Heritage Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chanute, Kansas.
- Location
- 1630 W 2nd Street, Chanute, Kansas 66720
- CMS Provider Number
- 175249
- Inspections on file
- 21
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Heritage Health Care Center during CMS and state inspections, most recent first.
A resident with a history of stroke sequelae, depression, and dependence on staff for ADLs experienced an unwitnessed fall while attempting to self-toilet and was found sitting on the floor by the bed. Instead of assisting the resident up, an RN/LPN changed the resident’s socks and instructed the resident to turn, get onto hands and knees in a “prayer position,” and pull up from the floor into bed without staff assistance, reportedly stating this was to “teach a lesson” about falls. The resident later reported feeling angry and very embarrassed by the interaction, while other staff stated they would have assisted a resident from the floor and followed fall protocol.
The facility failed to ensure proper reconciliation and regular counting of controlled substances, including overflow narcotics, which led to the discovery that 12 hydrocodone tablets were missing for a resident. A CMA and an LN found only 18 tablets in an overflow bottle that was documented as containing 30, and the LN altered the count on the narcotic sheet without promptly notifying administration, while the CMA delayed reporting the discrepancy until the next day. The hydrocodone had been received from a third-party pharmacy and locked in overflow storage without an initial pill count at the time the narcotic sheet was created, and no further counts were performed for several days until staff attempted to refill the med cart and identified the shortage.
Surveyors identified unsanitary conditions in food preparation and storage areas, including soiled equipment, undated and unlabeled food items, improper thawing of meat at room temperature, and food debris on surfaces and carts. These actions did not comply with facility policies for sanitation and food safety.
Surveyors observed that all dumpsters outside the kitchen were left open with trash scattered around them, and this condition persisted over multiple observations. Dietary staff confirmed that dumpsters were supposed to remain closed, and facility policy required covered dumpsters and clean surrounding areas to prevent insect or rodent attraction.
The facility did not ensure that controlled substances on a medication cart were properly reconciled by two staff members at shift changes, as required by policy. Documentation showed missing signatures and incomplete verification, with staff confirming that both outgoing and incoming personnel should sign off on the narcotic count.
Surveyors found that a medication cart was left unlocked and unattended, containing various medications including narcotics, and that insulin vials and pens in a treatment cart were either expired or not dated when opened. Staff interviews confirmed that carts should be locked and insulin pens dated, but these practices were not consistently followed, contrary to facility policy.
A resident with panic disorder and depression was prescribed multiple psychotropic and antipsychotic medications without documented informed consent. Facility policy required that residents or their representatives be informed of the benefits, risks, and alternatives before starting such medications, but this was not done in this case.
Two residents were discharged or transferred from the facility without the required notification to the state Ombudsman, as confirmed by record review and staff interview. One resident had severe cognitive impairment and was discharged to the community, while another with CHF and moderate cognitive impairment was transferred to a hospital. Documentation of Ombudsman notification was missing in both cases.
A resident with multiple complex medical conditions, including a pressure ulcer and dependence on staff for ADLs, did not receive scheduled bathing assistance as required. Documentation showed only one shower was provided in a month, with no refusals recorded, despite the resident's requests for showers and facility policy requiring regular bathing and documentation. Staff interviews confirmed the expectation for regular bathing and proper documentation, but these were not met for this resident.
Two residents with pressure ulcers did not receive wound care and assessments in accordance with professional standards, as weekly nurse skin assessments were either missing or lacked required measurements and descriptions. Nursing staff confirmed that wound assessments should include measurements and detailed descriptions, but these were not documented, and the facility did not provide a policy for pressure ulcer monitoring.
Staff did not consistently clean, date, or properly store nebulizer equipment for several residents receiving breathing treatments. Equipment was observed left open to air on furniture, not dated, and not stored in bags as required by facility policy. Residents and staff confirmed that proper cleaning and storage procedures were not followed.
Resident Required to Self-Lift After Fall, Causing Anger and Embarrassment
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse when a licensed nurse required the resident to get up from the floor without assistance after an unwitnessed fall. The resident had a history of cerebral infarction with sequelae and depression, used a wheelchair and walker, and required staff assistance with all ADLs, including transfers and toileting. His care plan identified him as at risk for falls related to weakness and high‑risk medications and directed staff to carry out all interventions to prevent falls and to provide partial to moderate assistance with toilet use, transfers, and bed mobility. Despite these documented needs, after the resident experienced an unwitnessed fall while attempting to self‑toilet and was found sitting on the floor leaning against his bed, staff did not physically assist him up. Nursing documentation showed that staff replaced the resident’s slick socks with gripper socks and slippers, then encouraged him to turn around, get on his knees, and pull himself up from the floor into bed. Official statements recorded that a CMA heard the nurse state she made the resident remain on the floor “to teach him a lesson” while she completed tasks and then made him get off the floor without assistance. Another statement documented that the resident reported the nurse told him to get into a “prayer position” and pick himself up, and that she was upset and argued with him about how many falls he had. During interview, the resident confirmed that the nurse instructed him to get into a praying position and get himself off the floor without her assistance, which made him feel angry and very embarrassed. Other staff interviewed indicated that they would have assisted a resident up from the floor and notified the nurse, and administrative staff characterized the nurse’s actions as inappropriate.
