Garden Terrace At Overland Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Overland Park, Kansas.
- Location
- 7541 Switzer Road, Overland Park, Kansas 66214
- CMS Provider Number
- 175158
- Inspections on file
- 27
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Garden Terrace At Overland Park during CMS and state inspections, most recent first.
A resident with dementia and multiple behavioral health diagnoses experienced escalating aggression, wandering, and self-harm statements. The facility did not adequately assess or document behavioral triggers, failed to update the care plan with individualized interventions, and often did not notify the provider or representative of significant behavioral changes. Staff interventions were frequently ineffective, and the resident's behaviors continued to escalate, resulting in harm and eventual hospital transfer.
A resident with dementia and mental health diagnoses exhibited escalating aggression, suicidal ideation, and behavioral disturbances, especially after medication changes. Despite repeated documentation of these behaviors in the EMR, there was no evidence that the provider was notified as required by facility policy, resulting in a lack of timely intervention until the resident required emergency transfer.
Multiple residents with severe cognitive impairment were observed undressed or exposed in public or semi-public areas, and staff provided care or moved residents without seeking their permission or engaging with them. Staff also failed to manage resident interactions during meals in a way that preserved dignity, and did not follow the facility's own behavioral health policy emphasizing individualized, respectful care.
Several residents were administered antipsychotic medications without appropriate clinical indications, risk versus benefit documentation, or recent attempts at gradual dose reduction. Staff interviews revealed uncertainty about proper indications for these medications, and consultant pharmacist reviews lacked recommendations for continued use. Facility policy required thorough documentation and regular evaluation, but these steps were not consistently followed.
Multiple residents with dementia and high fall risk experienced preventable accidents and injuries due to staff failing to keep call lights within reach, improper use of mechanical lifts, lack of supervision during transfers, and allowing access to bed controls. These actions and inactions were contrary to the facility's own care plans and fall management policies.
Multiple residents with dementia and cognitive impairments exhibited ongoing behaviors such as aggression, wandering, and entering peers' rooms, while staff interventions were limited and care plans lacked individualized, person-centered strategies. Staff often relied on redirection, which was frequently ineffective, and there was no facility policy on dementia care available when requested. These deficiencies resulted in repeated incidents affecting residents' dignity and quality of life.
Two residents with dementia were administered antipsychotic medications without appropriate indications, and the consultant pharmacist did not identify or report these irregularities or recommend gradual dose reductions as required. Nursing staff were unclear about proper indications and the process for acting on pharmacy reviews, and the physician did not document risk versus benefit for continued antipsychotic use. Facility policies requiring documentation and interdisciplinary review were not followed, resulting in continued unnecessary medication administration.
Several residents did not have documentation showing that the PCV20 vaccine was offered, administered, or declined, and staff interviews revealed uncertainty and inconsistency in tracking and offering the vaccine. Facility records lacked evidence of PCV20 consent, declination, or historical administration, despite policy requirements.
Nursing staff removed food items from a resident's meal trays without physician authorization, despite care plan and dietary orders specifying her diet. Staff cited concerns about blood glucose but did not follow proper procedures, leading to the resident attempting to retrieve the removed food. Facility policy and administrative staff confirmed that such removal was not permitted.
A resident with severe cognitive impairment and total care needs sustained a head laceration during staff-assisted transfer. Staff failed to immediately notify the physician or document the incident at the time of injury, resulting in delayed medical evaluation and treatment. The deficiency was due to lack of timely communication and adherence to facility protocols.
A resident who completed therapy and was discharged home did not receive the required CMS Notification of Medicare Non-Coverage (NOMNC) form at the end of a Medicare Part A episode. Staff interviews confirmed the facility's practice of not issuing NOMNC notices to residents discharged home with Medicare A days remaining, contrary to policy.
Two residents did not have comprehensive, person-centered care plans addressing their specific needs. One resident's care plan lacked instructions for daily shaving preferences, resulting in inconsistent personal hygiene, while another resident's plan omitted details for oxygen therapy and BiPAP use, leading to uncertainty among staff about respiratory care. Staff interviews and observations confirmed these omissions and a lack of clear communication regarding individualized care.
A resident with a history of stroke, hemiplegia, and severe cognitive impairment exhibited ongoing verbal and physical aggression toward staff during ADLs, transfers, and medication administration. Despite repeated incidents, including staff injuries and skin tears, the care plan was not updated to include additional person-centered interventions, and staff expressed uncertainty about available strategies beyond reapproaching the resident.
A resident with severe cognitive impairment and physical limitations did not receive daily assistance with shaving as preferred, resulting in several days of facial hair growth. Staff provided shaving only on scheduled shower days and were unaware of the resident's daily preference, which was not documented in the care plan. Facility policy required respect for resident dignity and individual choices.
A resident with severe cognitive impairment and multiple comorbidities, including edema managed by diuretic therapy, was repeatedly observed without TED hose in the mornings despite physician orders and care plan directives. Nursing staff interviews revealed unclear responsibility for ensuring the application of TED hose, resulting in the resident not receiving the prescribed treatment.
Two residents with significant risk factors for pressure ulcers, including one with dementia and diabetes and another with a history of cellulitis and existing pressure ulcers, were observed in bed without their physician-ordered heel protectors or suspension boots in place. Staff interviews confirmed that the devices were not always applied as ordered, and that both nurses and CNAs were responsible for ensuring their use. This failure to follow orders and facility policy placed the residents at increased risk for pressure ulcer development.
