Greeley County Hospital Ltcu
Inspection history, citations, penalties and survey trends for this long-term care facility in Tribune, Kansas.
- Location
- 506 3rd Street, Tribune, Kansas 67879
- CMS Provider Number
- 17E071
- Inspections on file
- 18
- Latest survey
- November 6, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Greeley County Hospital Ltcu during CMS and state inspections, most recent first.
Housekeeping staff sorted soiled laundry using only gloves as PPE, without gowns or other clothing barriers, as confirmed by staff interviews and facility policy. This practice created the potential for transfer of infectious material from soiled to clean laundry during sorting and folding.
Three residents who had previously received a single dose of Prevnar 13 did not have documentation showing they were offered or refused the updated CDC-recommended pneumococcal (PVC20) immunization. The facility's records and staff interviews confirmed that the required vaccinations had not been offered or documented for these individuals, despite a policy stating vaccines would be administered per CDC guidelines.
A resident with dementia, major depressive disorder, and Parkinson's disease was administered Seroquel without clear documentation of the targeted behaviors, unsuccessful nonpharmacological interventions, or a risk versus benefit analysis. Physician orders listed varying diagnoses for the antipsychotic use, and the care plan lacked specific behavioral indications, resulting in a deficiency related to unnecessary psychotropic medication use.
A resident with significant cognitive and mobility impairments, identified as high risk for falls, experienced a fall resulting in a head hematoma and hip fracture. Staff did not ensure the resident wore appropriate footwear or that the required chair alarm was in use, as outlined in the care plan. The fall occurred when the resident attempted to ambulate without assistance, and the alarm was found inactive and not positioned correctly, contributing to the incident.
The Consultant Pharmacist did not identify or address missing administration parameters for PRN opioid and diuretic medications for a resident, nor did they address an unapproved diagnosis for antipsychotic use in another resident. Orders lacked specific guidelines, and monthly medication reviews failed to recommend clarifications, despite facility policies requiring such oversight.
A resident with chronic pain and edema received PRN opioid and diuretic medications without specific physician parameters for administration. Staff relied on the resident’s requests and their own judgment to determine dosing and frequency, as the orders lacked clear instructions regarding pain levels or criteria for use, resulting in inconsistent medication administration.
A resident with multiple sclerosis and other conditions was served a hot beverage in a Styrofoam cup instead of the prescribed Kennedy cup, leading to a spill and second-degree burn. The incident occurred due to outdated COVID-19 guidelines, resulting in the use of disposable containers. The resident's limited mobility and hand contractures contributed to the accident.
The facility failed to submit accurate staffing information through the PBJ, as required by CMS, indicating no licensed nurse coverage on specific dates. However, payroll data showed that a licensed nurse was on duty 24/7. This discrepancy placed 16 residents at risk for inadequate staffing.
A facility failed to perform weekly skin assessments and follow-up documentation for a resident with a history of dermatitis, venous thrombosis, and anemia, who was at risk for skin issues. Despite the care plan requiring weekly skin inspections, the facility did not adhere to this, missing several weeks of assessments. Skin issues identified on two occasions were not followed up in a timely manner, placing the resident at risk for further complications.
A facility failed to date a vial of Fiasp insulin for a resident, risking the administration of expired or ineffective medication. An observation revealed the vial was accessed but not dated, contrary to the facility's policy requiring opened vials to be dated and discarded within 28 days. This oversight was confirmed by an administrative nurse.
Failure to Use Appropriate PPE Barriers During Soiled Laundry Sorting
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices in the laundry department. During observations and interviews, housekeeping staff reported that soiled laundry was sorted using only gloves as personal protective equipment (PPE), without the use of gowns or other clothing barriers. Staff acknowledged that this practice had been ongoing and recognized the potential for transferring infectious material from soiled to clean laundry during sorting and folding. Review of the facility's laundry procedures confirmed that the policy required only gloves when handling dirty or soiled laundry and did not address the use of gowns or aprons as additional barriers.
Failure to Offer and Document CDC-Recommended Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer or document the offering of the CDC-recommended pneumococcal (PVC20) immunization to three residents. Each of these residents had documentation in their electronic health records of having previously received a single dose of Prevnar 13 on various dates, but there was no evidence that they had been offered or refused any further pneumococcal vaccinations as required by current guidelines. This lack of documentation and offering was identified through observation, interview, and record review. During an interview, an administrative nurse confirmed that the facility had been reviewing the pneumococcal immunization status of current residents but had not yet offered the updated pneumococcal vaccinations. The facility's policy stated that pneumonia vaccines would be administered per CDC guidelines, but the required actions had not been completed for the affected residents at the time of the survey.
