Good Samaritan Society - Decatur County
Inspection history, citations, penalties and survey trends for this long-term care facility in Oberlin, Kansas.
- Location
- 108 E Ash Street, Oberlin, Kansas 67749
- CMS Provider Number
- 175356
- Inspections on file
- 20
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Good Samaritan Society - Decatur County during CMS and state inspections, most recent first.
The facility did not submit complete and accurate nurse staffing data through the PBJ system as required, despite having adequate licensed nurse coverage on the dates in question. The PBJ report indicated missing coverage due to inaccurate data submission, which was the responsibility of a former HR staff member.
The facility did not maintain a secure and accurate system for the emergency medication kit, leaving it unlocked and without an inventory list, and failed to properly label and date a resident's Insulin aspart pen. Staff were unable to account for missing medications from the E-Kit, and there was no system in place for reconciling medication usage, contrary to facility policy.
The facility did not ensure that the director of food and nutrition services was a certified dietary manager, as the staff member in this role was still in the process of obtaining certification and had not yet taken the required test. The facility also lacked a policy outlining the qualifications for this position, and a registered dietician only visited twice a month to review residents' diets.
The facility failed to notify the Ombudsman and provide written bed-hold policy information to a resident and their family during multiple hospital transfers, and did not complete a required recapitulation and medication reconciliation in the discharge summary for another resident. These actions did not follow facility policies for resident transfers and discharges.
A resident with dementia and impaired vision, dependent on staff for all ADLs, did not have access to a functional pair of glasses for an extended period. Despite care plan directives and physician orders requiring staff to ensure the resident wore her glasses, the glasses remained broken and the resident's representative was not notified. Staff interviews revealed a lack of communication and follow-through, resulting in the resident being without her necessary visual aid.
A resident with a history of hypertension and vascular conditions was administered metoprolol without physician-ordered blood pressure parameters. Staff confirmed that daily blood pressure readings were taken, but the medication order lacked specific parameters as required by facility policy, resulting in a deficiency related to medication management.
A resident's Insulin Aspart pen was discovered in the medication cart without a date indicating when it was opened. A licensed nurse confirmed the pen had been used and was not labeled as required, and the administrative nurse stated that staff are expected to document both the opened and expiration dates on insulin pens. The facility could not provide a policy on insulin pen storage and labeling when asked.
Multiple residents with severe cognitive impairments and high care needs were left in unkempt conditions, without adequate personal hygiene, and without access to scheduled activities or staff interaction due to insufficient nursing and activity staff. Staff reported that the number of CNAs was inadequate to meet residents' ADL needs, especially for those requiring two-person transfers, and that activities were outdated and not consistently provided. Administrative staff acknowledged the issues with activity programming but maintained that staffing was appropriate, despite evidence to the contrary.
Multiple residents with severe cognitive impairments and high ADL needs were observed unkempt, in soiled or wrinkled clothing, with food debris on their bodies and wheelchairs, and left unattended without engagement in activities. Staff interviews revealed that inadequate CNA staffing prevented completion of personal hygiene and grooming, and administrative staff had conflicting views on staffing sufficiency, despite facility policy requiring adequate staff to meet resident needs.
Multiple residents with cognitive and physical impairments did not receive proper assistance with ADLs, personal hygiene, or engagement in meaningful activities. Residents were observed in unkempt and soiled conditions, left unattended for long periods without staff interaction, and did not consistently receive drinks or snacks between meals. Staff interviews confirmed that inadequate staffing prevented completion of necessary care and activities, and the activity calendar was outdated and not individualized. Administrative staff and direct care staff disagreed on whether staffing was sufficient to meet residents' needs.
Multiple residents with severe cognitive and physical impairments were left without meaningful activities or staff engagement, often sitting unattended in the activity room with only recorded hymnals playing. Staff interviews revealed insufficient staffing to provide both personal care and activities, and the activity calendar was rarely updated to reflect current resident interests. Administrative staff confirmed that activities were outdated and did not meet all residents' needs, resulting in a lack of meaningful interaction and engagement.