A resident with dementia and multiple physical impairments, who was fully dependent on staff for care, did not have prescribed knee extension braces applied as required by the care plan. Despite clear documentation and no record of refusal, staff failed to ensure the braces were used, as confirmed by multiple observations and staff interviews.
A resident with an indwelling catheter and severe cognitive impairment was observed with a visibly full catheter bag and tubing on multiple occasions, with staff failing to empty the bag as required by physician orders and facility policy. Staff interviews confirmed that the bag should be emptied at least every shift and as needed to prevent urine backflow and infection, but the care plan lacked specific instructions for emptying frequency.
A resident with dementia, CHF, and hypoxia did not have a documented physician order with dosing instructions for oxygen therapy, and the care plan lacked direction for oxygen and BiPAP use. Observations showed oxygen tubing in use and left unbagged on a dining table. Staff confirmed that equipment should be stored in a sanitary manner and that respiratory care should be included in the care plan.
A resident sustained two separate head injuries while under the care of a CNA who lacked appropriate competencies, including improper use of a mechanical lift and failure to seek assistance during care. Both incidents resulted in lacerations requiring sutures, with delayed nursing assessment and notification to the medical provider, and incomplete documentation of the events.
Two residents received medications without required monitoring or complete orders. For one resident, staff did not obtain or record blood pressure and pulse prior to administering a beta-blocker as ordered, and a topical pain medication order lacked a specified dosage. Staff interviews confirmed these omissions, and facility policy required adherence to prescriber orders and proper documentation.
Two residents with severe cognitive impairment and terminal diagnoses were receiving hospice care, but their facility care plans did not include specific directions for staff collaboration with hospice providers, such as contact information, services, equipment, or visit frequency. Staff confirmed that hospice information was kept in a separate binder and not integrated into the facility's care plans, contrary to facility policy, resulting in a lack of coordinated care.
A resident with severe cognitive impairment and a history of aggressive behavior was physically abused by a CNA after the resident hit the CNA. The incident occurred when the CNA told the resident they could not have sugar due to diabetes, leading to an argument. The CNA retaliated by punching the resident, resulting in a bruise and pain. The facility's failure to follow the resident's care plan and manage the situation appropriately led to the abuse.
A cognitively impaired resident with a history of expressing a desire to leave eloped from the facility due to inadequate supervision. The resident was found outside in high temperatures after exiting through a stairwell door with a disabled alarm. Despite previous behaviors indicating a risk, the resident's elopement risk was not properly assessed or addressed in the care plan.
The facility failed to provide appropriate dementia care for a resident with severe cognitive impairment and Parkinson's disease. Staff did not consistently follow the resident's care plan, leading to incidents of inappropriate handling and language. This inconsistency affected the resident's well-being.
A facility failed to provide necessary assistive care and services for a resident with multiple fractures and dementia, leading to improper handling of weight-bearing restrictions and inconsistent ADL assistance. This resulted in the resident experiencing pain and potential risk of injury due to lapses in communication and documentation among staff.
Failure to Provide Individualized Dementia Care and Behavioral Management
Penalty
Summary
The facility failed to provide appropriate dementia care and services to a resident diagnosed with vascular dementia, cognitive communication deficit, major depressive disorder, and anxiety disorder. The resident exhibited ongoing and escalating behaviors, including aggression towards staff and other residents, wandering, and verbalizations of self-harm and suicidal ideation. Despite these behaviors, the facility did not adequately assess, identify, record, or respond to the resident's specific behavioral triggers, nor did they reassess and update the care plan with individualized interventions tailored to the resident's needs. The care plan lacked resident-specific strategies for managing behaviors and triggers, and staff interventions were often ineffective. Documentation in the resident's medical record revealed multiple instances where the resident displayed aggressive and unsafe behaviors, such as attempting to strike staff, refusing care, wandering, and making statements about wanting to die. Staff frequently attempted verbal redirection, which was documented as ineffective in many cases. There were also several occasions where the facility failed to notify the resident's provider or representative of significant behavioral changes, including suicidal statements and increased agitation following medication changes. The facility's own policy required individualized, person-centered care plans and prompt notification of changes in condition, but these were not consistently followed. Interviews with staff confirmed that the care plan did not include resident-specific interventions for dementia and that triggers for behaviors were not identified. Staff reported increased behavioral issues after medication changes, including aggression and sleep disturbances, but provider notifications were not always documented or made. The facility's deficient practice resulted in ongoing harm, as the resident's behaviors escalated without effective intervention, ultimately leading to the resident's transfer to the hospital for further evaluation and care.
