Frankfort Community Care Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Frankfort, Kansas.
- Location
- 510 N Walnut Street, Frankfort, Kansas 66427
- CMS Provider Number
- 175417
- Inspections on file
- 22
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 20 (1 serious)
Citation history
Health deficiencies cited at Frankfort Community Care Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a known risk for wandering exited the facility unsupervised after staff failed to respond promptly to a door alarm. The resident traveled in a wheelchair across the driveway and into the street before being retrieved by staff, despite care plan interventions and facility policy requiring immediate response to such incidents.
The facility did not ensure that the Medical Director attended all required quarterly QAA Committee meetings, with documentation showing only three meetings held in the year and a six-month gap between two meetings. Administrative staff confirmed the absence of both required quarterly meetings and the Medical Director at some meetings, contrary to facility policy.
Staff did not follow enhanced barrier precautions during wound care for a resident with a draining ankle wound. During a dressing change, only gloves were used, and a gown was not worn as required by facility policy for high-contact care activities involving wounds. Both a nurse and an administrative nurse later confirmed that enhanced barrier precautions should have been in place.
The facility did not employ a full-time certified dietary manager to oversee food and nutrition services for its 27 residents. Instead, a recently hired dietary staff member without certification or ongoing training was responsible for meal preparation and distribution, contrary to facility policy requiring a certified dietary manager in the absence of a full-time dietitian.
Kitchen staff did not consistently obtain or document food temperatures before serving meals, including ground pork chop, to residents. Meals were plated and served without verifying that food was at a safe temperature, and the omission was only corrected after prompting, with the ground pork chop found at 105°F, below the required hot holding temperature.
The facility did not consistently document daily temperatures for freezers, refrigerators, and food, nor did it reliably record sanitizer PPM levels for sinks and buckets, as required by policy. Dietary staff acknowledged ongoing issues with staff compliance in these areas, leading to lapses in food safety monitoring and documentation.
A resident was not given the required CMS Form 10123 (ABN) when Medicare-covered skilled services were ending. Staff interviews and record review confirmed the notice was not provided or documented, despite facility policy requiring advance notification to inform the resident of potential financial liability and appeal rights.
Two residents were transferred to the hospital without timely notification to the Long-Term Care Ombudsman, and one did not receive written information about the facility's bed hold policy as required by facility policy. Staff interviews confirmed that notifications were either delayed or missed, and documentation was lacking in the clinical records.
Two residents did not have comprehensive care plans addressing all of their needs. One resident with lymphedema lacked care plan documentation and staff guidance for compression garment use, despite physician orders and frequent refusals. Another resident with PTSD and depression had a care plan that did not include trauma-based triggers or individualized interventions for PTSD, even though psychiatric evaluations documented ongoing symptoms. Facility policies required person-centered, trauma-informed care plans, but these were not implemented for the affected residents.
Staff did not properly store a resident's nebulizer mask and oxygen tubing as required, leaving them uncovered on equipment instead of in designated bags, despite physician orders and facility policy. The resident, who had COPD and required regular respiratory treatments, confirmed that staff usually placed the items in separate bags, but this was not consistently done.
A resident with PTSD and MDD did not have trauma-based triggers or individualized interventions documented in their care plan, despite behavioral health notes indicating ongoing symptoms. The care plan only addressed depression related to a stroke, and staff confirmed the omission of PTSD-related information, which was required by facility policy.
A resident with orthostatic hypotension and other conditions received midodrine for low blood pressure on multiple occasions when their blood pressure readings were above the physician-ordered parameters. The MAR showed repeated administration of the medication outside of prescribed limits, and staff confirmed that the medication was not held as ordered.
A resident's insulin flex pen was found on the medication cart without the required opened and expiration dates. Both an LPN and an administrative nurse confirmed that nursing staff are responsible for labeling insulin pens when opened, in accordance with facility policy and professional standards.
A resident with a terminal prognosis and multiple chronic conditions was admitted to hospice care, but the facility failed to include specific hospice service details in the care plan or coordinate care with the hospice provider as required. Staff confirmed the absence of a coordinated care plan, resulting in a deficiency related to the lack of documented collaboration and communication with hospice.
A resident with dementia and severe cognitive impairment was not adequately protected from intimidation and potential abuse by a nurse. The nurse was reported to have forcefully pulled the resident into a chair and made derogatory comments about dementia patients. Despite the facility's investigation not substantiating the abuse allegation, the nurse's actions and comments indicated a lack of understanding of dementia care, placing the resident at risk for impaired psychosocial well-being.
