Kearny County Hospital Ltcu
Inspection history, citations, penalties and survey trends for this long-term care facility in Lakin, Kansas.
- Location
- 607 Court Pl, Lakin, Kansas 67860
- CMS Provider Number
- 17E531
- Inspections on file
- 15
- Latest survey
- December 3, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Kearny County Hospital Ltcu during CMS and state inspections, most recent first.
The facility failed to implement and update fall prevention interventions for several residents with severe cognitive impairments, leading to multiple falls and injuries. One resident suffered sinus fractures, another had multiple falls without proper interventions, and a third experienced a hip fracture requiring surgery. The care plans were not updated timely, and observations showed inadequate supervision and assistance, increasing the risk of further falls.
The facility failed to develop person-centered care plans and complete Care Area Assessments (CAAs) for several residents, leading to deficiencies in addressing their specific needs. One resident with multiple diagnoses did not have a care plan addressing psychotropic, diuretic, opioid, or nebulized medication use. Additionally, CAAs for six residents were incomplete or not conducted, affecting areas like cognitive loss and falls. Staff interviews confirmed issues with CAA completion, placing residents at risk for uncommunicated care needs.
The facility failed to accurately complete the MDS for several residents, leading to uncommunicated care needs. A resident's MDS inaccurately documented antipsychotic medication use and failed to record a major injury fall. Another resident's MDS inaccurately reflected the use of a chair alarm and failed to document a minor injury fall. Additionally, a resident's MDS inaccurately documented the use of psychotropic and opioid medications, which were not administered. These inaccuracies were confirmed by the MDS Nurse, indicating a failure to accurately reflect the residents' current status.
The facility failed to ensure RN coverage for eight consecutive hours daily, seven days a week, over a period of several months. This deficiency was identified through a review of staffing records, which showed 39 days without the required coverage. Administrative staff confirmed the issue and acknowledged the absence of a staffing policy, placing residents at risk of inadequate care.
The facility failed to maintain sanitary food storage and preparation practices, with unsealed and unlabeled food items found in refrigerators and freezers. Temperature logs were not properly maintained, with multiple instances of out-of-range temperatures documented. The facility's policy required specific temperature ranges, but these were not consistently met, and the recent change in temperature recording methods may have contributed to the issues.
The facility did not properly maintain and dispose of garbage, with two dumpsters found open, contrary to policy. The Dietary Manager was unaware of the requirement to keep trash covered, and the Administrative Nurse thought the city was responsible for dumpster maintenance. This could lead to pest issues.
The facility failed to manage resources effectively, impacting the well-being of all 25 residents. Deficiencies included improper care documentation, inaccurate advanced directives, and failure to maintain a clean environment. There were also issues with discharge notifications, incomplete assessments, and inadequate fall prevention, leading to serious injuries. Additionally, improper storage and cleaning of medical equipment posed infection risks, and lapses in medication management and staff training compromised resident care.
The facility failed to accurately complete PBJ reports for RN and Licensed Nursing Coverage, lacking RN coverage for eight consecutive hours daily and 24-hour Licensed Nurse coverage on specific dates. Administrative Staff A acknowledged the issue, citing partial coverage due to 12-hour shifts. The absence of a PBJ reporting policy contributed to the deficiency, risking inadequate resident care.
The facility did not conduct an annual performance improvement project as part of its QAA program, which is required to focus on high-risk or problem-prone areas. Despite quarterly meetings, no project was completed, potentially affecting all 25 residents. Administrative Nurse D acknowledged the deficiency, noting it was a work in progress.
The facility failed to maintain an effective infection control program, as clean linens were transported uncovered, and respiratory care was inconsistent with professional standards. Nebulizer equipment was not properly dated or cleaned, and oxygen supplies were stored improperly. Additionally, staff did not use enhanced barrier precautions for a resident with a Foley catheter and pressure ulcer, lacking necessary signage and PPE. The facility also lacked specific policies on respiratory equipment care and enhanced barrier precautions.
The facility failed to adhere to antibiotic stewardship principles, resulting in inappropriate antibiotic use. Antibiotics were prescribed before culture results were available, leading to residents completing ineffective courses. The EHR systems' lack of communication and incorrect documentation by the charge nurse further hindered proper antibiotic monitoring.
The facility did not employ a qualified Infection Preventionist (IP) to manage its Infection Prevention and Control Program (IPCP). Instead, the facility relied on a hospital IP to assist Administrative Nurses who had not completed IPCP training. This failure to designate a qualified IP could impact all 25 residents.
The facility failed to ensure that four CNAs met the required 12 hours of in-service training annually. Training records showed that the CNAs had less than the required hours, with Administrative Staff A confirming the deficiency and the absence of additional training records. The facility also did not provide a policy on CNA continuing education when requested.
The facility failed to ensure complete and accurate documentation of advanced directives for several residents. A resident's DNR form was only in the Code Status binder, not in the EHR. Another resident lacked a DNR order in the EHR, and two residents had DNR forms signed by a DPOA without the DPOA paperwork uploaded. Staff interviews revealed inconsistent procedures for handling advanced directive paperwork, leading to incomplete documentation.
The facility failed to maintain a clean and homelike environment for several residents. Observations revealed a chair repaired with duct tape, a bureau drawer with loose veneer, and cracked fall mats, all identified as non-cleanable surfaces. Housekeeping staff did not report these issues, and the facility lacked a policy on maintaining a clean environment, potentially spreading infections and affecting residents' well-being.