Lack of Documented Indication and Rationale for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident received antipsychotic medication only with an appropriate indication and documented physician rationale, including unsuccessful attempts at nonpharmacological interventions and a risk versus benefit analysis for continued use. The resident in question had diagnoses of dementia, major depressive disorder, and Parkinson's disease, and was assessed as having moderately impaired cognition. The care plan documented the use of Seroquel, an antipsychotic, for depression and dementia, but did not specify the targeted behaviors for which the medication was prescribed. Additionally, the care plan directed staff to monitor for side effects and effectiveness, but lacked documentation of the specific behaviors being targeted by the medication. Physician orders for the antipsychotic medication listed varying diagnoses over time, including dementia with behaviors, major depressive disorder, and anxiety, without clear documentation supporting the indication for use. The facility's policy required clear and accurate physician orders, including diagnosis or indication for use, and periodic reassessment of the medication's effectiveness. However, the records did not show evidence of unsuccessful nonpharmacological interventions or a documented risk versus benefit analysis for the continued use of the antipsychotic medication, leading to the deficiency.
Failure to Implement Fall Prevention Interventions Results in Resident Injury
Penalty
Summary
Staff failed to implement fall prevention interventions for a resident with multiple high-risk factors, including atrial fibrillation, dementia, major depressive disorder, Parkinson's disease, and a history of falls. The resident required substantial to maximal staff assistance for transfers and mobility, used a walker and wheelchair, and was assessed as a high fall risk. The care plan specified the use of a chair sensor alarm to notify staff when the resident attempted to get up unassisted, and staff were instructed to ensure the alarm was moved between seating surfaces and was functioning when in use. The care plan also required staff to ensure the resident wore appropriate footwear and that the environment was free of hazards. On the day of the incident, the resident was found on the floor in front of the bathroom, alert but holding her head and complaining of pain. She was wearing regular socks, with her shoes left by her recliner, and her call light was attached to the recliner, not within her reach. The chair sensor alarm, which was supposed to be in use, was found at the foot of the bed and was not active at the time of the fall. There were no environmental hazards identified in the room. The resident sustained a head hematoma and was later diagnosed with a fractured hip, requiring hospitalization and surgery. The facility's investigation could not determine the exact cause of the fall, as it was unwitnessed, but identified contributing factors including the resident ambulating without non-skid footwear and the absence of an active chair alarm. The failure to ensure the implementation of these fall prevention interventions, as outlined in the resident's care plan, directly led to the resident's fall and subsequent injuries.
Consultant Pharmacist Failed to Identify Missing PRN Parameters and Unapproved Antipsychotic Diagnosis
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and addressed the lack of specific parameters for the use of as-needed (PRN) opioid and diuretic medications for one resident, and failed to address an unapproved diagnosis for the use of an antipsychotic medication for another resident. For the first resident, the medical record showed multiple diagnoses including chronic pain, polyneuropathy, and major depressive disorder. The resident received PRN oxycodone and bumetanide, but the physician's orders lacked specific parameters for administration, such as pain level or type, and guidelines for edema. The Medication Administration Records indicated frequent administration of these medications, and both nursing staff and administrative staff confirmed that the orders lacked necessary parameters. The monthly medication regimen reviews conducted by the CP did not include recommendations or clarifications regarding these missing parameters. For the second resident, the medical record documented diagnoses of dementia, major depressive disorder, and Parkinson's disease. The resident received Seroquel, an antipsychotic, with the physician's order citing major depressive disorder and anxiety as the indications. However, the care plan did not specify targeted behaviors for the use of Seroquel, and the diagnosis for its use was changed by nursing staff without proper documentation or physician input. The CP did not address the appropriateness of the diagnosis for the antipsychotic during monthly reviews. Administrative staff acknowledged that the diagnosis for Seroquel was not appropriately documented and that the CP had not raised this issue. Facility policies required pharmacy services to be provided in accordance with state and federal regulations, including clear and accurate physician orders for antipsychotic medications and regular review of medication appropriateness by the CP. Despite these policies, the CP did not identify or report the lack of specific parameters for PRN medications or the inappropriate diagnosis for antipsychotic use, resulting in deficiencies in medication management and oversight.