A cognitively impaired resident with a history of exit-seeking behavior and identified as high risk for elopement managed to exit through a window without setting off the alarm, despite wearing a Wander Guard bracelet. The resident's care plan included interventions to distract from wandering and identify behavior patterns, but these measures were insufficient. The window lacked proper security measures, such as a missing screen, which facilitated the elopement. The incident highlighted gaps in supervision protocols and environmental safeguards for residents with cognitive impairments and elopement risks.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A cognitively impaired resident with diagnoses including subarachnoid hemorrhage, dementia, anxiety, and insomnia, and who was identified as high risk for wandering, exited the facility unsupervised. The resident, who used a wheelchair and wore a Wander Guard, was able to open a delayed-egress door that alarmed upon activation. Despite the alarm sounding, no staff responded immediately. The resident propelled herself across the driveway and into the city street, traveling approximately 200 feet before being noticed by staff. At the time of the incident, the nurse on duty heard the alarm and saw the resident exiting but did not immediately respond to the door. Instead, the nurse returned to the nurse's station and only later proceeded down the hall, at which point the resident was already outside in the street. The nurse called for assistance, and a CNA responded, retrieving the resident and bringing her back inside. The facility's video footage confirmed that the resident was outside unattended for approximately three minutes and that the nurse did not maintain continuous visual observation of the resident during the elopement. The resident's care plan documented her as an elopement risk and included interventions such as structured activities, reorientation strategies, and signage on facility doors. However, the care plan was not effectively implemented, as staff failed to respond promptly to the door alarm and did not prevent the resident from leaving the premises. The facility's policy required immediate response to alarms and supervision of residents at risk for elopement, but these procedures were not followed, resulting in the resident's unsupervised exit.
Removal Plan
- Immediate 1:1 supervision with behavior monitoring were initiated for R7.
- Nursing counseling was provided to LN H and her supervisor on the facility's Elopement and Wandering policy.
- Facility-wide education was implemented regarding the immediate retrieval of a resident during an exit attempt in conjunction with a review of the elopement policy.
- Plan of care meetings were held with R7's family.
- A Behavior Monitoring log was initiated to assess for exit-seeking behaviors, restlessness, or patterns warranting intervention.
- The facility pharmacy consultant performed a focused medication review related to the resident's increased exit seeking to find family, brief recall of direction, and intermittent agitation.
- Administration contacted their door lock company to assess and repair any issues identified.
- The Director of Nursing submitted a report to the Kansas State Board of Nursing regarding LN H's failure to communicate that she did not have eyes on R7 the entire time of the elopement.
Failure to Hold Quarterly QAA Meetings with Medical Director Attendance
Penalty
Summary
The facility failed to ensure that its Medical Director attended all required quarterly Quality Assessment and Assurance (QAA) Committee meetings. Documentation provided by the facility showed that QAA meetings were held on three occasions within the year, but there was a six-month gap between two of the meetings, and only three out of four required quarterly meetings were documented. Additionally, the Medical Director was absent from one of the documented meetings. Administrative staff confirmed that QAA meetings should be held quarterly and that the Medical Director is required to attend, verifying both the lack of quarterly meetings and the Medical Director's absence at some meetings. The facility's policy states that the QAA committee, which includes the Medical Director among other key staff, is responsible for overseeing and implementing the quality assurance and performance improvement program. The committee is required to meet at least quarterly to fulfill its responsibilities, which include analyzing performance data, identifying and resolving care quality problems, and communicating findings to the administrator and governing body. The failure to hold quarterly meetings and ensure the Medical Director's attendance represents a deviation from both regulatory requirements and the facility's own policy.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Staff failed to implement enhanced barrier precautions (EBP) during wound care for a resident with a right outer ankle wound that exhibited green drainage. During the dressing change, a licensed nurse and a consultant entered the resident's room, donned gloves, and proceeded with the wound care procedure, including removing the old dressing, cleansing the wound, and applying a new dressing. At no point during the high-contact care activity did staff utilize both gloves and gowns as required by the facility's EBP policy for residents with wounds, nor was the resident placed on EBP at the time of care. Both the licensed nurse and the administrative nurse later acknowledged that the resident should have been on EBP, in accordance with the facility's policy, which mandates gown and glove use for high-contact care activities involving residents with wounds. The policy specifically lists wound care as an activity requiring EBP, but this protocol was not followed during the observed dressing change, resulting in a failure to ensure a sanitary environment and prevent the potential transmission of communicable diseases.