Failure to Accurately Report Staffing Data in PBJ Submission
Penalty
Summary
The facility failed to submit complete and accurate staffing information through the Payroll Based Journaling (PBJ) system as required by CMS. Although the facility maintained licensed nurse coverage 24 hours a day and had adequate staffing on the dates in question, the PBJ report for Fiscal Year Quarter 4, 2024, indicated missing licensed nurse coverage on several specific dates. Review of the facility's daily nursing staff coverage confirmed that licensed nurse coverage was present on those dates, but the submitted PBJ data did not accurately reflect this. The human resource staff member responsible for submitting the PBJ during that period was no longer employed at the facility. The facility's policy required complete and accurate reporting of direct care staffing information to CMS in the specified format.
Failure to Secure and Reconcile Emergency Medication Kit and Label Insulin
Penalty
Summary
The facility failed to maintain a secure and accurate system for managing medications in the emergency medication kit (E-Kit). During an inspection, the E-Kit was found unsecured on the medication room counter, lacking the required inventory list. Staff were unable to locate the inventory sheet, and it was confirmed by multiple nurses that the E-Kit should be secured with a zip tie and that an inventory list should be present inside the kit. Additionally, the staff did not consistently check to ensure the E-Kit was locked after use. An audit revealed missing medications, including vials of Haldol, lidocaine, and ampules of Phenergan, and there was no system in place for reconciling the medications removed from the E-Kit. Furthermore, the facility failed to properly label and date a resident's Insulin aspart pen, which is necessary for accurate medication administration and billing. The pharmacist delivered the E-Kit unlocked and provided an inventory list, but did not supply a reconciliation sheet for tracking medication usage. The facility's policy required the E-Kit to be kept locked, with an inventory list posted, and for record keeping to be in accordance with state pharmacy regulations. These lapses in medication management and record keeping placed residents at risk for inaccurate billing and potential medication errors.
Unqualified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the director of food and nutrition services possessed the required qualifications of a certified dietary manager (CDM). During an initial tour of the kitchen, the staff member responsible for dietary services stated she was currently taking classes to become certified but had not yet taken the certification test. It was also noted that a registered dietician visited the facility twice a month to review residents' diets and address any weight loss. Additionally, administrative staff confirmed that the dietary manager had not yet achieved certification and would be taking the test soon. The facility was unable to provide a policy regarding the qualifications for a Certified Dietary Manager when requested.
Failure to Provide Required Notifications and Complete Discharge Documentation
Penalty
Summary
The facility failed to provide required notifications and documentation related to resident transfers and discharges. Specifically, when a resident with multiple complex diagnoses, including a femur fracture, diabetes, COPD, CHF, and chronic kidney disease, was transferred to the hospital on several occasions, there was no evidence in the clinical record that the resident's family received written information regarding the facility's bed-hold policy. Additionally, there was no documentation that the Office of the Long-Term Care Ombudsman was notified of the resident's hospital transfers, as required by facility policy. The same resident experienced multiple hospital admissions for events such as a transient ischemic attack and stroke-like symptoms, yet each transfer lacked the required notifications to both the family and the Ombudsman. The facility's own bed-hold policy stipulated that written information about bed-hold duration and payment policies must be provided at the time of transfer, and that a copy should be sent with the resident to the hospital for the representative. The discharge and transfer policy also required that the Ombudsman be notified of transfers, but these steps were not documented as completed. In a separate case, another resident was transferred to a different facility to be closer to family. The discharge summary for this resident was incomplete, lacking a recapitulation of the resident's stay and a reconciliation of medications, despite the facility's policy requiring these elements to be included in the discharge documentation. Administrative staff confirmed that the medication reconciliation section was not completed, and acknowledged that it should have been done according to policy.
Failure to Provide Functional Glasses for Visually Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident with impaired vision had access to a functional pair of glasses as required by her care plan and physician orders. The resident, who had diagnoses including dementia, hypertension, and a history of falls, was dependent on staff for all activities of daily living and required full assistance, including the use of a wheelchair and mechanical lift. Her care plan and medical orders specified that staff were to assist with her glasses, ensuring they were worn during awake hours and stored in the medication room when not in use. Despite these directives, the resident's glasses remained broken for an extended period, and she was observed without them on multiple occasions. Staff interviews and record reviews revealed that the facility was aware of the broken glasses since early July, but the resident's representative was not notified, and no action was taken to repair or replace the glasses. Administrative staff stated they were unaware of the issue and would have acted had they known. The facility's policy required staff to report problems with glasses to a licensed nurse, but this did not occur, resulting in the resident not having access to her necessary visual aid for an extended period.
