Holton Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Holton, Kansas.
- Location
- 1121 W 7th Street, Holton, Kansas 66436
- CMS Provider Number
- 175435
- Inspections on file
- 21
- Latest survey
- August 26, 2025
- Citations (last 12 mo.)
- 39
Citation history
Health deficiencies cited at Holton Health Care Center during CMS and state inspections, most recent first.
The facility did not provide sufficient nursing staff on weekends, as confirmed by PBJ data and administrative staff interviews. The facility also lacked a policy for addressing low weekend staffing, affecting the care of multiple residents.
Two CNAs employed for over a year did not have documented annual performance evaluations, and facility leadership confirmed responsibility for ensuring these were completed. No policy regarding annual performance reviews was provided.
The facility did not employ a full-time certified dietary manager to oversee food and nutrition services for its 34 residents. Instead, a staff member without the required certification or enrollment in a dietary manager program was responsible for these duties, with oversight from an RD who visited monthly. No policy for the dietary manager position was available.
Surveyors found unsanitary conditions in the kitchen and dining area kitchenette, including undated and unlabeled food, dirty equipment, improper dish storage, and pest presence. Staff were unclear about cleaning responsibilities and did not consistently follow facility policies for food safety and sanitation.
Surveyors identified multiple infection control deficiencies, including two residents' respiratory equipment not being stored in a sanitary manner, lack of gown use by laundry staff when sorting soiled linens, and clean laundry being transported uncovered. The facility also failed to maintain documentation for Legionella monitoring due to missing records.
The facility did not implement the required elements of an antibiotic stewardship program, as evidenced by missing documentation in the Infection Control Log, including organism identification, antibiotic duration, and infection details. Administrative staff were unable to provide complete surveillance records, and the antibiotic surveillance binder could not be located, despite a policy requiring systematic tracking.
Two CNAs employed for over a year did not complete the required 12 hours of annual in-service education, including training in dementia care and abuse prevention. Administrative staff confirmed responsibility for tracking these requirements, but no policy was provided to support compliance.
Surveyors found that the facility failed to provide a clean and homelike environment, with equipment left in hallways, a hole in a resident's wall, and flies present in common areas. Staff interviews indicated a lack of awareness and inconsistent adherence to facility policies regarding cleanliness and equipment storage.
Surveyors identified failures in psychotropic medication management, including lack of physician order clarification for an antidepressant, missing documentation of gradual dose reduction for an antipsychotic, absence of required 14-day stop dates on PRN antianxiety medications for two residents, and failure to monitor behaviors for a resident on antidepressants. Staff interviews revealed gaps in knowledge and oversight, and facility policies regarding order clarification and medication review were not followed.
The facility did not complete required Care Area Assessment (CAA) analyses for several residents, with multiple care areas either missing analysis or only documented as 'will continue to monitor.' This failure was confirmed by staff interviews and record reviews, and resulted in incomplete assessments for areas such as functional abilities, nutrition, falls, incontinence, cognitive loss, and pressure ulcers, placing residents at risk for unidentified care needs.
Hazardous areas and materials, such as an unlocked electrical panel closet and a cabinet with chemicals and a razor, were left unsecured despite the presence of cognitively impaired, mobile residents. Additionally, a resident with significant cognitive and physical impairments who regularly smoked did not have a current smoking safety assessment in the EMR, and staff could not provide one when asked.
The facility did not ensure that monthly drug regimen reviews by the consultant pharmacist were properly conducted, documented, or acted upon for several residents. This included failures to attempt or document gradual dose reductions for antipsychotic medications, to clarify orders lacking administration parameters or dosing instructions, and to monitor the continued use of certain medications as recommended. Nursing and administrative staff interviews revealed a lack of follow-through on pharmacy recommendations and missing documentation.
Surveyors found that drugs and biologicals, including insulin and tuberculosis vials, were not labeled with open dates and that multiple expired medications were stored in medication carts and the medication room. Nursing staff confirmed the lack of labeling and the presence of expired medications, which were not removed as required by facility policy.
The facility did not ensure adequate dietary staffing, resulting in only one staff member being present in the kitchen, which led to delays in meal service and challenges in maintaining kitchen cleanliness. Administrative staff were aware of the shortage, and residents experienced late meal distribution compared to posted service times.
A resident who had consented to receive the PCV20 and Influenza vaccines did not receive them, and there was no documentation of administration. Additionally, two other residents were not offered these vaccines, and the facility could not provide records of vaccine offers or declinations. Staff were unable to locate the necessary documentation, despite facility policy requiring all residents to be offered these immunizations.
