Lakepoint El Dorado, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in El Dorado, Kansas.
- Location
- 1313 S High Street, El Dorado, Kansas 67042
- CMS Provider Number
- 175124
- Inspections on file
- 20
- Latest survey
- January 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lakepoint El Dorado, Llc during CMS and state inspections, most recent first.
The facility failed to provide written notification to residents and their representatives for hospital transfers, affecting residents with complex medical conditions. This deficiency involved multiple residents and was confirmed by staff interviews, revealing a systemic issue with the facility's notification process.
The facility failed to provide six residents with written information about the bed hold policy during hospital transfers, risking their ability to return. Despite complex medical conditions, the policy was only given upon admission, not during subsequent transfers, as confirmed by staff interviews.
A facility's Consultant Pharmacist failed to identify and report medication administration errors for several residents. One resident received blood pressure medication outside prescribed parameters, while another was given an antipsychotic for an unapproved diagnosis. A third resident was administered multiple blood pressure medications outside physician-ordered parameters. The CP's monthly reviews did not document these irregularities, placing residents at risk for unnecessary medication use.
A facility failed to maintain a medication error rate below 5%, resulting in a 16% error rate. A resident with multiple health conditions received blood pressure medications despite their diastolic blood pressure being below the physician-ordered parameters. The CMA acknowledged the error after reviewing the parameters, and the facility lacked a policy for medication errors.
The facility failed to ensure proper storage and monitoring of medications and biologicals, risking ineffective medication for residents. The East medication room had refrigerators with unrecorded temperatures for nine days in December and contained expired yogurts. LN J confirmed the lack of documentation and disposed of the expired items, while Administrative Nurse D stated that night shift staff should record temperatures daily. No policy was provided for medication and biological storage.
The facility failed to develop comprehensive care plans for two residents, one requiring dialysis care and the other with diabetes mellitus. The first resident's care plan lacked focus on dialysis care, despite diagnoses of end-stage renal disease and diabetes. Observations showed non-compliance with fluid restrictions. The second resident's care plan did not address diabetes management, despite a history of severely uncontrolled diabetes and insulin use. The facility's policy required individualized care plans, but these deficiencies placed both residents at risk of impaired care.
A resident with COPD, diabetes, Sjogren's syndrome, and epilepsy developed a productive cough and coarse lung sounds. Despite notifying the physician on two occasions, the facility failed to ensure timely follow-up, resulting in a delayed response and treatment. The resident was eventually prescribed azithromycin for bronchitis, but the delay placed them at risk for further complications.
A facility failed to ensure a low air-loss mattress was functioning for a resident with multiple diagnoses, leading to a fall. Another resident with Alzheimer's disease was not assessed for safe recliner use or provided with updated toileting interventions after falls. The facility did not implement necessary interventions, placing residents at risk for further falls.
A facility failed to monitor and document a dialysis resident's fluid restriction, as ordered by a physician. The resident, with end-stage renal disease, was on a 1200 ml daily fluid restriction, but records lacked evidence of monitoring. Staff interviews revealed a lack of awareness and documentation of the resident's fluid intake, and the facility did not provide a policy on fluid restriction.
A facility failed to provide trauma-informed care for a resident with PTSD by not identifying trauma-based triggers or implementing individualized interventions. Despite having a trauma care plan, staff were unaware of the resident's PTSD diagnosis or potential triggers, and the care plan lacked specific interventions. This placed the resident at risk for decreased psychosocial well-being and ineffective treatment.
Two residents received blood pressure medications outside physician-ordered parameters, risking physical decline. One resident with multiple health conditions was given amlodipine, hydralazine, hydrochlorothiazide, and losartan despite low DBP readings. Another resident with Alzheimer's and other conditions received lisinopril outside parameters. The facility lacked a policy for administering these medications.
Two residents were administered the antipsychotic medication quetiapine without an approved diagnosis or physician-documented rationale, including risk versus benefit. Despite facility policies emphasizing non-pharmacological interventions for dementia-related behaviors, records for both residents lacked necessary documentation. Staff interviews confirmed awareness of the inappropriate use of psychotropic medications for dementia, yet no attempts were made to justify or change the medication use.
The facility failed to ensure proper collaboration with hospice services for two residents receiving end-of-life care. The care plans for both residents lacked specific details about hospice services, such as contact information, supplies, medications, and staff visit schedules. This deficiency placed the residents at risk of inadequate care, despite the facility's policy to maintain high-quality palliative care.
