Holiday Resort Of Salina
Inspection history, citations, penalties and survey trends for this long-term care facility in Salina, Kansas.
- Location
- 2825 Resort Drive, Salina, Kansas 67401
- CMS Provider Number
- 175423
- Inspections on file
- 25
- Latest survey
- September 2, 2025
- Citations (last 12 mo.)
- 43
Citation history
Health deficiencies cited at Holiday Resort Of Salina during CMS and state inspections, most recent first.
A resident with HIV and multiple comorbidities did not receive the prescribed antiretroviral medication, Biktarvy, during their stay because the facility failed to coordinate payment approval with the pharmacy and did not act on information about available grant funding, despite repeated notifications and documentation of the medication's necessity.
Two residents did not receive their prescribed medications due to failures in transcribing physician orders and lack of follow-through by facility staff. One resident missed HIV medication for 13 days because the facility did not respond to pharmacy requests for payment approval, despite being informed of available grant funding. Another resident did not receive a diabetes medication for four weeks because the order was not entered into the facility's records, and there was no documentation of discontinuation. These actions were not in accordance with the facility's medication administration policy.
Dietary staff did not follow standardized recipes or use measured ingredients when preparing pureed meals for a resident on a texture-modified diet, instead blending foods with unmeasured liquids and without recipe reference, contrary to facility policy and placing the resident at risk for inadequate nutrition.
Dietary staff did not fully cover their hair and facial hair while preparing and serving food, and unsanitary conditions were observed in the kitchen, including buildup of grease and fuzz on equipment. These actions were not in compliance with facility policies requiring thorough hair restraint and regular cleaning of food service areas.
The facility's QAA Committee did not adequately identify or address several deficiencies, including improper administration and documentation of antipsychotic medication for a resident with a language barrier, lack of communication devices, failure to notify the Ombudsman during a hospital transfer, absence of comprehensive care plans, missed bathing for dependent residents, unsafe smoking and transfer practices, unposted nursing staffing, lack of non-pharmacological interventions, failure to notify a physician of abnormal blood sugars, improper diet preparation, poor kitchen hygiene, lack of collaboration with hospice, failure to offer Prevnar 20 vaccination, and maintenance issues with the walk-in freezer.
Several residents were not offered the pneumococcal PCV20 vaccine, nor was there documentation of consent, declination, or physician contraindication, as required by CDC guidance. Staff interviews confirmed the absence of a system to determine vaccine eligibility or track offers and refusals, and the facility's policy was outdated and not followed.
The facility did not maintain the kitchen walk-in freezer in safe working order, as the door had persistent ice buildup and would not close properly. Staff had to regularly remove ice to keep the door shut, and food was previously discarded due to temperature issues. Multiple contractors were unable to fix the problem, and no preventative maintenance policy was provided.
A resident was administered psychotropic medications without a clear clinical indication or was given medications that restrained their ability to function, resulting in a deficiency related to medication management.
A resident with multiple chronic conditions and significant care needs was discharged without receiving the required Bed Hold Notification or notification to the State Ombudsman Agency. The facility's records did not show that these notifications were provided as required by policy, and staff confirmed the omission.
A deficiency was cited when a resident's care plan did not include all necessary needs, lacked measurable timetables, and failed to specify actionable steps, resulting in incomplete planning and documentation for the resident's care.
A resident with severe cognitive impairment and Spanish as a preferred language did not have individualized communication methods implemented. Staff were often unable to communicate effectively, leading to the resident's agitation and frustration. The care plan lacked a communication focus, and no communication tools or policies were in place to support the resident's needs.
Two residents who required staff assistance with bathing did not consistently receive showers as scheduled, despite care plans and facility policy specifying their preferences. Documentation and observations showed missed showers and lack of refusal documentation, resulting in poor hygiene for both residents.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment did not meet safety standards, and there was a lack of appropriate measures and oversight to protect residents from potential harm.
A resident diagnosed with dementia did not receive the necessary treatment and services appropriate for their condition, as required by regulatory standards.
A resident with diabetes, depression, and dementia had multiple blood glucose readings outside the physician-ordered parameters, but the physician was not notified as required. Staff interviews and record reviews confirmed that the necessary notifications were not documented, despite facility policy and care plan directives.
Two residents receiving hospice care did not have care plans that clearly documented the coordination between facility and hospice staff, including the frequency of hospice visits and the specific care and supplies provided. Staff interviews revealed uncertainty about hospice involvement, and the care plans lacked required details as outlined in the facility's hospice policy.
