Halstead Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Halstead, Kansas.
- Location
- 915 Mcnair Street, Halstead, Kansas 67056
- CMS Provider Number
- 175446
- Inspections on file
- 16
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Halstead Health And Rehabilitation Center during CMS and state inspections, most recent first.
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.
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.
The facility failed to provide required written notification to the LTCO for six residents who were transferred from the facility, including five discharged home and one transferred to another facility, as shown by review of the admission/discharge report. A social services staff member stated she only notifies the LTCO when a resident is transferred to a hospital and had not notified the LTCO for residents going home or to another facility, while an administrative staff member stated she expected all transfers to be reported to the ombudsman. The facility could not produce a policy addressing LTCO notification for residents transferred to another facility or discharged home.
The facility failed to ensure daily nurse staffing postings were accurate and complete. Surveyors observed multiple posted staffing sheets that did not include total hours worked and, at one point, did not list the facility name. Review of additional dates showed the same omission of total hours worked. An administrative nurse reported that a night-shift nurse completed and posted the next day’s staffing sheet and indicated that a column labeled "actual hours" was intended to represent total hours worked, despite the facility’s written policy requiring clear computation and recording of staffing levels and census information on the Daily Nurse Staffing form.
A resident with a history of diabetes and neuropathy developed stage two pressure ulcers due to the facility's failure to assess and notify the provider in a timely manner. Despite being at risk, the resident's blisters were not addressed for six days, leading to open wounds. Staff interviews revealed lapses in protocol adherence, and administrative nurses admitted the delay was unacceptable.
A cognitively impaired resident suffered burns from hot soup due to the facility's failure to check food temperatures before serving. The resident, who required extensive assistance and had severe cognitive impairment, placed his fingers in the hot soup, resulting in blisters. Staff interviews revealed a lack of routine temperature checks, and the facility did not provide a policy on food temperatures.
A facility with 41 residents was found to have deficiencies in food storage and preparation. Observations revealed improperly dated and sealed food items, and a staff member failed to clean a thermometer between uses and did not measure soup temperature before serving. These practices could lead to foodborne bacteria affecting all residents receiving meals.
The facility failed to implement enhanced barrier precautions and properly clean respiratory equipment, leading to potential infection risks. Staff lacked training on EBP, and observations showed improper PPE use during care for residents with pressure ulcers, catheters, and tracheostomies. Additionally, nebulizers and CPAP masks were not cleaned or stored according to professional standards, posing a risk of spreading infectious organisms.
The facility failed to maintain a sanitary environment by not providing lids for soiled linen cans in shower rooms and a biohazard container in the soiled utility room. Additionally, the laundry room had a large crack with broken tiles, exposing cement and creating an uneven surface. These issues were acknowledged by the Maintenance Director and Administrative Staff, and the facility lacked a policy on covering trash cans in soiled utility rooms.
The facility failed to maintain a clean and homelike environment for its 41 residents. Observations included frayed carpeting in hall transitions, a loose sewer cleanout cap, broken tiles with jagged edges in a shower area, and an unknown black substance between tiles. These issues were confirmed by the Maintenance Director and Administrative Staff, contrary to the facility's policy to provide a safe and comfortable environment.
The facility failed to develop comprehensive care plans for residents, including those with dysphagia, pressure ulcers, and those receiving psychotropic medications and nebulized therapy. This led to inadequate care and services, as care plans lacked necessary dietary modifications, wound management, behavior monitoring, and equipment maintenance instructions.
The facility failed to provide proper respiratory care for residents, including improper cleaning and storage of nebulizers, inadequate tracheostomy care, and improper CPAP storage. Observations revealed nebulizers with unknown residue, lack of backup trach equipment, and CPAP masks improperly stored, indicating non-compliance with professional standards.
The facility failed to respond promptly to the Consultant Pharmacist's Medication Regimen Review (MRR) and Gradual Dose Reduction (GDR) recommendations for several residents, leading to potential risks of unnecessary medication use. The facility's policy required timely responses to pharmacist recommendations, but delays of over 30 days were noted, placing residents at risk.
A resident with multiple health conditions, requiring total assistance with ADLs, did not receive dignified care during incontinent care when staff failed to close the window blinds. The resident expressed discomfort with the lack of privacy, and the facility did not provide a policy on dignity when requested.
A facility failed to comply with a resident's advanced directives by allowing a guardian to sign a DNR order without judicial approval. The resident, diagnosed with dementia and other conditions, had a care plan that did not document the presence of a guardian, and the facility's policy lacked guidance for such situations.
