Kaw River Care And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Edwardsville, Kansas.
- Location
- 750 Blake Street, Edwardsville, Kansas 66111
- CMS Provider Number
- 175219
- Inspections on file
- 20
- Latest survey
- June 25, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Kaw River Care And Rehab during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and physical limitations developed a second-degree burn on the left arm and shoulder of unknown origin after exhibiting increased pain, resistance to care, and unusual behavior. Staff were unable to fully assess or document the resident's complaints, and the injury was discovered only after multiple attempts to provide care. The facility's investigation did not determine the cause of the burn, and documentation and assessment practices were found to be inconsistent.
Staff failed to follow transfer protocols and use a gait belt for a resident with hemiplegia, resulting in a fall and hip fracture, and did not implement required fall prevention interventions for another resident with cognitive impairment and a history of falls, as nonskid strips were missing from the bathroom. Communication lapses among staff contributed to these deficiencies.
The facility did not consistently provide structured or varied activities for residents on weekends, as shown by activity calendars and confirmed by resident council members and staff interviews. Residents reported limited engagement, often only watching TV or reading, and staff acknowledged not leading activities on weekends, contrary to facility policy.
The facility did not complete required annual performance reviews for several CNAs and a CMA who had been employed for over a year, and lacked a policy for nurse aide performance evaluations. Documentation confirming performance reviews within the past 12 months was not available for these staff members.
Surveyors found that three opened insulin pens were not dated, an unlocked and unattended medication cart was left in a hallway, and expired vaccines were stored in the medication refrigerator without proper temperature log documentation. Administrative and licensed staff confirmed these practices did not follow facility policy for medication security and labeling.
A resident with severe cognitive and physical impairments, including an indwelling catheter, was repeatedly observed with their catheter collection bag visible from the hallway and not covered by a dignity bag. Staff interviews confirmed that the expectation was to cover catheter bags or place them out of view, but this was not done, contrary to facility policy on resident dignity.
Two residents received PRN Ativan orders for anxiety without the required 14-day stop date, despite facility policy and staff acknowledgment of this requirement. One resident had severe cognitive impairment and multiple diagnoses, while the other had intact cognition but significant physical and behavioral needs. Nursing staff and administration confirmed that the omission of the 14-day limit was contrary to established procedures.
A resident with significant mobility impairments and a history of falls was transferred by a single CNA without a gait belt, contrary to the care plan requiring two-person assistance. The resident fell, sustained a hip fracture, and required hospitalization and surgery. Despite the major injury, administrative staff did not report the incident to the State Agency, citing the resident's initial communication and delayed onset of severe pain.
The facility did not provide required bed hold notices to a resident with multiple chronic conditions upon hospitalization, nor did it provide written transfer notifications to another resident with severe cognitive and physical impairments during multiple unplanned discharges to an acute hospital. Administrative staff confirmed these notifications were not consistently given, contrary to facility policy.
A resident with complex medical needs, including a tracheostomy and decreased mobility, did not have a care plan that included staff instructions for ADL care and functional assistance. Staff interviews revealed that CNAs lacked access to the care plan and relied on nurses for special instructions, while administrative staff discussed interventions in meetings but did not ensure comprehensive, measurable objectives for ADL support were documented.
A resident with multiple complex medical conditions and a history of repeated falls did not have their care plan consistently updated with new interventions after each fall. Despite documented incidents where the resident was found on the floor and sometimes unable to recall the event, the care plan was not revised in accordance with facility policy, and staff communication about interventions was inconsistent.
A resident with hemiparesis following a stroke did not receive restorative range of motion (ROM) exercises or therapy, despite a care plan indicating the need to maintain or improve mobility and prevent contractures. Staff and administration confirmed the absence of a restorative therapy program, and the resident reported never having received ROM exercises since admission.
The facility did not include the daily census number on posted nurse staffing sheets for an extended period, as required. This omission was confirmed during a review of records and through interviews with administrative staff, who acknowledged the deficiency.
The facility did not ensure a clear and documented communication process with hospice providers for two residents receiving hospice care. Care plans lacked evidence of collaboration, and staff were uncertain about accessing hospice information, supplies, and care details. This resulted in incomplete documentation and potential gaps in care coordination between the facility and hospice services.