Failure to Reconcile Overflow Narcotics Resulting in Missing Hydrocodone
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper narcotic reconciliation, including regular counts of all controlled substances and those stored as overflow, which resulted in missing hydrocodone tablets for a resident. The facility reported that staff discovered 12 hydrocodone tablets were missing after a discrepancy was identified between the documented count and the actual number of pills in the bottle. The narcotic dispensing record for the resident’s hydrocodone showed that a count of 30 tablets had been crossed out and changed to 18, with the change initialed by two individuals and dated and timed, followed by documentation that one tablet was administered, leaving a remaining count of 17. According to witness statements, a CMA requested assistance from an LN to obtain hydrocodone from the overflow cabinet to refill the medication cart. When they counted the pills in the overflow bottle, they found only 18 tablets, while the narcotic count sheet indicated 30. The LN then corrected the count on the sheet from 30 to 18 without immediately notifying administration of the discrepancy, and the CMA also delayed reporting the error until the following day. The facility’s investigation determined that when the hydrocodone was originally picked up from a third-party pharmacy and placed in the overflow cabinet, the LN who secured the medication created a narcotic count sheet but did not count the contents of the bottle at that time. The investigation further documented that the hydrocodone bottle was not recounted between the initial correct count performed later that same day by two LNs and the subsequent count several days later when the 12 missing tablets were discovered. During this period, no additional counts of the overflow narcotics were performed, and the discrepancy was only identified when staff attempted to move the medication from overflow storage to the medication cart. The facility’s failure to consistently perform and reconcile narcotic counts, including for overflow medications, and the delay in reporting the discrepancy by involved staff, led to the identification of missing hydrocodone tablets for the resident.
Failure to Maintain Sanitary Food Preparation and Storage Conditions
Penalty
Summary
Surveyors observed multiple failures in food preparation and storage practices that did not meet sanitary standards. During a kitchen tour, they found a heavily soiled microwave, window areas with dried-on food and liquid, and a stationary can opener with moist food residue. The preparation table and a three-tiered cart used for breakfast had food debris, and several plastic containers for condiments and baking ingredients were grimy and sticky. A large roast was found thawing at room temperature, contrary to facility policy. In the reach-in refrigerator, several opened food items, including sour cream and liquid eggs, were undated, and containers of peaches, mayonnaise, and mustard had dried-on food substances. Spilled salsa contaminated other items and surfaces in the refrigerator. In the dining room snack area, the counter and snack cart were sticky and dirty, with food debris and grime on the cart wheels. The resident refrigerator/freezer contained multiple opened and undated or unlabeled food items, including mixed fruit, sodas, shakes, and ice cream, with some items having exploded in the freezer. Dietary staff confirmed improper thawing practices and acknowledged the need for correction. Facility policies required regular cleaning and proper labeling and dating of foods, as well as approved thawing methods, which were not followed in these instances.
Improper Disposal of Garbage and Refuse
Penalty
Summary
During an environmental tour of the kitchen, surveyors observed that the lids to all three dumpsters located outside the kitchen were left open, with trash present on the ground around the dumpsters. These observations were made at two separate times on the same day, confirming that the issue persisted. Further interview with dietary staff confirmed that staff were expected to keep dumpster lids closed at all times. Review of the facility's policy indicated that dumpsters should be kept covered when not being loaded and that the surrounding area should remain clean to minimize debris and the attraction of insects or rodents.
Failure to Reconcile Controlled Substances on Medication Cart
Penalty
Summary
The facility failed to properly reconcile controlled substances on the medication cart, as required by policy. Specifically, review of the controlled substance reconciliation log for the east hallway cart showed that on one occasion, only the day shift nurse signed off, with no evidence of a second staff member verifying the count. Additionally, there was no documentation or signatures indicating that a reconciliation was completed for a subsequent shift. Interviews with a Certified Medication Aide and an administrative nurse confirmed that the expectation is for two staff members to count and verify controlled substances at each shift change, in accordance with facility policy. The lack of dual verification and missing signatures on the reconciliation log demonstrated a failure to follow established procedures for controlled substance accountability.
