Kansas Soldiers Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Dodge, Kansas.
- Location
- 200 Custer, Unit 98, Fort Dodge, Kansas 67801
- CMS Provider Number
- 175513
- Inspections on file
- 19
- Latest survey
- September 2, 2025
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Kansas Soldiers Home during CMS and state inspections, most recent first.
The facility did not provide proper care for pressure ulcers and failed to prevent new ulcers from developing. Surveyors found that a resident did not receive consistent assessment, monitoring, or treatment for pressure ulcers, and that preventive measures were not adequately implemented for those at risk.
Surveyors observed that dietary staff failed to consistently follow proper hand hygiene and glove use during food preparation and serving. Staff were seen discarding soiled gloves into uncovered trash cans, donning new gloves without hand washing, and handling multiple food items and equipment with the same gloves, contrary to facility policy. These actions resulted in unsanitary food handling conditions.
The facility did not ensure that kitchen garbage and refuse were properly maintained and disposed of, as observed when trash cans inside lacked lids and outside bins were found with lids open. Staff were unable to account for the missing or open lids, which was not in accordance with the facility's waste disposal policy requiring sealed containers.
The facility did not consistently implement an infection prevention and control program, failing to use Enhanced Barrier Precautions for residents with catheters, wounds, or artificial openings. Staff were observed providing catheter care without required PPE or aseptic technique, and there was no signage or accessible PPE in resident areas. Administrative nurses were unaware of updated CMS requirements, and infection tracking was not performed in real time. The facility also lacked a water management program and policy to prevent Legionella.
The facility did not implement an effective antibiotic stewardship program, failing to track and trend antibiotic use for several residents who received antibiotics for urinary tract infections. Nursing staff confirmed that antibiotic use was not consistently documented or reviewed for appropriateness, and the infection control policy did not address these deficiencies.
The facility did not complete annual performance evaluations for five CNAs employed for over a year, as shown by employee file reviews and staff interviews. No signed evaluations were found for these CNAs, and the facility could not provide a policy on annual evaluations, despite an expectation for full compliance.
Staff failed to administer medications according to professional standards, with multiple residents receiving late medications and staff not verifying orders using the electronic MAR. Nursing staff acknowledged overdue medications and the absence of a liberalized medication pass policy, while administrative staff confirmed expectations for timely administration were not met.
A medication error rate of 52.94% was identified when a certified medication aide administered multiple scheduled medications to a resident significantly later than the prescribed time, based on incorrect training about what constitutes a late dose. The facility did not have a liberalized medication pass policy, and the nurse confirmed that medications were expected to be given on time.
A resident with major depressive disorder and intact cognition was prescribed a daily antidepressant without a documented informed consent form. Staff interviews confirmed the absence of the required consent, and the facility could not provide a policy on informed consent for psychotropic medications.
A resident with COPD and atrial fibrillation, who was cognitively intact but had impaired mobility, was required to wear a seatbelt on a motorized wheelchair that he could not independently release. Staff and documentation failed to assess or address the seatbelt as a restraint, and no care plan or physician order was in place. The resident reported he was told to wear the seatbelt without being given a choice, and staff confirmed no safety assessment or documentation existed for seatbelt use.
A resident with depression and anxiety was routinely administered antipsychotic and antidepressant medications without documented evidence of behaviors warranting antipsychotic use, unsuccessful nonpharmacological interventions, or a risk versus benefit analysis. Staff and pharmacy consultant interviews confirmed the lack of appropriate diagnosis and documentation, and the facility could not provide a policy on psychotropic medication use.
A resident with depression, anxiety, and pain continued to receive Celebrex despite a consultant pharmacist's recommendation to consider discontinuation due to elevated creatinine and low hemoglobin. The physician declined the recommendation without providing a rationale, and staff interviews revealed uncertainty about documentation requirements for pharmacy recommendations, contrary to facility policy.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that the facility did not consistently follow established protocols for pressure ulcer prevention and care, resulting in inadequate interventions for residents with existing ulcers and insufficient preventive actions for those at risk.
Failure to Maintain Sanitary Food Preparation and Handling Practices
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the kitchen, specifically in the preparation and serving of food. During a kitchen tour, three barrel-type trash cans were found without lids, and staff were unable to locate one of the missing lids. Dietary staff were seen discarding soiled gloves into an uncovered trash can and then donning new gloves without washing their hands. Additionally, staff were observed handling multiple food items and kitchen equipment with the same pair of gloves, including touching plates, bread, and containers, without changing gloves or washing hands in between tasks. The Certified Dietary Manager confirmed that staff are expected to provide food in a safe and healthy environment and that annual food handling training is provided. The facility's hand washing policy requires frequent hand washing, especially after handling soiled equipment and during food preparation, to prevent cross-contamination. However, observations revealed that staff did not consistently follow these procedures, resulting in unsanitary food handling practices.