The facility did not document the offering, administration, or informed declination of the COVID-19 vaccine for three residents, and was unable to provide records or a policy regarding vaccination. Administrative staff confirmed the absence of required documentation and cited staff changes as a possible cause.
Multiple flies were observed in dining, kitchen, and nurse's station areas, with residents and staff reporting persistent fly problems and using fly swatters during meals. Staff interviews revealed a lack of awareness and action regarding pest control, and records showed the last pest control service occurred months earlier, contrary to facility policy requiring regular pest management.
Two residents were not reasonably accommodated when one was repeatedly left without access to her call light, despite care plan instructions, and another was pushed in a wheelchair without foot pedals. Staff confirmed that call lights should be within reach and foot pedals should be used during transport, but these practices were not followed.
A resident was not provided with the required cost information on the Advanced Beneficiary Notice (ABN) for continued skilled services, as the ABN lacked documentation of the cost for ongoing care. This was confirmed by an administrative nurse, and the facility's policy requires that such information be included to inform Medicare beneficiaries of their potential payment liability.
A resident with chronic pain, diabetes, depression, anxiety, muscle weakness, respiratory failure, and vision difficulties did not have a comprehensive care plan addressing key areas such as medication administration, dehydration risk, falls, pressure ulcers, psychosocial well-being, ADLs, activities, vision, and bowel/bladder function. Although assessments and CAAs identified these needs, the care plan lacked specific interventions, and staff confirmed the care plan was incomplete despite having access to it.
A resident with ESRD and dependent on dialysis did not have their care plan updated to include critical information such as the dialysis provider, visit frequency, chair time, or access site details. The EMR also lacked a physician order for dialysis and access site monitoring, and MDS assessments did not document dialysis care. Staff confirmed access to care plans, but the required updates were not made, contrary to facility policy.
A resident with severe cognitive impairment and multiple medical conditions did not have her required level of eating assistance and monitoring documented in her care plan. Staff relied on verbal communication and the Kardex for care instructions, resulting in the resident being left alone and struggling to eat without help.
A resident with COPD and multiple comorbidities had their nebulizer mask left on a bedside table without a sanitary container, contrary to physician orders and facility policy. Staff interviews confirmed that respiratory equipment should be cleaned and stored in a labeled plastic bag, but this was not done, resulting in a failure to maintain proper respiratory care practices.
A resident with end-stage renal disease requiring hemodialysis did not have daily monitoring or documentation of their AV fistula access site for complications, and there was no physician order for dialysis or access site monitoring in the medical record. Nursing staff assessed the site only on dialysis days, contrary to facility policy and care plan requirements.
A resident with PTSD and other mental health diagnoses did not have trauma-based triggers identified or individualized interventions implemented in their care plan. The trauma-informed care assessment was missing from the record, and the care plan lacked direction for PTSD, despite facility policy requiring such measures. Staff interviews confirmed the expectation for trauma-informed care, but documentation and planning did not meet these standards.
A resident was not provided with hospice services, nor was assistance given to transfer the resident to a facility that could arrange for hospice care.
The facility did not maintain or retain daily posted nurse staffing data for the required period, as confirmed by record review and staff interviews. The DON was identified as ultimately responsible for ensuring compliance with the facility's policy, which mandates that nurse staffing information be readily available and kept for at least 18 months.
A resident with a history of cerebral infarction, dementia, and Parkinson's disease fell from her wheelchair and sustained nasal bone fractures when a CNA propelled her without using foot pedals. The resident, who required assistance for mobility, planted her feet and fell forward. The facility's policies emphasized the importance of using appropriate interventions to minimize fall risks, but the failure to use foot pedals directly led to the incident.
A resident experienced a fall in a facility van, resulting in a shoulder injury. Despite complaints of pain and an x-ray showing a shoulder subluxation, staff failed to notify the physician and delayed obtaining an orthopedic referral. The resident's condition worsened, requiring surgical intervention, highlighting a deficiency in timely communication and follow-up procedures.
A resident with dementia and cerebral infarction, dependent on staff for all ADLs, sustained a fracture due to improper transfer by a CNA who did not use the required Hoyer lift. The care plan specified total dependence on staff for transfers, but the CNA transferred the resident without the lift, leading to the injury. The facility's investigation confirmed the CNA's failure to follow the care plan.
A resident experienced a medial subluxation of the right shoulder after her electric wheelchair tipped during a van transport when the seatbelt came unfastened. The facility's transportation policy lacked specific guidelines for wheelchair use and seat belt safety, contributing to the incident.