Failure to Secure and Label Medications and Insulin in Carts
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling, storage, and security of drugs and biologicals. An unlocked and unattended medication cart was found in the east hall, containing various medications including Talzenna, Gabapentin, and narcotics stored in a lock box. Additionally, the east treatment cart contained an opened Novolog insulin vial that had expired, as well as Tresiba and Lantus insulin pens that were not dated when opened, making it impossible for staff to determine their expiration. Interviews with staff confirmed that medication carts should be locked when unattended and that insulin pens are expected to be dated upon opening, in accordance with facility policy. The facility's policy also requires all medications and biologics to be kept in locked compartments, with scheduled two medications under double lock, but these procedures were not consistently followed.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was fully informed and understood their health status, care, and treatments, specifically regarding the use of psychotropic and antipsychotic medications. Record review revealed that a resident with diagnoses of panic disorder and depression was prescribed multiple psychotropic medications, including duloxetine, risperidone, and trazodone, for depression, resistant depression, and insomnia. However, the electronic medical record did not contain documentation of informed consent for these medications. An administrative nurse confirmed that it was the facility's expectation for staff to obtain psychotropic drug consents prior to medication initiation. The facility's policy required that residents, families, or representatives be informed of the benefits, risks, and alternatives before starting or increasing psychotropic medications. Despite this policy, there was no evidence that informed consent was obtained for the resident's psychotropic and antipsychotic medications.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the state Ombudsman of the discharge or transfer of two residents, as required by facility policy. One resident with severe cognitive impairment was admitted with the goal of discharging to the community and was later discharged accompanied by family, but there was no documentation in the electronic medical record (EMR) that the Ombudsman was notified of this discharge. Social Services staff confirmed that the Ombudsman had not been notified as required. The facility's policy states that the Ombudsman, along with the resident and their representative, must be notified of emergency transfers or discharges. Another resident with a diagnosis of congestive heart failure and moderately impaired cognition was discharged to a critical access hospital. The EMR for this resident also lacked documentation of Ombudsman notification regarding the discharge. Upon request, the facility was unable to provide evidence that the Ombudsman had been notified for either resident. The deficiency was identified through interviews and record reviews, which confirmed the lack of required notifications.
Failure to Provide Required Bathing Assistance for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for activities of daily living (ADLs), including bathing, did not receive the necessary assistance with bathing. The resident had multiple diagnoses, including a cutaneous abscess, COPD, end stage renal disease, a periprosthetic fracture, a Stage 2 pressure ulcer, and anxiety disorder. Documentation in the electronic health record and shower sheets showed that the resident received only one shower during the month of July, with no documented refusals for bathing. The care plan and assessments indicated the resident required staff assistance for bathing and other ADLs, and the facility policy required staff to provide and document bathing or refusals. Observations confirmed that the resident was dependent on staff for mobility and hygiene, and interviews with the resident and staff revealed that the resident had requested showers but did not receive them as scheduled, resulting in the resident having to perform bed baths independently. Staff interviews confirmed that bathing was to be offered at least twice weekly, and refusals were to be documented, but there was no evidence of refusals or consistent bathing provided. This failure to provide necessary ADL care was based on direct observation, record review, and interviews.
Failure to Provide Proper Pressure Ulcer Assessment and Documentation
Penalty
Summary
The facility failed to provide necessary wound care and services in accordance with professional standards of practice for two residents with pressure ulcers. For one resident with multiple diagnoses including COPD, hypothyroidism, and a Stage 3 pressure ulcer, the care plan directed weekly skin assessments and wound care per facility guidelines. However, electronic health records showed that weekly nurse skin assessments were either not performed or lacked required wound measurements and descriptions. There was also a delay in initiating the weekly assessments, and some assessments were missing entirely. The facility did not provide a policy related to pressure ulcer monitoring. Another resident, diagnosed with mild protein-calorie malnutrition and cachexia, was admitted with two Stage 2 and one Stage 3 pressure ulcers. The care plan directed weekly skin assessments but did not specify preventative measures for pressure sores. Physician orders were in place for wound care, but documentation in the electronic medical record lacked evidence of wound measurements, wound bed evaluation, and effectiveness of treatments. Weekly skin assessments and skilled evaluations failed to include measurements or descriptions of the wounds. Interviews with nursing staff and administrative nurses confirmed that wound assessments were supposed to include measurements and detailed descriptions, but these were not documented. Staff were unable to determine the healing status of the wounds due to incomplete documentation. The facility did not provide a policy related to pressure ulcer monitoring, and the lack of proper documentation and assessment placed the residents at risk for complications and delayed healing.
Failure to Maintain Sanitary Storage and Cleaning of Nebulizer Equipment
Penalty
Summary
Facility staff failed to implement sanitary storage and maintenance of nebulizer breathing treatment devices for multiple residents. Observations revealed that nebulizer equipment, including tubing and masks, was left open to the air on chairs and bedside tables, not dated, and sometimes placed on paper towels to dry but not stored in a sanitary manner. In several instances, the equipment was attached to machines sitting on the floor or chair, and there was no evidence of proper cleaning or dating. Residents reported that their nebulizer equipment was regularly left out in this manner, and one resident stated that his nebulizer had not been rinsed out since his admission. Interviews with staff confirmed that nebulizers and oxygen tubing should have been dated, cleaned after each use, and stored in a bag once dry, in accordance with facility policy. However, observations and resident reports indicated that these procedures were not consistently followed. The facility's own policy required cleaning, disassembly, rinsing with sterile or distilled water, air drying, and storage in a zip lock bag, but these steps were not observed in practice for the residents sampled.
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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