Improper Disposal and Maintenance of Kitchen Garbage and Refuse
Penalty
Summary
The facility failed to properly maintain and dispose of kitchen garbage and refuse, as observed during two separate inspections. During a kitchen tour, three barrel-type trash cans were found without lids, and staff were only able to locate lids for two of them. Additionally, an inspection of the outside garbage bins revealed that two out of eight bins had their lids open, despite calm weather conditions. The Certified Dietary Manager was unable to provide a reason for the open lids at the time of observation. According to the facility's waste disposal policy, all garbage is to be disposed of daily and placed in sealed containers outside the premises.
Failure to Implement Infection Control Program and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain a consistent infection prevention and control program, as evidenced by the lack of implementation of Enhanced Barrier Precautions (EBP) for residents with indwelling catheters, wounds, and surgical artificial openings. Observations revealed that staff did not use required personal protective equipment (PPE) such as gowns during high-contact care, and there was no signage or accessible PPE in or around the rooms of affected residents. Staff members, including a CNA, were unaware of EBP requirements and did not follow aseptic technique when providing catheter care, such as cleaning the outlet tube with an alcohol wipe after emptying the drainage bag. Administrative nurses confirmed they were not aware of the updated CMS directive for EBP and acknowledged that infection control logs were not completed or reviewed in a timely manner to track and trend infections as they occurred. Additionally, the facility did not have a documented water management program to mitigate the risk of Legionella and other waterborne pathogens, nor did it have a policy addressing the prevention of Legionella. The infection control program documentation was incomplete, lacking evidence of surveillance systems to identify and track infections in real time. The facility's failure to implement these infection control measures and maintain proper documentation had the potential to contribute to the spread of infections among residents, particularly those with indwelling devices or wounds.
Failure to Monitor and Document Antibiotic Use
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program that included an antibiotic stewardship program with protocols for antibiotic use and a system to monitor antibiotic use. Review of facility records showed that, out of a census of 51 residents and a sample of 15, seven residents received antibiotics during the review period. However, the infection control surveillance log did not document tracking or trending of antibiotic use for residents with recurrent urinary tract infections who received gentamycin bladder irrigations or for those who received amoxicillin for urinary tract infection. The log lacked documentation for these cases, and the administrative nurse confirmed that antibiotic use was not consistently tracked or trended, and that the July log was incomplete. Interviews with administrative nursing staff revealed that antibiotics were prescribed by physicians, but the facility did not conduct formal reviews or audits to determine the appropriateness or effectiveness of antibiotic use. The administrative nurse stated that documentation was typically completed at the end of each month and not tracked daily. Additionally, the facility's infection control policy did not address the identified areas of concern related to antibiotic stewardship and monitoring.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for five Certified Nurse Aides (CNAs) who had been employed for over 12 months, as identified through interviews and review of employee files. The review of records showed that none of the five CNAs had a performance evaluation signed by management within the required 12-month period. During an interview, administrative staff confirmed the expectation for 100 percent compliance with annual evaluations, but the facility was unable to provide a policy regarding annual performance evaluations. The census at the time was 51 residents, and the lack of evaluations was observed for CNAs with varying lengths of employment, some dating back several years.
Failure to Administer Medications According to Professional Standards
Penalty
Summary
The facility failed to ensure that medication administration services met professional standards of quality. Observations revealed that a Certified Medication Aide (CMA) prepared medications for residents without verifying orders using the electronic Medication Administration Record (MAR). Multiple residents' names were highlighted in pink on the computer screen, indicating overdue medications. When questioned, the CMA did not provide an explanation and walked away. A Licensed Nurse (LN) confirmed that 14 residents had overdue medications scheduled for 07:30 AM, and acknowledged that the facility did not have a liberalized medication pass policy. The LN stated that it was difficult to administer medications on time to independent residents and that staff did not have time to locate them for timely administration. Further observations showed that another CMA administered 07:30 AM scheduled medications to a resident at 09:52 AM, resulting in 18 oral and one inhaled medication being given late, with the resident declining a nasal spray. Interviews with administrative nursing staff confirmed that medications were expected to be administered on time and that the facility did not have a policy allowing for flexible medication pass times. The facility's policy required adherence to the right drug, dose, time, route, indication, and documentation, but staff training and practice did not align with these standards, as evidenced by the late administration and lack of MAR verification.