The facility did not consistently post the required daily nurse staffing information, with observations showing either outdated or missing reports on multiple occasions. Staff confirmed that posting the current day's staffing report was their responsibility, but this was not reliably completed as per facility policy.
A resident experienced a loss of dignity when a CNA failed to return after turning off the call light, leaving the resident incontinent for two hours. The resident, dependent on staff for care due to medical conditions, felt humiliated. Staff interviews revealed that inadequate care was due to staffing shortages, which was acknowledged by the facility's administrative nurse.
The facility failed to provide consistent bathing and showering for three residents, leading to a deficiency in care. A resident with spinal stenosis and severe obesity, another with diabetes and heart failure, and a third with severe cognitive impairment were all affected. Despite being scheduled for regular showers, they received inadequate hygiene care over a month. Staff interviews revealed that lack of staffing was a significant factor, with some staff expressing concern over the inadequate care provided.
Failure to Provide Physician-Ordered HIV Medication Due to Lack of Coordination and Approval
Penalty
Summary
A deficiency occurred when the facility failed to provide a physician-ordered medication, Biktarvy, to a resident diagnosed with HIV, among other conditions such as COPD, osteoporosis, and multiple fractures. The resident's electronic health record and care plans documented the need for Biktarvy, and the physician's order specified daily administration. Despite this, the medication was not available or administered throughout the resident's stay, as evidenced by repeated nursing notes indicating the medication was 'waiting on delivery' or 'on order' for an extended period. The pharmacy received the order for Biktarvy and attempted to process it, but insurance denied coverage. The pharmacy then contacted the facility for payment approval, as the medication cost exceeded the threshold requiring facility authorization. Multiple emails were sent to the facility requesting approval, but the facility did not respond in a timely manner. Administrative staff acknowledged the lack of response and indicated that the process for obtaining pre-approval or alternative funding was not completed prior to the resident's admission, despite being informed by the discharging hospital that grant funding was available to cover the medication. Interviews with facility staff confirmed awareness of the resident's need for Biktarvy and the existence of grant funding, but no action was taken to secure the medication or utilize the available funding. The facility's own medication administration policy required medications to be administered as ordered and for refusals or issues to be documented and communicated, but these procedures were not followed. As a result, the resident did not receive the prescribed HIV medication during their stay.
Failure to Transcribe and Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to ensure that physician orders for medications were correctly transcribed and administered to two residents upon admission, resulting in significant medication errors. One resident, with diagnoses including HIV, COPD, osteoporosis, and multiple fractures, did not receive the prescribed HIV medication, Biktarvy, for 13 days during their stay. Documentation in the Medication Administration Record (MAR) and nurses' notes repeatedly indicated that the medication was 'waiting on delivery' or 'on order,' but the medication was never provided. The pharmacy had attempted to obtain payment approval from the facility due to the high cost of the medication, but did not receive a response from the facility's administrative nursing staff, despite multiple emails and assurances that a response would be given. Social services staff had been informed by the discharging hospital that a grant would cover the medication, and this information was shared with the facility's administrative nurses, but no further action was taken to secure the medication for the resident. A second resident, admitted with diagnoses including protein-calorie malnutrition, diabetes mellitus, atrial fibrillation, and cerebral infarction, did not receive the prescribed diabetes medication, Mounjaro, for four weeks. The hospital discharge orders included Mounjaro, but the medication was not transcribed into the facility's Medication Administration Record (MAR) or electronic medical record (EMR), and there was no documentation that the order had been discontinued. The pharmacy consultant confirmed that the medication list sent by the facility did not include Mounjaro, and nursing staff verified that the physician's order for Mounjaro had not been discontinued and should have been continued at the facility. The facility's own medication administration policy required that medications be administered in accordance with written physician orders and that all administration, refusals, or holds be documented in the MAR. In both cases, the failure to correctly transcribe and follow through on physician orders led to residents not receiving essential medications as prescribed, with documentation and interviews confirming the lapses in communication and follow-through among facility staff and between the facility and the pharmacy.
Failure to Use Standardized Recipes for Pureed Diet Preparation
Penalty
Summary
Dietary staff failed to follow standardized recipes when preparing pureed diets for a resident requiring texture-modified meals. Observations showed that staff blended various food items, such as a barbecued rib patty, vegetables, potatoes, and a lemon bar, without referencing or using measured amounts of liquids as specified in facility recipes. The staff used unmeasured amounts of meat juice and milk to achieve the desired consistency, and there was no evidence that recipes were consulted during preparation. The facility's policy required the use of standardized recipes for all mechanically altered foods to ensure quality, flavor, and nutritive value. However, during the preparation of pureed meals, staff did not adhere to these requirements, as confirmed by the absence of recipes at the preparation stations and the lack of measured ingredients. This failure placed residents at risk for inadequate nutrition due to improper preparation of pureed diets.