Failure to Maintain Adequate Weekend Nursing Staff
Penalty
Summary
The facility failed to ensure adequate nursing staff was available every day to meet the needs of all residents, specifically on weekends. A review of the CMS Payroll-Based Journal (PBJ) data for two fiscal quarters showed the facility triggered for excessively low weekend staffing. During interviews, administrative staff confirmed that the facility experienced low staffing levels on weekends during the identified period and acknowledged ongoing struggles with staffing. Additionally, the facility was unable to provide a policy addressing low weekend staffing. These findings were based on a census of 34 residents, with a sample of 12 residents reviewed.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete yearly performance evaluations for two Certified Nurse Aides (CNAs) who had been employed for more than 12 months. A review of staffing records showed that both CNAs did not have documented annual performance evaluations available upon request. During an interview, the administrative nurse confirmed that she and the director of nursing were responsible for ensuring these evaluations were completed annually for direct care staff. Additionally, the facility was unable to provide a policy regarding the requirement for yearly performance reviews.
Lack of Certified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager to oversee food and nutrition services for its 34 residents. Interviews with dietary staff revealed that the current staff member responsible for dietary management was not registered for a dietary manager program and had only been with the facility for a few months. Administrative staff confirmed that there was no certified dietary manager employed and that the individual in the role was not enrolled in the necessary training. The facility relied on a Registered Dietitian who visited monthly, and no policy for the dietary manager position was provided during the review.
Failure to Maintain Sanitary Food Storage and Preparation Standards
Penalty
Summary
Surveyors observed multiple failures to maintain sanitary dietary standards in the facility's kitchen and dining area kitchenette. The dietary manager was not wearing a hair net, and dishes were not stored inverted as required. The steam table and refrigerator had visible dried food and sticky, dirty handles. Inside the refrigerator, several food items, including goulash, mixed vegetables, Cool Whip, sour cream, cucumbers, and cut-up lettuce, were found undated and open. The freezer contained undated and unlabeled hamburger patties, French fries, and chicken strips, all open to air. Sugar and flour bins on the floor were open, undated, and had old food particles and sticky substances. The ice machine in the dining area kitchenette had a dark brown substance along the spout and drain, and a bucket under the kitchen cabinet contained a black substance surrounded by dead bugs. The refrigerator temperature log was outdated, and food items in the refrigerator and freezer were undated and unlabeled. Flies were observed on plates and bowls, and dried eggs were present on the steam table. Interviews with dietary staff revealed a lack of knowledge regarding proper dating and labeling of food, as well as uncertainty about cleaning responsibilities for certain areas and equipment. Staff admitted to being short-staffed and behind on cleaning and temperature logging. The facility's policies required head coverings, regular cleaning, and clear assignment of cleaning tasks, but these were not being followed. These actions and inactions resulted in unsanitary food storage, preparation, and serving conditions, placing residents at risk for food-borne illness.
Infection Control Deficiencies in Respiratory Equipment, Laundry Handling, and Legionella Monitoring
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in several areas. Two residents' respiratory equipment was not stored in a sanitary manner: one resident's nasal cannula was found wrapped around a canister handle in the room, and another resident's nebulizer was left on a bedside table without a clean barrier or sanitary container. Staff interviews confirmed that respiratory equipment should be cleaned, air-dried, and stored in a plastic bag with the resident's name and date, as per facility policy, but this was not followed in these instances. Additionally, the laundry room lacked a gown for staff to wear while sorting dirty laundry, and laundry staff were unaware of the requirement to use a gown. Clean laundry was observed being transported uncovered, with clothing and linens placed on top of the cart, contrary to facility policy that requires clean laundry to be covered and handled in a sanitary manner. The facility was also unable to provide documentation of trend and tracking for Legionella monitoring, as required by their policy, due to a change in staffing and missing records.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement the core elements of an antibiotic stewardship program as part of its infection prevention and control efforts. A review of the Infection Control Log for the period from August 2024 through July 2025 revealed missing documentation, including organism identifications, duration of antibiotic prescriptions, and the specific infections treated. When requested, the facility was unable to provide evidence of tracking antibiotic use, as the binder for antibiotic surveillance could not be located. Administrative staff confirmed the inability to locate more than one month of surveillance records. The facility's own Antibiotic Stewardship policy, revised in June 2023, stated the purpose was to optimize antibiotic use and reduce unnecessary laboratory tests through a systematic approach, but the required documentation and tracking were not in place.