The facility failed to accurately complete the MDS for two residents, leading to uncommunicated care needs. One resident's MDS inaccurately documented oxygen therapy, while another's MDS lacked documentation of cognitive and depressive assessments. Staff interviews confirmed these inaccuracies, indicating a failure to adhere to MDS procedures.
A facility failed to update a resident's care plan to include nebulizer use and maintenance, despite the resident's chronic respiratory failure and hypoxia. Staff were unaware of proper nebulizer handling, and the care plan lacked necessary documentation, leading to a deficiency in care.
A resident with diabetes and neuropathy, requiring total assistance with ADLs, did not receive care for facial hair removal, despite expressing discomfort. Observations showed facial hair remained unaddressed, and staff interviews revealed a lack of planning for this care. The facility lacked a policy on ADLs, contributing to the oversight.
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.
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 Notify LTCO of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide required written notification to the Office of the Long-Term Care Ombudsman (LTCO) for six residents who were transferred from the facility, including five residents who were discharged home and one resident who was transferred to another facility. Review of the admission/discharge report for the period from 02/14/26 to 04/14/26 showed these six transfers, but there was no corresponding documentation that the LTCO had been notified of these discharges. During an interview, the social services staff member reported that she only notifies the LTCO when a resident is transferred to a hospital and acknowledged that she had not notified the LTCO when residents were transferred home or to another facility. In a separate interview, an administrative staff member stated that she expected that any transfers from the facility would be reported to the ombudsman. The facility was unable to provide a policy addressing notification of the ombudsman for residents transferred to another facility or discharged home when requested.
Inaccurate and Incomplete Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that its posted daily nurse staffing sheets contained accurate and complete information, including the facility name and total hours worked, as required. On 04/13/26 at 08:00 AM, the posted staffing sheet did not include the total hours worked. On 04/14/26 at 09:30 AM, the posted staffing sheet again lacked the total hours worked and also did not list the facility name. Review of prior daily staffing sheets dated 05/13/25 and 03/18/26 showed that these postings also did not include the total hours worked. During an interview on 04/14/26 at 11:48 AM, Administrative Nurse D explained that the night shift nurse completed the next day’s staffing sheet and posted it before the start of the next shift, and stated that the column labeled “actual hours” represented the total hours worked. The facility’s policy, “Daily Nurse Staff Posting,” dated 11/28/17, required that at the beginning of each shift the charge nurse compute the number of full-time equivalents on duty, record this on the Daily Nurse Staffing form, and post it in designated locations so it could be easily seen and read, and also required that the facility census be recorded and updated with any admissions or discharges throughout the day. This deficiency centers on the inconsistency between the facility’s policy requirements for daily nurse staffing postings and the actual content of the posted forms, which repeatedly lacked required elements such as total hours worked and, on at least one occasion, the facility name.
Failure to Timely Assess and Treat Pressure Ulcers
Penalty
Summary
The facility failed to assess and provide timely treatment for a resident, identified as R13, who developed pressure ulcers. R13 had a medical history including diabetes mellitus type two, neuromuscular dysfunction of the bladder, and idiopathic peripheral autonomic neuropathy. The resident was at risk for pressure ulcers, as indicated by a Braden Score of 14, and required maximal to total assistance with activities of daily living. On May 8, 2024, staff observed two intact blisters on R13's coccyx but failed to notify the provider until six days later, by which time the blisters had developed into stage two pressure ulcers. The facility's records showed a lack of evidence that the wound and skin nurse was notified of R13's condition on the day the blisters were first observed. The skin wound assessment was not conducted until May 14, 2024, and the physician's order for treatment was not documented in the electronic health record. Observations on May 16, 2024, revealed two open areas on the resident's left upper buttock near the coccyx, with no barrier cream applied after incontinence care, contrary to the care plan. Interviews with staff indicated a failure to follow protocol for notifying the charge nurse and provider of new skin conditions. The administrative nurses acknowledged the delay in assessment and treatment was unacceptable, and the physician extender confirmed the expectation for timely notification and documentation of treatment orders. The facility's policy stated that residents should not develop pressure ulcers unless unavoidable, emphasizing the need for timely assessment and care planning.