The facility failed to provide written notification to residents or their representatives, and the LTCO, for transfers to the hospital. This was identified for three residents whose EHRs lacked documentation of the required notifications. Interviews revealed staff were unaware of the notification requirements, and the facility could not provide a related policy.
The facility failed to provide a written bed hold policy notice to three residents or their representatives during hospital transfers. A review of the EHR showed no documentation of such notifications, and staff interviews revealed a lack of awareness about the requirement. The facility did not have a policy available for written bed hold notifications, contributing to the deficiency.
The facility failed to complete Quarterly MDS assessments in a timely manner for eight residents, as identified during an annual survey. The delays ranged from 10 to 36 days, placing residents at risk for unmet care needs and inaccurate assessments. The facility's policy requires timely completion and submission of assessments, which was not adhered to, as confirmed by the MDS Nurse.
A facility failed to complete comprehensive MDS assessments in a timely manner for ten residents, with delays ranging from 18 to 366 days. This was identified during an annual survey and confirmed by the MDS Nurse. The facility's policy requires timely completion and submission of assessments to ensure accurate reflection of residents' current status.
The facility failed to update care plans with fall prevention interventions for residents with a history of falls, including those with dementia and Alzheimer's. Multiple falls occurred without new interventions being documented, and staff interviews revealed care plans were not updated within the expected timeframe. The facility's fall prevention protocol was not adequately followed, placing residents at risk for further falls with injury.
The facility failed to provide proper respiratory care for several residents by not cleaning and storing nebulizers and nasal cannulas according to professional standards. Observations showed nebulizers with unknown liquids and undated, while oxygen tubing was improperly stored, posing infection risks. Staff interviews confirmed the lack of a respiratory care policy, contributing to these deficiencies.
A medication cart containing oral, topical, and inhaled medications was found unlocked and unattended in a hallway, not in the line of vision of staff. The CMA responsible stated the lock would not engage if drawers were not fully closed. This placed nine cognitively impaired, independently mobile residents at risk. The facility's policy required carts to be locked when not in use.
The facility failed to document pneumococcal vaccine consent or declination for five residents and lacked historical immunization records for three of them. Additionally, two residents' influenza vaccine consent forms were missing a required witness signature. Interviews confirmed these documentation issues, which were contrary to the facility's vaccination policy.
A facility failed to maintain resident dignity by using undignified terminology in medical records and not honoring a resident's food preferences. A resident with multiple health issues was documented as being placed at a 'feeder table,' contrary to the facility's dignity policy. Staff interviews confirmed the expectation to avoid labels and refer to residents by their preferred names, highlighting a breach in maintaining resident dignity and respect.
The facility failed to create baseline care plans for two residents within 48 hours of admission, as required. The EHR for one resident showed no baseline care plan, and the comprehensive care plan was delayed by 15 days. For the other resident, the comprehensive care plan lacked initial goals based on admission orders. An administrative nurse was unaware of the requirement for timely baseline care plans, leading to potential uncommunicated needs.
The facility failed to develop and implement comprehensive care plans for residents, including one with multiple medical conditions and medication needs. The care plans lacked necessary interventions and monitoring for psychotropic, diuretic, opioid, and nebulized medications. Observations showed residents appeared calm, but interviews revealed outdated care plans and missing policies for person-centered care plan development. These deficiencies could lead to uncommunicated needs, affecting residents' well-being.
A cognitively impaired resident with dementia and depression was not accurately assessed for nutritional status upon admission. The resident's care plan lacked nutritional interventions, and there was no dietary profile or dietician assessment in the EHR. Observations showed the resident's food preferences were not documented, and the dietician was unaware of the resident's admission, leading to unaddressed nutritional needs.
A facility failed to ensure a physician conducted and documented an in-person admission visit for a resident with dementia and depression. The resident required assistance with eating and was dependent on wheelchair mobility. Despite being admitted, there was no physician visit note in the EHR for over a month, and progress notes lacked documentation of a physician visit. An interview confirmed the resident had not been seen by a physician since admission, and the initial provider visit occurred 41 days later. The facility lacked a policy on physician visits, leading to the deficiency.
The facility failed to provide appropriate dementia care for two residents, as evidenced by inadequate individualized interventions and care plan documentation. One resident, diagnosed with Alzheimer's, was left alone with minimal supervision, and staff were unaware of her diagnosis. Another resident, with dementia and depression, exhibited behaviors such as yelling and hallucinations, but the care plan lacked documentation of individualized interventions. The facility's failure to implement and revise care plans placed residents at risk for impaired functioning and well-being.
A facility failed to act on a pharmacist's medication review for a resident with dementia, epilepsy, and depression. The resident's EHR lacked documentation of non-pharmacological interventions, and the facility did not provide documentation of the required medication regimen review and attempted gradual dose reduction. Staff interviews revealed inconsistencies in documenting and implementing interventions, contributing to the deficiency.
A facility failed to ensure a 14-day stop date or clinical rationale for a resident's PRN Ativan order, a psychotropic medication, despite the resident not receiving any doses. The resident, diagnosed with anxiety disorder, COPD, and Alzheimer's, appeared calm and relaxed during observations. An administrative nurse was unaware of the regulatory requirement for a stop date, and the facility's policies were not followed, leading to the potential for unnecessary medication use.