Failure to Ensure Required In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that two Certified Nurse Aides (CNAs), both employed for more than 12 months, completed the required 12 hours of in-service education within the past year. Record review showed that neither CNA had documentation of completing the necessary in-services, including education in dementia care and abuse prevention. During an interview, the administrative nurse confirmed that she and the director of nursing were responsible for ensuring completion of yearly in-service requirements. Additionally, the facility was unable to provide a policy related to required yearly in-services.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to maintain a clean, safe, and homelike environment for its residents. During a walk-through, equipment such as a wheelchair, a Hoyer lift, and two commodes were found stored in the hallway, and a six-inch square hole was noted in the wall behind a resident's bed. Additionally, flies were present in several areas of the facility, including the dining room, kitchen, and nurse's desk, over a period of several days. Interviews with staff revealed that while work orders for repairs were reportedly submitted and maintenance made regular rounds, some staff were unaware of the equipment being left in hallways and the extent of the fly problem. The facility's policy required a safe, clean, and comfortable environment, but these observations and staff statements indicated that the policy was not consistently followed, resulting in an environment that did not meet the required standards for cleanliness and homelikeness.
Deficient Psychotropic Medication Management and Oversight
Penalty
Summary
The facility failed to ensure proper management and oversight of psychotropic and related medications for several residents, as evidenced by multiple deficiencies in physician order clarification, gradual dose reduction (GDR) processes, PRN medication stop dates, and monitoring requirements. For one resident, the physician's order for an antidepressant was not clarified regarding its indication, despite the resident having multiple comorbidities including atrial fibrillation, COPD, and heart failure. Nursing staff and administration acknowledged that clarification should occur when an order is unclear or has an unusual indication, but this was not done in this case. Another resident receiving antipsychotic medication did not have documentation of a GDR attempt or a physician's statement that a GDR was contraindicated, as required by facility policy. Consulting pharmacist recommendations for GDR were not addressed by the physician, and monthly medication reviews were missing for several months. The director of nursing was expected to ensure these reviews were completed and retained, but this did not occur. Additionally, two residents had PRN orders for antianxiety medications (Lorazepam and Ativan) that lacked the required 14-day stop dates. Nursing staff were unaware of this requirement, and the director of nursing was responsible for entering orders and reviewing pharmacy recommendations. Another resident prescribed antidepressant medication did not have documented monitoring of behaviors for anxiety and depression, and staff were unaware that such monitoring was necessary. These failures were contrary to facility policies on order transcription, physician order clarification, and psychotropic drug management.
Failure to Complete Required Care Area Assessment Analyses
Penalty
Summary
The facility failed to complete the Care Area Assessment (CAA) analysis for several residents within the required time frame, as identified through observation, record review, and interviews. Specifically, the CAAs for multiple care areas such as Functional Abilities, Nutritional Status, Falls, Urinary Incontinence and Indwelling Catheter, Psychotropic Drug Use, Cognitive Loss/Dementia, Psychosocial Well-Being, Mood State, Behavioral Symptoms, Activities, Communication, Delirium, and Pressure Ulcer were either missing or lacked proper analysis. In several instances, the documentation only stated 'will continue to monitor' (wctm) instead of providing a comprehensive analysis of the triggered care areas. This was observed in the records of four residents, where the required CAA analysis was not completed as per facility policy and regulatory requirements. Interviews with facility staff confirmed that the MDS assessments were completed off-site by regional staff, and that all triggered CAAs should include a complete analysis with measurable goals to inform the resident's person-centered care plan. The facility's policy emphasized that the Care Area Assessment Summary is essential for developing individualized care plans and that all Care Area Triggers must be addressed. The lack of proper CAA analysis placed residents at risk for unidentified care needs, as the assessments did not adequately address underlying causes, risk factors, or other contributing factors for the identified care areas.
Failure to Secure Hazards and Complete Smoking Assessment
Penalty
Summary
The facility failed to secure hazardous areas and materials, including an unlocked closet containing electrical panels and an unlocked cabinet with a razor and cleaning chemicals, despite the presence of eight cognitively impaired, independently mobile residents. Observations revealed that the electrical panel closet remained unsecured over multiple days, and staff members, including licensed nurses, housekeeping, and maintenance, were unsure or unaware of the requirement to keep these areas locked. Additionally, a shower room cabinet containing potentially dangerous items was found with the padlock open and the key left in the lock, and hazardous products were left out in the open. The facility's own policy required the environment to be as free of accident hazards as possible, but this was not followed. The facility also failed to assess a resident with multiple diagnoses, including hemiparesis, aphasia, bipolar disorder, dysphagia, anxiety, depression, and vascular dementia, for smoking safety. The resident's care plan noted that smoking was a favorite activity, but there was no current smoking assessment in the electronic medical record, and staff could not provide one when requested. The resident was observed requesting to go outside to smoke on several occasions, and staff interviews confirmed that smoking assessments were expected to be completed but were not present for this resident.