Failure to Ensure Safe Food Temperature for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure a safe environment for a cognitively impaired resident, identified as R35, by not checking the temperature of a bowl of soup before serving it. R35, who had severe cognitive impairment due to Alzheimer's disease and vascular dementia, suffered burns that developed into blisters on two fingers of his right hand after placing them in the hot soup during mealtime. The resident's medical records indicated he required extensive assistance for all cares and had tremors, which could necessitate staff assistance during feeding. Observations and interviews revealed that dietary staff did not routinely check the temperature of food before serving it to residents. On one occasion, a dietary staff member served soup at a temperature of 154 degrees Fahrenheit without verifying its safety for consumption. Interviews with staff, including a CNA and an LN, confirmed that R35 was dependent on staff for meals and communicated his needs through non-verbal cues due to his cognitive impairments. The facility did not provide a policy regarding food temperatures when requested, indicating a lack of established procedures to ensure food safety for residents, particularly those with cognitive impairments. This oversight led to the incident where R35 sustained burns from the hot soup, highlighting a deficiency in the facility's supervision and safety measures for preventing accidents.
Deficiencies in Food Storage and Temperature Measurement
Penalty
Summary
The facility, with a census of 41 residents, was found to have deficiencies in food storage and preparation practices during a survey. Observations in the main kitchen revealed that several food items, including onions, cheese slices, lunch meat, ice cream, hamburger patties, and mozzarella cheese, were not properly dated or sealed after being opened. This lack of proper food storage could potentially lead to foodborne bacteria affecting all residents receiving meals from the kitchen. Additionally, dietary staff failed to adhere to sanitary practices while measuring food temperatures. A staff member was observed using a thermometer on multiple food items without cleaning it between uses, which could lead to cross-contamination. Furthermore, the same staff member did not measure the temperature of a soup before serving it to a resident, indicating a lack of adherence to proper food temperature measurement procedures. The facility's policy on food storage required proper wrapping and labeling of food items, but no policy was provided for serving temperatures at the time of service.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the lack of implementation and adherence to enhanced barrier precautions (EBP) for residents with specific medical needs. Observations revealed that staff did not use appropriate personal protective equipment (PPE) during procedures involving residents with pressure ulcers, urinary catheters, and tracheostomies. Interviews with staff, including licensed nurses and certified nurse aides, indicated a lack of training and awareness regarding EBP, which was supposed to be implemented by 04/01/24. The facility's administrative and consultant nurses acknowledged the absence of a policy and training for EBP, despite being aware of the implementation deadline. Additionally, the facility failed to properly clean and store respiratory equipment, such as nebulizers and CPAP masks, for several residents. Observations showed that nebulizers were not cleaned between uses, with clear residues and liquids left in the atomizer chambers. Residents and staff were unaware of the proper cleaning procedures, and the facility's policy lacked specific instructions for maintaining nebulizer equipment. Similarly, a CPAP mask was improperly stored on a resident's nightstand, contrary to the facility's respiratory care policy. The deficiencies in infection control practices have the potential to spread infectious organisms among vulnerable residents. The facility's failure to implement EBP and ensure proper cleaning of respiratory equipment highlights significant lapses in adhering to professional standards of care. These practices were not in line with the facility's policies, which were intended to prevent possible respiratory illnesses and ensure the safety and well-being of residents.
Sanitary Environment Deficiencies
Penalty
Summary
The facility was found to have several deficiencies related to maintaining a sanitary environment, as observed during an environmental tour. Specifically, the facility failed to provide lids or covers for soiled linen cans in the shower rooms located on the 100, 200, 300, and 400 halls. Additionally, the biohazard container in the soiled utility room was also found without a lid or cover. These deficiencies were confirmed by the Maintenance Director and Administrative Staff, who acknowledged that these containers should always be covered. Furthermore, the facility's laundry room was noted to have a large crack on the floor with broken or missing tiles, exposing cement and creating an uneven walking surface with unknown debris inside the crack. The facility was unable to provide a policy related to the requirement for lids or covers on trash cans in the soiled utility rooms when requested. These practices were identified as having the potential to create an unsanitary environment affecting all residents in the facility.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its 41 residents, as evidenced by several deficiencies observed during a physical environmental tour. The tour, conducted with the Maintenance Director, revealed frayed carpeting at the floor transitions from the main area to both the 200 and 300 halls. Additionally, a floor sewer cleanout cap in the 200 hall was found to be loose and easily lifted. In the 400 hall shower, two tiles along the base and corner of a divider wall were broken, exposing jagged edges. Furthermore, an unknown black substance was observed between the tiles at the transition between the floor and the wall in the 200 hall shower. These findings were confirmed by both the Maintenance Director and Administrative Staff, who acknowledged the issues and indicated they would be addressed immediately. The facility's policy, dated 04/27/18, stated that housekeeping and maintenance services would be provided to ensure a safe, clean, comfortable, and homelike environment, which was not upheld in this instance.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for several residents, leading to inadequate care and services. One resident with dysphagia did not have a care plan that included necessary dietary modifications and speech therapy interventions, despite having a history of choking episodes. The resident's care plan lacked guidance on the recommended pureed diet and mechanical soft foods, and there was no documentation of the speech therapist's recommendations being incorporated into the care plan. This oversight placed the resident at risk for choking and inadequate nutritional management. Another resident with a pressure ulcer did not have a care plan addressing the management and treatment of the ulcer. The resident, who required total assistance with activities of daily living and was incontinent, developed a stage two pressure ulcer that was not promptly addressed in the care plan. The facility's staff failed to notify the wound and skin nurse in a timely manner, and the care plan was not updated to include interventions for the pressure ulcer, leaving the resident at risk for further skin breakdown and inadequate wound care. Additionally, the facility did not develop a care plan for a resident receiving psychotropic medications, which included monitoring for behaviors related to the use of these medications. The resident, who had diagnoses of major depressive disorder and anxiety disorder, was receiving multiple psychotropic medications without a care plan to monitor their effects on mood and behavior. Furthermore, another resident using nebulized medication therapy for chronic respiratory conditions did not have a care plan addressing the care and maintenance of the nebulizer equipment, potentially compromising the effectiveness of the treatment.