A resident with dementia and depression was not provided with a dietary profile or assessment of food preferences upon admission to the facility. The resident expressed dissatisfaction with the food provided, specifically disliking cucumbers and preferring chips with her meal. Interviews revealed that the resident had not been assessed by the dietician, and there was no communication about the resident's admission, leading to unknown nutritional needs and preferences.
The facility did not comply with federal requirements to post daily nurse staffing information, including total hours worked by staff and the daily resident census. Observations and record reviews showed missing data on staffing sheets, and administrative staff were unaware of these requirements. No policy was in place for posting this information.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to identify, implement, and reevaluate fall prevention interventions for several residents, leading to multiple falls and injuries. Resident 21, who had severe cognitive impairment and a history of falls, experienced a fall resulting in multiple sinus fractures. Despite being at high risk for falls, the facility did not update her care plan with new interventions until 12 days after the incident. Observations revealed that Resident 21 was often left to ambulate independently without assistance, despite her unsteady gait and the need for stand-by assistance. Resident 20, also with severe cognitive impairment and a history of falls, experienced multiple falls without appropriate interventions being documented or implemented. The care plan lacked documentation for a chair alarm and new fall interventions for several incidents. Observations showed that Resident 20 was often seated in a recliner without a chair alarm and was pushed in a wheelchair without foot pedals, increasing the risk of falls. Resident 18, with severe cognitive impairment and a history of falls, experienced multiple falls, including one that resulted in a hip fracture requiring surgery. The facility's fall investigation reports lacked immediate interventions to mitigate fall risks, and the care plan was not updated with new interventions following these incidents. The facility's failure to implement effective fall prevention measures placed these residents at risk for further falls and injuries.
Deficiencies in Care Plan Development and CAA Completion
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans for several residents, leading to deficiencies in addressing their specific needs. For instance, one resident with diagnoses including anxiety disorder, COPD, CHF, and Alzheimer's disease, was not provided with a care plan that included interventions related to psychotropic, diuretic, opioid, or nebulized medication use. Despite receiving various medications, the resident's care plan lacked a stop date for Ativan and did not document the rationale for its continued use. Observations showed the resident appeared calm and relaxed, but interviews with staff revealed that care interventions were not updated in the facility's records. Additionally, the facility failed to complete Care Area Assessments (CAAs) for six residents, which are essential for identifying underlying causes, contributing factors, and risk factors. These assessments were either incomplete or not conducted at all, affecting areas such as cognitive loss, urinary incontinence, falls, and psychotropic drug use. For example, one resident's CAA documented a decline in condition with an increased dose of psychotropic medication, but the analysis was incomplete. Another resident's CAA noted a high risk for falls due to seizure activity and behaviors, yet the analysis was insufficient. Interviews with facility staff, including the MDS Nurse, confirmed issues with the completion and submission of CAAs. The MDS Nurse admitted uncertainty about what to document in the CAA notes, leading to incomplete analyses and risk findings. The facility's policy on RAI and CAA completion emphasizes the importance of accurate assessments to reflect the resident's current status, but the failure to adhere to this policy placed residents at risk for uncommunicated care needs.
Inaccurate MDS Documentation Leads to Uncommunicated Care Needs
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for several residents, leading to uncommunicated care needs. For Resident 21, the MDS inaccurately documented the administration of antipsychotic medications and failed to record a major injury fall during the lookback period. This discrepancy was confirmed by the MDS Nurse, who acknowledged that the resident had not received antipsychotic medication and had experienced a significant fall resulting in fractures and a hematoma. Resident 20's MDS inaccurately reflected the use of a chair alarm and failed to document a minor injury fall. Observations revealed that the resident did not have a chair alarm, contrary to what was recorded in the MDS. The MDS Nurse confirmed these inaccuracies, noting that the resident had experienced a fall and did not have a chair alarm during the lookback period. For Resident 74, the MDS inaccurately documented the use of psychotropic and opioid medications, which the resident did not receive during the lookback period. The MDS Nurse confirmed these inaccuracies, highlighting the lack of evidence for the administration of these medications. Additionally, Resident 18's MDS failed to capture falls that occurred during the lookback period, and Resident 8's MDS inaccurately documented the administration of antiplatelet medication. These inaccuracies were confirmed by the MDS Nurse, indicating a failure to accurately reflect the residents' current status.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week, as required. This deficiency was identified through a review of the Payroll Based Journal (PBJ) and the facility's schedule for licensed nurses, which revealed a lack of consecutive eight-hour RN coverage on 39 days from July 1, 2023, through June 30, 2024. Specific dates across multiple fiscal quarters were noted where RN coverage was insufficient, with some days having only partial coverage due to 12-hour shifts that did not align with the required eight-hour consecutive coverage. Administrative staff acknowledged the lack of consecutive eight-hour RN coverage on the specified days, and it was noted that the facility did not have a policy related to staffing coverage. The absence of such a policy and the failure to provide the required RN coverage placed all residents at risk of lack of assessments and inappropriate care, as there was no assurance that residents' needs were being adequately met during the uncovered hours.