Failure to Ensure Proper Drug Regimen Review and Physician Response
Penalty
Summary
The facility failed to ensure that monthly drug regimen reviews (MRRs) by the consultant pharmacist were properly conducted, documented, and acted upon for multiple residents. For one resident with diagnoses including schizoaffective disorder and Parkinson’s disease, the medical record and MDS lacked documentation that a gradual dose reduction (GDR) for antipsychotic medication was attempted or that the physician documented a contraindication. The facility was unable to provide evidence of physician responses to the consultant pharmacist’s recommendations for GDR, and several months of MMRs were missing. Interviews revealed that nursing staff did not address the MMRs, and administrative staff expected the director of nursing to ensure physician review and retention of these records. Another resident with heart failure and atrial fibrillation had orders for as-needed diuretic medication that lacked administration parameters. The consultant pharmacist did not identify or report this irregularity, and the facility could not provide evidence of notification or clarification. Additionally, the consultant pharmacist requested clarification for the indication of an antidepressant, but the facility was unable to provide MMRs for several months. Nursing staff acknowledged that orders should have administration instructions and that unclear orders should be clarified, but did not address the MMRs as required. Further deficiencies included a resident with end-stage renal disease who had an order for Voltaren gel without dosing instructions, which was not identified or reported by the consultant pharmacist. Another resident receiving antidepressant medication did not have evidence of monitoring for continued use as recommended by the consultant pharmacist. Lastly, a resident prescribed lorazepam as needed for anxiety lacked documentation that the consultant pharmacist’s recommendation for a 14-day stop date was acknowledged or acted upon. Staff interviews confirmed a lack of awareness regarding the need for monitoring and stop dates, and administrative staff stated that the director of nursing was responsible for ensuring pharmacy reviews were completed.
Failure to Properly Label and Remove Expired Medications
Penalty
Summary
Surveyors observed that drugs and biologicals in the facility were not consistently labeled or stored according to accepted professional standards. During reviews of medication carts and the medication room, several vials of insulin and tuberculosis medication were found without dates indicating when they were opened. Additionally, some insulin vials were found to be expired. Licensed nursing staff confirmed the lack of open dates and the presence of expired vials, acknowledging that these should have been destroyed. Further inspection revealed multiple expired oral medications, including midodrine, meclizine, furosemide, and cyclobenzaprine, stored in the medication carts for several residents. Nineteen expired over-the-counter medications were also found on supply shelves in the medication room. Staff confirmed the expired status of these medications and removed them from storage. The facility's policy required medications to be stored according to manufacturer recommendations and for the pharmacist to routinely inspect for outdated or discontinued medications, but these procedures were not followed as observed.
Insufficient Dietary Staffing Leads to Delayed Meal Service and Poor Kitchen Sanitation
Penalty
Summary
The facility failed to provide sufficient staff with the appropriate competencies and skill sets to carry out the functions of the Food and Nutrition Services. On the day of the survey, only one dietary staff member was present in the kitchen, who reported being unable to keep the kitchen clean, cook food, and do dishes due to understaffing. Two other dietary staff members were unavailable on Mondays and Tuesdays, and although there were applicants, no new hires had been made. Administrative staff acknowledged awareness of the staffing shortage. Observations showed that approximately ten residents were waiting in the dining room past the posted breakfast service time before trays were distributed. The facility did not provide a policy for dietary staffing.
Failure to Administer and Document Flu and Pneumonia Vaccines
Penalty
Summary
The facility failed to administer the Pneumococcal Conjugate Vaccine (PCV20) and Influenza vaccine to a resident who had provided signed consent and was within the required vaccination date range. The resident's electronic medical record and consent form confirmed eligibility and consent for both vaccines, as well as receipt of educational information. However, there was no evidence in the clinical record that either vaccine had been administered, and the facility was unable to provide documentation of administration upon request. Additionally, the facility did not offer the PCV20 and Influenza vaccines to two other residents, and there was no documentation or evidence that these vaccines were offered or declined. Administrative staff and nursing staff were unable to locate records of vaccine administration or signed declinations, citing staff changes as a possible reason for the missing information. The facility's own policy required that all residents be offered these immunizations, but this was not followed for the residents in question.
