Lansing Care And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Lansing, Kansas.
- Location
- 210 Plaza Drive, Lansing, Kansas 66043
- CMS Provider Number
- 175228
- Inspections on file
- 21
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Lansing Care And Rehab during CMS and state inspections, most recent first.
A cognitively impaired, wheelchair-dependent resident with severe dementia, impaired balance, and a history of falls required extensive staff assistance and two-person participation for bed mobility and transfers per the care plan. During an attempted transfer to bed while the resident was resisting, two CNAs repositioned the wheelchair, causing the resident’s angled left leg to strike the bed frame, after which the resident screamed that staff had broken her knee; one CNA then performed a hug transfer without the other’s help. The event was reported to a nurse, who initially noted no visible injury and believed the resident’s pain was at baseline, but bruising and significant pain on palpation were identified later, and imaging subsequently revealed an oblique proximal tibia and fibula fracture with soft tissue swelling that orthopedics characterized as acute. The facility’s accident policy emphasized maintaining an environment free from accident hazards and providing supervision and assistance based on individual risk factors.
A resident's CPAP mask was found unbagged and resting directly on a bedside table, contrary to facility protocols requiring respiratory equipment to be stored in dated bags when not in use. Staff interviews confirmed inconsistent adherence to this practice. Additionally, the facility lacked a comprehensive, facility-specific water management program to address Legionella and other waterborne pathogens, with only general documentation and a single test on record, and no evidence of ongoing risk assessment or monitoring.
Staff did not consistently lock medication and treatment carts containing treatment supplies, PRN creams, and insulin pens when the carts were not within the nurses' line of sight. Facility policy and staff interviews confirmed that carts should be locked when unattended to ensure safe and secure storage of drugs and biologicals.
A resident with multiple chronic conditions was admitted to hospice, but the facility did not document the required physician order for hospice admission, failed to complete the Significant Change MDS and CAA within required timeframes, and omitted details about hospice-provided medications and equipment from the care plan. Staff interviews confirmed that this information should have been included per facility policy.
Two residents experienced a lack of dignity and respect during care interactions. One resident, dependent on staff for all ADLs and cognitively intact, was spoken to disrespectfully by a CNA in her room. Another resident with severe cognitive impairment and physical limitations was fed by staff standing over him in the dining area, with his bare abdomen exposed to others. Staff interviews and facility policy confirmed these actions did not meet expected standards for resident dignity and respectful care.
A resident with severe cognitive impairment and total dependence on staff for care was subjected to verbal and emotional abuse when a CNA forcibly took away her comfort item and used derogatory language. This action violated the resident's care plan and the facility's abuse prevention policy, which require staff to treat all residents with respect and dignity.
A resident with dementia and severely impaired cognition was administered antipsychotic medications without appropriate physician documentation, including rationale, evidence of unsuccessful nonpharmacological interventions, or risk-benefit assessment. The facility's records included an unsigned consent form and lacked the required supporting documentation, despite policy requirements for such oversight.
A resident with multiple chronic conditions was admitted to hospice, but the facility did not complete the required Significant Change MDS or Care Area Assessment within the mandated timeframe. The resident's EMR also lacked a hospice admission order, and staff interviews revealed delays and unclear responsibility for MDS completion.
A resident with severe cognitive impairment, multiple medical diagnoses, and a history of falls did not have fall prevention interventions implemented as directed by the care plan. Observations revealed the call light was out of reach and the fall mat was not placed by the bed as required, despite staff and facility policy stating these measures should be in place.
A consultant pharmacist did not identify or report the absence of an Abnormal Involuntary Movement Scale (AIMS) test for a resident prescribed Reglan, despite the resident's medical history and ongoing medication regimen. Monthly medication reviews lacked documentation or recommendations for the required AIMS test, and nursing staff confirmed the assessment was not completed or available when requested.
A resident receiving Reglan for nausea, with a history of CHF, diabetes, and GERD, was not monitored for adverse effects using the AIMS test or any alternative method. Staff indicated that the facility's system did not trigger AIMS testing for this medication, and no policy for monitoring medication side effects was available upon request.