Food Storage and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to store, prepare, and serve food in a sanitary manner, which could potentially lead to food-borne illnesses among residents. During an inspection, several issues were identified in the kitchen and storage areas. Observations included unsealed and uncovered food items in the refrigerator and freezer, such as a tray of fruit-gelatin dessert, sandwich baggies with unidentifiable food, and bags of hotdogs, pepperoni, and fish patties, all lacking proper labeling and dates. Additionally, a sealed container of bulk breadcrumbs and several containers of cereal were found without documented opening dates, and the cereal had a use-by date that had already passed. The facility also had twenty cutting boards with uncleanable surfaces, showing discoloration and deep slices. Temperature logs for refrigerators and freezers were not maintained according to the facility's policy, with numerous instances of out-of-range temperatures documented. The facility's policy required refrigerators to be maintained between 33 and 36 degrees Fahrenheit and freezers between -0 to -10 degrees Fahrenheit. However, from 09/10/24 to 10/22/24, multiple refrigerators and freezers were repeatedly documented as out-of-range, and some lacked temperature logs for certain periods. Interviews with dietary staff revealed that the facility had recently changed its method of recording temperatures, which may have contributed to the lack of proper documentation and monitoring. The Dietary Manager acknowledged the issues and stated that staff were expected to label and date opened food items and notify her of any out-of-range temperatures, which was not consistently done.
Improper Garbage Disposal Practices
Penalty
Summary
The facility failed to maintain and dispose of garbage and refuse properly, as observed during an inspection. Two out of seven dumpsters were found with their lids open, which is against the facility's waste disposal policy that requires all waste to be covered unless in production. The Dietary Manager was unaware of the requirement to keep trash covered, and the Administrative Nurse mistakenly believed that the city was responsible for the maintenance of the dumpsters. This oversight in maintaining sanitary conditions for garbage disposal had the potential to lead to the harborage and feeding of pests.
Resource Mismanagement and Care Deficiencies
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, impacting the well-being of all 25 residents. The deficiencies included improper care and documentation practices, such as referring to a resident's dining area as a 'feeder table,' which risked the resident's psychosocial well-being. Additionally, the facility did not ensure accurate completion of advanced directives for several residents, potentially leading to uncommunicated end-of-life care preferences. The facility also failed to maintain a clean and homelike environment, which could spread infections and negatively affect residents' psychosocial health. There were issues with notifying residents or their representatives about facility-initiated discharges or transfers, including the bed hold policy, which could impair residents' ability to return to the facility. Furthermore, the facility did not complete comprehensive assessments and care plans in a timely manner, risking unmet care needs and inaccurate assessments. Other significant deficiencies included the failure to implement effective fall prevention interventions, resulting in serious injuries for some residents. The facility also did not ensure proper storage and cleaning of medical equipment, posing a risk of respiratory infections. Additionally, there were lapses in medication management, infection control, and staff training, all of which could compromise resident care and safety.
Inaccurate PBJ Reporting and RN Coverage Deficiency
Penalty
Summary
The facility failed to accurately complete Payroll Based Journal (PBJ) reports for Registered Nurse (RN) coverage and Licensed Nursing Coverage, as required by the Centers for Medicare and Medicaid Services (CMS). Specifically, the facility did not ensure RN coverage for eight consecutive hours a day, seven days a week, and did not maintain Licensed Nurse coverage 24 hours a day. This deficiency was observed across multiple quarters, with specific dates lacking the required RN coverage. The absence of consistent RN coverage placed all residents at risk of inadequate assessments and inappropriate care. During an interview, Administrative Staff A acknowledged the lack of consecutive eight-hour RN coverage on the specified days, noting that some days had partial coverage due to 12-hour shifts. The facility also failed to provide a policy on PBJ reporting, further contributing to the inaccurate completion of PBJ reports over four quarters. This oversight in staffing documentation and coverage posed a risk to the residents' well-being, as it could lead to insufficient care and assessments.
Failure to Conduct Annual Performance Improvement Project
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) program conducted at least one performance improvement project annually, focusing on high-risk or problem-prone areas identified through data collection and analysis. This deficiency was identified during an observation, interview, and record review, which revealed that the required members of the facility's Quality Assurance Performance Improvement (QAPI) program met at least quarterly. However, no annual performance improvement project had been conducted, as confirmed by Administrative Nurse D, who stated that it was a work in progress. The facility's policy, dated August 2024, emphasized the continuous improvement of systems and processes to support high-quality patient services, yet the lack of an annual project has the potential to affect all 25 residents of the facility.
Infection Control and Respiratory Care Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. Staff were observed transporting clean linens without covering the linen cart, exposing them to potential contamination. This practice was contrary to the facility's policy, which mandates that clean linens be transported using covered carts to prevent the transmission of microorganisms. Additionally, the facility's Infection Prevention Plan had not been reviewed annually, which is a requirement for maintaining an effective infection control program. The facility also failed to provide respiratory care consistent with professional standards for several residents. Observations revealed that nebulizer equipment was not dated, rinsed, or air-dried after use, and oxygen supplies were not stored in a clean manner. Specifically, nebulizers were found with clear liquid in the chamber and were not dated, while oxygen tubing was improperly stored, with some tubing found on the floor. Interviews with staff confirmed that these practices were not in line with the expected standards of care. Furthermore, the facility staff did not utilize enhanced barrier precautions when providing catheter and wound care to a resident with a Foley catheter and an open pressure ulcer. There was no signage or equipment indicating the need for enhanced barrier precautions, and staff did not wear personal protective equipment during care. Interviews with staff revealed a lack of awareness and adherence to the necessary precautions for residents requiring such care. The facility also lacked specific policies on the care of respiratory equipment and enhanced barrier precautions, contributing to the deficiencies observed.
