Heritage Gardens Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oskaloosa, Kansas.
- Location
- 700 Cherokee, Oskaloosa, Kansas 66066
- CMS Provider Number
- 175333
- Inspections on file
- 24
- Latest survey
- July 21, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Heritage Gardens Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not consistently provide scheduled activities on weekends, as shown by activity calendars and confirmed by resident and staff interviews. While occasional church services, music, or movies were provided, there was no structured weekend activity program, despite facility policy requiring ongoing activities to support residents' well-being, including those with cognitive impairments.
Dietary staff did not follow approved recipes when preparing pureed meals for eight residents on a puree-textured diet, instead adding extra gravy to pureed pork chops, which altered the nutritional content. Facility policy required adherence to ordered diet texture and consistency.
Two residents' BIPAP masks and nasal cannulas were not stored in a sanitary manner, with equipment found on bedside tables, in wheelchairs, and wrapped around oxygen canisters, contrary to facility protocols requiring storage in dated, labeled bags. Staff interviews confirmed the correct procedures were not followed.
Several residents did not have documentation showing that the PCV20 vaccine was offered or declined, nor records of prior administration or contraindications. Nursing staff reported that immunization status was checked on admission and information was sent to the pharmacy, but records did not consistently reflect that the PCV20 vaccine was addressed as required by facility policy.
A resident with multiple medical conditions and dependent on staff for care was transferred to the hospital three times, but the facility did not provide the required written transfer/discharge notifications or bed-hold notices to the resident's legal representative, as confirmed by staff interviews and record review.
A resident with multiple chronic conditions, including CHF and on diuretic therapy, did not consistently have daily weights obtained or documented as ordered by the physician. Staff interviews revealed unclear follow-through on responsibilities for obtaining and documenting weights, and the EMR showed multiple missed entries without consistent documentation of refusals.
A resident with severe cognitive impairment, limited mobility, and incontinence was observed seated in a wheelchair without a pressure redistribution cushion, despite documented risk for pressure ulcers and care plan instructions requiring such interventions. Staff interviews confirmed the absence of the cushion, and facility policy mandated preventative measures for residents at risk.
Two residents with cognitive and physical impairments experienced repeated falls due to staff not consistently implementing fall prevention interventions as outlined in their care plans. Despite care plans requiring education on call light use and ensuring call lights were within reach, observations and interviews showed these measures were not reliably followed, resulting in continued fall risks.
A resident with multiple chronic conditions requiring oxygen therapy and BIPAP support had their respiratory equipment, including a BIPAP mask and nasal cannula, improperly stored on a bedside table and in a wheelchair seat instead of in dated, labeled bags as required by facility policy and physician orders. Staff interviews confirmed the expected storage procedures were not followed, and the resident's care plan lacked specific instructions for equipment care.
A resident with severe dementia and multiple care needs did not receive consistent dementia-related care services. The care plan lacked specific interventions for aggressive behaviors, and staff did not consistently use non-pharmacological approaches during episodes of aggression or wandering. The resident was observed entering peers' rooms and experiencing non-injury falls, with staff reporting challenges in keeping him engaged and redirecting him, contrary to the facility's dementia care policy.
Failure to Provide Consistent Weekend Activities for Residents
Penalty
Summary
The facility failed to consistently provide scheduled activities for residents on weekends, as evidenced by a review of the activity calendars for April and May 2025, which showed no listed activities during weekends. Interviews with residents during a council meeting confirmed that there were no consistent or regular weekend activities provided by staff. Further interviews with staff, including a CNA and a licensed nurse, revealed that while church groups or visitors occasionally provided services or music, and movies were sometimes played, there was no structured or scheduled activity program in place for weekends. The activity staff confirmed the absence of scheduled weekend activities and noted that although administrative staff were assigned on weekends and could initiate activities, this was not consistently done. The facility's own policy required an ongoing program of activities tailored to residents' assessments, care plans, and preferences, designed to support their physical, mental, and psychosocial well-being. At the time of the deficiency, the facility had 28 residents with moderately or severely impaired cognition, who were at risk of decline due to the lack of consistent weekend activities.