Failure to Notify Provider of Resident's Escalating Behaviors and Suicidal Statements
Penalty
Summary
The facility failed to notify a resident's provider of new or escalating behaviors, as required by policy. The resident in question had a history of vascular dementia, cognitive communication deficit, major depressive disorder, and anxiety disorder, and was admitted to the facility before being transferred to the hospital. The resident exhibited significant behavioral symptoms, including aggression, wandering, restlessness, physical aggression towards staff and other residents, suicidal and death statements, and increased agitation, particularly following the discontinuation of certain medications. Despite these behaviors being documented in the electronic medical record (EMR), there was no evidence that the provider was notified of these incidents over multiple periods. The care plan for the resident lacked individualized interventions related to the resident's specific behaviors and triggers. Multiple behavior notes documented incidents such as aggression, attempts to strike or bite staff, suicidal ideation, and increased fall risk. These behaviors were observed and recorded by staff, but the medical record did not show that the provider was informed of these significant changes or incidents, including after medication changes that appeared to exacerbate the resident's symptoms. Interviews with nursing staff confirmed that provider notification was expected in such cases, but documentation of such notifications was absent during critical periods. The facility's policy required immediate notification of the resident, physician, and representative when there was a significant change in the resident's physical, mental, or psychosocial status. However, the provider was not notified of the resident's escalating behaviors, suicidal statements, or increased agitation and aggression, particularly after medication adjustments. This lack of timely communication with the provider persisted until the resident's condition deteriorated to the point of requiring emergency intervention and hospital transfer.
Failure to Ensure Resident Dignity and Respect in Care Environment
Penalty
Summary
The facility failed to maintain a dignified care environment for several residents, as evidenced by multiple observations of residents with severe cognitive impairment being exposed or undressed in public or semi-public areas. One resident was repeatedly observed with her pants and briefs pulled down and touching the inside of her briefs in a room near the dining area, rather than in her own bedroom. Another resident was seen walking with her hand down her shirt, exposing her upper chest, without staff present to assist. Staff were also observed placing a clothing protector on a resident at the dining table without asking or speaking to her, and another resident was pulled away from an activity and taken to bed without being consulted or spoken to about her preferences. Additionally, there were incidents where residents' interactions during meals were not managed in a way that preserved dignity. One resident began grabbing food from another's tray, prompting the second resident to leave the table in frustration. Interviews with staff confirmed that residents were expected to be fully clothed in public areas and that staff were supposed to ask permission before providing care or moving residents. The facility's own behavioral health policy emphasized individualized approaches to care and promoting emotional and psychosocial well-being, which was not reflected in the observed practices.
Failure to Ensure Appropriate Use and Documentation for Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that several residents were free from unnecessary antipsychotic medication use without appropriate clinical indications or documented gradual dose reductions (GDRs). Specifically, four residents were administered antipsychotic medications for diagnoses such as dementia and psychosis, but the medical records lacked evidence of appropriate indications for use, physician-documented risk versus benefit statements, or recent attempts at GDRs. In several cases, the care plans directed staff to consult with pharmacy and physicians regarding dose reductions and to educate residents and families about the risks and benefits of these medications, but there was no documentation that these steps were consistently followed. For one resident with diagnoses including psychosis, Alzheimer's disease, and dementia with agitation, the electronic medical record showed ongoing antipsychotic medication orders with no recent GDR attempts or consultant pharmacist recommendations for continued use. Another resident with severe cognitive impairment and multiple behavioral symptoms was receiving two antipsychotic medications, but the consultant pharmacist's review did not include recommendations for appropriate indications. A third resident, newly admitted with dementia and other comorbidities, was prescribed an antipsychotic for dementia without an approved indication, and the consultant pharmacist had not yet reviewed the case. A fourth resident with multiple diagnoses, including dementia and psychosis, was on a high dose of antipsychotic medication, but the record lacked a physician-documented rationale for the risks versus benefits of continued use. Interviews with nursing staff and administration revealed uncertainty about appropriate indications for antipsychotic use, with staff acknowledging that dementia alone should not be used as a justification. The facility's own policy required that only necessary medications be used, with documentation of adequate indicators for use and regular evaluation of ongoing need, but these requirements were not met in the reviewed cases. Observations of the residents confirmed their ongoing use of antipsychotic medications without the necessary supporting documentation or clinical justification.
Failure to Prevent Accidents and Ensure Safe Environment for Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents with significant cognitive and physical impairments. One resident with dementia, a history of cervical vertebra fracture, and a high fall risk was repeatedly observed in a reclined Broda chair with her call light out of reach, despite her care plan specifying that the call light should always be within reach. Staff interviews confirmed that the resident was unable to reposition herself or access the call light independently, and that all residents on the unit were considered high fall risks. The facility's own policy required interventions to minimize fall risk, but these were not consistently implemented as observed during the survey. Another resident with severe cognitive impairment, bilateral lower extremity impairment, and total dependence on staff for transfers and mobility suffered two separate head lacerations during staff-assisted transfers. In both incidents, documentation was incomplete or lacking, with no root-cause analysis or clear description of how the injuries occurred. Staff interviews revealed improper use of mechanical lifts, lack of supervision, and failure to immediately report and document injuries. Witness statements indicated that staff left the resident unattended during transfers, and that the resident became agitated, leading to injury. The facility's fall management policy required assessment and care planning for fall risks, but these procedures were not adequately followed. A third resident with dementia, unsteadiness, and a history of falls was found on the floor with a head laceration after an unwitnessed fall. The resident's bed was found in a high position, and the bed control was accessible to the resident, despite staff stating that residents with dementia should not have access to bed controls due to fall risk. The facility lacked an assessment to determine if the resident was safe to operate the bed device. The care plan required staff to ensure the resident was not put to bed until fatigued and to keep the call light within reach, but these interventions were not consistently implemented. The facility's failure to follow its own policies and care plans placed residents at risk for preventable falls and injuries.
