with a census of 93 residents, failed to ensure that agency direct care staff received the required training on resident rights. This deficiency was identified through a review of the training records for two agency Certified Nurses Aides (CNAs), referred to as CNA QQ and CNA RR. The credentialing files for both CNAs lacked evidence of completed training on resident rights, which is a critical component of their responsibilities in providing care to residents. During an interview, Administrative Nurse D revealed uncertainty about who was responsible for verifying that agency staff had completed the necessary training. Although some training could be accessed online, there was no clear process for verifying and retaining training information for all agency staff. The facility's Staff Competency policy, dated June 2023, mandates that all nurse aide personnel participate in regularly scheduled in-service training, including training on resident rights. The failure to ensure this training was completed placed residents at risk for impaired care and decreased quality of life.
Deficiency in Staff Training on Abuse, Neglect, and Exploitation
Penalty
Summary
The facility, with a census of 93 residents, failed to ensure that all direct care staff received the required training on abuse, neglect, and exploitation (ANE). This deficiency was identified through a review of training records and interviews. Specifically, the credentialing files for two agency Certified Nurses Aides (CNAs), referred to as CNA QQ and CNA RR, lacked evidence of completed ANE training. This oversight placed residents at risk for abuse, neglect, and exploitation. During an interview, Administrative Nurse D revealed uncertainty about who was responsible for verifying that agency staff had completed the required training. Although some contracted agency staff training could be viewed online, there was no clear process for verifying and retaining training information for all agency providers. The facility's Staff Competency policy, dated June 2023, required all nurse aide personnel to participate in regularly scheduled in-service training classes, including ANE training. However, the facility did not ensure the completion of this training for all staff providing care, leading to the identified deficiency.
Infection Control Training Deficiency for Agency Staff
Penalty
Summary
The facility, with a census of 93 residents, failed to ensure that agency direct care staff received the required infection control training, which is a part of its infection prevention and control program. During a review of the training records for agency Certified Nurses Aides (CNAs) QQ and RR, it was found that their credentialing files lacked evidence of completed infection control training. This deficiency was identified during a record review and interviews conducted on specific dates. Administrative Nurse D indicated uncertainty regarding who was responsible for verifying that agency staff had completed the required training. Although some contracted agency staff training could be viewed online, there was no clear process for verifying and retaining this information for all agency providers. The facility's Staff Competency policy, dated June 2023, required all nurse aide personnel to participate in regularly scheduled in-service training classes, including infection control. However, the facility did not ensure the completion of this training, placing residents at risk for impaired care and decreased quality of life.
Deficiencies in Resident Call Light Accessibility and Wheelchair Safety
Penalty
Summary
The facility failed to ensure that the call lights for several residents, including those with significant medical conditions, were within reach, which placed them at risk for injury and delayed care. Resident 14, who had diagnoses of congestive heart failure, kidney failure, and hypertension, was found with his call light on the floor, out of reach, while care was being provided. Despite the facility's policy requiring call lights to be accessible, staff did not ensure this, leaving the resident vulnerable to unmet care needs. Similarly, Resident 48, who had a history of hypertension, stroke, and hemiplegia, was found with his call light under the bed and out of reach. His spouse had to use her call light to summon assistance. The facility's policy and staff interviews confirmed that call lights should be within reach, yet this was not adhered to, compromising the resident's ability to call for help when needed. Additionally, Resident 45, who had multiple sclerosis and dementia, was observed with her call light draped over a lamp, out of reach, while she struggled to eat lying flat in bed. This oversight was repeated on multiple occasions, despite the care plan directing staff to ensure the call light was accessible. Furthermore, Resident 10, with severe cognitive impairment, was pushed in a wheelchair without foot pedals, risking injury. The facility's failure to provide necessary equipment and assistance for these residents highlights significant deficiencies in meeting their care needs.