Failure to Maintain Sanitary Food Preparation and Service Practices
Penalty
Summary
Dietary staff failed to adhere to proper hair restraint protocols while preparing and serving food. Observations revealed that staff members wore beard nets and hair nets that did not fully cover their facial hair or the back of their hair. One staff member was seen entering the kitchen without a hair net, only putting it on after retrieving it from a closet. These actions were in direct violation of the facility's Hair Restraint policy, which requires all hair and facial hair to be fully covered by appropriate restraints during food production, dishwashing, and serving. Additionally, the kitchen environment was found to be unsanitary, with a stove hood covered in brownish gray fuzz and convection ovens with fan and motor assemblies coated in brownish grease and gray fuzz. The facility's Cleaning Rotation policy mandates regular cleaning and sanitation of kitchen equipment and areas, with tasks assigned and documented by staff. The Certified Dietary Manager confirmed that both dietary and maintenance staff are responsible for cleaning, and verified the presence of the unsanitary conditions during the survey.
Multiple Deficiencies in Quality Assessment and Resident Care
Penalty
Summary
The facility failed to ensure its Quality Assessment and Assurance Committee effectively identified and addressed multiple deficient practices affecting resident care and facility operations. Deficiencies included the lack of clinical rationale and documentation for administering antipsychotic medication to a resident with a language barrier, failure to notify the Ombudsman and provide a bed hold policy during a hospital transfer, and the absence of a comprehensive care plan addressing communication, dementia care, and antipsychotic use. Additionally, the facility did not provide communication devices for a Spanish-speaking resident, failed to provide bathing as care planned for dependent residents, and did not ensure a safe smoking environment or use a gait belt for safe transfers, resulting in a fall. Further deficiencies were observed in the failure to post daily nursing staffing, provide non-pharmacological interventions before administering antipsychotic medication, notify a physician of out-of-range blood sugars, and follow a pureed diet recipe. The facility also did not maintain proper kitchen hygiene, including staff not covering facial hair, unclean equipment, expired supplements, and unlabeled food. There was a lack of collaboration between facility and hospice care plans, failure to offer Prevnar 20 vaccination, and maintenance issues with the walk-in freezer door. QAA meetings were held monthly and included the medical director, but these ongoing issues indicate the committee did not adequately identify or address these areas of deficient practice.
Failure to Offer and Document Pneumococcal Vaccination per CDC Guidance
Penalty
Summary
The facility failed to offer, obtain informed declination, or secure physician-documented contraindications for the pneumococcal PCV20 vaccination for several residents, as required by the latest CDC guidance. Record reviews for five residents revealed that none had documentation indicating they were offered the PCV20 vaccine, had received it, or had signed a consent or declination form. Additionally, there was no evidence that the facility or resident representatives had been provided with or signed the necessary consent or declination forms for the vaccine. Interviews with facility staff confirmed that there was no definitive system in place to determine resident eligibility for the PCV20 vaccine or to track whether residents had been offered or declined the vaccination. The facility's existing policy referenced offering pneumococcal vaccinations and obtaining vaccination histories at admission, but it did not reflect current CDC recommendations for PCV20, nor was it being followed in practice. As a result, eligible residents were not consistently assessed or documented for pneumococcal vaccination status.
Failure to Maintain Walk-In Freezer in Safe Operating Condition
Penalty
Summary
The facility failed to ensure that the kitchen walk-in freezer was maintained in a safe operating condition. Observations revealed that the freezer door had significant ice buildup on the frame, making it difficult to close completely. Maintenance staff acknowledged ongoing issues with the freezer door, including frequent ice accumulation and the need for staff to manually remove ice to keep the door shut. It was also noted that about a year prior, food stored in the freezer had to be discarded due to the freezer's temperature being out of range. Dietary staff confirmed that the ice buildup had been a persistent problem, requiring regular intervention to maintain functionality. Consultant staff reported that multiple local contractors had been contacted to repair the freezer, but none were able to fully resolve the issue, and documentation of these attempts was not available. The facility had also experienced related issues, such as a leaking roof that contributed to water entering the freezer and the freezer door coming off at one point, which was subsequently repaired and sealed. Despite ongoing efforts to address the problem, including contacting an out-of-town contractor, the freezer remained in disrepair. Additionally, the facility was unable to provide a preventative maintenance policy when requested.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear clinical indication or were given medications that limited their functional abilities, contrary to regulatory requirements.