Failure to Obtain Physician-Ordered Blood Pressure Parameters for Antihypertensive Medication
Penalty
Summary
The facility failed to obtain physician-ordered blood pressure parameters for a resident receiving metoprolol to treat hypertension. The resident had a medical history including hypertension, occlusion and stenosis of the right carotid artery, and occlusion and stenosis of the right posterior cerebral artery. The resident was cognitively intact, independent with activities of daily living, and did not ambulate. The care plan directed staff to monitor and report signs and symptoms of malignant hypertension and to administer medication as ordered. However, the physician's order for metoprolol did not specify blood pressure parameters, and this omission was confirmed by both a licensed nurse and an administrative nurse during interviews. The facility's policy required staff to document vital signs and recognize significant changes in blood pressure, reporting symptoms such as lightheadedness, dizziness, blurred vision, or shallow breathing. Despite this, the lack of specific physician-ordered parameters for blood pressure monitoring in relation to the administration of metoprolol represented a failure to ensure the resident's drug regimen was free from unnecessary drugs and that medications were administered safely according to physician guidance.
Undated Insulin Pen Found in Medication Cart
Penalty
Summary
A deficiency was identified when a resident's Insulin Aspart pen was found in the medication cart without a date indicating when it was opened. Observation confirmed that the insulin pen had been used and was not labeled with the opened date, as required. A licensed nurse verified the pen was undated and acknowledged that staff are expected to date insulin pens upon opening. The administrative nurse also stated that staff should document both the opened date and expiration date on insulin pens. The facility was unable to provide a policy regarding the storage and labeling of insulin pens when requested.
Failure to Provide Sufficient Nursing Staff and Activities
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate skill sets and competencies to meet the needs of multiple residents, resulting in unmet activities of daily living (ADL), lack of personal hygiene, and insufficient engagement in activities. Several residents with severe cognitive impairments, including dementia and Alzheimer's disease, were observed to be dependent on staff for all ADLs. Observations revealed that residents were left in unkempt conditions, such as uncombed hair, wrinkled or soiled clothing, and food debris on their faces and wheelchairs. Residents were also left unattended in the activity room for extended periods without staff interaction or access to drinks and snacks, and scheduled activities were not provided as outlined in their care plans. Certified Nurse's Aides (CNAs) and other staff consistently reported that there were not enough CNAs on shift to complete all required resident care, especially given that over half of the residents required two-person assistance for transfers. Staff stated that the lack of adequate staffing led to delays in morning personal hygiene, cold meals, and incomplete care. Activity staff were also absent, and replacement coverage was not observed, resulting in residents missing scheduled activities and spiritual support. Staff interviews indicated that activities were outdated and not tailored to residents' current needs, and administrative staff were not seen assisting with resident care. Administrative staff acknowledged the high acuity of the resident population and the need for two-person transfers for many residents but maintained that staffing was appropriate. However, they also admitted that the activity calendar was rarely updated and did not meet all residents' needs. The facility's own policy required sufficient nursing staff to ensure resident safety and well-being, but observations and staff interviews demonstrated that this standard was not met, leading to deficiencies in resident dignity, care, and quality of life.
Failure to Ensure Resident Dignity and Personal Hygiene Due to Insufficient Staffing
Penalty
Summary
Surveyors identified that the facility failed to honor residents' rights to a dignified existence by not ensuring that multiple residents were well-groomed, clean, and dressed appropriately for the day. Observations revealed that several residents, all with significant cognitive impairments and dependent on staff for activities of daily living (ADLs), were left with uncombed hair, wrinkled or stained clothing, and food debris on their bodies and wheelchairs. In several instances, residents were left unattended in the activity room or in their own rooms without engagement in activities, and without staff present to assist or interact with them. Some residents were observed with visible food residue around their mouths after meals, and one resident was left in an uncomfortable, slouched position in a recliner with water out of reach. Interviews with multiple Certified Nurse's Aides (CNAs) consistently indicated that there was insufficient staffing to complete all required resident care, particularly for those needing two-person assistance for transfers. CNAs reported that the lack of adequate staff made it difficult to provide timely morning hygiene and personal care, resulting in residents being brought to breakfast and activities without being properly groomed or cleaned. Staff also noted that administrative personnel did not assist with resident care, and that the current staffing levels did not allow for the completion of all necessary ADLs and personal hygiene tasks. Administrative staff expressed differing views on staffing adequacy, with some acknowledging ongoing struggles to maintain sufficient staffing and others stating that staffing was appropriate. Despite this, administrative staff confirmed that a majority of residents required extensive assistance for transfers and ADLs. Facility policy required sufficient nursing staff to meet the needs of residents based on their acuity and care plans, but observations and staff interviews demonstrated that these standards were not being met, resulting in compromised resident dignity and psychosocial well-being.