Failure to Follow Approved Puree Diet Recipes
Penalty
Summary
The facility failed to follow nutritionally approved recipes during the preparation of pureed meals for eight residents on a puree-textured diet. Specifically, a dietary staff member was observed placing cooked pork chops into a food processor, adding several scoops of gravy, checking the consistency, and then adding more gravy before finalizing the pureed pork chops. The staff member stated that a total of four cups of gravy were added to the pork chops. Another staff member confirmed that the recipe for pureed pork chops was not followed, and acknowledged that the additional gravy increased the calorie content but did not diminish the nutritional value. The facility's policy required the food and nutrition services department to prepare and serve diets as ordered, including adhering to the specified texture and fluid consistency.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure that respiratory equipment, specifically BIPAP masks and nasal cannulas, were stored in a sanitary manner for two residents. One resident was observed lying in bed with a nasal cannula in use, while her BIPAP mask was placed directly on the bedside table and an oxygen nasal cannula was left in the seat of her wheelchair. Another resident's oxygen nasal cannula was found wrapped around the handle of an oxygen canister in the room. These storage practices did not meet sanitary standards. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that the expected protocol was to store BIPAP masks and nasal cannulas in a dated and labeled plastic bag when not in use. The facility's own infection prevention and control program required maintaining a safe and sanitary environment to prevent the transmission of communicable diseases, as per national standards and guidelines. The observed practices were inconsistent with these established protocols.
Failure to Document Consent or Declination for PCV20 Vaccination
Penalty
Summary
The facility failed to obtain and document consent or declination for the Pneumococcal Conjugate Vaccine (PCV20) for several residents. Specifically, clinical records for four residents lacked evidence that the PCV20 vaccine was offered or declined, and there was no documentation of prior administration or physician-documented contraindications. In some cases, records showed that other pneumococcal vaccines (such as PCV13 or PCV23) were pending or had been administered, but there was no follow-up or documentation regarding the PCV20 vaccine as required. Interviews with nursing staff revealed that immunization status was typically assessed on admission and that the process involved the nurse in charge, the DON, and the pharmacy. However, the records did not reflect that the required steps for offering or documenting the PCV20 vaccine were consistently followed. The facility's policy stated that pneumococcal immunizations would be offered in accordance with CDC guidelines, but the lack of documentation for these residents indicated that the policy was not fully implemented.
Failure to Provide Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge as soon as practicable and did not issue a bed-hold notice with the required information for a resident who experienced three facility-initiated transfers to the hospital. The resident, who had diagnoses of diabetes mellitus, congestive heart failure, and seizure disorder, was documented as having intact cognition and was dependent on staff for dressing and transfers. The resident's care plan and assessments consistently indicated a need for staff assistance with activities of daily living. Despite multiple hospital transfers, the facility did not send the required written notifications or bed-hold notices to the resident's legal representative. Interviews with administrative and social service staff confirmed that these notifications were not provided as required by facility policy. The facility's own policy stated that written notice specifying the duration of the bed-hold policy and information about the resident's return should be given at the time of transfer, but this was not followed for the resident in question.
Failure to Consistently Obtain and Document Daily Weights per Physician Order
Penalty
Summary
The facility failed to consistently follow a physician's order for obtaining daily weights for a resident with multiple complex medical conditions, including congestive heart failure, diabetes mellitus, obesity, repeated falls, hypertension, chronic obstructive pulmonary disease, edema, and dementia. The resident's care plan specifically required daily weights due to diuretic therapy and the potential for weight fluctuations, with instructions to notify the physician if certain weight gains occurred. Despite these orders, review of the resident's Treatment Administration Record (TAR) revealed numerous dates where weights were not documented, and there was a lack of consistent documentation regarding refusals of daily weights. Interviews with staff indicated that CNAs were responsible for obtaining daily weights and were to notify the nurse if unable to do so, while nurses were responsible for ensuring weights were obtained or refusals documented. However, the EMR showed multiple missed entries for daily weights and lacked consistent documentation of refusals. The facility's policy required maintaining a schedule of diagnostic tests and a reliable process for providing physician-ordered services, but this was not consistently followed for the resident in question.