Failure to Provide Consistent Dementia Care and Person-Centered Interventions
Penalty
Summary
The facility failed to provide consistent and appropriate dementia-related care services to multiple residents diagnosed with dementia and related cognitive impairments. Several residents exhibited behaviors such as physical and verbal aggression, wandering, entering other residents' rooms, taking belongings, and combative actions during activities of daily living (ADLs). Despite these ongoing behaviors, care plans often lacked person-centered interventions and specific staff directions tailored to the residents' individual needs. Staff responses were generally limited to redirection and reapproaching, which were frequently ineffective, and there was a lack of documented individualized strategies to address the challenging behaviors. For example, one resident with a history of strokes and severe cognitive impairment repeatedly became verbally and physically aggressive during ADL assistance, resulting in incidents such as hitting, pinching, and biting staff, as well as sustaining skin tears. Staff attempted redirection with minimal effect, and interviews revealed uncertainty among staff regarding the availability of person-centered interventions in the care plan. Another resident with severe cognitive impairment and a history of dementia exhibited wandering, aggression, and inappropriate behaviors, including entering other residents' rooms, taking items, and physical altercations with peers. Staff were observed intervening only after incidents occurred, and the care plan did not provide detailed, individualized interventions for these behaviors. Additional residents with dementia and related diagnoses were observed engaging in behaviors such as grabbing food from others, entering peers' rooms, and taking belongings. Staff interviews confirmed that supervision and redirection were expected, but there was a lack of clear, person-centered guidance in care plans. The facility was unable to provide a policy related to dementia care when requested, and the observed and documented deficiencies placed residents at risk for decreased quality of life, isolation, and impaired dignity, as noted in the report.
Failure to Identify and Report Inappropriate Antipsychotic Use and Lack of Gradual Dose Reduction
Penalty
Summary
The facility failed to ensure that the consultant pharmacist (CP) identified and reported the use of antipsychotic medications without appropriate indications for two residents diagnosed with dementia. For one resident with diagnoses including psychosis, Alzheimer's disease, and dementia with agitation, the medical record showed multiple orders for Seroquel, an antipsychotic, with the indication listed as psychosis. However, there was no appropriate indication documented for the use of this medication in a resident with dementia, and the CP did not recommend a gradual dose reduction (GDR) or address the lack of indication in their monthly reviews. The care plan directed staff to consult with pharmacy and the physician regarding dosage reduction and to discuss ongoing need for the medication, but these steps were not documented as completed. Interviews with nursing staff revealed uncertainty about appropriate indications for antipsychotic use in dementia and the process for communicating pharmacy review findings to physicians. A second resident, with diagnoses including dementia, cognitive communication deficit, and psychosis, was also prescribed Seroquel for psychosis. The resident's care plan included instructions for staff to consult with pharmacy and the physician to consider dosage reduction quarterly and to review behaviors and interventions. Despite this, the CP's monthly medication reviews over a year did not include recommendations regarding the inappropriate indication for the antipsychotic medication. Nursing staff interviews indicated a lack of clarity about their roles in acting on pharmacy reviews and ensuring correct indications for psychotropic medications were communicated to the physician. Facility policies required the pharmacist to report any irregularities to the attending physician, the medical record, and the director of nursing, and for the physician to document review and actions taken. The policies also emphasized the need for adequate documentation of medication indications and the use of non-pharmacological interventions. Despite these policies, the facility did not ensure that the CP identified or reported the lack of appropriate indications for antipsychotic use or recommended GDRs, nor did the physician document risk versus benefit for continued use in one case. These failures resulted in the continued administration of antipsychotic medications without proper justification or review.
Failure to Document PCV20 Vaccine Consent or Declination
Penalty
Summary
The facility failed to obtain consent or declinations for the Pneumococcal Conjugate Vaccine (PCV20) for several residents, as identified through record reviews and staff interviews. Specifically, five residents' records were reviewed for immunization status, and it was found that documentation was lacking for the offering, administration, or declination of the PCV20 vaccine. In some cases, records showed administration or declination of the PPSV23 vaccine, but there was no evidence that the PCV20 vaccine was addressed, nor was there documentation of a historical administration or physician-documented contraindication for PCV20. Interviews with nursing staff revealed inconsistencies in the tracking and administration process for immunizations. Staff members indicated that immunization status was tracked on the Treatment Administration Record (TAR) and by the infection preventionist, but there was uncertainty among staff regarding whether the PCV20 vaccine had been offered to residents. The facility's policy required adherence to state rules and incorporation of physician orders for pneumococcal vaccines, but the lack of documentation for PCV20 offerings or declinations indicated a failure to follow these procedures.
Failure to Accommodate Resident Food Preferences Due to Unauthorized Removal of Dietary Items
Penalty
Summary
Nursing staff failed to accommodate a resident's food preferences by removing dietary items from her meal trays, despite physician orders and care plan directives. Specifically, staff took toast and breadsticks from the resident's trays on multiple occasions, citing concerns about her blood glucose levels. The resident, who had a history of diabetes, Alzheimer's disease, and multiple other medical conditions, was on a regular diet with double protein and diabetic condiments as ordered by her physician. The care plan instructed staff to provide the diet as ordered and monitor intake, but staff instead made independent decisions to remove food items without consulting the physician. Observations and interviews revealed that both CNAs and licensed nurses routinely removed bread or dessert from diabetic residents' trays based on blood sugar readings, rather than following the prescribed diet orders. The resident was observed attempting to retrieve bread that had been taken away and even took bread from another resident's tray. Facility policy and administrative staff confirmed that residents should receive the food served on their trays and that staff should not remove food items. This practice was inconsistent with the resident's rights and the facility's own policies.