Failure in Antibiotic Stewardship and Monitoring
Penalty
Summary
The facility failed to ensure adherence to antibiotic stewardship principles, leading to inappropriate antibiotic use among residents. An interview with Administrative Nurse D revealed that antibiotics were often prescribed before culture and sensitivity reports were received, resulting in residents completing courses of antibiotics that were not effective against their infections. The facility's EHR system did not communicate with the hospital's EHR, complicating the evaluation of antibiotic appropriateness. Consequently, residents were sometimes not on the correct antibiotic, as the provider was not updated with the culture results in time. Additionally, the charge nurse was responsible for opening the Infection Prevent Report on the EHR but failed to complete or answer the questions correctly. This lack of proper documentation and communication contributed to the facility's inability to provide ongoing antibiotic stewardship, as outlined in their policy. The facility's policy, dated 05/2021, emphasized the importance of combating bacterial resistance and minimizing adverse effects related to antimicrobial treatments, but these goals were not met due to the deficiencies in monitoring and communication.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) who had completed specialized training in infection prevention and control to oversee the Infection Prevention and Control Program (IPCP). This deficiency was identified during interviews and record reviews, revealing that the facility did not employ a qualified IP. Instead, the facility relied on an IP from a hospital to answer questions for Administrative Nurse D and Administrative Nurse E, neither of whom had completed an IPCP. The facility's policy, dated May 2021, required the designated IP to manage the day-to-day functions of the infection prevention program, including developing a system for identifying, investigating, reporting, and preventing the spread of infections. The lack of a qualified IP has the potential to affect all 25 residents in the facility.
Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility failed to ensure that four out of five Certified Nurse Aides (CNAs) sampled met the required 12 hours of in-service training annually. The review of training records revealed that CNA N had 10 hours and 38 minutes, CNA R had nine hours and 32 minutes, CNA Y had 10 hours and six minutes, and Social Services Designee (SSD)/CNA X had nine hours and 24 minutes of documented training over the previous 12 months. Administrative Staff A confirmed the deficiency, acknowledging the lack of additional training records for these CNAs. Furthermore, the facility did not provide a policy related to CNA continuing education and in-service training when requested.
Incomplete Documentation of Advanced Directives
Penalty
Summary
The facility failed to ensure that advanced directives for five residents were thoroughly completed and accurately documented in the Electronic Health Records (EHR). Specifically, Resident 124 had a Do Not Resuscitate (DNR) form located only in the Code Status binder at the nurse's station, but there was no corresponding DNR order or uploaded document in the EHR. Similarly, Resident 15 lacked a DNR order in the EHR, and Residents 21 and 20 had DNR forms signed by a Durable Power of Attorney (DPOA) uploaded in the EHR, but the DPOA paperwork itself was missing. Resident 74 had no code order or scanned documents related to advanced directives in the EHR. These deficiencies were identified during an onsite annual survey, where it was noted that the care plans and physician orders in the EHR for these residents lacked the necessary advanced directive information. Interviews with facility staff revealed a lack of consistent procedures for handling advanced directive paperwork. Licensed Nurse G and Administrative Nurse D confirmed that DNR forms should be uploaded in the EHR and accompanied by a provider order, but this was not done for several residents. Social Service Designee X admitted to sometimes not seeing the DPOA paperwork when witnessing a DNR signed by a DPOA. Administrative Staff B acknowledged that the EHR system had changed, and all DPOA forms should have been uploaded, but this was not the case. The facility's policy on advanced directives required that residents provide a copy of their advanced directive to be scanned into the EHR, but this was not consistently followed, leading to incomplete documentation and potential miscommunication regarding residents' end-of-life care preferences.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for five residents, as observed during a survey. Resident 8 had a chair seat repaired with duct tape, which was identified as an un-cleanable surface. Resident 124 had a bureau drawer with missing and loose veneer, posing an accident hazard and also deemed un-cleanable. Additionally, residents 2, 74, 23, and 124 had fall mats in their rooms that were cracked and worn, making them non-cleanable surfaces. These conditions were confirmed by the Maintenance Director and Administrative Nurse during an environmental tour. Housekeeping staff reported that it was not their responsibility to report worn-down fall mats, although the Housekeeping Supervisor confirmed that staff should report such issues to maintain a homelike environment. The facility lacked a policy on maintaining a clean homelike environment, which contributed to these deficiencies. These practices had the potential to spread infections and negatively impact the residents' psychosocial well-being.
Failure to Notify Residents and Ombudsman of Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents or their representatives, as well as the Long-Term Care Ombudsman (LTCO), for facility-initiated transfers to the hospital. This deficiency was identified for three residents, who were transferred to the hospital and subsequently readmitted to the facility. The Electronic Health Records (EHR) for these residents lacked documentation of the required notifications, indicating a failure in the facility's discharge process. Interviews with facility staff revealed a lack of awareness regarding the regulatory requirement to notify the resident, their representative, or the LTCO in writing about discharges. The Social Services Designee (SSD) responsible for discharge notifications was unaware of this requirement, and the facility was unable to provide a policy related to discharge notifications when requested. This oversight placed residents at risk of making uninformed care choices.