Failure to Provide Safe, Assisted Transfer Resulting in Leg Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision during a transfer for a cognitively impaired resident with severe dementia, generalized muscle weakness, impaired balance, history of falls, and dependence on staff for transfers and mobility. The resident’s MDS and care plans documented severe cognitive impairment (BIMS score of 4), dependence on staff for wheelchair mobility and transfers, and the need for substantial to maximal assistance with bed mobility, transfers, and ADLs. The care plan further specified that two staff were to participate in repositioning and turning the resident in bed, and that staff were to observe for and report redness, open areas, scratches, cuts, and bruises to the nurse. On the date of the incident, two CNAs attempted to assist the resident into bed while the resident was resisting and hitting staff. One CNA reported that, due to the wheelchair’s “weird” position, the assisting CNA swung the wheelchair toward the bed frame to turn it while the resident’s left leg was positioned behind the right leg at an angle. During this maneuver, the resident’s left knee hit the bed frame, and the resident immediately screamed and yelled that staff had broken her knee, using expletives. The witness CNA stated that the bed frame height aligned with the area of the resident’s later-observed bruise and that the resident’s leg position at the time of impact was as she demonstrated, with the left leg angled behind the right. The witness CNA further reported that, after repositioning the wheelchair, the assisting CNA decided to perform a “hug” transfer of the resident into bed without the witness CNA’s help, and the resident again cried out that staff had broken her knee. The CNAs reported to the nurse that the resident had bumped her leg on the bed frame and cried out in pain. Following the incident, the nurse who was informed the next morning assessed the resident and did not initially observe redness or bruising, and believed the resident’s pain was at baseline, noting the resident had a history of leg pain and frequent refusal of pain medication. Two days after the incident, a CNA reported bruising below the resident’s left knee, and a nurse documented facial grimacing and yelling upon palpation of the lower leg. An x-ray obtained at that time showed an oblique fracture of the proximal tibia and proximal fibula with soft tissue swelling and age-indeterminate fractures. The orthopedic clinic later documented that, although the exact timing and mechanism of the fracture were unclear, there were acute findings on the x-rays, including well-defined fracture lines and absence of healing, and the fracture would be treated as acute. The facility’s own accident policy stated that the environment should be as free from accident hazards as possible and that resident safety, supervision, and assistance to prevent accidents were facility-wide priorities, using a systems approach that considers environmental hazards and individual resident risk factors.
Deficiencies in Infection Control: Improper CPAP Mask Storage and Inadequate Water Management Program
Penalty
Summary
The facility failed to ensure that a resident's continuous positive airway pressure (CPAP) mask was stored in a sanitary manner. During observation, the resident's unbagged CPAP mask was found resting directly on the bedside table, with no storage bag visible. The resident confirmed that the mask was usually not stored in a bag and that she did not have one for her CPAP mask. Interviews with staff revealed that the facility's practice was to store respiratory masks in dated bags when not in use, with the night shift responsible for ensuring bags were available and the day shift responsible for placing the mask in the bag. However, this protocol was not followed for the resident in question. Additionally, the facility failed to develop, implement, and maintain a comprehensive water management program to reduce the risk of Legionella and other waterborne pathogens. While documentation of Legionella testing and general monitoring instructions were available, they were not specific to the facility and lacked evidence of a risk assessment or ongoing monitoring to identify potential sources of Legionella growth. The maintenance staff was only aware of a single test conducted and did not have a detailed water management plan or diagram, indicating a lack of a systematic approach to water safety as required by facility policy.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
Staff failed to ensure that medication carts and treatment carts containing residents' treatment supplies, PRN creams, and insulin pens were always locked when not within the nurses' line of sight. On one occasion, a treatment cart was observed unlocked in a hallway, and an administrative nurse subsequently locked it. Interviews with nursing staff confirmed that facility policy requires medication and treatment carts to be locked if staff are not able to see them. The facility's policy, revised in October 2024, states that all drugs and biologicals must be stored in a safe, secure, and orderly manner.
Failure to Document Hospice Services and Orders in Resident Records
Penalty
Summary
The facility failed to provide a comprehensive description of the medication and equipment supplied by hospice services for a resident with diagnoses of congestive heart failure, diabetes mellitus, and gastroesophageal reflux. The resident was admitted to hospice services, but the Electronic Medical Record (EMR) did not include an order for hospice admission, and the order provided was only found on the hospice provider's certification form. Additionally, the Significant Change Minimum Data Set (MDS) was not completed following the resident's admission to hospice, and the Care Area Assessment (CAA) was not completed within the required 14-day period after the MDS was initiated. The resident's care plan documented the frequency of hospice nurse and aide visits but lacked details regarding the specific equipment and medications provided by hospice. Interviews with facility staff confirmed that care plans and Kardexes should include hospice information, such as equipment, medications, and services, but these details were missing. The facility's policy required written identification of hospice services and a physician's order with diagnosis and prognosis, but these requirements were not met for the resident in question.
