Lakepoint Wichita, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Wichita, Kansas.
- Location
- 1315 N West Street, Wichita, Kansas 67203
- CMS Provider Number
- 175466
- Inspections on file
- 20
- Latest survey
- January 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lakepoint Wichita, Llc during CMS and state inspections, most recent first.
The facility failed to submit accurate staffing information through the PBJ, as required by CMS, indicating low weekend staffing and missing RN hours for several days. A review showed appropriate staffing, and an administrative nurse suggested previous owners' incorrect submissions might be the cause. The facility's policy requires accurate staffing data submission, distinguishing between employees and agency workers, at least quarterly. This failure placed residents at risk for inadequate staffing.
The facility failed to use appropriate barriers for soiled laundry, lacked a waterborne pathogen prevention program, and did not implement Enhanced Barrier Precautions (EBP) for residents with specific conditions. Staff did not use gowns during high-contact care, and there was no documentation of a water management plan, increasing the risk of infection transmission.
The facility failed to ensure the Consultant Pharmacist identified and reported missing stop dates for PRN antianxiety medications for several residents, and did not respond to requests for a diagnosis for a resident's use of Effexor and Haldol. This oversight placed residents at risk for inappropriate medication use.
The facility failed to ensure that PRN psychotropic medications for several residents had a 14-day stop date or specified duration, as required by policy. This oversight was observed in residents prescribed antianxiety medications like Ativan and hydroxyzine without a stop date or physician's rationale for extended use. Additionally, some residents were prescribed medications like Effexor and Haldol without appropriate diagnoses, placing them at risk for unnecessary adverse side effects.
The facility failed to discard expired Prevnar vaccine vials and did not date insulin pens for several residents, risking ineffective medication administration. Staff confirmed the presence of expired vials and the lack of open dates on insulin pens, which violated the facility's Medication Storage and Labeling policy.
A resident with dementia and other conditions was referred to as a 'feeder' by staff, and assistance with meals was provided while standing, which was deemed undignified. The facility's policy on resident rights was not upheld, leading to a deficiency in maintaining the resident's dignity.
A facility failed to provide a resident with the CMS Form 10055, Advanced Beneficiary Notice (ABN), when their skilled services ended. The ABN, which informs beneficiaries about potential Medicare non-coverage and financial responsibility, was not given, leading to uninformed decisions. Administrative staff acknowledged the oversight, and the facility lacked an ABN policy.
A facility failed to notify the State Long Term Care Ombudsman of a resident's discharge to the hospital, as required by policy. The resident, who had multiple medical conditions and required assistance with daily activities, was found unresponsive with low blood sugar, leading to a hospital transfer. The responsible staff member was no longer employed, and the administrative nurse acknowledged the oversight.
Hazardous chemicals, including toilet bowl cleaner and Comet, were found unsecured in an unlocked cabinet in a facility, posing a risk to two cognitively impaired, independently mobile residents. The facility's policy required such chemicals to be stored in a locked area, which was not followed.
A resident with multiple sclerosis and a neurogenic bladder did not receive proper urinary catheter care, leading to a deficiency. Observations showed a CNA did not use a gown during care, and the catheter tubing was often on the floor, risking contamination. The facility failed to implement Enhanced Barrier Precautions due to misunderstanding, despite care plans and physician orders outlining necessary procedures.
The facility failed to complete trauma-informed care assessments and develop care plans for two residents with PTSD, depression, and anxiety. Both residents' care plans lacked interventions to identify triggers and prevent re-traumatization. Staff interviews revealed a lack of awareness about the residents' PTSD and the necessary assessments, despite the facility's policy emphasizing trauma-informed care.
The facility failed to coordinate care between the facility and hospice providers for two residents receiving hospice services. Both residents' care plans lacked specific instructions on hospice services, such as support visits, supplies, and medications. This deficiency was confirmed by the facility's administrative nurse and nurse consultant, placing the residents at risk for inadequate end-of-life care.
A resident with multiple health issues and cognitive impairment experienced repeated falls, including one resulting in a fractured wrist, due to inadequate interventions and lack of a comprehensive fall prevention plan. Despite being at high risk for falls, the facility failed to implement effective measures, such as a toileting schedule or consistent monitoring, to prevent these incidents.
