Legacy At College Hill
Inspection history, citations, penalties and survey trends for this long-term care facility in Wichita, Kansas.
- Location
- 5005 E 21st Street North, Wichita, Kansas 67208
- CMS Provider Number
- 175078
- Inspections on file
- 20
- Latest survey
- May 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Legacy At College Hill during CMS and state inspections, most recent first.
The facility did not maintain an effective pest control program, as evidenced by staff and resident reports of rodents and rodent droppings in rooms and common areas. A resident with intact cognition showed surveyors two dead mice caught in traps she placed under her bed, and housekeeping staff found rodent droppings and a dead rodent during cleaning. The pest control service had been discontinued due to unpaid invoices, and the facility's policy requiring ongoing pest control was not followed.
A resident with intact cognition and a housekeeper reported that a section of flooring at the dining room entrance had been missing and covered with water-saturated blankets for several weeks, creating ongoing safety concerns. Administrative staff confirmed the issue was due to a broken pipe and noted a lack of documentation and unresolved payment issues for repairs, resulting in failure to provide a safe and homelike environment.
A resident with dementia, depression, and traumatic brain injury, who was assessed as at risk for elopement, was able to exit the facility unsupervised due to staff failing to keep the Elopement Risk Book current and accurate. The book, used to alert staff to residents at risk for elopement, contained outdated information, lacked required photos and face sheets, and staff were unclear about which residents were at risk or responsible for updates. This lapse in documentation and supervision led to an increased risk of elopement for affected residents.
The facility failed to implement a water management program for Legionella and did not follow proper infection control practices for storing oxygen equipment. Two residents had unbagged oxygen tubing and nasal cannulas left in their wheelchairs, exposing them to potential contamination. The facility lacked documentation of completed water management processes and did not provide a policy for sanitary storage of medical equipment.
The facility failed to maintain a safe and sanitary environment in the main dining room and 400 hall, with issues such as missing flooring, grayish-black substances on vents and air conditioners, and missing mopboard. These deficiencies were verified by staff, who acknowledged the lack of maintenance personnel, placing residents at risk for health issues and falls.
The facility's kitchen failed to meet professional food safety standards, with uncovered food items improperly stored in the refrigerator, maintenance issues like missing tiles and substances on pipes, and expired sanitizer test strips. These deficiencies placed 65 residents at risk for foodborne illness.
The facility failed to offer or obtain informed declination for the pneumococcal PCV20 vaccination for several residents, as per CDC guidance. A review of medical records showed a lack of consent or informed declination for the vaccine, placing residents at risk. Interviews with staff confirmed the absence of a systematic approach to determine vaccination eligibility, relying instead on external medical directors without a definitive tracking system.
A resident was transferred to the hospital without being provided with written information regarding the facility's bed hold policy. The resident, who had multiple serious medical conditions, was transferred due to a decline in health. The facility failed to obtain a signed acknowledgment from the resident's representative, placing the resident at risk of not being able to return to the facility.
A facility failed to implement a person-centered care plan for a resident with PTSD, major depressive disorder, and traumatic brain injury. The care plan lacked specific interventions for PTSD, despite the resident's diagnosis since 2022. Administrative nurses were unaware of this omission, which violated the facility's policy for comprehensive care plans. This deficiency risked the resident's psychosocial well-being and treatment effectiveness.
A resident with cognitive and physical impairments, requiring supervision while smoking, sustained a cigarette burn due to unsupervised smoking. Despite facility policies and care plans indicating the need for supervision, the resident continued to smoke without oversight, obtaining cigarettes from family or other residents. This failure to enforce smoking policies placed the resident and others at risk for smoke or fire-related hazards.
A resident with end-stage renal disease required dialysis three times a week, but the facility failed to document essential details in the care plan, such as the dialysis schedule and site care. This deficiency was confirmed by an administrative nurse and observed during an interview with the resident, who expressed concerns about meal timing related to dialysis sessions.
A facility failed to provide trauma-informed care for a resident with PTSD, major depressive disorder, and traumatic brain injury. The resident's care plan lacked specific interventions to address PTSD triggers, and staff were unaware of this omission. Interviews revealed an expectation for staff to manage PTSD triggers, but no structured guidance was provided. This deficiency placed the resident at risk for decreased psychosocial well-being and ineffective treatment.