Lack of Certified Dietary Manager for Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager to oversee food and nutrition services for its 27 residents. Observations showed that a dietary staff member, who had only recently started working at the facility, was responsible for meal preparation and distribution but was not certified and had not begun certification classes. Interviews with staff confirmed that this individual lacked the required certification. The facility's own policy requires that, in the absence of a full-time dietitian, a certified dietary manager must be designated to oversee food and nutrition services, but this standard was not met.
Failure to Obtain and Document Food Temperatures Prior to Meal Service
Penalty
Summary
Kitchen staff failed to consistently take and document food temperatures before serving the noon meal to residents. During meal preparation, a dietary staff member ground pork chops and placed them in a steam table, then served plates to three residents without obtaining or recording the food temperatures. When questioned, the staff member stated that temperatures had been taken earlier but not documented, and subsequently took temperatures of the main and pureed meals, but not the ground pork chop. The staff member then plated meals for two residents with ground pork chop without checking the temperature, only doing so after being reminded, at which point the ground pork chop measured 105 degrees Fahrenheit. Facility policy requires staff to verify food temperatures to prevent foodborne illness, maintaining hot foods at or above 135 degrees Fahrenheit and cold foods at or below 41 degrees Fahrenheit. The dietary staff member acknowledged forgetting to check the temperature of the ground meat before serving it. Another dietary staff member confirmed that food temperatures should be checked before serving and noted ongoing efforts to improve compliance with this requirement.
Failure to Consistently Document Food Storage and Sanitation Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety, as evidenced by multiple instances of incomplete documentation and monitoring. During a kitchen tour, it was observed that daily temperature logs for seven freezers and three refrigerators were missing numerous entries for both morning and evening checks throughout the month. Additionally, the daily sink and bucket sanitizer PPM logs lacked documentation for a significant number of opportunities, indicating that the concentration of sanitizing solutions was not consistently monitored or recorded. The daily food temperature logs also showed multiple days where meal temperatures were not documented for breakfast, lunch, or dinner. Dietary staff confirmed ongoing issues with staff compliance in recording required temperatures for freezers and meals. The facility's own policy required daily checks and documentation of refrigerator and freezer temperatures upon first opening and at closing, as well as proper sanitation practices. Despite these requirements, the facility did not ensure consistent adherence to its policies, resulting in lapses in food safety monitoring and documentation.
Failure to Provide Required Medicare Advance Beneficiary Notice
Penalty
Summary
The facility failed to provide the required CMS Form 10123, Advanced Beneficiary Notice (ABN), to a resident or their representative when Medicare-covered skilled services were ending. Record review and staff interviews confirmed that the ABN, which informs beneficiaries about potential non-coverage and their financial liability, was not given to the resident when their skilled services ended. The form is intended to allow residents to make informed decisions about continuing services and to appeal Medicare decisions, but there was no documentation that the resident or their representative received this notice. Administrative staff interviews revealed that responsibility for issuing the ABN was assigned, but the required documentation could not be located, and staff confirmed the form was not provided. The facility's own policy required that the ABN be issued at least two calendar days before the end of Medicare-covered services, but this procedure was not followed, resulting in the deficiency.
Failure to Notify Ombudsman and Provide Bed Hold Policy Information During Hospital Transfers
Penalty
Summary
The facility failed to notify the Office of the Long-Term Care Ombudsman regarding the hospital transfers of two residents. For one resident with diagnoses including orthostatic hypotension, vertigo, depression, and a left artificial hip joint, the clinical record showed a hospital admission for a left hip hemiarthroplasty. There was no evidence in the electronic medical record or nurse's notes that the Ombudsman was notified of this transfer, and staff interviews confirmed that notification was not completed at the time of transfer, but rather was typically done at the end of the month. Another resident, with diagnoses of schizophrenia, diabetes mellitus type 2, chronic pain, left lower extremity amputation, and dementia, was transferred to the hospital for a scheduled amputation. The clinical record lacked documentation that the resident or their family received written notification of the facility's bed hold policy prior to transfer, and there was also no evidence that the Ombudsman was notified of the transfer. Staff interviews confirmed that the bed hold notification was not provided and that Ombudsman notification was missed. Facility policies required that residents and/or their representatives be notified in writing of impending transfers or discharges, including the reasons for the move, and that a copy of the notice be sent to the Ombudsman. Policies also required that written information about bed hold policies be provided to residents or their representatives at the time of transfer. These requirements were not met for the two residents in question, as documented in the clinical records and confirmed by staff.
