Garden Valley Retirement Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Garden City, Kansas.
- Location
- 1505 E Spruce Street, Garden City, Kansas 67846
- CMS Provider Number
- 175175
- Inspections on file
- 19
- Latest survey
- July 9, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Garden Valley Retirement Village during CMS and state inspections, most recent first.
Dietary staff did not consistently use or have access to standardized recipes when preparing pureed meals for four residents, resulting in food being prepared without proper guidance for nutritional value, portion size, or palatability. Staff relied on their own judgment for measurements and serving sizes, and there was confusion about the number of pureed portions needed. The facility's policy required standardized recipes for all menu items, but this was not followed.
A resident with multiple complex medical conditions and a recent amputation did not have her discharge needs identified or an appropriate discharge plan created. Despite her clear desire to return to the community and significant barriers to safe discharge, there was no documentation of social service notes, progress notes, or a discharge plan. Staff confirmed that discharge planning and documentation were not completed as required.
A resident with a history of muscle weakness and impaired mobility did not receive ongoing support to maintain ambulation after discharge from PT. Despite documented ability to ambulate short distances with assistance, there was no evidence of a restorative or walking program, and staff were unclear about responsibilities for ambulation. The care plan lacked instructions for ambulation, and communication between therapy and nursing was insufficient, resulting in the resident not receiving services needed to maintain ADL abilities.
A resident who was dependent on staff for personal hygiene and had a care plan directing regular shaving was observed over several days with prominent, unshaven facial hair, despite expressing a preference to be clean shaven and being unable to shave independently. Staff interviews indicated shaving was done on shower days or by request, but the resident remained unshaven until several days later, demonstrating a failure to provide timely ADL care.
A resident with dementia and hemiparesis experienced multiple falls, some with injury, due to the facility's failure to consistently implement and update fall prevention interventions. Required safety measures such as Dycem pads and brake extenders were not always in place on the resident's wheelchair, and staff did not reliably document or follow through on therapy orders or adapt interventions to the resident's worsening cognitive impairment.
A resident with a PICC line did not receive a dressing change every five days as ordered, and the IV antibiotic administered was not labeled with required information. Documentation of the dressing change was missing, and staff confirmed the dressing was overdue and the medication bag was unlabeled.
A resident with vascular dementia and major depressive disorder experienced a breakdown in medication management when staff failed to promptly implement and document provider orders following a consultant pharmacist’s medication review. Conflicting documentation, lack of staff understanding of the medication review process, and unclear facility policies led to confusion over dose changes for an antidepressant, placing the resident at risk of unnecessary medication use.
Failure to Use Standardized Recipes for Pureed Diets
Penalty
Summary
The facility failed to provide food prepared in accordance with standardized recipes for four residents on pureed diets. Observations revealed that dietary staff did not have access to or did not use recipes for pureed menu items, including Orange Chicken, Lo Mein noodles, and apple pie. Staff members confirmed they could not find the necessary recipes and sometimes relied on their own judgment for preparation and portion sizes. During meal preparation, staff pureed apple pie using a recipe intended for apple crisp and did not follow measurement guidelines, instead pouring apple juice directly from the container. The temperature of the pureed apple pie was recorded at 80 degrees, and there was confusion among staff regarding the correct serving size for desserts. Interviews with dietary staff indicated that recipes were not always used to ensure proper nutritional value or portion sizes for residents on pureed diets. One staff member reported not always using recipes and relying on usual serving amounts. Additionally, there was a discrepancy in the number of pureed desserts prepared, as only three portions were plated for four residents, with the explanation that one resident was transitioning to a regular diet. The facility's policy required the use of standardized recipes for all menu items, including pureed and therapeutic diets, but this was not consistently followed.