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to promptly address and resolve recurring grievances reported by the Resident Council, which placed residents at risk for decreased psychosocial well-being and impaired quality of life. The Resident Council Minutes from December 2023 through May 2024 documented ongoing concerns about staff cell phone usage, resident care, call light response times, bathing, care for cognitively impaired residents, and cleanliness of dining areas. Despite these issues being repeatedly raised, the minutes often lacked documentation of actions taken or resolutions achieved. Specific concerns included the night shift not completing cleaning tasks, aides using cell phones excessively, and delays in personal care for impaired residents. Additionally, there were issues with inconsistent shower schedules, untimely medication administration, and inadequate snack availability. The Resident Council also reported that dining room cleanliness was not maintained, with food trays left out, floors sticky, and tables dirty. These concerns were consistently noted in the minutes, but management responses were often vague, and no concrete outcomes were documented. Observations on May 20 and 21, 2024, confirmed the Resident Council's concerns about cleanliness, with food trays left in the dining room overnight and visible dirt and stains on floors and walls. The Resident Council expressed frustration that their repeated complaints about cleanliness and other issues had not been addressed effectively. The facility's policy supports resident involvement in operations, but the lack of action on these grievances suggests a failure to uphold this policy, impacting residents' quality of life.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations of unclean and unsanitary conditions. On several occasions, surveyors noted dirty trays with leftover food, soiled drink cups, and food crumbs left in the dining areas from the previous night's meal. Additionally, there were strong foul odors near the ice machine and in various hallways, particularly a heavy urine smell in the south hall and outside certain residents' rooms. These conditions were observed over multiple days, indicating a persistent issue with cleanliness and sanitation. Several resident rooms were found in unsatisfactory conditions, with sticky residues on the floors and strong urine odors present. For instance, one resident's room had an unknown liquid spill that remained uncleaned for over an hour, and another resident's room had a portable urinal on the bedside table with a sticky floor and a strong urine smell. The call light in one resident's room was found out of reach, posing a potential safety risk. These observations suggest a lack of regular cleaning and maintenance in resident areas, contributing to an environment that is neither safe nor comfortable. The facility's policy on maintaining a safe, clean, and homelike environment was not adhered to, as evidenced by the unclean dining rooms and resident rooms. The administrative nurse acknowledged staffing issues, including call-ins and ill dietary staff, which may have contributed to the failure to clean the dining rooms and resident areas adequately. Despite these challenges, the facility did not ensure that the environment was maintained according to its policy, placing residents at risk of infection and decreased psychosocial well-being.
Failure to Update Care Plans for Resident Needs and Preferences
Penalty
Summary
The facility failed to revise the care plans for several residents, leading to uncommunicated care needs and potential risks. Resident 28, who had intact cognition and required substantial assistance for daily activities, was assessed as safe to smoke with supervision. However, her care plan lacked interventions related to her smoking assessment or safe smoking practices, despite staff acknowledging that smoking interventions should be included in the care plan. Similarly, Resident 87, with severe cognitive impairment and requiring oxygen therapy, was also assessed as safe to smoke with supervision. Yet, her care plan did not reflect her smoking status or the necessary safety protocols, even though staff confirmed that such interventions should be documented. This oversight placed both residents at risk for impaired care due to the lack of communicated care needs. Additionally, the facility failed to update the care plans for other residents to reflect their preferences and needs. Resident 1's care plan did not acknowledge his preference to be called "Grandpa," despite staff and the resident himself confirming this preference. Resident 31's care plan lacked direction for the use of side rails, and there was no documented assessment or consent for their use. Resident 43's care plan did not include his preferences for personal hygiene assistance, such as shaving, which was evident from his unshaven appearance and his statements. These deficiencies highlight the facility's failure to maintain accurate and individualized care plans, potentially compromising resident care.