Failure to Document COVID-19 Vaccination Status and Informed Declinations
Penalty
Summary
The facility failed to offer or obtain informed declinations or a physician-documented contraindication for the COVID-19 vaccination for three residents. Record reviews for these residents showed no documentation in the electronic medical record (EMR) under the Immunization tab indicating that the COVID-19 vaccine was offered, declined, historically administered, or that a physician-documented contraindication was present. Upon request, the facility was unable to provide any records of consent, declination, or physician-documented contraindication for these residents. Interviews with administrative staff confirmed that documentation for the vaccines given or signed declinations could not be found. Staff changes were cited as a possible reason for the missing information, and the facility was also unable to provide a policy related to the administration of the COVID-19 vaccination. This lack of documentation and policy resulted in a failure to ensure proper vaccination status tracking for the affected residents.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of flies in resident and staff areas. On several occasions, flies were seen in the dining area, nutrition kitchenette, nurse's station, and kitchen, including on plates and bowls. Residents were observed swatting flies before meals, and one resident reported that her table partner brings a fly swatter to meals due to the persistent presence of flies. Staff interviews confirmed the ongoing issue, with a Certified Medication Aide noting that flies enter through the patio, especially when wheelchair residents take time to go outside to smoke. Further interviews revealed a lack of awareness and action regarding the fly problem among nursing staff and administration. A Licensed Nurse stated she was unaware of a pest control program specifically for flies, and the Administrative Nurse indicated she was not aware of the issue, believing maintenance should address it. The facility's pest control policy requires a written agreement with an outside pest service for regular, comprehensive pest control, but the last documented pest control service was several months prior, and no evidence was provided of ongoing or targeted efforts to address the fly infestation.
Failure to Ensure Call Light Accessibility and Safe Wheelchair Transport
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents. One resident, who had diagnoses including hypertension, dementia, anxiety, major depressive disorder, and emphysema, and was assessed as having moderately impaired cognition, was found on two separate occasions with her call light clipped to the privacy curtain at the bottom of her bed, out of her reach. Her care plan specifically directed staff to ensure the call light was within her reach and to encourage her to use it for assistance. Staff interviews confirmed that call lights should always be within residents' reach and should not be clipped to the privacy curtain. Additionally, another resident was observed being pushed by staff into the dining room without foot pedals attached to her wheelchair. Staff interviews confirmed that foot pedals should be applied when pushing a resident in a wheelchair. The facility did not provide a policy regarding accommodation of needs. These actions and inactions resulted in a failure to meet the residents' needs as outlined in their care plans and facility expectations.
Failure to Provide Cost Information on ABN for Skilled Services
Penalty
Summary
The facility failed to provide required cost information on the Advanced Beneficiary Notice (ABN) CMS form 10055 for a resident receiving skilled services. Specifically, the ABN for one resident did not include documentation regarding the cost for continued skilled services ending on 7/24/25. This omission was identified during a review of records for three residents sampled for Medicare Liability Notices out of a total sample of twelve. An administrative nurse confirmed that the ABN should have included the cost to properly notify the resident. The facility's policy, dated 11/05/24, requires timely notices about Medicare eligibility and coverage, including informing beneficiaries of their potential payment liability.
Failure to Develop Comprehensive Care Plan for Resident with Multiple Needs
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with multiple complex medical conditions, including chronic pain, diabetes mellitus, depression, anxiety, muscle weakness, respiratory failure, and vision difficulties. Despite documentation in the resident's electronic medical record and Minimum Data Set (MDS) assessments indicating the need for assistance with activities of daily living (ADLs), toileting, bed mobility, and bathing, the care plan lacked direction for several critical areas such as medication administration, risk of dehydration, falls, pressure ulcers, psychosocial well-being, ADLs, activities, vision difficulties, and bowel and bladder function. The Care Area Assessments (CAAs) identified these needs and recommended follow-up or monitoring, but these were not translated into specific, measurable care plan interventions. Staff interviews confirmed that all nursing staff had access to the resident's care plan and Kardex, and that the director of nursing was responsible for ensuring the care plan was developed and updated. However, the care plan did not reflect the resident's individualized care needs as identified in the assessments and CAAs. The facility's policy required the development and implementation of a comprehensive, person-centered care plan with measurable objectives and time frames, but this was not followed for the resident in question.
Failure to Update Care Plan for Dialysis-Dependent Resident
Penalty
Summary
The facility failed to revise the care plan for a resident with end-stage renal disease (ESRD) who was dependent on dialysis. The resident's care plan did not include essential information such as the dialysis provider, frequency of visits, days of the week, chair time, or the location and assessment frequency of the access site. Additionally, the electronic medical record lacked a physician order for dialysis and monitoring of the access site. The Minimum Data Set (MDS) assessments did not document that the resident had received dialysis during the observation periods. The care plan only included general monitoring instructions and did not specify individualized dialysis-related care needs. Interviews with facility staff confirmed that all nursing staff had access to the resident's care plan and Kardex, and that the director of nursing was responsible for ensuring the care plan was current and person-centered. Despite this, the care plan was not updated to reflect the resident's dialysis requirements. The facility's policy required comprehensive, person-centered care plans to be developed and revised by the interdisciplinary team after each assessment, but this was not followed for the resident in question.