Failure to Develop Comprehensive, Individualized Care Plans for Residents with Lymphedema and PTSD
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with specific medical and psychological needs. For one resident diagnosed with lymphedema, the care plan did not include documentation of the condition or provide staff with directions regarding the use of a prescribed compression glove and wrap. Although the physician's order specified how and when to apply the compression garments, and staff were aware of the resident's frequent refusals and discomfort, this information was not reflected in the care plan. Observations and staff interviews confirmed that the resident often refused the compression garments, and staff continued to report refusals to the physician, but the care plan was not updated to guide staff actions or document refusals appropriately. Another resident with diagnoses of posttraumatic stress disorder (PTSD), major depressive disorder, and diabetes mellitus had a care plan that addressed depression but did not include individualized interventions or triggers related to PTSD. The psychiatric evaluation documented the resident experienced intrusive thoughts, flashbacks, and anxiety related to military trauma, and was prescribed medication intended to address both depression and PTSD symptoms. However, the care plan lacked any mention of trauma-based triggers or specific strategies for staff to support the resident in managing PTSD symptoms, despite facility policy requiring trauma-informed, individualized care planning. Facility policies required comprehensive, person-centered care plans that address all resident needs, including measurable objectives and timetables, and specifically called for trauma-informed care planning. The deficiencies were identified through record review, staff interviews, and direct observation, revealing that the care plans did not reflect current standards of practice or the individualized needs of the residents as required by facility policy.
Failure to Properly Store Respiratory Equipment
Penalty
Summary
Staff failed to provide necessary respiratory care and services for a resident with chronic obstructive pulmonary disease (COPD), diabetes mellitus, depression, and anxiety. The resident was independent in daily activities and required supplemental oxygen and nebulizer treatments as ordered by the physician. Observations revealed that the nebulizer mask was repeatedly left uncovered on top of the nebulizer machine, and the oxygen tubing and nasal cannula were wound up and placed uncovered between the oxygen concentrator handle and machine, rather than being stored in the designated fabric bags as required by facility policy and physician orders. Interviews with the resident, a licensed nurse, and an administrative nurse confirmed that the proper procedure was to store the oxygen tubing and nebulizer mask in fabric bags when not in use. The facility's infection prevention policy also directed staff to keep these items in labeled plastic bags between uses. Despite these directives, staff did not consistently follow the required storage protocols, resulting in a failure to provide safe and appropriate respiratory care for the resident.
Failure to Identify and Address Trauma-Based Triggers for Resident with PTSD
Penalty
Summary
The facility failed to identify and address trauma-based triggers for a resident diagnosed with posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). The resident's electronic medical record documented these diagnoses, and the care plan only addressed depression related to a stroke, with no mention of PTSD triggers or individualized interventions. Despite behavioral health notes indicating the resident experienced intrusive thoughts and flashbacks related to military service, as well as difficulty sleeping and anxiety, the care plan did not include strategies to prevent re-traumatization or address the resident's PTSD. Observations and interviews confirmed that the care plan lacked documentation of trauma-based triggers and individualized interventions for PTSD. The facility's policy required trauma-informed and culturally competent care, including universal screening for trauma exposure and individualized care planning in collaboration with residents and families. However, the care plan for this resident did not reflect these requirements, and staff acknowledged the omission after review. The deficiency was identified through observation, record review, and staff interviews.
Failure to Hold Blood Pressure Medication per Physician Parameters
Penalty
Summary
The facility failed to follow physician-ordered parameters for administering blood pressure medication to a resident diagnosed with orthostatic hypotension, vertigo, depression, and nonrheumatic aortic valve stenosis. The physician's order specified that midodrine should be held if the resident's blood pressure exceeded 140/85 mmHg. However, the Medication Administration Records (MAR) for July, August, and September documented multiple instances where the resident received midodrine despite blood pressure readings above the ordered threshold. These instances were confirmed by a licensed nurse, who verified that the medication was not held as directed by the physician's order. The resident's care plan identified her as being at risk for adverse reactions due to her medication regimen and directed staff to monitor for side effects and administer medications as ordered. The facility's policy required staff to check and verify vital signs before administering medications when necessary. Despite these directives, staff administered midodrine outside of the prescribed parameters on several occasions, as evidenced by the MAR and staff interviews.