Deficient Respiratory Care Practices
Penalty
Summary
The facility failed to provide proper respiratory care for several residents, as evidenced by observations, interviews, and record reviews. For one resident with pulmonary fibrosis and chronic respiratory failure, the nebulizer was not cleaned or stored according to professional standards. The resident was capable of self-administering medication but was not trained on cleaning procedures, and staff did not clean the nebulizer after each use. Observations revealed the nebulizer with unknown residue and liquid droplets, indicating improper maintenance. Another resident with congestive heart failure and chronic respiratory failure also experienced improper nebulizer care. The nebulizer was found with unknown liquid in the atomizer chamber, and staff were unaware of the cleaning protocol. The resident was dependent on staff for care, yet the nebulizer was not cleaned after each use, as required by professional standards. Interviews with staff confirmed a lack of awareness and adherence to the cleaning process. Additionally, a resident with a tracheostomy did not receive care in line with professional standards. The resident reported not having seen a pulmonologist since receiving the trach and stated that the trach had never been changed. Observations showed a lack of backup trach equipment and suction machine in the room, and staff were not performing routine suctioning. The facility also failed to properly store a CPAP mask for another resident, as it was found on the nightstand in contact with other items, contrary to professional standards.
Delayed Response to Pharmacist Recommendations
Penalty
Summary
The facility failed to respond in a timely manner to the Consultant Pharmacist's Medication Regimen Review (MRR) and Gradual Dose Reduction (GDR) recommendations for several residents, including those identified as R8, R24, R26, R33, and R35. This deficiency was observed through a combination of interviews, record reviews, and observations, which revealed that the facility did not act upon the pharmacist's recommendations within the timeframes outlined in their own policies. For instance, the facility delayed responding to a recommendation regarding the timing of medication administration for a resident by 36 days, contrary to the policy that required a response within seven days. The report highlights specific cases where the facility's inaction placed residents at risk of receiving unnecessary medications. For example, R33's medication regimen was not adjusted in a timely manner despite the pharmacist's recommendation to ensure compliance with CMS regulations on antimicrobial use. Similarly, R26's fasting blood sugar levels were not addressed promptly, and the facility took over 30 days to respond to the pharmacist's concerns. Additionally, R35's sleep assessment related to the use of Trazadone for insomnia was not documented or addressed as recommended by the pharmacist. The facility's Drug Regimen Review policy, dated 11/28/17, required the pharmacist to complete a monthly review and report any irregularities to the attending physician, medical director, and Director of Nursing (DON). The policy stipulated that the physician should respond within seven days, and any irregularities not requiring physician intervention should be acted upon by the DON or designee within three days. However, the facility consistently failed to adhere to these timelines, as evidenced by the delayed responses and incomplete documentation of actions taken in response to the pharmacist's recommendations.
Failure to Ensure Dignified Care During Incontinent Care
Penalty
Summary
The facility failed to ensure that a resident received care in a dignified manner during incontinent care when the window blind was left open. The resident, who had diagnoses including diabetes mellitus type two, neuromuscular dysfunction of the bladder, and idiopathic peripheral autonomic neuropathy, required maximal to total assistance with activities of daily living and was always incontinent of bladder and bowel. During an observation, it was noted that certified nursing assistant (CNA) N and certified medication aide (CMA) U did not close the window blinds while providing incontinent care to the resident, whose bed was directly in front of the window. This oversight was acknowledged by both staff members and the resident expressed discomfort with the situation, stating a preference for privacy. The resident's care plan indicated the need for two staff members for bed mobility and specified procedures for incontinent care, including the application of barrier cream. However, the physician's order lacked specific instructions for incontinent or skin care. The facility also failed to provide a policy on dignity when requested. This deficiency in maintaining the resident's dignity during care placed the resident at risk for decreased psychosocial well-being.