Failure to Maintain Resident Dignity and Respect During Care Interactions
Penalty
Summary
The facility failed to provide a dignified care environment for two residents, resulting in deficiencies related to respect and dignity. One resident with quadriplegia, diabetes, anxiety disorder, and major depressive disorder, who was cognitively intact and dependent on staff for all activities of daily living, experienced an incident where a Certified Nurse's Aide (CNA) entered her room and responded to her inquiry with, "it's none of your business." The resident alleged the CNA used abusive language, which was partially corroborated by the CNA's admission to making a disrespectful comment. The care plan for this resident required at least two staff members to be present during interactions due to a history of allegations, but the report does not specify if this protocol was followed during the incident. Another resident with a history of stroke, diabetes, aphasia, and severe cognitive impairment, who was dependent on staff for all activities of daily living except eating, was observed being assisted with meals in a manner that did not maintain his dignity. Staff were seen standing over the resident while feeding him at the dining table, and his bare abdomen and right side were exposed to peers. Facility staff interviews confirmed that the expected practice was to sit beside residents while assisting with eating and to ensure residents' skin was covered in the dining area, but these standards were not upheld during the observed incidents. Facility policies on resident rights and respect and dignity, as well as staff interviews, emphasized the importance of treating residents with respect, maintaining their dignity, and following specific protocols for care and communication. However, the observed actions and interactions with the two residents did not align with these policies, resulting in a failure to honor the residents' rights to a dignified existence and respectful treatment.
Staff-to-Resident Verbal and Emotional Abuse Incident
Penalty
Summary
A staff-to-resident verbal and emotional abuse incident occurred involving a resident with severe cognitive impairment, dementia, muscle weakness, repeated falls, and dependence on staff for all activities of daily living. The resident, who used a wheelchair and relied on a stuffed bear as a coping mechanism, was subjected to abusive language by a Certified Nurse's Aide (CNA). The CNA forcibly took the resident's bear away against her wishes and called her a derogatory name. This incident was witnessed by another CNA, who reported the event. The resident's care plan required staff to provide structured routines, positive feedback, and activities compatible with her abilities, emphasizing respect and dignity. Despite these directives and the facility's policy prohibiting all forms of abuse, the staff member failed to uphold these standards, resulting in verbal and emotional abuse. The facility's policy defined mental abuse to include verbal conduct causing humiliation or agitation, which was directly violated in this incident.
Lack of Physician Documentation for Antipsychotic Use in Resident with Dementia
Penalty
Summary
The facility failed to ensure that a resident with dementia and severely impaired cognition received antipsychotic medications only with appropriate physician documentation and rationale. The resident, who also had diagnoses of repeated falls, muscle weakness, and Parkinson's disease, was prescribed Haloperidol for hallucinations and Seroquel for anxiousness. The medical record and care plan indicated ongoing use of these medications, with monthly pharmacist reviews and physician oversight of recommendations. However, the facility was unable to provide documentation from the physician that included a clear rationale for the continued use of antipsychotic medications, evidence of multiple unsuccessful attempts at nonpharmacological interventions, or an assessment of the risks versus benefits for this resident. Additionally, the consent form for psychoactive medication therapy was unsigned and lacked the required physician documentation. Interviews confirmed that the facility used preprinted consent forms and that the resident was on hospice services, with the family requesting continuation of the antipsychotic medication. The facility's policy required that psychotropic drugs be used only when necessary for specific conditions and not for staff convenience or discipline, and that residents or their representatives have the right to refuse such treatment. Despite these requirements, the necessary physician documentation supporting the use of antipsychotic medication for this resident was not present.
Failure to Complete Significant Change MDS and CAA for Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment and the associated Care Area Assessment (CAA) for a resident who was admitted to hospice services. The resident, who had diagnoses of congestive heart failure, diabetes mellitus, and gastroesophageal reflux, was admitted to hospice, but the required Significant Change MDS was not completed within the mandated timeframe. Additionally, the CAA was not completed within 14 days after the initiation of the Significant Change MDS. The resident's electronic medical record did not contain an order for hospice admission, although an order was present on the hospice provider's certification form. Interviews with facility staff revealed that the nurse responsible for completing the MDS was behind due to providing direct care to residents. Another staff member indicated that both administrative and corporate staff were responsible for ensuring timely MDS completion as required by CMS. The facility was unable to provide a policy regarding the required timing for MDS completion when requested by surveyors.
Failure to Implement Fall Prevention Interventions as Directed by Care Plan
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plan for a resident with multiple medical conditions, including hypertension, diabetes, a history of stroke, pelvic fracture, dysphagia, aphasia, and severe cognitive impairment. The resident was dependent on staff for all activities of daily living except eating, was nonverbal or rarely understood, and used a staff-propelled Broda chair for mobility. The care plan specified that the resident's bed should be kept in the lowest position, a fall mat should be placed next to the bed, and the call light should be within reach. However, during observations, the call light was found out of the resident's reach, and the fall mat was not positioned next to the bed as required, but instead was folded up next to the Broda chair. Interviews with facility staff, including a Certified Medication Aide, a Licensed Nurse, and an Administrative Nurse, confirmed that call lights should be within reach and fall mats should be placed by the bed for residents who require them. The facility's own policy emphasized the importance of maintaining an environment free from accident hazards and prioritizing resident safety and supervision. Despite these policies and care plan directives, the required fall prevention measures were not consistently implemented for this resident.