Failure to Provide Written Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a written bed hold policy notice to three residents or their representatives when they were transferred to a hospital. This deficiency was identified during a review of the Electronic Health Records (EHR) for the residents, which showed that there was no documentation of written notification regarding the bed hold policy at the time of their discharge to the hospital. The residents involved were discharged on different dates, and upon their readmission, there was no evidence that the facility had informed them or their representatives about the bed hold policy, nor was there any notification sent to the Long-Term Care Ombudsman (LTCO). Interviews with facility staff revealed a lack of awareness regarding the regulatory requirement to provide written bed hold notices. Licensed Nurse G indicated that the Social Services Designee (SSD) X was responsible for handling the bed hold process. However, SSD X admitted to not knowing about the requirement to notify residents or their representatives in writing upon discharge. Administrative Nurse D also confirmed that SSD X was responsible for discharge notifications and was unaware of the need for written notices at the time of transfer. The facility did not have a policy related to written bed hold notifications available when requested, which contributed to the deficiency.
Delayed MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete Quarterly Minimum Data Set (MDS) assessments in a timely manner for eight residents, which was identified during an onsite annual survey. The surveyor noted that the assessments were either in progress or completed late, placing the residents at risk for unmet care needs and inaccurate assessments. The facility reported a census of 25 residents, and the sample included 12 residents, out of which eight residents had delayed MDS assessments. The residents affected were identified as R8, R10, R12, R17, R18, R19, R20, and R21. The review of the Electronic Health Record (EHR) on 10/21/24 revealed specific delays in the completion and submission of the quarterly MDS for these residents, ranging from 10 to 36 days late. The facility's policy on Resident Assessment Instrument (RAI) and Care Area Assessment (CAA) Completion, dated 10/2020, requires that assessments accurately reflect the resident's current status and be completed and submitted according to regulatory time periods. During an interview, the facility's MDS Nurse confirmed the delays in completing the assessments. This deficiency in timely MDS assessments was documented as a concern by the surveyor.
Delayed MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments in a timely manner for ten residents, as identified during an onsite annual survey. The surveyor noted that the assessments were either in progress or completed late, which was confirmed by the facility's MDS Nurse. The residents affected included R8, R10, R12, R15, R17, R18, R19, R20, R21, and R124. The delays in completing and submitting the MDS assessments ranged from 18 to 366 days, with some assessments not completed or submitted as required. The facility's policy on Resident Assessment Instrument (RAI) and Care Area Assessment (CAA) Completion, dated October 2020, mandates that assessments accurately reflect the resident's current status and be completed and submitted within regulatory time periods. The failure to adhere to these timelines placed the residents at risk for unmet care needs and inaccurate assessments, as the MDS is crucial for determining appropriate care for residents. The deficiency was identified through a review of the Electronic Health Records (EHR) and confirmed through an interview with the facility's MDS Nurse.
Failure to Update Fall Prevention Care Plans
Penalty
Summary
The facility failed to update care plans with fall prevention interventions for several residents who had a history of falls, placing them at risk for further falls with injury. Resident 20, diagnosed with dementia and parkinsonism, experienced multiple falls without new interventions being documented in the care plan. Despite having a chair alarm, it was not consistently used, and several falls lacked proper documentation and risk management reports. Interviews with staff revealed that care plans were not updated within the expected 24-hour timeframe, and the facility's fall prevention protocol was not adequately followed. Resident 15, diagnosed with Alzheimer's disease, also experienced a fall without new interventions being added to the care plan. The risk management report for the fall lacked review and immediate intervention to prevent another fall. Staff interviews indicated that the process for updating care plans with new interventions was not consistently followed, leading to a lack of timely updates in the care plans. Resident 21, with diagnoses including dementia and degenerative arthritis, had multiple falls, including one that resulted in significant injury. The care plan was not updated with new interventions in a timely manner, and the facility's fall prevention protocol was not adhered to. Observations and interviews with staff highlighted a lack of communication and documentation regarding fall prevention measures, contributing to the facility's failure to adequately address the residents' fall risks.
Improper Respiratory Equipment Handling in LTC Facility
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for four residents, specifically in the cleaning and storage of nebulizers and nasal cannulas. Observations revealed that nebulizers for several residents, including R8, R12, R18, and R74, were improperly stored with unknown clear liquids in the atomizer chambers and were not dated. Additionally, nasal cannulas and oxygen tubing were found improperly stored, either draped over furniture or resting on the floor, which posed an infection control concern. These practices were observed multiple times, indicating a pattern of non-compliance with infection control protocols. Interviews with facility staff, including a Licensed Nurse and an Administrative Nurse, confirmed that nebulizers should be rinsed and dried after each use, and oxygen equipment should be stored in a sanitary manner. However, the facility lacked a policy related to respiratory care, contributing to the improper handling and storage of respiratory equipment. The presence of used nebulizer equipment in R18's room, which was not required for their care, further highlighted the facility's failure to maintain a safe and sanitary environment for residents, increasing the risk of respiratory infections.
Unattended and Unlocked Medication Cart Found in Facility
Penalty
Summary
The facility failed to ensure the secure storage of medications when a medication cart was found unlocked and unattended in a hallway between the dining and commons areas. This cart contained oral, topical, and inhaled medications and was not within the line of vision of the attending staff. The Certified Medication Aide (CMA) responsible for the cart acknowledged that it should have been locked when not attended and noted that the lock would not engage if the drawers were not fully closed, despite appearing locked. The lock had been recently replaced by maintenance, but the issue persisted. The incident placed nine cognitively impaired, independently mobile residents at risk. Interviews with staff, including a Licensed Nurse (LN) and an Administrative Nurse, confirmed that the responsibility for ensuring the cart was locked fell on the person holding the keys. The facility's policy required medication carts to be locked when not in use. Despite the recent maintenance work on the lock, the problem continued, indicating a need for a new medication cart to ensure compliance with the facility's medication storage policy.