Failure to Label Insulin Flex Pens with Opened and Expiration Dates
Penalty
Summary
The facility failed to ensure that insulin flex pens used for a resident were properly labeled with the date they were opened and their expiration date. During an observation of the medication treatment cart, it was found that a resident's Lantus insulin flex pen was not labeled with either the opened date or the expiration date. Interviews with a licensed nurse and an administrative nurse confirmed that the nursing staff were responsible for labeling and dating insulin flex pens when opened. The facility's own policy, as well as professional guidelines, require that medications be labeled with the resident's name, medication name, prescribed dose, strength, and expiration date when applicable. The lack of labeling was directly observed and verified by staff.
Failure to Coordinate and Document Hospice Services in Care Plan
Penalty
Summary
The facility failed to ensure coordinated care and services between the facility and hospice for a resident with a terminal prognosis and multiple diagnoses, including senile degeneration of the brain, dementia, atrial fibrillation, and basal cell carcinoma. The resident was admitted to hospice care and required staff assistance with activities of daily living due to severely impaired cognition and bilateral lower extremity contractures. The care plan for the resident did not include specific instructions regarding the hospice services being provided, such as the frequency and type of hospice support visits, supplies and medical equipment covered by hospice, medications provided, or hospice contact information. Record review and staff interview confirmed that the facility lacked a care plan that coordinated with the hospice plan of care. The facility's policy required collaboration and communication with hospice to ensure the resident's needs were met, but this was not reflected in the resident's care plan. The deficiency was identified through observation, record review, and staff verification, demonstrating a lack of coordination and documentation necessary for the provision of hospice services.
Failure to Protect Resident from Intimidation and Potential Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R1, from intimidation and potential abuse. R1, who had diagnoses of dementia, depression, and high blood pressure, was documented as having severely impaired cognition and required substantial assistance with activities of daily living. The resident exhibited behaviors such as frequent crying, wandering, and threatening actions, and was at risk for declines in functioning and communication. Despite these needs, an incident occurred where a licensed nurse, identified as LN G, was reported to have pulled R1 down into her chair forcefully, which was perceived as abusive by a witness. The incident was captured on camera footage, showing R1 standing up from her wheelchair and LN G reaching out to pull R1 back into the chair. Witness statements from staff members indicated that LN G expressed frustration with R1 and made derogatory comments about dementia patients. Although the facility's investigation, including a review by the sheriff's office, did not substantiate the abuse allegation, the actions of LN G were seen as inappropriate and indicative of a lack of understanding of dementia care. The facility's failure to protect R1 from potential abuse and intimidation was evident in the handling of the situation by LN G. The nurse's actions and comments towards R1, combined with the lack of immediate intervention to prevent such behavior, placed R1 at risk for impaired psychosocial well-being. The facility's protocols for abuse and neglect were not effectively implemented, as evidenced by the incident and the subsequent investigation findings.
Elopement Incident Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to provide adequate supervision to prevent cognitively impaired Resident (R) 1, who was identified as high risk for elopement, from eloping through a facility window. Despite being equipped with a Wander Guard bracelet, R1 managed to exit through a window without setting off the alarm. R1 had a history of exit-seeking behavior since admission, expressed a desire to leave the facility, and was frequently observed gazing out of a window towards his home. The facility's care plan for R1 included interventions to distract him from wandering and to identify patterns of his behavior, but these measures proved insufficient in preventing the elopement incident on 03/30/24. R1's medical history indicated diagnoses of dementia, requiring assistance with personal care and supervision for ambulation. The Cognitive Loss/Dementia Care Area Assessment highlighted R1's cognitive impairment and elopement risk, while the Wandering Risk Assessment confirmed R1 as a high-risk wanderer. Despite these assessments and care plans in place, R1 managed to elope through a window that lacked proper security measures, such as a missing screen. The incident not only exposed R1 to immediate jeopardy but also raised concerns about the facility's ability to provide adequate supervision for residents with high elopement risks. The series of events leading to R1's elopement highlighted gaps in the facility's supervision protocols and interventions for residents at risk. R1's behavior, history of exit-seeking, and expressed desire to leave the facility were clear indicators of the need for heightened vigilance. The facility's failure to prevent R1's elopement through a window that lacked proper security measures underscored the critical importance of tailored supervision and environmental safeguards for residents with cognitive impairments and elopement risks.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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