Failure to Ensure Safe Environment and Follow Care Plans
Penalty
Summary
The facility failed to ensure an environment free from potential hazards for several residents, leading to preventable accidents and injuries. One resident, with severe cognitive impairment and a history of falls, was found in a room with a bed rail that had a significant gap between the mattress and the wall, posing a risk of entrapment. Additionally, the resident's care plan included a portable urinal to prevent self-transfer attempts, but it was not available in the room, leading to the resident attempting to transfer himself to the bathroom without assistance. Another resident, also with severe cognitive impairment, was not assessed for the safe use of an electric recliner, which she preferred over a bed. Despite her recent cognitive decline, there was no documentation of her ability to operate the recliner safely. Staff were unaware of whether she could safely transfer herself or use the recliner's controls, placing her at risk for falls and injuries. The facility also failed to implement care-planned fall interventions for two other residents. One resident, with a history of falls and severe cognitive impairment, did not have the required visual cues in his room to prompt him to use the call light for assistance. Another resident, with multiple medical conditions and severe cognitive impairment, was found with his bed in a high position, contrary to the care plan directive to keep it in a low position to prevent falls. These oversights in following care plans and assessing equipment safety contributed to an unsafe environment for the residents.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to properly label and store medications in two of four medication carts, which placed residents at risk for adverse outcomes or ineffective medication regimens. During an observation on the north unit, two opened insulin pens were found undated in a medication cart. Additionally, a medication cart on the south unit was observed to be unlocked and unattended in the hallway. Licensed Nurse J confirmed that all insulin pens should have an open date listed once placed in the medication cart. Administrative Nurse D also stated that medication carts should be locked when unattended and that insulin pens need to be labeled and dated once removed from the refrigerator and placed into the cart. The facility's Medication Storage policy, dated June 2023, requires that all drugs and biologicals be stored in a safe, secure, and orderly manner, with compartments containing these items locked when not in use. The policy also specifies that carts used to transport medications should not be left unattended if open or potentially accessible to others. The failure to adhere to these policies could potentially lead to adverse consequences or ineffective treatment for the residents involved.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to sanitary infection control standards, particularly in the implementation of enhanced barrier precautions, hand hygiene, and the proper cleaning and storage of medical equipment. During an initial walkthrough, surveyors observed trash bags filled with soiled incontinence products placed directly on the floor outside several residents' rooms. Additionally, oxygen nebulizer masks were found resting on contaminated surfaces without clean storage bags, and a bag of soiled linens was left on the floor in a hallway. Further observations revealed that a licensed nurse failed to maintain proper hygiene while checking a resident's blood glucose level. The nurse placed the glucometer on a chair and the floor without using a clean barrier, and did not sanitize the equipment before returning it to the medication cart. The nurse also wore soiled gloves while handling various items, including the medication cart, before performing hand hygiene. Another resident's indwelling urinary catheter drainage bag was observed touching the floor as the resident moved through the facility, with staff failing to intervene. The facility's infection control policy, revised in April 2023, mandates that all resident care devices be cleaned adequately to prevent pathogen spread, and that hand hygiene be performed before, during, and after contact with residents or potentially soiled surfaces. Despite this, staff did not follow these protocols, as evidenced by the improper handling of oxygen therapy equipment, urinary catheters, and the failure to wear protective gowns when required. The facility's failure to follow these standards placed residents at risk for infectious diseases.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure staff provided care in a dignified manner for two residents, R66 and R78, which placed them at risk for decreased self-esteem and decreased self-worth. R66, who had diagnoses including PTSD, hypertension, depression, and delusional disorder, was observed multiple times with his body uncovered and visible from the hallway, compromising his privacy. Despite staff attempts to keep him covered, R66's care plan lacked specific directions for managing his behavior of removing covers, which was part of his cognitive deficits and end-of-life condition. R78, diagnosed with cerebral infarction, diabetes mellitus, and depression, experienced a decline in cognitive function as indicated by her BIMS scores. During an interaction with a licensed nurse, R78 was addressed as "Honey," a term of endearment not specified in her care plan. The facility's policy emphasized treating residents with dignity and respect, recognizing their individuality, yet the staff's use of informal terms without resident approval did not align with these guidelines. The facility's policies on promoting and maintaining resident dignity were not adhered to, as evidenced by the lack of privacy for R66 and the inappropriate use of terms of endearment for R78. These deficiencies highlight the facility's failure to maintain the dignity and respect of its residents, as required by their own policies and procedures.