Deficiencies in Vaccination Documentation
Penalty
Summary
The facility failed to provide the necessary documentation for pneumococcal and influenza vaccinations for several residents. Specifically, five residents did not have the required pneumococcal vaccine consent or declination forms in their Electronic Health Records (EHR). Additionally, there was no documentation of historical pneumococcal vaccine immunization records for three of these residents. Two residents also lacked any documentation for consent or declination of the pneumococcal vaccine. Furthermore, the EHR for the influenza vaccine for two residents was missing a second witness signature on the consent forms, which is required to confirm that verbal consent was received. Interviews with administrative nurses confirmed these documentation deficiencies. Administrative Nurse D acknowledged the absence of declination forms and immunization records for the pneumococcal vaccine in the EHR for the affected residents. Administrative Nurse E confirmed that the influenza vaccine consent forms should have included a witness signature. The facility's policy on influenza and pneumococcal vaccines emphasizes the importance of these vaccinations in reducing mortality and healthcare costs, and it mandates that all residents be screened and documented for their immunization status upon admission. However, the facility did not adhere to this policy, resulting in the noted deficiencies.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to treat residents in a dignified manner, specifically in the case of Resident 17, who was documented in the medical record as being placed at a 'feeder table.' This terminology was used in the electronic charting, which is against the facility's dignity policy that emphasizes referring to residents by their preferred names and avoiding labels. Resident 17 had multiple health issues, including pulmonary fibrosis, psychosis, spinal stenosis, COPD, and cognitive decline, and required assistance with meals. The resident's care plan was updated to include the use of a divided plate to assist with meals, but the use of the term 'feeder table' in documentation was deemed undignified. Additionally, the facility did not honor the rights of Resident 124 regarding personal food preferences and choices, which is a violation of the resident's rights. Interviews with staff, including a Certified Medication Aide, a Licensed Nurse, and an Administrative Nurse, revealed that the expectation was to refer to residents by their preferred names and to correct any staff using labels. The facility's dignity policy, approved in October 2020, mandates that care should enhance each resident's dignity and respect, focusing on their individuality. The failure to adhere to this policy placed residents at risk for decreased psychosocial well-being.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop a person-centered baseline care plan for two residents, R74 and R124, within the required 48-hour timeframe following their admission. For R74, the Electronic Health Record (EHR) showed that a baseline care plan was not created, and the comprehensive care plan was only completed 15 days after admission. Similarly, for R124, the EHR lacked documentation of a baseline care plan, and the comprehensive care plan was created without initial goals based on admission orders and other necessary assessments. During an interview, Administrative Nurse D admitted to being unaware of the requirement for a baseline care plan within the first 48 hours of admission and did not know who was responsible for its completion. This lack of awareness and failure to complete the baseline care plans for R74 and R124 had the potential to lead to uncommunicated needs, as the necessary initial assessments and goals were not documented in a timely manner.
Deficient Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for three residents, focusing on Resident 74, who had multiple medical conditions including anxiety disorder, COPD, CHF, and Alzheimer's disease. The care plan for Resident 74 lacked interventions related to the use of psychotropic, diuretic, opioid, and nebulized medications. Despite having physician orders for medications such as Ativan, Norco, Ipratropium Bromide, Furosemide, and Duloxetine, the care plan did not include necessary interventions or monitoring for these medications. Observations showed Resident 74 appeared calm and relaxed, but interviews revealed that the care plan was not updated, and there was no policy provided for person-centered care plan development. Additionally, the care plan for another resident, R124, lacked interventions for activities of daily living, psychotropic medication use, visual function, abnormal behaviors, nutritional status, and pain. Another resident, R20, had a care plan that did not address the risk of falls despite a known history of falls. These deficiencies in care planning had the potential to lead to uncommunicated needs, negatively impacting the physical and psychosocial well-being of the residents.
Failure to Assess Nutritional Status of Cognitively Impaired Resident
Penalty
Summary
The facility failed to accurately assess the nutritional status of a cognitively impaired resident, identified as R124, upon admission. R124 had diagnoses of dementia and depression, with a BIMS score indicating moderately impaired cognition. Despite requiring setup for eating and having broken or loose-fitting dentures, the facility's Nutritional Status Care Area Assessment (CAA) did not identify any issues with her nutrition. The resident's care plan lacked interventions related to nutritional concerns, and there was no dietary profile or assessment from the Consultant Dietician in the Electronic Health Record (EHR) since admission. Observations and interviews revealed that R124 expressed dislike for certain foods provided and a preference for others, which were not documented or communicated. The Consultant Dietician confirmed not being informed of R124's admission and thus had not assessed her nutritional needs. The facility lacked a policy for Registered Dietician visits, contributing to the oversight. This deficiency placed R124 at risk for uncommunicated care needs and potential nutritional deficits.
Failure to Conduct and Document Timely Physician Admission Visit
Penalty
Summary
The facility failed to ensure that a physician conducted and documented an in-person admission visit for a resident, identified as R124, as required. R124's Electronic Health Record (EHR) indicated diagnoses of dementia and depression, with a Brief Interview for Mental Status (BIMS) score of ten, suggesting moderately impaired cognition. The resident required assistance with eating and was dependent on wheelchair mobility, with impairments noted on one side of the body. Despite being admitted to the facility, there was no physician visit note uploaded in the EHR as of over a month later, and progress notes from the admission date through the review date lacked any documentation of a physician visit. An interview with Administrative Nurse D confirmed that R124 had not been seen by a physician since admission, which was acknowledged as a concern. The initial provider visit was documented 41 days after admission, and the facility did not have a policy on physician visits, leading to the deficiency.