Failure to Provide Pressure Redistribution Cushion for At-Risk Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, limited mobility, and a history of incontinence and falls was not provided with a pressure redistribution cushion in his wheelchair, as required by his care plan and facility policy. The resident's medical records indicated diagnoses of dementia, benign prostatic hyperplasia, and acute kidney failure, and assessments consistently documented his risk for pressure ulcers due to incontinence and reduced mobility. The care plan specifically instructed staff to use pressure redistribution surfaces for the resident's bed and wheelchair if indicated, and the Braden Scale assessment confirmed his risk for developing pressure ulcers. Despite these documented risks and care plan instructions, observations on multiple occasions revealed that the resident was seated in his wheelchair without any cushion or pressure-reducing padding. Interviews with nursing staff and aides confirmed that the resident previously had a pressure-relieving cushion, but it was not present at the time of the observations, possibly due to issues with incontinence or falls. The facility's policy required implementation of preventative interventions, including pressure redistribution, for residents at risk, but this was not followed for the resident in question.
Failure to Implement and Maintain Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that fall prevention interventions were consistently implemented for two residents with significant cognitive and physical impairments. One resident with diagnoses including multiple sclerosis, epilepsy, and a history of falls had a care plan directing staff to educate and re-educate him on the use of his call light and to ensure needed items were within reach. Despite these interventions, the resident experienced multiple falls, and documentation showed that staff did not implement new interventions following these incidents. Staff interviews confirmed that while care plans and updates were accessible, there was a lack of consistent follow-through on implementing and updating fall prevention measures. Another resident with a history of encephalopathy, dementia, fractures, and multiple falls had a care plan requiring staff to keep her call light within reach and to respond promptly to requests for assistance. Observations revealed that the resident's call light was repeatedly placed out of reach, both hooked to the wall and on the bedside table, making it inaccessible. Staff interviews corroborated that call lights should be within reach, but this was not consistently practiced, directly contradicting the care plan directives. The facility's policy required maintaining an environment free of accident hazards and providing adequate supervision and assistive devices to prevent accidents. However, the failure to ensure that fall interventions, such as accessible call lights and updated care plans, were consistently implemented for these residents resulted in a deficiency. These lapses placed the residents at risk for further falls and injuries, as evidenced by the repeated incidents and lack of effective intervention.
Failure to Store Respiratory Equipment in a Sanitary Manner
Penalty
Summary
The facility failed to ensure the proper and sanitary storage of a resident's respiratory equipment, specifically a BIPAP mask and nasal cannula. During observation, the resident's BIPAP mask was found placed directly on the bedside table, and the oxygen nasal cannula was left in the seat of the resident's wheelchair, rather than being stored in a dated, labeled bag as required by facility policy and staff instructions. Interviews with staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that the expected practice was to store these items in a dated plastic bag to maintain sanitation. The resident involved had multiple medical conditions, including COPD, congestive heart failure, diabetes, obesity, and dementia, and required both oxygen therapy and a BIPAP device as part of their care. The care plan documented the need for oxygen therapy and BIPAP use, but lacked specific instructions for the care and storage of the oxygen cannula and BIPAP mask. Physician orders were in place for regular changing and dating of respiratory equipment, but these were not followed in practice, as evidenced by the unsanitary storage observed during the survey.
Failure to Provide Consistent Dementia Care Services
Penalty
Summary
The facility failed to provide consistent dementia-related care services for a resident diagnosed with dementia, benign prostatic hyperplasia, and acute kidney failure. The resident had severe cognitive impairment, as indicated by a BIMS score of zero, and required substantial to maximal assistance with daily activities, including dressing, hygiene, and mobility. The care plan identified risks such as cognitive loss, incontinence, falls, and skin breakdown, and instructed staff to keep the resident engaged in activities, calmly communicate, and anticipate his needs. However, the care plan lacked specific interventions for managing aggressive behaviors, and staff documentation did not reflect the use of non-pharmacological interventions during episodes of aggression or wandering. Observations and interviews revealed that the resident frequently wandered into peers' rooms and attempted to self-toilet, resulting in non-injury falls. Staff reported difficulty keeping the resident engaged and redirecting him from unsafe areas, but there was no evidence of consistent implementation of individualized behavioral interventions. The facility's dementia care policy required strategies to address triggers and behaviors, but the documentation and staff actions did not demonstrate adherence to these approaches, resulting in a failure to promote the resident's highest practicable level of well-being.
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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