Inaccurate PBJ Data Submission
Penalty
Summary
The facility failed to submit complete and accurate staffing information through the Payroll-Based Journal (PBJ) as required by the Centers for Medicare & Medicaid Services (CMS). The PBJ report for Fiscal Year 2023 Quarter 4 and Fiscal Year 2024 Quarter 1 indicated excessively low weekend staffing and a lack of Registered Nurse (RN) hours for several days in January, February, and March 2024. However, a review of the facility's records showed appropriate weekend staffing and RN coverage on the specified dates. An administrative nurse suggested that the discrepancy might be due to incorrect submissions by the previous company owners. The facility's policy mandates the submission of accurate staffing data, including the category of work for each direct care staff member, distinguishing between employees and agency or contract workers, and submitting this data to CMS at least quarterly. The failure to submit accurate PBJ data placed residents at risk for unidentified and ongoing inadequate staffing.
Inadequate Infection Control Measures in LTC Facility
Penalty
Summary
The facility failed to use appropriate barriers while handling soiled laundry, which could lead to cross-contamination between soiled and clean laundry. Maintenance Staff U confirmed that laundry staff only used gloves without wearing a barrier gown or apron while sorting soiled laundry. This practice was contrary to the facility's policy, which required the use of personal protective equipment to prevent the spread of infection. The facility also did not maintain an ongoing waterborne pathogen prevention program to address and mitigate the risk of Legionella. Maintenance Staff U reported that the procedure involved flushing toilets and running faucets and showers weekly in areas with fewer residents, but there was no documentation or evidence of a water management plan. This lack of documentation and monitoring placed residents at risk of contracting Legionella pneumonia. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) for three residents with conditions requiring such precautions. Observations revealed that staff did not use gowns during high-contact care activities, such as handling gastrostomy tubes and urinary drainage bags. Interviews with staff indicated a lack of understanding regarding EBP requirements, and there were no EBP signs or PPE available in the residents' rooms. This failure to implement EBP increased the risk of infection transmission among residents.
Failure to Ensure Proper Medication Management and Communication
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported the absence of required stop dates for as-needed (PRN) antianxiety medications for several residents, including R31, R37, R52, and R68. These medications, such as Ativan and hydroxyzine, were prescribed without a specified end date, which is a critical oversight in medication management. The CP's monthly medication regimen reviews for these residents did not include any recommendations or alerts regarding the missing stop dates, which is a deviation from the facility's Medication Administration policy. Additionally, the facility did not respond to the CP's request for a diagnosis for R17's use of Effexor and Haldol. Despite the CP's repeated requests for an update on the diagnosis for these medications, the facility's records lacked a physician's response or rationale for their continued use. This oversight placed R17 at risk for inappropriate use of psychotropic medications without a clear medical justification. The facility's failure to adhere to its own policies regarding medication regimen reviews and communication of findings to the physician or prescriber resulted in multiple residents being at risk for inappropriate or unnecessary medication use. The lack of stop dates and unaddressed CP recommendations highlight significant gaps in the facility's medication management processes, potentially leading to adverse effects for the residents involved.
Failure to Ensure Stop Dates for PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure that psychotropic medications prescribed on an as-needed (PRN) basis for several residents had a 14-day stop date or specified duration, as required by their policy. This oversight was observed in the cases of multiple residents who were prescribed antianxiety medications such as Ativan and hydroxyzine without a stop date or physician's rationale for extended use. For instance, one resident with diagnoses including depression and anxiety was prescribed Ativan without a stop date, placing them at risk for adverse medication side effects. Similarly, another resident with severe cognitive impairment was prescribed Ativan for restlessness without a stop date, despite exhibiting behaviors that could potentially be managed with non-pharmacological interventions. Additionally, the facility did not obtain appropriate diagnoses for the use of certain psychotropic medications for some residents. One resident was prescribed Effexor and Haldol without documented physician diagnoses or rationale for their continued use. This lack of documentation and oversight in medication management placed the resident at risk for unnecessary adverse side effects. The facility's policy required that psychotropic medications be accompanied by a qualifying diagnosis and a list of specific target behaviors to be monitored, which was not adhered to in these cases. The facility's failure to adhere to its psychotropic medication policy, which mandates a 14-day stop date for PRN medications and requires a physician's rationale for continued use, resulted in several residents being at risk for unnecessary medication side effects. The lack of proper documentation and monitoring of these medications, as well as the absence of non-pharmacological interventions, contributed to the deficiencies identified during the survey.