Failure to Notify Physician of Resident Head Injury
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in condition following a head injury sustained during staff-assisted care. The resident, who had severe cognitive impairment, dementia, a recent femur fracture, and was dependent on staff for all activities of daily living, was found with a three-centimeter laceration on his forehead. Staff discovered the injury after finding the resident in bed with a blood-soaked Band-Aid, and the wound was determined to require sutures. There was no documentation of nursing assessment or progress notes at the time of the injury prior to its discovery by the evening nurse. Witness statements from CNAs involved in the resident's care indicated that the injury occurred during or after a Hoyer lift transfer. Both CNAs left the resident unattended in his room, and upon returning, one CNA found the resident partially out of bed and later noticed the head wound after the resident became agitated and struck the CNA. The CNAs reported the injury to each other, but there was uncertainty about whether the incident was reported to a nurse or if the resident was assessed immediately, especially since the unit nurse had left early that day. The facility's policy required immediate notification of the physician for accidents requiring intervention. However, the physician was not notified until the evening nurse discovered the injury hours later, resulting in a delay in medical evaluation and treatment. The lack of timely documentation and communication with the physician constituted a failure to follow established protocols for changes in resident condition.
Failure to Issue Required Medicare Non-Coverage Notice Upon Discharge
Penalty
Summary
The facility failed to issue the required Center for Medicare/Medicaid Services (CMS) Notification of Medicare Non-Coverage Form 10123 (NOMNC) to a resident whose Medicare Part A episode began on 03/28/25 and ended on 04/16/25. The resident, who had met therapy goals and was discharged home, did not have documentation in the clinical record of receiving the NOMNC for this Medicare Part A episode. Interviews with Social Services and Administrative Nursing staff revealed that the facility did not provide NOMNC notices to residents discharged home with Medicare A days remaining, based on their understanding of the requirements. The facility's policy indicated a process for denial or end of benefits to inform residents and families, but this was not followed in the case reviewed.
Failure to Develop Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for two residents, resulting in uncommunicated care needs. For one resident with diagnoses including dementia, depression, cognitive communication deficit, and lack of coordination, the care plan did not include specific directions regarding personal hygiene preferences, particularly shaving. Despite the resident expressing a preference to be shaved daily and not to grow a beard, staff only provided shaving on shower days, and there was no documentation of his preference in the care plan or Kardex. Staff interviews confirmed that personal hygiene preferences were not clearly communicated or accessible, and observations over several days showed the resident with unshaven facial hair. Another resident with dementia, congestive heart failure, abnormal lung findings, and hypoxia had a care plan that lacked direction for oxygen therapy and the use of a BiPAP machine at bedtime, despite physician orders for these interventions. The care plan only noted the presence of equipment supplied by hospice but did not specify how or when to use the oxygen or BiPAP. Observations showed the resident using oxygen, but the tubing was not stored properly when not in use. Staff interviews revealed uncertainty about the correct oxygen flow rate and confirmed that respiratory care needs were not included in the care plan. The facility's policy required timely, person-centered, comprehensive care plans developed and revised by an interdisciplinary team with input from the resident or their representative. However, both residents' care plans lacked essential individualized information, and staff were not consistently aware of or able to access the residents' specific care preferences and needs, as evidenced by direct observation, record review, and staff interviews.
Failure to Revise Care Plan for Resident-Centered Behavioral Interventions
Penalty
Summary
The facility failed to revise the care plan to include resident-centered functional abilities for a resident with a history of cerebrovascular accident (CVA), hemiplegia, hemiparesis, muscle weakness, and severely impaired cognition. The resident's care plan directed staff to reassure her and to leave and return later if she was resistive with activities of daily living (ADLs), but did not include other person-centered interventions despite ongoing behavioral issues. Multiple behavior and event notes documented that the resident was frequently verbally and physically aggressive toward staff during assistance with ADLs, transfers, and medication administration. Incidents included hitting, pinching, kicking, biting, and grabbing staff, as well as verbal refusals and threats. Staff attempts to redirect the resident were minimally effective, and the resident continued to display aggressive behaviors during care. There were also documented instances of the resident sustaining skin tears during these episodes. Interviews with staff revealed uncertainty about the availability of person-centered interventions in the care plan and a reliance on reapproaching the resident later. The facility's policy required timely, person-centered, comprehensive care plans that are reviewed and revised by an interdisciplinary team, with updates made when changes in the resident's condition occur. Despite ongoing behavioral challenges and injuries, the care plan was not revised to include additional person-centered interventions.