A cognitively impaired resident was sexually abused by another resident in a LTC facility. Despite previous observations of inappropriate contact, the facility failed to update care plans or document behavior issues, leading to an incident where a CNA observed the abuse. The facility's policy on abuse was not effectively implemented.
A cognitively impaired resident was not protected from sexual abuse by another resident with a history of inappropriate touching. Despite multiple observations of inappropriate behavior, the facility failed to update care plans or document incidents, leading to a deficiency.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding facility-initiated transfers or discharges to hospitals. This deficiency was identified for several residents, including those with complex medical conditions such as chronic respiratory failure, congestive heart failure, and diabetes mellitus. The lack of written notification extended to the State Long Term Ombudsman, which is a requirement for ensuring residents' rights and informed care choices. For instance, one resident with multiple diagnoses, including urinary tract infections and acute kidney failure, was transferred to the hospital multiple times without receiving written notification of the transfer. The facility's records lacked evidence of any written communication to the resident or their representative, and the facility's staff confirmed that the process had changed under new administration, leading to the discontinuation of such notifications. Similarly, other residents with conditions like COPD, sepsis, and dementia were also transferred to hospitals without receiving the required written notifications. Interviews with facility staff revealed a systemic issue where the responsibility for providing written notifications was unclear, and the facility's policy on emergency transfers was not being followed. This failure to notify placed residents at risk for uninformed care choices and impaired their rights.
Failure to Provide Bed Hold Policy Upon Hospital Transfers
Penalty
Summary
The facility failed to provide six residents with written information regarding the facility's bed hold policy when they were transferred to the hospital. This deficiency was identified through observations, record reviews, and interviews. The residents affected included those with complex medical conditions such as chronic respiratory failure, congestive heart failure, diabetes, and other serious health issues. The lack of documentation and communication regarding the bed hold policy placed these residents at risk of not being permitted to return to the facility and resume residence. The facility's bed hold policy, dated May 2024, required that residents and their representatives be informed in writing about the facility and state bed-hold policies upon admission. However, the facility did not provide this information upon each transfer to the hospital, as evidenced by the clinical records of the residents. Interviews with administrative and nursing staff revealed that the process had changed with the new administration, and the notification of the bed hold policy was only signed upon admission, not during subsequent transfers. Specific cases highlighted in the report include residents who were transferred multiple times to the hospital for various medical emergencies, such as urinary tract infections, respiratory distress, and possible transient ischemic attacks. Despite these transfers, there was no evidence in the clinical records that the bed hold policy was provided to the residents or their representatives. This oversight was confirmed by staff interviews, where it was acknowledged that the policy was not reissued upon each hospital transfer, contrary to the facility's documented policy requirements.
Consultant Pharmacist Fails to Identify Medication Administration Errors
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported medication administration outside of physician-ordered parameters for several residents. Resident 1 received lisinopril, a blood pressure medication, outside the prescribed parameters multiple times over three months. Despite the physician's order to hold the medication if the diastolic blood pressure (DBP) was less than 60, the medication was administered when the DBP was below this threshold on numerous occasions. The CP's monthly Medication Regimen Reviews (MRR) did not document these irregularities, placing the resident at risk for unnecessary medication use and related complications. Resident 20 was administered quetiapine, an antipsychotic, for a diagnosis of dementia, which is not a CMS-approved indication. The CP initially noted the lack of an appropriate diagnosis and recommended a gradual dose reduction, but the physician did not provide a rationale for the continued use of the medication. Subsequent MRRs by the CP failed to readdress the issue, leaving the resident at risk for unapproved medication use. Similarly, Resident 31 was prescribed Seroquel, another antipsychotic, for dementia without a documented clinical rationale or approved indication. The CP did not identify or report this deficiency in the MRRs. Resident 18 received multiple blood pressure medications, including amlodipine, hydralazine, hydrochlorothiazide, and losartan, outside the physician-ordered parameters. The medications were administered when the DBP was below the specified threshold, contrary to the physician's orders. The CP's MRRs from October to December did not identify or report these discrepancies. The facility's policy required the CP to review medication regimens monthly and communicate any potential or actual problems to the responsible physician and the Director of Nursing, which was not adhered to in these cases.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 16% error rate during the survey. The incident involved a resident with multiple diagnoses, including cerebral infarction, hemiparesis, COPD, diabetes mellitus, dementia, and hypertension. The resident's care plan required careful administration of medications, including those with Black Box Warnings, and monitoring of blood pressure parameters before administering antihypertensive medications. On the day of the incident, a Certified Medication Aide (CMA) administered the resident's morning medications, including several blood pressure medications, without adhering to the physician-ordered parameters. The resident's diastolic blood pressure was below the threshold specified in the physician's orders, but the CMA proceeded with the administration. The CMA later acknowledged the error upon reviewing the parameters. The facility did not provide a policy for medication errors, contributing to the observed deficiency.