Failure to Comply with Resident's Advanced Directives
Penalty
Summary
The facility failed to honor a resident's right to make decisions regarding their own medical treatment, specifically concerning the establishment of a Do Not Resuscitate (DNR) order. The resident in question, who had diagnoses of unspecified dementia, unspecified intellectual disabilities, and chronic atrial fibrillation, was found to have a DNR order signed by their guardian. However, the facility's policy and state law require that a guardian cannot sign a DNR form unless it is approved by the judicial system. The resident's care plan did not document the presence of a guardian, and the guardianship document lacked direction regarding advanced directives. The deficiency was identified through a review of the resident's electronic health record (EHR) and interviews with facility staff. The facility's advanced directives policy did not provide guidance on situations where a resident has a guardian, leading to the inappropriate signing of the DNR by the guardian. This oversight resulted in a failure to comply with the resident's rights and state law, as confirmed by a consultant nurse during an interview.
Inaccurate MDS Documentation for Two Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for two residents, leading to uncommunicated care needs. For one resident, identified as R19, the MDS inaccurately documented the use of oxygen therapy. Despite having diagnoses of pulmonary fibrosis and chronic respiratory failure, the resident's records, including the Electronic Health Records (EHR), Care Area Assessment (CAA), and Medication Administration Record (MAR), lacked documentation of oxygen use. Observations confirmed the absence of oxygen equipment in the resident's room, and interviews with staff revealed that the incorrect MDS entry was presumed to be a clerical error. Another resident, identified as R9, had an incomplete MDS related to cognition and depression. The resident, who had diagnoses of diabetes mellitus type two and dementia, required total assistance with activities of daily living and was receiving hospice care. The MDS lacked documentation of the Brief Interview for Mental Status (BIMS) and the Patient Health Questionnaire (PHQ-9), which are essential for assessing cognitive and depressive symptoms. Interviews with staff confirmed that sections C and D of the MDS were not completed before the Assessment Reference Date (ARD), resulting in an incomplete assessment. The facility's policy for conducting the MDS, as documented, requires data gathering by a licensed nurse or interdisciplinary team member and review by a Registered Nurse. However, the inaccuracies in the MDS for both residents indicate a failure to adhere to these procedures, placing the residents at risk for uncommunicated care needs.
Failure to Update Care Plan for Nebulizer Use
Penalty
Summary
The facility failed to review and revise the person-centered care plan for Resident 30, specifically regarding the use, care, and maintenance of nebulizer equipment. Resident 30 had diagnoses of congestive heart failure and chronic respiratory failure with hypoxia, requiring oxygen and nebulized medication therapy. However, the care plan lacked documentation related to nebulized medication use or the care and maintenance of the nebulizer equipment. Observations revealed that the nebulizer was improperly stored with an unknown clear liquid in the atomizer chamber, and staff were unaware of the proper handling and cleaning procedures for the nebulizer equipment. Interviews with staff indicated a lack of awareness and understanding of the care plan and its updates. Certified Nurse Aides were not informed about the special handling or cleaning of the nebulizer equipment, and there was confusion about how often care plans should be updated. The facility's policy required the development of a care plan that includes measurable objectives to meet the resident's needs, but this was not adhered to, leading to a deficiency in the care provided to Resident 30.
Failure to Provide Facial Hair Removal for Resident
Penalty
Summary
The facility failed to ensure that Resident 13 received appropriate care for the removal of facial hair, which was necessary for maintaining the resident's psychosocial well-being. Resident 13, who had diagnoses of diabetes mellitus type two and idiopathic peripheral autonomic neuropathy, was documented as having intact cognition with a BIMS score of 14. The resident required total assistance with activities of daily living (ADLs) except for eating, and moderate assistance with personal hygiene. Despite this, the care plan lacked specific directions for staff regarding bathing assistance and facial hair removal, and there were no physician's orders for facial hair removal. Observations on two consecutive days revealed that Resident 13 had noticeable facial hair, which the resident expressed was bothersome. Interviews with staff indicated that facial hair should be removed on shower days, yet the assigned CNA had not planned to remove the facial hair. Furthermore, the facility was unable to provide a policy on ADLs, highlighting a gap in the care provided to Resident 13. This oversight placed the resident at risk for decreased psychosocial well-being due to the lack of attention to personal grooming needs.
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Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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