Failure to Provide Bed Hold and Ombudsman Notification at Discharge
Penalty
Summary
The facility failed to provide a Bed Hold Notification and notification to the State Ombudsman Agency regarding the discharge of a resident with multiple complex medical conditions, including hemiplegia, hemiparesis following a stroke, chronic kidney disease, diabetes mellitus, obesity, nicotine dependence, lymphedema, polyarthritis, COPD, and chronic respiratory failure with hypoxia. The resident required significant assistance with activities of daily living, used a wheelchair for mobility, and was frequently incontinent of urine. The resident's medical record documented several discharges and entries, but lacked evidence of a Bed Hold Notification for one of the discharges, as required by facility policy. Social Services staff confirmed responsibility for providing discharged residents with the facility's bed hold policy and notifying the State Ombudsman Agency, but acknowledged that this was not done for the resident in question during certain hospitalizations. The facility's written policy required that a notice specifying the duration of the bed-hold policy be issued to the resident or their representative upon transfer to a hospital or therapeutic leave, but this was not consistently followed in this case.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain all necessary elements to ensure comprehensive care as required.
Failure to Provide Alternative Communication Methods for Non-English Speaking Resident
Penalty
Summary
The facility failed to implement alternative communication methods for a resident with severe cognitive impairment whose preferred language was Spanish. The resident had diagnoses including dementia, Alzheimer's disease, major depressive disorder, and diabetes mellitus, and required substantial staff assistance for activities of daily living. The resident's care plan did not include an individualized area addressing communication needs. Observations showed that staff were unable to effectively communicate with the resident, as most did not speak Spanish and resorted to gestures or told the resident to speak English. The lack of Spanish-speaking staff and absence of communication tools led to repeated instances where the resident became agitated, anxious, or cried out in Spanish without being understood. Interviews with staff confirmed that communication barriers existed, with staff acknowledging they often did not know what the resident wanted or was saying. Staff reported that the resident would become frustrated and agitated when not understood, and medication was administered to manage this agitation. Although an application to assist with communication was mentioned, it had not been downloaded or made available to staff. The facility was unable to provide a policy for communication, further indicating a lack of structured approach to address the resident's communication needs.
Failure to Provide Consistent Bathing Services
Penalty
Summary
The facility failed to provide consistent bathing services for two residents who required staff assistance with bathing. One resident with multiple sclerosis, heart failure, and dementia was care planned to receive assistance with washing her back and hair during showers twice per week, as per her preference. However, bathing records showed that she did not receive a shower for a 13-day period, and there was no documentation of her refusing showers during that time. Observations confirmed that her hair was greasy, and she reported not receiving showers as scheduled. Staff interviews indicated that the resident did not refuse her baths, and the facility's policy required that baths and showers be performed and documented according to resident preferences. Another resident with intellectual disabilities and vascular dementia, who was dependent on staff for showering, was scheduled to receive showers twice a week in the evenings. Documentation showed significant gaps between showers, with the last recorded shower followed by a period of five days without a shower, and the resident was observed with greasy hair. The facility's policy required that showers be provided and documented as scheduled to maintain hygiene and dignity, but this was not consistently followed for these residents.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the occurrence of accidents. The deficiency centers on the lack of appropriate measures to identify and eliminate hazards, as well as insufficient oversight to safeguard residents from potential harm.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
A deficiency was identified regarding the provision of appropriate treatment and services to a resident who displays or is diagnosed with dementia. The report indicates that the facility failed to ensure that a resident with dementia received the necessary care and services tailored to their diagnosis and needs. Specific actions or omissions by facility staff led to this deficiency, as the required interventions or supports for the resident's dementia were not provided as expected.