High Medication Error Rate Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required. During the survey, 35 medication administration opportunities were observed, resulting in 22 errors and a calculated error rate of 52.94 percent. One resident's July Medication Administration Record/Treatment Administration Record showed 18 oral medications, two nasal sprays, and one inhaled medication scheduled for administration at 07:30 AM. Observation revealed that a Certified Medication Aide administered the 07:30 AM medications at 09:52 AM, outside the one-hour window before or after the scheduled time, resulting in 18 late oral medications and one late inhaled medication; the resident declined the nasal spray. The Certified Medication Aide reported being trained by another aide who instructed that medications were only considered late after 10:00 AM. The Administrative Nurse confirmed the scheduled time and stated there was no liberalized medication pass policy in place. Facility policy requires medications to be administered at the right time, among other standards.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain an informed consent form for a psychotropic medication prescribed to a resident diagnosed with major depressive disorder. The resident, who demonstrated intact cognition as evidenced by BIMS scores of 15 and 14 on recent assessments, was receiving bupropion HCl daily for depression. Documentation in the resident's care plan and assessment area noted the use of antidepressant medication and the need to monitor for adverse effects, but there was no evidence of a signed informed consent for the psychotropic medication in the resident's electronic medical record. Observations confirmed the resident's daily activities and use of assistive devices, while interviews with facility staff revealed that only two other residents had consent forms on file for psychotropic medications. The administrative nurse acknowledged the absence of an informed consent for this resident, and a consultant confirmed that all psychotropic medications should have consent forms, noting that the necessary form had been sent to the administrative nurse previously. The facility was unable to provide a policy on informed consent for psychotropic medications.
Failure to Assess and Document Use of Wheelchair Seatbelt as Physical Restraint
Penalty
Summary
Staff failed to ensure an environment free from physical restraints for a resident who used a motorized wheelchair with a seatbelt. The resident, who had diagnoses including COPD and atrial fibrillation and demonstrated intact cognition, was observed wearing a seatbelt that he could not independently release. Documentation in the electronic health record, care plan, and physician orders did not address the use of the seatbelt, nor was there evidence of an assessment of the resident's ability to release it. Staff interviews confirmed that the resident was required to wear the seatbelt, was unable to remove it on his own, and that no seatbelt safety assessment or care plan was in place for any resident. The resident reported he was told he had to wear the seatbelt and did not have a choice in the matter. Observations showed the seatbelt remained engaged for extended periods, and staff were responsible for applying and releasing it. Staff also indicated that not all residents required seatbelts and that it was policy for residents using electric wheelchairs to wear them, but there was no clear process for evaluating whether a seatbelt constituted a restraint. The facility's policy required a practitioner's order for a restraint, but no such order or documentation was present for the seatbelt. The lack of assessment, documentation, and resident choice led to the use of a physical restraint without proper justification or oversight.
Failure to Document Indication and Rationale for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medication, specifically an antipsychotic, had an appropriate clinical indication or a documented physician rationale for its continued use. The resident had diagnoses of depression and anxiety, with cognitive impairment documented over time. Despite the use of antipsychotic and antidepressant medications, there was no evidence in the medical record of behaviors that would warrant antipsychotic use, nor was there documentation of unsuccessful nonpharmacological interventions or a risk versus benefit analysis for the continued use of the antipsychotic. The resident's care plan included general instructions for monitoring and consulting with the pharmacy and physician, but lacked specific documentation of attempts at gradual dose reduction or alternative therapies. Review of the medication regimen and pharmacy consultant notes did not identify a clear diagnosis or justification for the antipsychotic medication, and staff interviews confirmed uncertainty regarding the appropriateness of the diagnosis for the medication. The facility was unable to provide a policy on psychotropic medication use. These actions and omissions resulted in the resident being at risk for adverse effects associated with unnecessary psychotropic medication use.
Failure to Document Physician Rationale for Pharmacy Recommendation
Penalty
Summary
The facility failed to act upon a consultant pharmacist's recommendation during the monthly medication regimen review for a resident with diagnoses of depression, anxiety, and pain. The pharmacist identified elevated creatinine levels and low hemoglobin in the resident's laboratory results and recommended considering discontinuation of Celebrex due to potential renal or gastrointestinal involvement. The physician responded to the recommendation by declining to discontinue the medication but did not provide a rationale for this decision, as required by facility policy. Documentation in the resident's electronic health record and care plan confirmed ongoing administration of Celebrex despite the pharmacist's concerns. Interviews with facility staff revealed a lack of understanding regarding the requirement for physicians to document a rationale when not following pharmacy recommendations. The administrative nurse and pharmacy consultant both indicated that a rationale was only necessary for gradual dose reductions of psychotropic medications, not for other pharmacy recommendations. The facility's drug regimen review policy, however, required an appropriate response from physicians concerning previous drug regimen review recommendations or drug irregularities, which was not met in this case.
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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