Failure to Document and Provide Required Eating Assistance
Penalty
Summary
The facility failed to ensure that a resident's care plan accurately reflected the required assistance and monitoring needed during meals. The resident in question had multiple diagnoses, including severely impaired cognition, and was documented as needing supervision or touching assistance with eating, as well as partial to full assistance with other activities of daily living. Despite these needs, the resident's care plan only addressed nutritional goals and meal monitoring, lacking specific instructions regarding the level of assistance and monitoring required while eating. Observations showed the resident eating alone in the dining room without staff present, struggling to access food on her plate. Interviews with staff revealed that information about residents' assistance needs was communicated verbally or through the Kardex, rather than being clearly documented in the care plan. Some staff were unsure if or how the required assistance should be reflected in the care plan, and the facility's policy required a comprehensive, person-centered care plan based on assessment findings.
Nebulizer Mask Not Stored Sanitarily After Use
Penalty
Summary
Staff failed to ensure that a resident's nebulizer mask was stored in a sanitary manner, as required by facility policy and physician orders. The resident, who had diagnoses including hypertension, dementia, anxiety, major depressive disorder, and emphysema with COPD, required assistance with most activities of daily living and had a care plan specifying that her nebulizer should be rinsed after each use and kept dry. Despite these instructions, observations showed the nebulizer was left on the bedside table without a clean barrier or sanitary container. Interviews with facility staff, including a Certified Medication Aide, a Licensed Nurse, and an Administrative Nurse, confirmed that respiratory equipment should be cleaned, air dried, and stored in a labeled plastic bag when not in use. The facility's own policy also directed staff to keep delivery devices covered in a plastic bag. However, these procedures were not followed for the resident in question, resulting in a failure to provide safe and appropriate respiratory care.
Failure to Monitor and Document Dialysis Access Site
Penalty
Summary
The facility failed to provide appropriate monitoring and documentation for a resident with end-stage renal disease who required hemodialysis. Specifically, the nursing staff did not monitor the resident's arteriovenous (AV) fistula access site for complications at least daily, nor did they document the presence of thrill and bruit every day as required. The resident's care plan included instructions for monitoring and reporting signs of infection, insufficiency, bleeding, and peripheral edema, but there was no physician order in the electronic medical record for dialysis or for monitoring the access site. Additionally, the Minimum Data Set (MDS) assessments did not document that the resident received dialysis during the observation periods. Licensed nursing staff reported assessing the access site only before and after dialysis sessions and documenting these assessments on the dialysis communication sheet, but not on non-dialysis days. The facility's dialysis policy required that residents needing dialysis receive services consistent with professional standards and the care plan. Administrative staff confirmed that a physician's order for dialysis and daily monitoring of the access site was expected but not present in the resident's record.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to identify trauma-based triggers and implement individualized interventions for a resident with a diagnosis of post-traumatic stress disorder (PTSD). The resident's electronic medical record documented multiple mental health diagnoses, including PTSD, panic disorder, major depressive disorder, anxiety, and bipolar disorder, with a Brief Interview of Mental Status (BIMS) score indicating intact cognition. Despite these diagnoses, the resident's care plan did not include any direction or interventions specific to PTSD, and the trauma-informed care assessment was missing from the resident's record. The Psychotropic Drug Use Care Area Assessment also lacked analysis related to trauma-informed care. Interviews with facility staff confirmed that the social services department was responsible for completing trauma-informed care assessments and that residents with PTSD should have care plans to prevent re-traumatization. However, the care plan for this resident only noted a favorite activity and did not address past trauma or provide personalized interventions. The facility's own policy required culturally competent, trauma-informed care that minimized triggers and re-traumatization, but this was not reflected in the resident's documentation or care planning.
Failure to Arrange Hospice Services
Penalty
Summary
The facility failed to arrange for the provision of hospice services for a resident or assist the resident in transferring to a facility that would provide such services. This deficiency indicates that the necessary steps were not taken to ensure the resident received appropriate hospice care or was transferred to a setting where hospice services could be arranged.
Failure to Maintain and Retain Nurse Staffing Data
Penalty
Summary
The facility failed to maintain and retain daily posted nurse staffing data for the required 18-month period. During a review of staffing sheets covering a specific timeframe, the facility was unable to provide the requested documentation. Interviews with administrative staff revealed that the management team had assigned responsibility for posting and retaining daily nursing hours, with the DON ultimately accountable for compliance with the regulation. The facility's policy required that nurse staffing information be readily available and maintained in the Human Resources Department for at least 18 months or as required by state law. However, the required documentation was not available for review as mandated.