Failure to Develop and Document Discharge Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to ensure that the discharge needs of a resident were identified and that an appropriate discharge plan was created. The resident, who had a complex medical history including a recent surgical amputation, acute osteomyelitis, cellulitis, morbid obesity, COPD, muscle weakness, unsteadiness, a Stage 4 pressure ulcer, venous insufficiency, peripheral vascular disease, and hypertension, required substantial to maximum assistance with activities of daily living. Despite her cognitive intactness and clear communication of her desire to return to the community, the facility did not document a comprehensive discharge plan or progress notes addressing her needs and preferences for discharge. The resident expressed significant concerns about her ability to live independently, including financial limitations, housing challenges, and the need for her support animal. She reported that no one at the facility was assisting her with discharge arrangements, and she was not provided with information about when Medicare coverage would end. The resident also stated that she would leave the facility against medical advice if necessary, as she could not afford to remain once Medicare stopped paying. She indicated that her previous living situation required repairs and that she faced barriers to public housing due to her criminal record and the presence of her service animal. Interviews with facility staff confirmed that discharge planning documentation was lacking. The social services staff member responsible for discharge planning acknowledged that there were no social service admission notes, progress notes, or a documented discharge plan in the resident's record. The administrator confirmed that discharge planning should begin at admission and be updated regularly, but was unaware that this had not occurred for the resident. The facility's discharge policy did not address the discharge planning process, contributing to the lack of appropriate planning and documentation.
Failure to Maintain Resident's Ambulation and ADL Abilities Post-Therapy
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received services to maintain their abilities in activities of daily living (ADL). The resident had a history of right shoulder dislocation, muscle weakness, and unsteady gait, and was documented as having intact cognition. Assessments indicated the resident was dependent on staff for most ADLs but was independent with wheelchair mobility. Physical therapy records showed the resident participated in gait training and was able to ambulate short distances with assistance, with a goal to increase ambulation distance. However, after discharge from therapy, there was no evidence in the electronic health record of a formal or informal walking or restorative program to maintain the resident's ambulation abilities. Observations and interviews revealed that the resident expressed a desire to continue therapy and questioned why it had been discontinued. Staff interviews indicated confusion regarding who was responsible for restorative care and ambulation, with some staff unaware of the resident's ambulation abilities or care plan requirements. The care plan lacked specific instructions for staff to ambulate the resident, and staff reported only performing such activities if directed by the care plan. Therapy staff stated that recommendations for maintaining function were typically communicated to nursing, but in this case, nursing staff reported not receiving any such recommendations after therapy discharge. The facility's policy required providing care and services to maintain or improve residents' ADL abilities, including mobility and ambulation, in accordance with assessed needs and preferences. Despite this, the resident did not receive ongoing support to maintain ambulation after therapy ended, and there was a lack of communication and documentation regarding the continuation of restorative activities. This resulted in the resident not receiving necessary services to maintain functional abilities as required.
Failure to Provide Timely Assistance with Personal Hygiene (Shaving)
Penalty
Summary
Staff failed to provide adequate assistance with activities of daily living (ADLs) for a resident who required maximal help with personal hygiene, including shaving. The resident had a history of muscle weakness, lower extremity impairment, and was dependent on staff for dressing, footwear, transfers, and hygiene tasks. The care plan directed staff to shave the resident on bath days and as needed, but observations over several days showed the resident had prominent, unshaven facial hair and reported a preference to be clean shaven. The resident stated he could not shave himself and could not recall the last time he was shaved. Interviews with staff revealed that shaving was typically performed on scheduled shower days or upon resident request, and that staff were busy, sometimes leaving shaving to licensed nurses if not completed by CNAs. The administrative nurse expected staff to shave residents daily and as needed, regardless of cognitive status. Despite these expectations and the resident's dependence on staff, the resident was observed multiple times with unshaven facial hair until it was finally removed after several days, indicating a failure to provide consistent and timely ADL care as required by the care plan and facility policy.