Improper Storage and Monitoring of Medications and Biologicals
Penalty
Summary
The facility failed to ensure proper storage and monitoring of medications and biologicals in one of its two medication rooms, which placed residents at risk of receiving ineffective medication. During an observation, it was found that the East medication room had two refrigerators, and the temperatures for these refrigerators were not assessed and recorded for nine out of 17 days in December 2024. Additionally, one refrigerator contained 24 Activa yogurts with expiration dates ranging from September 2024 to November 2024. Licensed Nurse J confirmed the lack of temperature documentation and disposed of the expired yogurts. Administrative Nurse D verified that the refrigerator temperatures should be recorded daily by the night shift nursing staff. The facility did not provide a policy related to the storage of medication and biologicals.
Failure to Develop Comprehensive Care Plans for Dialysis and Diabetes Management
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident, identified as R29, who required dialysis care. R29's electronic medical record documented diagnoses of end-stage renal disease, diabetes mellitus, and hypertension, among others. Despite these conditions, R29's care plan did not include a focus or staff direction for dialysis care. Observations revealed that R29 was not compliant with her fluid restriction, a critical component of dialysis care, as she was seen with a large mug and a supply of soda pop in her room. Interviews with staff, including a CNA and a licensed nurse, confirmed the absence of dialysis care interventions in R29's care plan. Another resident, identified as R36, also lacked a comprehensive care plan addressing diabetes mellitus and insulin use. R36's medical record included diagnoses such as type 2 diabetes with ketoacidosis, cerebral infarction, and chronic pain syndrome. Despite receiving insulin and other medications, R36's care plan did not provide guidance for managing diabetic conditions and insulin use. A history and physical note indicated a history of severely uncontrolled diabetes, and the resident had been admitted to the ICU for an insulin drip due to diabetic ketoacidosis. Interviews with administrative staff confirmed the absence of diabetic care guidance in R36's care plan. The facility's policy required individualized, interdisciplinary care plans based on residents' needs, strengths, limitations, and goals. However, the facility failed to ensure that care plans for R29 and R36 included necessary interventions for dialysis and diabetes management, respectively. This oversight placed both residents at risk of impaired care due to uncommunicated care needs.
Failure to Follow Up with Physician for Resident's Respiratory Symptoms
Penalty
Summary
The facility failed to follow up with the physician for a resident, identified as R10, who became ill with a productive cough and coarse lung sounds. R10 had a medical history of chronic obstructive pulmonary disease (COPD), diabetes mellitus, Sjogren's syndrome, and epilepsy. The resident was on hospice care and required oxygen therapy. On 06/17/24, a nurse documented that R10 had a productive cough with thick green sputum and notified the physician, but there was no follow-up documented in the Electronic Medical Record (EMR) when the physician did not respond. On 06/24/24, another nurse noted that R10 had a harsh cough with coarse lung sounds and sent a second fax to the physician requesting a chest X-ray and other interventions. The physician responded on 06/24/24, asking how long R10 had symptoms and scheduled an appointment for 07/03/24. The physician's order on 07/03/24 directed the administration of azithromycin for bronchitis. Interviews with staff revealed that the physician was difficult to reach, and the facility's policy required timely communication of medical care problems. The lack of follow-up placed R10 at risk for physical decline and complications due to delayed physician involvement.
Failure to Ensure Functioning Equipment and Assess Resident Needs
Penalty
Summary
The facility failed to ensure that a low air-loss mattress for a resident with multiple diagnoses, including Parkinson's disease, dementia, and a history of falls, was functioning properly. This resident, who was on hospice care and had severely impaired decision-making skills, was found face down on the floor next to his bed with the mattress unplugged. The incident resulted in a bruise and bleeding on the resident's right knee and toe. Staff interviews revealed that the mattress was not turned on, and the bed did not have bolsters at the time of the fall, despite the resident being assessed as high risk for falls. Another resident with Alzheimer's disease and a history of falls was not assessed for the safe use of a recliner or provided with updated toileting interventions after sustaining multiple falls. This resident, who had severely impaired cognition and was frequently incontinent, was not on a toileting plan despite several falls related to attempts to reach the bathroom. The resident was found to have fallen multiple times, including sliding out of a recliner and scooting across the floor to the bathroom without activating the call light. The facility's policies required that residents be provided with an environment free from accident hazards and that fall risk assessments and interventions be implemented. However, the facility failed to implement necessary interventions for the resident using the recliner and did not identify toileting needs as a causative factor for repeated falls. This oversight placed the resident at risk for further falls and injury.