A resident with cognitive impairments made racially derogatory remarks towards a CNA, leading to a loud verbal altercation in the dining room. The CNA responded unprofessionally, drawing attention from other staff and residents, which violated the facility's policy on treating residents with dignity and respect.
Failure to Protect Cognitively Impaired Resident from Injury of Unknown Origin
Penalty
Summary
A cognitively impaired resident with a history of vascular dementia, cerebrovascular disease, and significant physical and cognitive limitations sustained a second-degree burn of unknown origin to the left arm and shoulder. The resident was known to be at high risk for falls, had impaired decision-making, and required substantial assistance with activities of daily living. In the days leading up to the injury, the resident became increasingly combative, resistant to care, and complained of pain, but refused interventions. Documentation in the medical record noted pain complaints and resistance to care, but lacked specific details about the location of pain or the interventions offered. On the day the injury was discovered, multiple CNAs attempted to provide care but were met with combative behavior and were only able to change the resident's brief, leaving other clothing unchanged due to resistance. The resident remained in bed on the left side for an extended period, which was unusual for his baseline activity level. Staff noted the resident was not acting like himself, was in visible distress, and repeatedly complained of pain, particularly in the left arm and leg. When staff were finally able to reposition the resident, they discovered significant skin sloughing and blistering on the left arm, consistent with a second-degree burn. The injury was not present the previous day, and the resident was subsequently sent to the hospital for evaluation. The facility's investigation was unable to determine the cause of the burn. Environmental checks, review of meals and linens, and staff interviews did not reveal any source of hot fluids or environmental hazards. The investigation also noted inconsistent documentation and assessment practices, with staff failing to fully assess or document the resident's complaints of pain and changes in behavior. The lack of thorough assessment and documentation, combined with the resident's cognitive impairment and inability to communicate the cause of the injury, resulted in the resident sustaining a significant injury of unknown origin.
Failure to Ensure Safe Transfers and Implement Fall Interventions
Penalty
Summary
A deficiency occurred when staff failed to provide a safe environment free from accident hazards for a resident with hemiplegia and a history of falls. The resident required two-person assistance and the use of a gait belt for transfers, as documented in her care plan following a previous fall with major injury. Despite these directives, a new CNA transferred the resident alone and without a gait belt after the resident insisted on immediate assistance. During the transfer, the resident lost her balance and fell, resulting in a hip fracture that required hospitalization and surgical intervention. The CNA later acknowledged feeling pressured and not following established protocols due to the resident's insistence and a busy shift. Additionally, the facility failed to implement and maintain new fall prevention interventions for another resident with multiple diagnoses, including cognitive impairment, muscle weakness, and a history of repeated falls. The care plan for this resident included the placement of nonskid strips in the bathroom as a fall intervention following a previous incident. However, observations on multiple occasions revealed that the nonskid strips were not present in the resident's bathroom, indicating that the intervention was not carried out as planned. Interviews with staff revealed inconsistencies in how fall interventions were communicated and implemented. Some CNAs reported relying on nurses for updates about new interventions, while others referenced a communication board, but there was uncertainty about how effectively this information was shared. The facility's own policy required prompt investigation and documentation of accidents and incidents, but the lack of follow-through on care plan interventions and proper transfer protocols contributed to preventable falls and injuries for both residents.
Inconsistent Weekend Activities Provided for Residents
Penalty
Summary
The facility failed to provide consistent and varied weekend activities for its residents, as evidenced by a review of the activity calendars for March, April, and May 2025, and interviews with residents and staff. While the calendars listed some activities such as hydration carts, daily chronicles, activity carts, movie matinees, TV worship, and occasional special events, resident council members reported that activities rarely occurred on weekends and lacked variety even on weekdays. Residents stated that they typically watched TV or read during weekends and expressed a desire for more interactive group activities led by staff. Staff interviews further revealed that activities staff allowed residents to "do their own thing" on weekends, leaving the activity cart available but not actively facilitating activities. A CNA confirmed that she did not conduct activities on weekends when she worked. The facility's own policy required the provision of activities on all days, including weekends and holidays, but this was not consistently implemented, resulting in a lack of structured and engaging activities for residents during weekends.