Failure to Issue Advance Beneficiary Notices
Penalty
Summary
The facility failed to issue the CMS Form 10055 Advance Beneficiary Notice of Non-coverage (ABN) to two residents, R5 and R36, who remained in the facility for custodial care after their Medicare Part A episodes ended. R5's Medicare Part A coverage began on February 17, 2024, and ended on May 5, 2024, while R36's coverage began on November 29, 2023, and ended on December 27, 2023. Despite the end of their Medicare coverage, the facility did not provide the required ABN forms, which are necessary to inform residents of their potential financial liability for services not covered by Medicare. Interviews revealed that Social Services Y had never issued an ABN Form CMS-10055 and was unaware of its purpose or usage. Consultant GG mentioned having seen the form used in other facilities but not in this one. The facility's policy, last revised in February 2024, designated the Business Office Manager or Designee as the contact for Medicare-related information, with a notice to be posted conspicuously in the facility. However, the failure to issue the ABN forms placed the residents at risk of uninformed treatment decisions and unexpected costs.
Resident Abuse Due to Rough Treatment by CNA
Penalty
Summary
The facility failed to protect a resident, identified as R28, from staff-to-resident abuse and mistreatment. R28, who had a medical history including muscle weakness, morbid obesity, bipolar disorder, seizures, and peripheral vascular disease, required substantial assistance for daily activities. Despite having intact cognition, R28 experienced intentional rough treatment from a Certified Nurse Aid (CNA) during incontinence care. The incident involved the CNA pushing hard on R28's back, causing severe pain, and almost resulting in R28 falling off the bed. The resident's roommate intervened by yelling at the CNA to stop, but the CNA continued and left the room afterward. The incident was reported by another resident, R15, to the administrative staff, leading to an investigation. The facility's investigation revealed that the CNA involved was suspended and later terminated due to an unrelated domestic violence allegation. The facility's abuse prevention program, which includes training on identifying and reporting abuse, was in place, but the incident highlighted a failure in its implementation. Interviews with staff indicated that abuse training was conducted frequently, and staff were expected to report any alleged abuse immediately. However, the incident with R28 demonstrated a lapse in ensuring the resident's safety and comfort during care, as the CNA did not adhere to the expected standards of care and reporting protocols.
Misappropriation of Resident's Debit Card by Staff
Penalty
Summary
The facility failed to protect a resident, identified as R38, from the misappropriation of her debit card by staff, leading to unauthorized charges. R38, who has multiple medical diagnoses including multiple sclerosis, morbid obesity, Parkinson's disease, and major depressive disorder, was cognitively intact and independent in many activities of daily living. Despite this, she was at risk for decreased psychosocial well-being due to her medical conditions and personal history of grief. The incident occurred when R38 entrusted her debit card to two Certified Nurses Aides (CNAs) to purchase items from the facility's vending machines. Subsequently, unauthorized transactions totaling $577.50 were made using her card. The facility's report indicated that R38 discovered the fraudulent charges upon receiving her bank statement and reported them to the facility's administrative and social services staff. The unauthorized transactions included online purchases from various retailers. The facility's investigation revealed that the two CNAs involved were suspended, with one being terminated and the other placed on a Do Not Return list for agency staff. The facility's failure to prevent the misuse of R38's debit card by its staff resulted in a deficiency related to the protection of residents' belongings and financial assets.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as R14, to address interventions for activities of daily living (ADLs) and enteral feeding. R14's electronic medical record documented diagnoses of congestive heart failure, kidney failure, and hypertension. The resident's admission Minimum Data Set (MDS) indicated intact cognition and varying levels of assistance required for ADLs. Despite these documented needs, R14's care plan lacked specific directions for ADL care and enteral feeding, which was observed during a survey when R14 was receiving enteral feeding via a gastrostomy tube. During the survey, a licensed nurse acknowledged the omission in R14's care plan and intended to inform the administrative nurse. The administrative nurse confirmed that the comprehensive care plan should have included all concern areas triggered by the MDS, indicating a failure to incorporate these into R14's care plan. The facility's policy required that care plans be based on thorough assessments, including the MDS and physician's orders, and be revised as the resident's condition changed. The omission placed R14 at risk for impaired care due to uncommunicated care needs.
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Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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