A facility failed to ensure the Consultant Pharmacist identified and reported missed insulin administrations and blood sugar readings for a resident with diabetes. The resident's medical records showed numerous undocumented instances of insulin administration and blood sugar readings over several months. Despite the facility's policy, the CP did not report these omissions, placing the resident at risk for unnecessary medication administration and complications.
A resident with diabetes and other medical conditions did not receive physician-ordered insulin and blood sugar checks as required. Over several months, staff failed to sign off on multiple doses of insulin and blood sugar readings, with no documentation explaining the omissions. This placed the resident at risk for unnecessary medication administration and complications.
The facility failed to ensure CMS-approved indications for antipsychotic medications for three residents, leading to the risk of unnecessary medication administration. One resident was prescribed Vraylar without a documented physician response to a pharmacist's request for an appropriate indication. Another resident was prescribed risperidone for an unapproved indication of anxiety, and a third resident's clinical record lacked documentation for the continued use of Seroquel. These deficiencies placed the residents at risk for unnecessary medication use.
The facility failed to label and discard insulin medications properly, risking ineffective doses for residents. Observations showed unlabeled insulin flex pens and vials, with some having incorrect expiration dates. Licensed nurses confirmed the need for proper labeling and discarding per policy, which was not followed, placing residents at risk.
A facility failed to ensure proper collaboration with a hospice provider for a resident, leading to inadequate end-of-life care. The resident's care plan lacked essential information such as contact details for the hospice provider, a list of medical supplies, and a schedule of hospice staff visits. This deficiency was identified through observations, record reviews, and staff interviews, highlighting a lack of communication and coordination between the facility and the hospice provider.
A resident with Alzheimer's and Down's Syndrome, dependent on staff for care, developed a stage four pressure ulcer due to the facility's failure to reposition him every two hours, monitor his skin weekly, and provide timely wound treatments. Despite hospice staff's education efforts, the facility continued to neglect repositioning and peri-care duties, leading to further skin breakdown and additional pressure ulcers.
The facility failed to update care plans for three residents, leading to deficiencies in care. A resident with Alzheimer's and muscle weakness had a pressure ulcer worsen to stage four and a urinary catheter inserted, but the care plan was not updated. Another resident with diabetes and hemiplegia developed a foot wound, which was not included in the care plan. A third resident with a urinary catheter had a care plan that did not reflect his ability to manage the catheter independently. These oversights violated the facility's policy requiring care plan updates with changes in residents' conditions.
A resident with a history of diabetes and hemiplegia developed an ulcer on her right foot, but the facility failed to provide the ordered treatments, including pressure-relieving boots and regular dressing changes. Observations showed the resident's boot was often on the floor, and staff did not consistently monitor or document the wound's status. Interviews revealed confusion among staff about the care plan, and the facility's policy lacked clear guidelines for wound assessment frequency.
Two residents in a LTC facility were not provided timely incontinence care, resulting in saturated briefs and urine-soaked linens. One resident with Alzheimer's and Down's Syndrome was frequently found wet despite a care plan for two-hour checks. Another resident with hemiplegia and dementia was not changed for several hours, contrary to the care plan. The facility's policy required scheduled toileting, but it was not followed, leading to inadequate care.
A resident with pain and restless leg syndrome missed multiple doses of Norco and a Fentanyl patch due to the facility's failure to reorder medications timely. Despite experiencing significant pain, the facility did not document attempts to notify the physician or pharmacy. Staff interviews revealed a lack of awareness and communication regarding the medication shortage, and the facility's policy lacked clear instructions for reordering medications.