Inadequate Dementia Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate dementia care for two residents, R19 and R124, as evidenced by inadequate individualized interventions and care plan documentation. R19, diagnosed with Alzheimer's disease, anxiety, insomnia, depressive disorder, urinary tract infection, and hypertension, was assessed to have severely impaired cognition. Despite this, the care plan lacked documentation of individualized interventions and measurable outcomes related to R19's Alzheimer's diagnosis. Observations revealed that R19 was left alone in the activity room with minimal supervision, and staff were unaware of R19's Alzheimer's diagnosis, indicating a lack of communication and understanding of the resident's needs. Similarly, R124, who was diagnosed with dementia and depression, exhibited behaviors such as yelling at staff and experiencing hallucinations. The care plan for R124 also lacked documentation of individualized interventions and measurable goals regarding her behaviors. Despite receiving antipsychotic and antidepressant medications, there was no evidence of non-pharmacological interventions being attempted prior to medication administration. Staff interviews revealed a lack of awareness and understanding of R124's care needs, further contributing to the deficiency. The facility's failure to implement individualized interventions and revise care plans accordingly for both residents placed them at risk for impaired ability to achieve and maintain their highest practicable level of functioning and well-being. The facility's Behavior Management in Dementia Care policy, which requires monitoring and documentation of all dementia-related behaviors and interventions, was not adhered to, resulting in inadequate care for residents R19 and R124.
Failure to Act on Pharmacist's Medication Review
Penalty
Summary
The facility failed to act upon the pharmacist's monthly medication review (MRR) for a resident, identified as R18, on 06/30/24. The resident had a history of dementia, epilepsy, frontotemporal neurocognitive disorder, and depression, and was receiving multiple medications, including an antidepressant and an opioid. The MRR conducted by Consultant Pharmacist HH included a recommendation for a gradual dose reduction (GDR) and diagnosis review, but the facility did not have documentation of the specific medication targeted by the GDR or the facility's or physician's response to the recommendation. The resident's electronic health record (EHR) lacked documentation of non-pharmacological interventions attempted by staff, which was a requirement before administering antipsychotic medications. The facility's care plan for the resident included interventions such as consulting with a pharmacist and physician to use the lowest effective dose of medications and monitoring for side effects and effectiveness. However, there was no evidence that these interventions were followed, and the facility did not provide documentation of the required MRR and attempted GDR. Interviews with facility staff revealed a lack of clarity and communication regarding the documentation and implementation of interventions for the resident. Certified Nursing Assistant Q and Licensed Nurse G provided inconsistent information about the process for documenting and implementing interventions. Administrative Nurse D confirmed the missing MRR/GDR report and the lack of documentation related to non-pharmacological interventions. The facility's failure to ensure the resident was free of unnecessary psychotropic medications and to document non-pharmacological interventions contributed to the deficiency.
Failure to Ensure 14-Day Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medications. Specifically, a resident with diagnoses of anxiety disorder, COPD, and Alzheimer's disease had a PRN order for Ativan, a psychotropic medication, without a required 14-day stop date or documented clinical rationale for continued use beyond the initial 14 days. The resident's electronic health record showed no evidence of the medication being administered, yet the order remained active without the necessary regulatory compliance. Observations of the resident indicated that they appeared relaxed and calm during various times, suggesting no immediate need for the PRN medication. An interview with an administrative nurse revealed a lack of awareness regarding the regulatory requirement for a 14-day stop date on PRN psychotropic medications. The facility's policies on psychotropic monitoring and medication administration emphasized the need for such stop dates or clinical rationales, yet these were not adhered to in this case, leading to the potential for unnecessary medication use.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to accommodate a resident's dietary preferences, specifically for Resident 124, who was diagnosed with dementia and depression. The resident's Electronic Health Record (EHR) did not include a dietary profile or documentation of food preferences, likes, or dislikes. Despite being on a regular diet with mechanical soft texture and regular/thin consistency fluids, the resident expressed dissatisfaction with the food provided, specifically mentioning a dislike for cucumbers and a preference for chips with her taco salad. The resident's care plan also lacked documentation regarding her dietary preferences. Interviews with facility staff revealed that the resident had not been assessed by the Consultant/Registered Dietician since admission, and there was no communication from the dietary staff to the consultant about the resident's admission. This oversight resulted in the resident's nutritional needs and preferences being unknown, which was acknowledged as a concern by both the administrative nurse and the consultant dietician. The facility's policy on resident rights emphasizes the importance of autonomy and choice, which was not upheld in this case due to the lack of assessment and documentation of the resident's dietary preferences.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to ensure compliance with federal requirements for posting daily nurse staffing information. During an observation, it was noted that the daily staffing sheets displayed at the nurse's station did not include the total number or actual hours worked by both licensed and unlicensed staff, nor did they include the daily resident census. A review of the Daily Schedule Nursing Hours sheets from the previous month also revealed the absence of this required information. When interviewed, Administrative Staff A and Administrative Nurse D admitted they were unaware of the federal requirement to complete daily staffing sheets with these elements. Additionally, the facility did not have a policy in place for posting nurse staffing information.
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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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