Failure to Identify and Report Missing AIMS Test During Drug Regimen Review
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported medication irregularities for a resident with multiple diagnoses, including congestive heart failure, diabetes mellitus, and gastroesophageal reflux. The resident had intact cognition and was receiving insulin, a diuretic, and an antidepressant, as documented in the Minimum Data Set (MDS) and Care Area Assessment (CAA). The resident was also prescribed Reglan (Metoclopramide HCl), an antiemetic, to be taken before meals for nausea. Despite this, the Monthly Medication Reviews (MMRs) for August and September did not include documentation or recommendations for an Abnormal Involuntary Movement Scale (AIMS) test, which is necessary to monitor for adverse effects associated with Reglan. Interviews with nursing staff revealed that AIMS testing was not completed for the resident, and the facility was unable to provide evidence of an AIMS test when requested. The administrative nurse acknowledged that the CP should have identified the lack of an AIMS test and that the issue was brought to the attention of both the CP and the corporate office. The facility's policy required the pharmacy to have access to complete medical records and the ability to document in the resident's record, but the deficiency occurred due to the CP's failure to identify and report the missing AIMS test during the monthly drug regimen review.
Failure to Monitor for Adverse Effects of Reglan
Penalty
Summary
The facility failed to ensure appropriate monitoring for adverse effects of the medication Reglan (Metoclopramide HCl) for a resident with diagnoses including congestive heart failure, diabetes mellitus, and gastroesophageal reflux. The resident's medical record documented the use of multiple medications, including insulin, a diuretic, and an antidepressant, and indicated intact cognition. The care plan specified that medications would be administered as ordered and that the resident would be monitored for side effects, with documentation of effectiveness. Despite a physician's order for Reglan to be administered before meals for nausea, the facility was unable to provide evidence of an Abnormal Involuntary Movement Scale (AIMS) test or any other method of monitoring for side effects related to this medication. Staff interviews revealed that AIMS testing was not triggered for this resident because Reglan was not classified as a psychotropic medication in the facility's system. Additionally, the facility could not provide a policy related to monitoring medication side effects when requested.
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.
The facility failed to coordinate hospice services within the care plans for two residents receiving hospice. Both residents had severe cognitive impairment and extensive ADL needs, and their MDS assessments documented hospice care. Their care plans included general directions about ADL assistance, pain monitoring, and consulting with hospice or the physician, but omitted key hospice-specific details such as hospice contact information, visit schedules, services to be provided, and what supplies, equipment, and medications hospice would furnish. Clinical record review and interviews with an administrative nurse confirmed that there was no documented coordination between hospice and facility care plans, contrary to the facility’s hospice policy requiring an interdisciplinary plan integrating hospice and facility services.
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 Coordinate Hospice Services in Resident Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain a coordinated hospice plan of care that integrated hospice services with facility services for two residents receiving hospice. For one resident with Alzheimer’s disease, CAD, and atrial fibrillation, the Significant Change MDS documented severely impaired cognition and extensive assistance needs for bed mobility and transfers, and indicated the resident was receiving hospice services. The resident’s care plan noted a terminal prognosis due to Alzheimer’s, directed staff to adjust ADL care, consult the physician for hospice care in the facility, and monitor and treat pain, but it did not include instructions on hospice services such as hospice staff visit schedules, supplies, medical equipment, or medications covered by hospice. The clinical record showed the resident had been admitted to hospice care months earlier, yet there was no documented evidence of coordination of care between hospice and the facility. For the second resident, diagnosed with PVD, DM, HTN, and atherosclerotic heart disease, the Significant Change MDS showed severe cognitive impairment with a BIMS score of two and dependence on staff for most ADLs, and documented that the resident received hospice services. The resident’s care plan recorded admission to hospice and directed staff to adjust ADL provision, encourage participation as desired, assess coping, respect wishes, and consult with the physician and hospice for continuing hospice care, as well as monitor for pain and notify the physician and hospice for breakthrough pain. However, the care plan lacked a hospice contact number, information on what supplies, equipment, and medications hospice would provide, and details on when hospice staff would be in the building and what care they would deliver. Observations and staff interviews confirmed these omissions. One resident was observed in bed receiving eye drops from a CMA, and during record review, the Administrative Nurse acknowledged that the facility care plan lacked specific information coordinating with the hospice care plan. For the second resident, the Administrative Nurse verified that the care plan did not contain information regarding hospice visits, phone numbers, or medical supplies provided by hospice, and stated that such information should be on the resident’s care plan. These findings were inconsistent with the facility’s Hospice Services policy, which required an interdisciplinary care plan integrating facility and hospice services, including coordination of services and supplies provided by the hospice provider.
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