Failure to Provide Person-Centered Assistance with Personal Hygiene
Penalty
Summary
Staff failed to provide necessary assistance with personal hygiene for a resident diagnosed with dementia, depression, cognitive communication deficit, and lack of coordination. The resident's medical record and MDS assessments documented severely impaired cognition and a need for substantial to maximum assistance with personal hygiene and dressing. The care plan indicated the resident required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene, but did not include specific directions regarding the resident's personal preferences for hygiene care. Over several days, the resident was repeatedly observed in common areas with several days of facial hair growth, despite stating a preference to be shaved daily and not to grow a beard. Interviews with staff revealed that shaving was typically performed only on shower days, and staff were unaware of the resident's daily shaving preference or where such preferences would be documented. Nursing staff acknowledged that the resident's choice should be listed in the care plan, and administrative staff stated that resident preferences were collected at admission but could be limited by cognitive impairment. The facility's policy required respect for resident dignity and individual preferences.
Failure to Apply TED Hose as Ordered for Edema Management
Penalty
Summary
The facility failed to follow a physician's order to apply thrombo-embolic-deterrent (TED) hose to a resident's lower extremities each morning to manage edema. The resident, who had multiple diagnoses including pain, hypertension, insomnia, cognitive-communication deficit, history of falls, muscle weakness, hyperlipidemia, aphasia, COPD, and dementia, was documented as requiring substantial to maximal assistance with daily activities and was receiving diuretic therapy for edema. The care plan and physician's orders specified that TED hose should be applied every morning and removed at bedtime to support skin integrity and manage swelling. Despite these orders, observations on multiple mornings showed the resident without TED hose, wearing only nonskid socks. Interviews with nursing staff and administration revealed a lack of clarity regarding responsibility for ensuring the TED hose were applied as ordered. Staff acknowledged that it was a shared duty among nursing personnel, but the resident was repeatedly observed without the prescribed compression stockings during morning hours.
Failure to Consistently Apply Ordered Pressure-Reducing Devices
Penalty
Summary
Surveyors identified that the facility failed to ensure the consistent application of physician-ordered pressure-reducing devices, specifically heel protectors and suspension boots, for two residents with significant risk factors for pressure ulcer development. One resident, with diagnoses including dementia, diabetes mellitus, and muscle weakness, had orders for bilateral heel suspension boots to be worn at all times when in bed, as well as instructions to encourage non-weight bearing on the right heel. Despite these orders, observations revealed that the resident was found in bed with her heels directly on the mattress and the suspension boots not in use. Staff interviews confirmed that the boots were not always applied, with a CNA expressing concern about falls if the resident attempted to ambulate while wearing them. A licensed nurse was unsure of the specific devices in place without checking the care plan, and administrative staff stated it was the responsibility of all staff to ensure devices were used as ordered. Another resident, with a history of cellulitis, hip fracture, muscle weakness, Alzheimer's disease, and existing stage 2 pressure ulcers, also had physician orders for heel protectors to be worn at all times when in bed. Multiple observations documented that this resident was in bed without heel protectors, with heels resting directly on the mattress. Staff interviews indicated that both nurses and CNAs had access to care plans and the Kardex, which outlined the need for heel protectors, and that it was the responsibility of both roles to ensure the devices were applied as ordered. The facility's own policy on skin integrity and pressure ulcer prevention required care consistent with professional standards to prevent pressure ulcers and to ensure the use of pressure-reducing devices as ordered. Despite this, the failure to apply the ordered devices as observed and confirmed by staff interviews placed both residents at increased risk for the development or worsening of pressure ulcers.
Failure to Apply Prescribed Knee Braces for Dependent Resident
Penalty
Summary
A deficiency was identified when staff failed to apply prescribed knee braces to a resident with significant cognitive and physical impairments. The resident, who had diagnoses including dementia, diabetes, pain, and a history of falls, was dependent on staff for all activities of daily living and unable to communicate needs. The care plan specified that the resident was to wear knee extension braces daily for as long as tolerated, and there was no documentation of the resident refusing the braces. However, during multiple observations, the resident was seen in a Broda chair without the knee braces applied. Interviews with nursing staff and review of facility policy revealed that all nursing staff had access to the resident's care plan and were responsible for ensuring the application of special equipment such as braces. Staff confirmed that any refusal to use such equipment would be documented, but no such documentation existed for this resident. The facility's restorative nursing policy emphasized the importance of promoting residents' optimal function through proactive care planning and monitoring, yet the required intervention of applying knee braces was not carried out as directed.
Failure to Provide Timely Catheter Care and Prevent UTI
Penalty
Summary
Staff failed to provide appropriate treatment and services to prevent potential urinary tract infections for a resident with an indwelling catheter. The resident, who had diagnoses including dementia with agitation, urinary retention, and chronic kidney disease, required extensive assistance and had severely impaired cognition. The care plan directed staff to perform catheter care every shift, keep the catheter bag and tubing below the level of the bladder, and observe for pain, discomfort, and signs of infection. However, the care plan did not specify the frequency for emptying the catheter bag. Observations revealed that the resident's catheter bag and tubing were visibly full of urine on multiple occasions throughout the day, including during lunch and later in the afternoon. Staff did not empty the catheter bag until after the resident was transferred back to bed, despite the bag being full for an extended period. Interviews with staff confirmed that the catheter bag should be emptied at least every shift and as needed, and that allowing the bag and tubing to become overfilled could result in urine backing up into the bladder, causing pain or infection. The facility's policy required regular emptying of the catheter bag to maintain unobstructed urine flow and prevent infection. Despite this, the resident's catheter bag was not emptied as required, and the care plan lacked clear instructions on the frequency of emptying. This failure to follow established protocols and physician orders resulted in the resident being placed at risk for complications and infection.