Failure to Use Wheelchair Foot Pedals Leads to Resident Fall
Penalty
Summary
The facility failed to prevent an avoidable accident involving a resident who was being propelled in a wheelchair without the use of foot pedals. The incident occurred when a Certified Nurse Aide (CNA) was pushing the resident, who had a history of cerebral infarction, dementia, and Parkinson's disease, down the hallway. The resident, who was dependent on staff for wheelchair mobility, planted her feet, leaned forward, and fell out of the wheelchair, resulting in nasal bone fractures. The resident's medical records indicated she had impaired cognition and poor safety awareness, requiring moderate to maximum assistance with mobility. Her care plan highlighted an increased risk for falls due to confusion, balance problems, and poor safety awareness. Despite these documented needs, the CNA did not utilize the foot pedals on the wheelchair, which were present but not in use at the time of the incident. The facility's policies on falls and assistive devices emphasized the importance of implementing relevant interventions to minimize fall risks and ensuring the appropriateness of devices for resident conditions. However, the failure to use foot pedals during wheelchair propulsion directly led to the resident's fall and subsequent injuries.
Removal Plan
- The facility updated R1's care plan to include foot pedal usage.
- The facility started educating nursing staff on using foot pedals during staff wheelchair propulsion.
- CNA M received a corrective action.
Failure to Report Abnormal X-ray Findings and Delay in Treatment
Penalty
Summary
The facility failed to ensure that a resident received care consistent with the standards of practice when staff did not report abnormal x-ray findings and did not obtain timely physician involvement for treatment. The resident, who had a history of essential hypertension and bone density disorders, experienced a fall in the facility's van, resulting in a shoulder injury. Despite the resident's complaints of shoulder pain and an x-ray revealing a medial subluxation of the shoulder joint, the staff did not notify the resident's physician of the x-ray results. The resident continued to experience shoulder pain affecting their activities of daily living, yet the facility delayed obtaining a referral to an orthopedic specialist. Although an order for a referral was obtained, the staff did not follow up to ensure an appointment was made until several weeks later. This delay resulted in the resident not receiving an orthopedic consultation until nearly two months after the initial injury, at which point the orthopedic physician identified a more severe injury requiring surgical intervention. The facility's inaction and lack of timely communication with healthcare providers placed the resident in immediate jeopardy. The resident's medical records lacked evidence of proper notification to the physician regarding the x-ray results and ongoing pain. Interviews with facility staff revealed a lack of consistent follow-up procedures for referrals and physician notifications, contributing to the delay in addressing the resident's medical needs.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to provide safe activities of daily living (ADLs) care to a resident, resulting in a fracture across the right distal femur. The resident, who had diagnoses of dementia and cerebral infarction, was dependent on staff for all ADLs. Her care plan specified the use of a Hoyer lift for transfers, indicating total dependence on staff. However, a Certified Nurse Aide (CNA) transferred the resident without the lift, using a one-to-one method, which was inconsistent with the care plan. The incident occurred when CNA M transferred the resident from her bed to a wheelchair without using the Hoyer lift, despite the care plan's directive. The CNA's witness statement revealed that she cradled the resident during the transfer, which was not the approved method. This action led to the resident sustaining a bruise and subsequent fracture, which was discovered later that day. The facility's investigation confirmed that the CNA did not follow the care plan, and she was placed on the do not return list. Interviews with other staff members indicated that the resident was typically transferred using a Hoyer lift with the assistance of two staff members. The facility's policy required staff to provide care in accordance with the care plan, which was not followed in this instance. The failure to adhere to the care plan and use the appropriate transfer method directly contributed to the resident's injury.
Failure to Prevent Accident During Resident Transport
Penalty
Summary
The facility failed to prevent an accident involving a resident during a van transport to a medical appointment. On the specified date, the resident's seatbelt came unfastened, causing her electric wheelchair to tip towards the right, resulting in her right arm and shoulder hitting the lift gate. This incident led to a medial subluxation of the resident's right glenohumeral joint, as confirmed by an x-ray taken two days later. The resident involved had a history of essential hypertension and disorders of bone density and structure in the right shoulder. She required varying levels of assistance with activities of daily living (ADLs) due to impairments in her upper and lower extremities. Despite having intact cognition, the resident was at an increased risk for falls and injuries due to impaired balance and mobility limitations, as documented in her care plan and assessments. The facility's transportation policy lacked specific guidelines for wheelchair use, seat belt safety, and accident prevention. During the incident, the transportation staff had secured the resident's wheelchair with anchors and a lap band, but the seatbelt became unbuckled, leading to the accident. The facility was unable to determine how the seatbelt came unfastened, and the incident was not addressed in the facility's transportation policy.
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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