Failure to Complete Annual Nurse Aide Performance Reviews
Penalty
Summary
The facility failed to complete the required annual performance reviews for nurse aides and a certified medication aide, as evidenced by the lack of documentation for performance evaluations within the past 12 months for multiple staff members who had been employed for over a year. A review of the staffing list showed that several CNAs and a CMA did not have records of a performance review being conducted in the last 12 calendar months. Additionally, the facility did not have a policy in place for conducting nurse aide performance evaluations. This deficiency was confirmed through record review and staff interview, with administrative staff unable to locate evidence of completed performance reviews as required.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed that three opened insulin pens on the east hall nurse medication and treatment cart were not dated when opened, as required by facility guidelines. Licensed staff confirmed the lack of dating, which is necessary to ensure insulin pens are disposed of 28 days after opening. Additionally, the west hall nurse treatment cart was found unlocked and unattended, with administrative staff confirming that medication carts should not be left unsecured when not in the direct presence of licensed staff. A licensed nurse was located nearby but not attending the cart at the time. Further observations revealed that the medication room refrigerator contained expired medications, including two vials of Prevnar 23 vaccine and three vials of Moderna COVID-19 vaccine, as well as missing temperature log documentation for the month. Administrative staff verified that expired medications should be removed from use and that insulin pens should be dated upon opening. Facility policies require all drugs and biologicals to be stored securely, with expired or discontinued medications removed from use, and medication carts locked when unattended.
Failure to Provide Dignity Bag for Catheter Collection Bag
Penalty
Summary
Staff failed to respect a resident's right to dignity by not providing a dignity bag to cover the resident's indwelling catheter collection bag. The resident, who had multiple complex medical conditions including multiple sclerosis, seizures, respiratory failure, pneumonia, pressure ulcers, and required a gastrostomy tube and supplemental oxygen, was completely dependent on staff for all activities of daily living. The resident's care plan directed staff to keep the catheter bag below the level of the bladder and to provide routine catheter care, but did not include instructions to use a dignity bag to cover the catheter collection bag. On multiple occasions, surveyors observed the resident lying in bed with the catheter collection bag visible from the hallway and not covered by a dignity bag. Interviews with nursing staff and administration confirmed that the expectation was for catheter bags to be covered with a dignity bag or placed on the side of the bed away from the doorway, both when the resident was in and out of the room. The facility's policy emphasized the right of residents to a dignified existence and to be treated with respect, but this was not followed in the observed instances.
Failure to Include 14-Day Stop Date on PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that as-needed (PRN) antianxiety medication orders for two residents included a required 14-day time limit, as mandated for psychotropic medications. For one resident with multiple diagnoses including psychotic disorder, major depressive disorder, epilepsy, and vascular dementia, the electronic medical record showed an active PRN order for Ativan (lorazepam) without a 14-day discontinuation date. This resident had severely impaired cognition and required significant assistance with daily activities. The care plan noted the use of high-risk medications and directed staff to limit dosages and durations, but the PRN Ativan order did not comply with the 14-day requirement. A second resident, with diagnoses including hemiplegia following a stroke, major depressive disorder, and insomnia, also had a PRN Ativan order lacking a 14-day stop date. This resident had intact cognition but required substantial to total assistance with functional abilities and had a history of behavioral issues. The care plan directed staff to administer medications as ordered and monitor for side effects, but the PRN order for Ativan did not include the necessary time limitation. Interviews with nursing staff and administration confirmed that the responsibility for ensuring correct order entry, including the 14-day stop date for PRN psychotropic medications, rested with the nurse taking off the order. Both the facility's policy and staff statements acknowledged the requirement for a 14-day limit on PRN psychotropic medications, but this was not implemented for the two residents in question.