Lack of Parameters for PRN Opioid and Diuretic Administration
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs by not obtaining specific parameters for as needed (PRN) administration of opioid and diuretic medications. For one resident with multiple diagnoses including chronic pain, polyneuropathy, and edema, physician orders for PRN oxycodone and bumetanide lacked clear guidelines regarding the level or type of pain, the number of tablets to administer, or specific criteria for edema. The resident’s medical record showed frequent use of PRN pain medication and diuretics, with medication administration records indicating variable dosing and frequency without documented parameters. Staff interviews confirmed that the resident often determined the dose of oxycodone to take and requested PRN bumetanide as needed, with no specific instructions from the physician regarding administration criteria. The facility’s policy required medications to be administered only as prescribed and in a safe and effective manner, but the orders for PRN medications did not provide sufficient detail to guide staff in their administration. Observations and interviews revealed that staff relied on the resident’s requests and their own judgment rather than clear physician instructions, resulting in inconsistent medication administration. The lack of specific parameters for PRN opioid and diuretic use constituted a failure to ensure the resident’s drug regimen was free from unnecessary drugs, as required by regulation.
Failure to Prevent Hot Liquid Accident
Penalty
Summary
The facility failed to ensure an environment free from accidents for a resident with multiple sclerosis, major depressive disorder, dysphagia, and weakness. The resident, who had intact cognition and required set-up assistance with eating, was assessed to be at risk for spills from hot liquids and was supposed to receive hot beverages in a lidded cup. However, during a period of isolation due to COVID-19, the resident was served a hot beverage in a Styrofoam cup instead of the prescribed Kennedy cup. The incident occurred when the resident, due to limited mobility, hand contractures, and weakness, accidentally punctured the Styrofoam cup, causing the lid to pop off and the hot liquid to spill onto her abdomen. This resulted in a second-degree burn, characterized by redness, fluid-filled blisters, and tenderness. The resident was subsequently taken to the hospital for assessment and treatment of the burn. The deficiency was attributed to the dietary staff operating under outdated COVID-19 guidelines, which led to the use of disposable containers instead of the resident's prescribed Kennedy cup. The facility's failure to adhere to the resident's care plan and hot liquid assessment resulted in the accident and subsequent injury.
Inaccurate PBJ Data Submission
Penalty
Summary
The facility failed to submit complete and accurate staffing information through the Payroll Based Journal (PBJ) as required by the Centers for Medicare & Medicaid Services (CMS). The PBJ report for Fiscal Year 2024 Quarter 1 indicated that there was no licensed nurse coverage on several specific dates. However, a review of the facility's licensed nurse payroll data for those dates revealed that a licensed nurse was indeed on duty 24 hours a day, seven days a week. This discrepancy was verified by Administrative Nurse D, who confirmed that the facility had submitted nursing hours and data that lacked the coverage of agency and hospital RN coverage. The failure to submit accurate PBJ data placed the residents at risk for unidentified and ongoing inadequate staffing. The facility had a census of 16 residents at the time of the survey. The report highlights that the facility's submission of staffing information did not include the necessary details about the category of work for each person on direct care staff, such as whether the individual was an RN, LPN, certified nursing assistant, therapist, or other type of medical personnel as specified by CMS. This oversight in data submission could potentially lead to misinterpretations of staffing adequacy and compliance with regulatory requirements.
Failure to Conduct Weekly Skin Assessments and Follow-Up
Penalty
Summary
The facility failed to perform weekly skin assessments and follow-up documentation for a resident, identified as R9, who was at risk for skin issues. R9's medical history included dermatitis, venous thrombosis, and anemia, and the resident was noted to be at risk for pressure ulcers. Despite these risks, the facility did not conduct weekly skin assessments as required by the resident's care plan and the facility's skin assessment policy. The care plan specified that staff should perform weekly skin inspections and report any changes, but this was not adhered to. The deficiency was highlighted by the lack of follow-up documentation for skin issues identified on two separate occasions. On one occasion, an open wound was noted on R9's lower left leg, but no follow-up assessment was documented until three and a half weeks later. Similarly, another skin issue was identified on R9's toe, with no follow-up assessment for over two weeks. The facility's failure to document and follow up on these skin issues placed R9 at risk for further skin complications. This was confirmed by an administrative nurse who acknowledged the lack of documentation and follow-up.
Failure to Date Insulin Vial
Penalty
Summary
The facility failed to properly label and date a vial of insulin for a resident, identified as R15, which could lead to the administration of expired or ineffective medication. During an observation in the medication storage room, a vial of Fiasp insulin was found to have been accessed but not dated. This oversight was confirmed by Administrative Nurse D, who acknowledged that the vial should have been dated upon opening. The facility's policy mandates that multi-dose vials be dated when opened and discarded within 28 days unless otherwise specified by the manufacturer. The failure to date the insulin vial placed the resident at risk of receiving ineffective insulin.
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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