Failure to Monitor and Document Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident's physician-ordered fluid restriction was followed, monitored, and documented. The resident, who had end-stage renal disease and was dependent on dialysis, was on a fluid restriction of 1200 milliliters daily. However, the facility's records, including the Treatment Administration Record and Progress Notes, lacked evidence of monitoring and documentation of the resident's daily fluid intake. The resident admitted to not following the fluid restriction and keeping a supply of soda in her room, which was not accounted for by the staff. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's fluid restriction. A Certified Nurse Aide was uncertain about the resident's fluid restriction status, while a Licensed Nurse and an Administrative Nurse acknowledged the resident's non-compliance and the absence of documentation. The facility did not provide a policy regarding fluid restriction when requested, further indicating a deficiency in managing the resident's fluid intake, which placed the resident at risk of fluid overload and related complications.
Failure to Implement Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, as they did not identify trauma-based triggers or implement individualized interventions to prevent re-traumatization. The resident, who also had a history of cerebrovascular accident and hemiplegia, was documented to have intact cognition and impaired hearing. Despite having a trauma care plan initiated, the plan lacked specific interventions to address potential triggers, and staff were unaware of any triggers or the cause of the resident's PTSD. Observations and interviews revealed that staff, including a CNA and a licensed nurse, were not informed about the resident's PTSD diagnosis or potential triggers. The facility's trauma-informed care policy emphasized the importance of identifying and managing trauma-related triggers, yet the resident's care plan did not reflect this. The administrative nurse confirmed that the care plan lacked information about the resident's traumas or possible triggers, which placed the resident at risk for decreased psychosocial well-being and ineffective treatment.
Failure to Adhere to Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to adhere to physician-ordered parameters for administering blood pressure medications to two residents, R18 and R1, which placed them at risk for physical decline and other related complications. For R18, the facility's staff administered multiple blood pressure medications, including amlodipine, hydralazine, hydrochlorothiazide, and losartan, despite the resident's diastolic blood pressure (DBP) being below the ordered parameters on numerous occasions across October, November, and December 2024. The Certified Medication Aide (CMA) responsible for administering these medications admitted to not being aware of the specific parameters and mistakenly gave the medications when the DBP was out of range. R18's medical history included conditions such as cerebral infarction, hemiparesis, chronic obstructive pulmonary disease (COPD), diabetes mellitus, dementia, and hypertension. The resident was dependent on staff for various activities of daily living and had intact cognition. Despite these complexities, the facility did not provide a policy for administering blood pressure medications or for checking blood pressure parameters, leading to the repeated administration of medications outside the prescribed limits. Similarly, R1, who had diagnoses including Alzheimer's disease, muscle weakness, major depressive disorder, and COPD, received lisinopril outside the physician-ordered parameters multiple times in October, November, and December 2024. The facility's failure to hold the medication when R1's blood pressure was below the specified parameters was confirmed by the Administrative Nurse. Like R18, R1's care plan included monitoring for complications due to medications with Black Box Warnings, yet the facility lacked a policy to guide staff in administering blood pressure medications according to physician orders.
Failure to Document Rationale for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that two residents, R20 and R31, had an approved diagnosis or a physician-documented rationale, including risk versus benefit, for the use of the antipsychotic medication quetiapine. This deficiency was identified through observation, record review, and interviews. R20's electronic medical record included multiple diagnoses, such as insomnia, mood disorder, unspecified dementia, and anxiety disorder. Despite receiving quetiapine for dementia-related behavioral disturbances, R20's records lacked evidence of a physician-documented rationale for the medication's use. The facility's policy emphasized the inappropriate use of psychopharmacologic medications for dementia-related behaviors, advocating for non-pharmacological interventions instead. Similarly, R31's records documented diagnoses of dementia with behavioral disturbances, major depressive disorder, and bipolar disorder. R31 received quetiapine for dementia, but the clinical records lacked a physician's documented rationale for its continued use. The facility was unable to provide this information upon request. Interviews with staff revealed awareness of the inappropriate use of psychotropic medications for dementia, yet there was no evidence of attempts to change the diagnosis or justify the medication's use. The facility's undated Psychotropic Medication Monitoring policy stated the importance of complying with state and federal regulations regarding psychopharmacological medications, including regular reviews for continued need and appropriate dosage. However, the facility failed to ensure that both R20 and R31 had a CMS-approved indication or the required physician documentation for the use of antipsychotic medications, placing them at risk for unnecessary medication administration and possible adverse side effects.