Failure to Report Major Injury Fall to State Agency
Penalty
Summary
The facility failed to report a resident's fall that resulted in a major injury to the State Agency as required. The resident involved had a history of hemiplegia and hemiparesis following a stroke, insomnia, delusions, major depressive disorder, a displaced closed fracture, and a history of falls. The resident required substantial assistance for activities of daily living and had a care plan directing staff to use a gait belt and provide two-person assistance for transfers. Despite these directives, the resident experienced a fall during a transfer when only one CNA assisted, and a gait belt was not used. Following the fall, the resident complained of pain and was later transported to the hospital, where a hip fracture was diagnosed and surgical intervention was performed. Documentation in the electronic medical record indicated that the resident had expressed pain and discomfort after the fall, and the incident was discussed by the interdisciplinary team. The CNA involved reported feeling pressured by the resident to proceed with the transfer alone and acknowledged not following the required protocol for assistance. Despite the severity of the injury and the circumstances of the fall, administrative staff did not report the incident to the State Agency. The rationale provided was that the resident was able to communicate what had happened and initially reported only mild pain, with the extent of the injury not becoming apparent until the following day. The facility's policy required prompt investigation and reporting of accidents and incidents, but this protocol was not followed in this case.
Failure to Provide Bed Hold Notices and Written Transfer Notifications
Penalty
Summary
The facility failed to provide required documentation and notifications related to bed-hold policies and transfer notifications for two residents who were hospitalized. For one resident with multiple chronic conditions, including COPD, respiratory failure, diabetes, anxiety disorder, and congestive heart failure, the facility did not provide a Bed Hold Notice to the resident or her representative upon transfer and admission to the hospital on two separate occasions. The resident's medical record and care plan indicated significant dependence on staff for daily activities and medication management, but there was no documentation that the bed hold policy or notice was given at the time of her hospitalizations. Another resident, who had severe cognitive impairment, multiple sclerosis, seizures, respiratory failure, pneumonia, pressure ulcers, and required a G-tube and supplemental oxygen, was transferred multiple times to an acute hospital with a return anticipated. The facility failed to provide the required written notification of transfer to this resident or his representative for each of these facility-initiated discharges. The resident's records documented repeated unplanned discharges and re-entries, but there was no evidence that the mandated notifications were provided as required by policy. Interviews with administrative staff confirmed that the facility had not been consistently providing bed hold notices or written notifications of transfer as required. The facility's own policies stated that residents and their representatives should be informed of the bed hold policy prior to transfer and receive written notification of transfer or discharge, but these procedures were not followed in the cases reviewed.
Failure to Develop and Implement Comprehensive ADL Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with multiple complex medical conditions, including hypertension, a history of stroke, tracheostomy, and gastrostomy status. The resident's medical record and assessments indicated a need for partial to moderate assistance with activities of daily living (ADLs) such as toileting, bathing, and personal hygiene, as well as decreased functional abilities due to impaired strength and mobility. However, the care plan only included directions for medication administration and communication during care, lacking specific staff instructions for ADL care and functional assistance. Interviews with staff revealed that certified nurse aides did not have access to the care plan and relied on nurses to communicate any special instructions. Administrative staff reported that interventions following incidents such as falls were discussed in meetings and added to the care plan, but there was no evidence that comprehensive, measurable objectives and time frames for ADL support were included for this resident. The facility's policy required individualized, person-centered care plans with measurable objectives and time frames, but this was not followed for the resident in question.
Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to revise the comprehensive care plan to include appropriate interventions for falls for a resident with a significant history of falls and multiple complex medical conditions. The resident's diagnoses included overactive bladder, psychotic disorder, substance dependence, delusional disorders, major depressive disorder, epilepsy, mood affective disorder, anxiety, hypertension, lack of coordination, muscle weakness, repeated falls, cognitive communication deficit, reduced mobility, flaccid hemiplegia, pain, and vascular dementia. The resident had severely impaired cognition, required substantial to maximum assistance with activities of daily living, and was frequently incontinent. The Minimum Data Set documented that the resident had experienced a fall with injury. Despite multiple documented falls, including incidents where the resident was found on the floor in his room, sometimes unable to recall the event or how he ended up on the floor, the care plan was not consistently updated to include new interventions after each fall. In several instances, the event notes specifically stated that the care plan lacked an intervention for the fall. Only after one fall was an intervention (placement of nonskid strips) documented, but subsequent falls did not result in additional care plan updates. Staff interviews revealed that nurses were expected to add interventions to the care plan after each fall, and that interventions were communicated during staff huddles. However, a CNA reported not having access to the care plan and relied on nurses for special instructions. The facility's policy required an individualized, comprehensive, person-centered care plan with measurable objectives and time frames to address each resident's needs. However, the care plan for this resident did not reflect timely or consistent updates following each fall event, as required by policy. This lack of care plan revision following repeated falls constituted a deficiency in the facility's care planning process.