Failure to Ensure Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with multiple diagnoses, including dementia, congestive heart failure, abnormal lung findings, and hypoxia. The resident's medical record lacked documentation of an active order for oxygen therapy and did not include dosing instructions for oxygen administration. Additionally, the care plan did not address the use of oxygen therapy or BiPAP, despite the presence of related physician orders and equipment provided by hospice. Observations revealed the resident using oxygen tubing at the dining table, and on another occasion, the tubing was left unbagged directly on the table. Interviews with staff confirmed that oxygen equipment should be stored in a sanitary manner, such as in a bag when not in use, and that a specific physician order with dosing instructions was required for oxygen administration. Staff also acknowledged that respiratory care, including the use of BiPAP, should be included in the resident's care plan. The facility's own policy required safe administration and storage of oxygen, which was not followed in this case.
Failure to Ensure Competent Staffing and Timely Injury Assessment
Penalty
Summary
The facility failed to ensure that staff possessed the necessary competencies and skills to safely provide direct care and nursing services, resulting in preventable injuries and delayed medical treatment for a resident. Certified Nurse's Aide (CNA) Q was involved in two separate incidents where the resident sustained head lacerations requiring sutures. In the first incident, the resident received a scalp laceration during a transfer from a wheelchair to a bed using a sit-to-stand lift, with no clear explanation or root-cause analysis documented. Witness statements were referenced but not provided, and the incident report lacked details on how the injury occurred. In the second incident, CNA Q turned the resident without additional staff assistance during incontinence care, resulting in the resident hitting his head on a wall outlet and sustaining a forehead laceration. The resident was found with a blood-saturated bandage, and there was no documentation of a nursing assessment at the time of injury. The physician was not notified until the next shift, and the facility could not provide evidence that the resident was assessed by a nurse immediately following the injury. Staff interviews confirmed that injuries were not reported or assessed as required by facility policy.
Failure to Monitor Medication Parameters and Complete Orders
Penalty
Summary
The facility failed to ensure that two residents received medications according to physician-ordered parameters and complete medication orders. For one resident with multiple diagnoses including dementia, psychosis, hypertension, and chronic obstructive pulmonary disease, the physician ordered metoprolol with specific parameters to hold the medication if the systolic blood pressure was below 110 or the pulse was below 60. However, review of the Medication Administration Record (MAR) for April and May showed that blood pressure and pulse were not obtained or recorded prior to administration of metoprolol on all documented occasions. Staff interviews confirmed that these vital signs should have been checked and documented before giving the medication, and that the medication should be held if readings were out of range. Additionally, the same resident had a physician's order for diclofenac gel to be applied topically to both knees, but the order did not specify the dosage amount to be applied. Staff acknowledged that the order was incomplete and should have included the dosage. Facility policies required proper monitoring, accurate documentation, and adherence to prescriber orders, but these were not followed in the cases identified, resulting in the administration of medications without appropriate monitoring or complete orders.
Failure to Coordinate Hospice Services in Resident Care Plans
Penalty
Summary
The facility failed to ensure a coordinated plan of care for two residents who were receiving hospice services. Both residents had severe cognitive impairments and multiple complex medical diagnoses, including dementia, chronic kidney disease, and end-stage conditions requiring total dependence on staff for activities of daily living. Their care plans indicated they were on hospice and included general comfort measures, but lacked specific directions for staff regarding collaboration with hospice providers, such as contact information, the services and equipment provided by hospice, and the frequency of hospice visits. Interviews with nursing staff and administrative personnel revealed that while hospice information was available in a binder at the nurse's station, this information was not integrated into the facility's care plans. Staff acknowledged that the care plans should match and include all services the residents received, but confirmed that the facility care plans did not contain the necessary details from the hospice plans of care. The facility's own hospice policy required that each resident's written plan of care include both the most recent hospice plan and a description of the services furnished by the facility to maintain the resident's well-being. Observations and record reviews confirmed that the lack of integration and coordination between the facility's care plans and the hospice providers' plans placed the residents at risk for inappropriate end-of-life care. The deficiency was identified through review of medical records, care plans, and interviews with staff, which consistently showed that the required coordination and documentation were not present in the facility's care planning process.
Resident Abuse Due to Staff Retaliation
Penalty
Summary
The facility failed to protect a cognitively impaired resident, identified as R1, from physical abuse by a staff member. On the morning of October 9, 2024, a Licensed Nurse (LN) overheard a Certified Nurse Aide (CNA) telling R1 that she could not have sugar due to her diabetes, which upset R1. The LN observed R1 hitting the CNA in the stomach, after which the CNA retaliated by punching R1 in the left upper arm. This incident was immediately reported to the Administrative Nurse, who removed the CNA from the facility pending an investigation. R1's medical records indicated a diagnosis of dementia with severe cognitive impairment, generalized muscle weakness, and Parkinson's disease. The resident's care plan noted a potential for physical and verbal aggression due to dementia and poor impulse control, with specific interventions outlined for staff to follow when R1 became agitated. However, these interventions were not followed, leading to the escalation of the situation and resulting in physical abuse. The incident was witnessed by LN G, who provided a notarized statement confirming the sequence of events. The facility's investigation corroborated the LN's account, noting that R1 had a bruise on her left upper arm and complained of pain following the incident. The facility's policy on abuse emphasized the right of residents to be free from abuse and highlighted the increased risk when residents exhibit behaviors that may provoke staff reactions. Despite these guidelines, the staff's failure to adhere to the care plan and manage R1's behavior appropriately resulted in the abuse.