Failure to Properly Store and Label Biologicals and Insulin Pens
Penalty
Summary
The facility failed to properly store and label biologicals, specifically by not discarding six expired vials of Prevnar vaccine in one of the medication rooms. During an observation, it was noted that these vials had an expiration date of August 2024, yet they were still present in the medication room in December 2024. Licensed Nurse K confirmed the presence of the expired vials and acknowledged that expired medications should be placed in a designated bin for destruction by the pharmacy. Administrative Nurse D also verified that expired medications should be disposed of appropriately, as per the facility's Medication Storage and Labeling policy. Additionally, the facility did not place open dates on insulin pens for several residents, which is a requirement for ensuring the effectiveness of the medication. Observations revealed that insulin pens for multiple residents lacked open and discard dates. Licensed Nurse J confirmed these findings and stated that staff should date insulin pens when opened. Administrative Nurse D reiterated the expectation for staff to place open dates on insulin pens. The failure to date these insulin pens was contrary to the facility's policy and placed residents at risk of receiving ineffective doses of insulin.
Failure to Promote Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to promote dignity for a resident, identified as R29, when staff referred to her as a 'feeder' and stood while assisting her with meals. R29, who had diagnoses including dementia, major depressive disorder, delusional disorder, anxiety, and hypertension, was dependent on staff for various activities, including eating. Observations revealed that a Certified Nurse Aide (CNA) referred to the dining area as the 'feeder table' and mentioned that residents who required assistance with eating were seated there. This language and approach were deemed undignified. Additionally, it was observed that a CNA stood beside R29 while assisting her with eating, which was addressed by administrative staff as a dignity issue. The facility's Resident Rights policy emphasized the right to a dignified existence and self-determination, which was not upheld in this instance. The actions of the staff, including the use of undignified language and standing while assisting with meals, contributed to the deficiency in maintaining and enhancing the resident's dignity and respect.
Failure to Provide Advanced Beneficiary Notice
Penalty
Summary
The facility failed to provide the CMS Form 10055, Advanced Beneficiary Notice (ABN), to a resident, identified as R429, or their representative when the resident's skilled services ended. This oversight was discovered during a review of the resident's clinical record, which lacked evidence of the ABN being provided. The ABN form is crucial as it informs beneficiaries that Medicare may not cover future skilled therapy and outlines the options available to them, including the potential financial responsibility if Medicare does not pay. The absence of this form placed the resident at risk for making uninformed decisions regarding their skilled services. Administrative Staff B admitted to contacting R429's representative by phone when it was time for the resident to be discharged from skilled care. During this conversation, the representative expressed a desire for the resident to remain in the facility for a few more days due to a family death. Although the staff member informed the representative about the increase in room price, they failed to provide the necessary information on the ABN form CMS 10055. This was confirmed by Administrative Staff A, who verified that the ABN was not provided. Additionally, the facility was unable to produce an ABN policy upon request, further highlighting the deficiency in their process.
Failure to Notify LTCO of Resident's Hospital Discharge
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman (LTCO) of a facility-initiated discharge of a resident, identified as R31, to the hospital. R31 had a range of medical conditions, including depression, anxiety, osteomyelitis, pain, atrial fibrillation, and peripheral vascular disease. The resident was documented to have intact cognition and required substantial assistance with daily activities. On a specific date, a nurse found R31 unresponsive with a low blood sugar level, prompting the family to request hospital evaluation. However, the facility's records lacked documentation of notifying the LTCO about this discharge. Interviews with facility staff revealed that the social service personnel responsible for notifying the LTCO was not employed at the time of R31's discharge, and the administrative nurse confirmed that the notification should have been sent. The facility's policy required notifying the LTCO of any facility-initiated transfer or discharge at the same time the resident or their representative was informed. The failure to notify the LTCO was a breach of this policy, placing the resident at risk for impaired rights.
Hazardous Chemicals Found Unsecured in Facility
Penalty
Summary
The facility failed to ensure an environment free from accident hazards by leaving hazardous chemicals in an unlocked wooden cabinet. During an observation, it was found that the cabinet contained a container of toilet bowl cleaner, a container of Comet, two aerosol spray deodorants, and a container of Virex. These items were accessible in the 200-hall quiet area near the visitor bathroom, posing a risk to two cognitively impaired, independently mobile residents. The labels on these products indicated that they could cause harm if ingested, inhaled, or if they came into contact with skin or eyes. Maintenance Staff verified the presence of these chemicals in the unlocked cabinet and acknowledged that they should have been stored in a locked housekeeping cart. The facility's Chemical Storage Policy, revised earlier in the year, required that all hazardous chemicals be stored in a locked area or used under supervision. The failure to adhere to this policy placed the residents at risk for preventable accidents or injuries.