Failure to Notify Physician of Out-of-Parameter Blood Glucose Readings
Penalty
Summary
The facility failed to notify the physician when a resident's blood glucose levels were outside of the parameters specified in the physician's orders. The resident in question had diagnoses of diabetes mellitus, major depressive disorder, and dementia, and required substantial assistance with daily activities. The care plan and physician's order directed staff to monitor blood glucose before meals and at bedtime, and to notify the physician if the blood glucose was greater than 300 mg/dL or less than 70 mg/dL. Despite this, the Medication Administration Record documented multiple instances where the resident's blood sugar readings were either above 300 mg/dL or below 70 mg/dL, and there was no evidence that the physician was notified as required. Staff interviews confirmed that the process for notifying the physician involved documenting the notification in a progress note, but review of the records did not show that such notifications occurred for the out-of-parameter blood glucose readings. The facility's policy required immediate consultation with the physician for significant changes in a resident's status, but this was not followed in the documented cases. The failure to notify the physician of abnormal blood glucose levels constituted a deficiency in ensuring the resident's drug regimen was free from unnecessary drugs and that care was provided according to physician orders.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure a coordinated plan of care for two residents who were receiving hospice services. For one resident with diagnoses including dementia, Alzheimer's disease, major depressive disorder, and diabetes mellitus, the care plan directed staff to coordinate with hospice and maintain comfort, but did not specify when hospice staff would be present or what care and supplies hospice would provide. The resident's care plan also lacked details on the specific roles and responsibilities of hospice staff in relation to the facility staff. Another resident, with chronic kidney disease, diabetes mellitus, overactive bladder, chronic lymphocytic leukemia, polyarthritis, Crohn's disease, and chronic pain syndrome, had a care plan that instructed staff to coordinate with hospice for comfort and care. However, this care plan also lacked information about the frequency of hospice staff visits, the specific disciplines involved, and the medications and supplies provided by hospice. Interviews with facility staff revealed uncertainty about the frequency of hospice nurse and aide visits, and the care plan did not reflect the actual coordination occurring between the facility and hospice provider. The facility's own hospice policy required that a significant change in status assessment be initiated and the plan of care updated to reflect coordination with hospice services. Despite this, the care plans for both residents did not include essential details about hospice involvement, such as visit schedules and supplies, resulting in a lack of clear coordination between the facility and hospice providers.
Failure to Consistently Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to consistently post the actual scheduled hours worked for nursing staff directly responsible for resident care per shift, as required by their policy. Observations revealed that on one occasion, the Daily Nurse Staffing Report posted was for the previous day, and on another occasion, there was no staffing report posted for part of the day. Interviews with staff confirmed that it was the night shift's responsibility to ensure the current day's staffing report was posted, but this was not done as required. The facility's policy specified that the number of licensed nurses and unlicensed nursing personnel providing direct care should be posted daily for each shift, but this was not consistently followed.
Failure to Maintain Resident Dignity Due to Staffing Issues
Penalty
Summary
The facility failed to protect a resident's dignity when a Certified Nurse's Aide (CNA) responded to the resident's call light, turned it off, and promised to return shortly but did not come back for two hours. During this time, the resident, who had a bowel movement, was left incontinent in bed, leading to feelings of humiliation and anger. The resident, who had intact cognition and was dependent on staff for most activities of daily living due to spinal stenosis, diabetes mellitus, and severe obesity, expressed that this incident made him feel humiliated and angry as he expected proper care for the money he paid. Observations and interviews with staff revealed a lack of adequate care due to staffing shortages, with multiple staff members, including a Certified Medication Aide (CMA), a CNA, and a Licensed Nurse (LN), acknowledging the issue. The facility's Resident Rights Policy emphasized the right to a dignified existence, which was not upheld in this instance. The administrative nurse expressed regret over the incident, acknowledging that a resident's dignity should always be maintained and care provided timely.
Inconsistent Bathing and Showering for Residents
Penalty
Summary
The facility failed to provide consistent bathing and showering for three residents, leading to a deficiency in care. Resident 1, who had diagnoses including spinal stenosis, diabetes mellitus, and severe obesity, was dependent on staff for most activities of daily living. Despite being scheduled for showers twice a week, Resident 1 only received four showers over a month, resulting in an unclean appearance and personal dissatisfaction. Similarly, Resident 3, who required moderate assistance for bathing, also received only four showers in the same period, leading to feelings of being dirty and smelly. Resident 11, with severe cognitive impairment and hemiplegia, was also affected by the facility's failure to provide scheduled bathing. This resident was dependent on staff for all personal hygiene needs and was scheduled for showers twice a week but only received three showers in a month. Observations noted an oily hair condition and a distinct odor of urine, indicating a lack of proper hygiene care. Interviews with facility staff, including a Certified Medication Aide, a Certified Nurse's Aide, and a Licensed Nurse, revealed that the lack of staffing was a significant factor contributing to the deficiency in care. Staff members expressed concern over the inadequate care provided to residents, with some stating that showers were not being completed as scheduled. An Administrative Nurse suggested that the issue might be related to documentation rather than the actual provision of care, indicating a need for staff training on proper documentation procedures.
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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