Removal Plan
- The facility suspended CNA M immediately pending investigation.
- The facility completed a skin assessment on R1 which revealed a bruise on R1's left upper arm.
- The facility notified the State Agency (SA) and law enforcement. Law enforcement obtained witness statements at the facility and provided a case number.
- The provider saw R1 following the incident.
- The facility completed an x-ray on R1's left arm/shoulder with no positive findings.
- The facility completed skin assessments on all residents on that unit.
- The facility interviewed all residents on that unit with a BIMS of 10 or higher for safety and abuse.
- Staff received abuse education.
- Social Services visited with R1 daily for three days.
- The facility terminated CNA M and banned her from returning.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent a cognitively impaired resident, who had a history of making comments about leaving and was at risk for falls, from eloping. On the day of the incident, the resident expressed a desire to go home to a housekeeping staff member, who then informed a licensed nurse. The nurse, however, did not immediately act on this information and was delayed by other tasks, during which time the resident left the facility unnoticed. The resident was found outside in the parking lot, sitting on the grass between two parked cars, in high temperatures. The door alarm for the stairwell, which the resident used to exit, did not sound because it had been turned off for unknown reasons. This lack of alarm allowed the resident to leave the building without staff being alerted, placing the resident in immediate jeopardy. The resident had a history of anxiety disorder, chronic respiratory failure, chronic kidney disease, and was dependent on supplemental oxygen. Despite these conditions and previous behaviors indicating a desire to leave, the resident's elopement risk was not adequately assessed or addressed in the care plan, contributing to the incident.
Removal Plan
- The facility placed R1 on one-on-one supervision.
- The facility updated R1's Care Plan to include the resident's risk for elopement.
- An Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held.
- Maintenance audited exit doors and alarms with continued audits planned.
- A key-access-only box was placed over the keypad for the second-floor stairwell door.
- Staff education on elopement was completed.
- An elopement drill was completed.
- Residents with a BIMS of 12 or below were audited.
- Residents at risk for elopement were audited with their care plans updated accordingly.
Failure to Provide Appropriate Dementia Care and Services
Penalty
Summary
The facility failed to provide appropriate dementia care and services for Resident 1 (R1), who was diagnosed with severe cognitive impairment, Parkinson's disease, and other related conditions. R1 exhibited behaviors such as physical aggression, rejection of care, and wandering. Despite having a care plan that included specific interventions to manage these behaviors, staff did not consistently follow these interventions. For instance, R1's care plan included preferences for music, television shows, and activities that could help in redirection, but these were not effectively utilized by the staff during incidents of agitation and aggression. On one occasion, Activity AA was observed smacking R1's hands and using inappropriate language when R1 attempted to grab coloring supplies. This incident was witnessed by Consultant GG, who intervened and reported the behavior. Activity AA's actions were not in line with the resident-specific interventions outlined in R1's care plan, which emphasized gentle redirection and engagement in meaningful activities. Additionally, staff members, including CNAs and activity personnel, had varying levels of awareness and access to R1's care plan, leading to inconsistent application of the prescribed interventions. Interviews with staff revealed that while some were aware of R1's care plan and the need for specific interventions, others were not. For example, CNA M stated that she did not have access to care plans and described general strategies for redirecting R1 that were not always aligned with the care plan. This lack of consistent knowledge and application of R1's care plan contributed to the deficient practice, affecting R1's ability to maintain her highest practicable level of physical, mental, and psychosocial well-being.
Failure to Ensure Proper ADL Assistance and Weight-Bearing Restrictions
Penalty
Summary
The facility failed to ensure that a resident (R1) received the necessary assistive care and services with activities of daily living (ADL) to maintain her highest practicable ability and promote independence. R1 had a complex medical history, including multiple fractures, dementia, and a history of falls. Despite these conditions, the facility did not provide adequate care instructions or follow through on weight-bearing restrictions, leading to inconsistent and potentially harmful care practices. For instance, R1's care plan lacked specific directions for ADL assistance and weight-bearing restrictions, and there were discrepancies in the staff's understanding and implementation of these restrictions. R1's medical records and staff interviews revealed that there were significant lapses in communication and documentation regarding her weight-bearing status. Although R1 was initially non-weight bearing on her lower extremities, staff were not consistently informed or aware of these restrictions. This led to instances where R1 was improperly assisted to walk, causing her pain and potentially risking further injury. For example, on one occasion, a Certified Nurse Aide (CNA) walked R1 to the bathroom despite her weight-bearing restrictions, resulting in R1 experiencing pain. The facility's policy on ADLs required that residents receive appropriate treatment and services to maintain and improve their ability to carry out daily activities. However, the facility did not adhere to this policy, as evidenced by the lack of clear care instructions and the failure to ensure staff were aware of and followed R1's weight-bearing restrictions. This deficiency placed R1 at risk for injury, pain, and decreased ability to perform ADLs, highlighting a significant lapse in the facility's care practices and communication protocols.
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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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