Failure to Provide Adequate ADL Care and Activities Due to Insufficient Staffing
Penalty
Summary
Surveyors identified that multiple residents with significant cognitive and physical impairments did not receive appropriate assistance with activities of daily living (ADLs), personal hygiene, and engagement in meaningful activities. Observations revealed that several residents were left in unkempt conditions, such as uncombed hair, wrinkled or soiled clothing, and food debris on their faces and wheelchairs. Residents were also left unattended in the activity room for extended periods without staff interaction or access to scheduled activities, and some went without drinks or snacks between meals. These findings were corroborated by staff interviews, which consistently reported insufficient staffing levels to meet residents' care needs, particularly for those requiring two-person assistance for transfers and lifts. The report details that residents with diagnoses including dementia, Alzheimer's disease, depression, anxiety, and other chronic conditions were dependent on staff for all or most ADLs. Care plans for these residents specified individualized needs, such as wearing a bra daily, having hair combed, participating in preferred activities, and receiving one-on-one visits. Despite these directives, residents were observed without proper grooming, in soiled or stained clothing, and not engaged in activities tailored to their preferences. Staff interviews confirmed that due to inadequate staffing, morning personal hygiene was often neglected, and activities were not consistently provided or updated to reflect residents' interests and needs. Activity staff were not always present, and when absent, there was no effective coverage or communication to ensure residents' activity needs were met. The activity calendar was described as outdated and rarely changed, and spiritual needs for certain residents were not addressed due to lack of outreach to appropriate clergy. Administrative staff acknowledged that not all activities met residents' needs and that staffing levels were a point of contention, with some administrators believing staffing was sufficient while direct care staff disagreed. Facility policy required sufficient nursing staff to maintain residents' highest practicable well-being, but observations and staff statements indicated this standard was not met.
Failure to Provide Resident-Centered Activities and Adequate Engagement
Penalty
Summary
Surveyors identified that the facility failed to provide a resident-centered activities program that incorporated the interests, hobbies, and cultural preferences of multiple residents, specifically those with severe cognitive impairments and high ADL dependency. Observations revealed that several residents, including those with dementia, Alzheimer's disease, depression, and anxiety, were left in the activity room without staff presence or engagement in meaningful activities. Residents were observed sitting idly or sleeping in their wheelchairs, with only hymnals playing on an iPad and no staff interaction. Additionally, residents were not offered drinks or snacks for extended periods, and personal hygiene needs were not consistently met, as evidenced by uncombed hair, wrinkled or soiled clothing, and food debris on their bodies and wheelchairs. Interviews with CNAs and activity staff confirmed that there was insufficient staffing to provide both personal care and activities, with staff reporting that the majority of residents required two-person assistance for transfers, leaving little time for hygiene or engagement. Activity staff admitted that the activity calendar was rarely updated and did not reflect the current interests or needs of the residents. When the designated activity staff was absent, there was no effective coverage, and other staff were often unaware of the activity schedule or unable to facilitate activities due to workload. Administrative staff acknowledged that the activities provided were outdated and redundant, and that the activity calendar did not meet all residents' needs. They also confirmed that over half of the residents required significant assistance for mobility and ADLs, further straining available staff resources. Facility policy required sufficient staffing to maintain residents' physical, mental, and psychosocial well-being, but observations and staff interviews indicated that this standard was not being met, resulting in a lack of meaningful interaction and activities for residents.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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