Failure to Ensure Collaboration with Hospice Services
Penalty
Summary
The facility failed to ensure proper collaboration between hospice providers and the facility for two residents, R10 and R42, who were receiving hospice services. R10, who was admitted to hospice on October 1, 2024, had a care plan that lacked specific details about the hospice services, such as contact information, supplies, medications, and the schedule of hospice staff visits. Despite the care plan directing staff to work cooperatively with the hospice team, these omissions placed R10 at risk of inadequate end-of-life care. Observations and interviews revealed that while hospice services were being provided, the care plan did not reflect the necessary details to ensure comprehensive care. Similarly, R42, who was admitted to hospice on October 25, 2024, had a care plan that failed to include specific instructions on how to collaborate with hospice services. The care plan did not detail the supplies and medications provided by hospice or the schedule of hospice staff visits. Although R42's hospice binder contained a plan of care, this information was not integrated into the care plan, leading to potential gaps in care coordination. Interviews with staff indicated a lack of clarity on hospice information being included in the care plan, which could affect the quality of care provided. The facility's policy on End of Life, Palliative, and Hospice Care, revised in May 2024, stated that the facility would maintain a relationship with hospice to ensure continuity of high-quality palliative care. However, the lack of detailed care plans for R10 and R42 demonstrated a failure to adhere to this policy, resulting in a deficiency that placed both residents at risk of inadequate end-of-life care.
Failure to Prevent Sexual Abuse of Cognitively Impaired Resident
Penalty
Summary
The facility failed to prevent the sexual abuse of a cognitively impaired resident, identified as R3, who lacked the ability to consent. On a specific date, a Certified Nurse Aide (CNA) observed another resident, R2, who was cognitively intact, with his hand inside R3's pant leg up to her groin area. R3 had severe cognitive impairment, as indicated by a Brief Interview of Mental Status (BIMS) score of three, and required staff supervision for mobility. The incident placed R3 in immediate jeopardy and at risk for trauma and a negative psychosocial impact. Prior to the incident, there were multiple observations and reports of R2 engaging in inappropriate physical contact with R3. These included touching R3's knee and arm, and R3's apparent discomfort and attempts to avoid R2's reach. Despite these observations, the facility's care plans for both residents lacked interventions related to preventing such contact. R2's care plan did not address any behavior issues, and R3's care plan did not include measures to protect her from unwanted touching by R2. The facility's response to previous reports of R2's behavior was inadequate. Although staff had observed and reported R2's inappropriate contact with R3, there was no documentation of behavior issues in R2's chart, and the care plans were not updated to reflect necessary interventions. The facility's policy on abuse, neglect, and exploitation was not effectively implemented, as evidenced by the failure to prevent the incident of sexual abuse involving R3.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a cognitively impaired resident, R3, from sexual abuse by another resident, R2, who was cognitively intact. R2, who had a history of inappropriate touching, was observed by a CNA with his hand inside R3's pant leg up to her groin area. R3, who had severe cognitive impairment and was unable to consent, was placed in immediate jeopardy due to this incident. The facility's care plan for R2 did not include any interventions related to his behavior, and there was a lack of documentation regarding his inappropriate actions. Prior to the incident, there were multiple observations and reports of R2's inappropriate behavior towards R3, including touching her knee and arm. Despite these observations, the facility did not update R2's care plan to address these behaviors, nor did they document these incidents in R2's progress notes. Staff members, including CNAs and administrative staff, witnessed these interactions but failed to take adequate action to prevent further occurrences. The facility's policy on abuse, neglect, and exploitation was not effectively implemented, as evidenced by the lack of documentation and intervention regarding R2's behavior. The facility's failure to protect R3 from sexual abuse and to document and address R2's inappropriate behavior resulted in a deficiency, placing R3 at risk for trauma and negative psychosocial impact.
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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