Deficiency in Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with a urinary catheter, leading to a deficiency in maintaining standards of care. The resident, who had multiple sclerosis and a neurogenic bladder, was dependent on staff for catheter management. Observations revealed that a Certified Nurse Aide (CNA) did not use a gown while performing catheter care, and the drainage port tip was allowed to touch urine in the container, which is against infection control protocols. Additionally, the facility did not provide alcohol wipes for cleaning the drainage port, and the catheter tubing was observed resting on the floor multiple times, increasing the risk of contamination. The facility's care plan and physician orders directed specific catheter care procedures, including monthly catheter changes, catheter care every shift, and the use of Enhanced Barrier Precautions (EBP). However, the facility did not implement EBP due to a lack of understanding, as confirmed by administrative staff. The facility's policy required the catheter and drainage bag to be maintained as a closed system, with the drainage bag kept lower than the bladder and emptied regularly. The failure to adhere to these protocols placed the resident at risk for catheter-related complications and urinary tract infections.
Failure to Implement Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to complete trauma-informed care assessments and develop trauma-informed care plans for two residents diagnosed with PTSD, depression, and anxiety. Resident 52's electronic medical record documented these diagnoses, but there was no evidence of a trauma-informed care assessment. The care plan for Resident 52 lacked interventions related to PTSD, such as identifying triggers and preventing re-traumatization. Observations and interviews with staff revealed a lack of awareness regarding the resident's PTSD and the necessary assessments. Similarly, Resident 71's electronic medical record documented diagnoses of PTSD, depression, anxiety, auditory hallucinations, and schizophrenia. However, there was no evidence of a trauma-informed care assessment after admission. The care plan for Resident 71 also lacked interventions related to PTSD. Staff interviews indicated a lack of awareness about the resident's PTSD and the required assessments. The facility's Trauma Informed Care policy emphasized the importance of implementing trauma-informed approaches to care. Despite this policy, the facility did not complete the necessary assessments and care plans for the residents with PTSD, placing them at risk for unmet behavioral and mental health needs.
Lack of Coordination in Hospice Care for Two Residents
Penalty
Summary
The facility failed to ensure coordinated care and services between the facility and hospice providers for two residents, R39 and R31, who were receiving hospice services. For R39, the electronic health record indicated severe cognitive impairment and required extensive assistance with activities of daily living. Despite being admitted to hospice care, R39's care plan lacked specific instructions on the services provided by hospice, such as the frequency and type of support visits, supplies, medical equipment, medications covered by hospice, and hospice contact information. This lack of coordination was confirmed by the facility's administrative nurse and nurse consultant. Similarly, R31, who had intact cognition and required substantial assistance with daily activities, was also receiving hospice services. However, R31's care plan did not include detailed instructions on hospice services, similar to the deficiencies found in R39's care plan. The care plan directed staff to work with hospice to ensure comfort and pain management but lacked specifics on hospice-provided services. This deficiency was also verified by the facility's administrative nurse and nurse consultant. The facility's End of Life Palliative Care and Hospice Care policy outlined the need for a comprehensive and timely interdisciplinary assessment and care plan development based on resident and family preferences, values, goals, and needs. However, the facility failed to implement this policy effectively, as evidenced by the lack of coordination and detailed care plans for residents R39 and R31, placing them at risk for inadequate end-of-life care.
Failure to Prevent Falls in Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide a safe environment for a resident, identified as R2, who experienced multiple falls, one of which resulted in a fractured wrist. R2 had a history of chronic respiratory failure, alcoholic cirrhosis of the liver, congestive heart failure, and anxiety, and was receiving hospice services. Despite these conditions, the facility did not implement adequate interventions to prevent falls, as evidenced by the lack of a change of condition assessment and a comprehensive fall care plan. R2's care plan and assessments indicated a high risk for falls due to factors such as weakness, decreased mobility, medication use, and recent admission to hospice. However, the facility's interventions were insufficient and inconsistent. For instance, after a fall on 06/05/24, the intervention was merely to educate the family not to move the resident. Subsequent falls on 06/12/24 and 06/27/24 resulted in interventions like rearranging furniture and re-educating the resident to use the call light, but these measures did not address the root causes of the falls. Observations and interviews revealed that R2 was often confused, hallucinated, and removed her oxygen tubing, which contributed to her falls. Despite being incontinent and requiring assistance with toileting, there was no documented toileting schedule or plan. Staff interviews confirmed that R2 was not on a toileting program, and the facility lacked a root cause analysis for her falls. The facility's policy for documenting accidents and incidents was not adequately followed, as evidenced by the lack of detailed assessments and interventions to prevent further falls.
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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