Failure to Provide Restorative Range of Motion Services
Penalty
Summary
A resident with a history of stroke resulting in hemiparesis, along with other medical conditions such as seizures, hypertension, and major depressive disorder, was identified as having limited physical mobility and functional limitations. The resident's care plan documented the need to maintain or improve mobility and prevent complications related to immobility, including contractures. Despite these documented needs, the resident did not receive any physical or occupational therapy, and there was no evidence of restorative range of motion (ROM) exercises being provided. The resident reported never having received ROM exercises or therapy since admission and expressed a desire for such interventions to prevent contractures. Observations confirmed that the resident's affected limb was not being actively exercised, and interviews with nursing staff and administration revealed that the facility did not have a restorative aide or an active restorative therapy program at the time. Staff indicated that exercises would typically be directed by the therapy department, but no such services were in place. The facility's own policy required that residents with limited ROM receive appropriate treatment and services, but this was not implemented for the resident in question.
Failure to Include Census on Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that the daily posted nurse staffing data included the facility census, as required. During a review of daily posted staffing sheets covering the period from January 1, 2024, to March 31, 2025, it was found that the census number was missing from all reviewed postings. The facility had a census of 37 residents at the time of the survey, and a sample of 12 residents was included in the review. Administrative staff confirmed that the staffing coordinator was responsible for posting the daily staffing sheet and acknowledged that the census number had not been included on these postings until the issue was recently identified.
Failure to Ensure Effective Communication and Documentation with Hospice Providers
Penalty
Summary
The facility failed to implement an effective communication process between the facility and the hospice provider for residents receiving hospice services. For one resident with multiple diagnoses including cerebrovascular accident, respiratory failure, congestive heart failure, diabetes, and major depressive disorder, the care plan documented the need for palliative care and outlined general care goals. However, the care plan did not include evidence of collaboration or communication with the hospice provider. Staff interviews revealed uncertainty about the contents of hospice binders, the process for obtaining supplies, and the accessibility of care plans, indicating a lack of clear procedures for documenting and sharing hospice-related information. Another resident with diagnoses of congestive heart failure, COPD, depression, and hypertension had a hospice care plan that directed staff to adjust care according to the resident's changing abilities and to work cooperatively with the hospice team. Despite this, the care plan lacked essential details such as hospice contact information, visit frequency, supplies and medications provided by hospice, and any durable medical equipment. The resident's hospice order and plan of care were available in the facility, but staff interviews again highlighted gaps in knowledge about the communication process and access to relevant information. The facility's policy allowed for contracting hospice services and outlined the need for coordination and communication, but in practice, there was no documented process ensuring that information was consistently shared and accessible to all staff. This deficiency was observed through record reviews, staff interviews, and direct observation, and affected at least two residents who were receiving hospice care.
Failure to Maintain Resident Dignity During Verbal Altercation
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident, identified as R1, who was admitted with a diagnosis of encephalopathy, cognitive communication deficit, amnesia, and acute kidney failure. R1 exhibited moderate cognitive impairment and had a history of verbal aggression and refusal of care. On the day of the incident, R1 was approached by a CNA for a shower, which R1 refused. Later, in the dining room, R1 made racially derogatory remarks towards CNA O, which led to a verbal altercation between them. CNA O responded to R1's racial slurs by raising her voice and engaging in a loud exchange with R1, which drew the attention of other staff and residents. Despite being advised by Social Services X to remove herself from the situation, CNA O continued to express her frustration loudly, repeating the derogatory term used by R1 multiple times. This incident was witnessed by other staff members, who provided statements about the altercation. The facility's policy on resident rights emphasizes treating residents with dignity and respect, particularly those with cognitive impairments. However, the actions of CNA O in this situation did not align with these guidelines, as she engaged in a confrontation with R1 instead of addressing the behavior professionally. This failure to manage the situation appropriately placed R1 and other residents at risk for impaired dignity and decreased quality of life.
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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