Failure to Implement and Maintain Effective Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when the facility failed to ensure an environment free from accident hazards and did not fully implement or update fall prevention interventions for a resident with a history of multiple falls. The resident had diagnoses of vascular dementia and hemiparesis/hemiplegia, with documented moderate to severe cognitive impairment, impaired mobility, and a history of falls. The care plan included several interventions such as keeping the environment clutter-free, ensuring appropriate footwear, using Dycem pads and brake extenders on the wheelchair, and encouraging the use of call lights for assistance. Despite these interventions, the resident experienced repeated falls, some resulting in injury, and the interventions were not consistently implemented or adjusted in response to the resident's changing condition and repeated incidents. Multiple fall notes documented that the resident was often found on the floor without appropriate footwear or non-skid socks, and sometimes without the use of the call light. The resident's wheelchair was at times not equipped with the required Dycem pad or brake extenders, and staff interviews revealed uncertainty about whether these interventions were in place or needed. Maintenance staff could not confirm that brake extenders had been installed, and there was no documentation of some interventions being completed. Additionally, the resident's cognitive impairment was well known among staff, who acknowledged that the resident would not reliably remember to use the call light or follow safety instructions, yet interventions were not modified to address this. The facility also failed to follow through on a physician's order for a physical therapy evaluation after a fall, with no evidence that the evaluation was completed or that a refusal was documented. Staff interviews and record reviews confirmed gaps in documentation and implementation of prescribed interventions. The facility's own policies required the maintenance and supervision of assistive devices and documentation of their use in the care plan, but these were not consistently followed for this resident.
Failure to Perform Timely PICC Dressing Change and Label IV Medication
Penalty
Summary
Staff failed to provide adequate care and services for a resident with a peripherally inserted central catheter (PICC) by not performing the required dressing change every five days and not labeling the intravenous (IV) antibiotic medication administered through the PICC. The resident, who had diagnoses including cellulitis, paraplegia, and a stage 4 pressure ulcer, was dependent on staff for multiple activities of daily living. The care plan and physician orders specified that the PICC dressing should be changed every five days and that medications should be administered as ordered, with staff monitoring for signs of infection. Record review and observations revealed that there was no documentation of the PICC line dressing being changed as required, and the dressing observed was two days overdue. Additionally, the IV Vancomycin bag being administered was not labeled with the resident's name, dosage, route, preparation date, or expiration date. Staff interviews confirmed the missed dressing change and the lack of labeling on the IV medication. Facility policy required proper care and labeling to prevent complications, but these procedures were not followed.
Failure to Implement Pharmacist Medication Review Recommendations and Provider Orders
Penalty
Summary
The facility failed to implement provider orders based on the Consultant Pharmacist’s (CP) monthly medication review (MRR) and did not ensure a medication review system that prevented duplication or omissions for a resident with vascular dementia and major depressive disorder. The resident’s medical record showed a history of moderately to severely impaired cognition, use of a wheelchair, and dependence on staff for daily activities. The resident was prescribed venlafaxine for depression, and the care plan included monitoring for side effects and routine evaluation for possible dose reduction. During the CP’s MRR, a recommendation was made to reduce the venlafaxine dose in accordance with federal guidelines. The physician responded in writing to decrease the dose, and a prescription was sent to the pharmacy. However, the electronic health record (EHR) lacked evidence that staff acknowledged or acted on this order promptly, and there was no progress note documenting the medication change. Later, conflicting documentation appeared, with the physician indicating disagreement with the dose reduction and referencing previous unsuccessful attempts at gradual dose reduction (GDR). The resident’s medication administration record eventually reflected a dose change, but the process was marked by confusion and lack of clear communication among staff and providers. Interviews with facility staff revealed a lack of understanding regarding the MRR process and the presence of two separate MRR forms from different providers for the same medication issue. The facility’s drug regimen review policy did not specify nursing responsibilities related to the MRR, contributing to the breakdown in communication and implementation of provider orders. This deficient practice placed the resident at risk of receiving unnecessary medications due to the failure to properly coordinate and document medication regimen changes.
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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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