The facility failed to maintain effective infection control practices, including improper glove removal and hand hygiene during resident care, and incorrect positioning of a urinary catheter drainage bag. Staff did not change gloves between tasks, and a resident's catheter bag was positioned above the bladder, contrary to facility policy.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations and staff interviews confirming the presence of rodents and rodent droppings in resident rooms and common areas. Pest control vendor reports documented a captured rodent and staff sightings of mice, with recommendations to keep doors closed. Despite these findings, the last documented visit from the pest control vendor was in March, and the service was discontinued due to unpaid invoices. Housekeeping staff reported finding rodent droppings, dried urine, and a dead rodent during deep cleaning of resident rooms, and these findings were reported to supervisors. A resident with intact cognition showed surveyors two dead mice in spring-loaded traps she had placed under her bed, stating this was not the first occurrence and that she needed more traps. Other staff, including a CNA and the maintenance supervisor, confirmed recent sightings of rodent droppings and evidence of rodents in the facility. The maintenance supervisor was unaware that residents were using their own traps and expressed surprise at the findings. The facility's policy requires an ongoing pest control program to ensure the building is free of rodents, but this was not maintained due to the cancellation of the pest control service.
Failure to Maintain Safe and Sanitary Environment Due to Prolonged Flooring Issue
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment for its residents. During an initial tour, it was noted that flooring was missing at the entrance of the dining room on the 300 hallway, with an area approximately four feet long by one foot wide covered by water-saturated blankets and surrounded by wet floor caution signs. This condition had persisted for at least two to three weeks, as confirmed by both a resident and a housekeeper. The resident, who was cognitively intact, expressed concerns about safety due to the persistent wet floor. Administrative staff confirmed that the flooring issue was due to a broken pipe under the floor, which had been assessed by a local plumber. However, there was no documentation or estimate available to verify the plumber's visit. The administrator also reported concerns about the facility's ability to pay for repairs, as invoices had not been paid by the corporate office since March 2025. The facility's policy required providing a safe, clean, and homelike environment, which was not met in this instance.
Failure to Maintain Accurate Elopement Risk Documentation and Supervision
Penalty
Summary
The facility failed to implement and maintain up-to-date interventions to mitigate the risk of elopement for a resident with significant cognitive impairment. The resident in question had diagnoses of dementia, depression, and traumatic brain injury, and was assessed as being at risk for elopement based on a recent increase in their elopement risk assessment score. The resident's care plan included the use of a WanderGuard bracelet, 15-minute visual checks, and specific monitoring instructions. Despite these interventions, the resident was able to exit the facility when a transportation company opened the door, indicating a lapse in supervision and monitoring. Staff relied on an Elopement Risk Book at the nurse's stations to identify residents at risk for elopement, but the book was not kept current. Observations and interviews revealed that the Elopement Risk Book contained outdated information, lacked resident photos and face sheets, and had discrepancies regarding which residents were currently at risk or had active WanderGuard devices. Staff members were unclear about which residents were at risk and who was responsible for updating the book, with some staff unaware of recent elopement incidents and the current status of the elopement risk documentation. The facility's policy required that each resident's risk for elopement be assessed upon admission and that a photo and face sheet be placed in the Elopement Risk Book. However, these requirements were not consistently followed, as evidenced by missing photos and outdated lists in the risk books at both nurse stations. This failure to maintain accurate and current elopement risk documentation contributed to the increased risk of elopement for residents identified as at risk.
Failure to Implement Water Management and Infection Control Practices
Penalty
Summary
The facility failed to implement a water management program for Legionella disease, which is a bacterium spread through mist and can cause pneumonia, particularly in adults over 50 and those with weakened immune systems. The facility was unable to provide documentation of any completed water management processes or testing results, as the last maintenance supervisor had left and the information could not be retrieved. Although the facility had materials for a water management process, there was no evidence that the process was completed, and no policy was provided related to the sanitary storage of oxygen or catheter tubing. Additionally, the facility did not adhere to acceptable infection control practices regarding the storage of oxygen tubing and nasal cannulas for two residents. Observations revealed that the oxygen tubing and nasal cannulas for these residents were left unbagged and placed in the seat of their wheelchairs, exposing them to potential contamination as staff and residents moved through the area. Administrative staff acknowledged that the oxygen equipment should have been stored in a bag when not in use, but this practice was not followed, placing residents at risk for infectious diseases.
Environmental Deficiencies in Dining Room and 400 Hall
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, particularly in the main dining room and the 400 hall. Observations revealed several issues, including a section of missing flooring in front of the shower room on the 400 hall, which was approximately 18 inches wide by five feet long and half an inch deep, exposing the concrete beneath. In the main dining room, there were four floor vents and two window air conditioners covered with a grayish-black fuzzy substance. Additionally, the windows around the dining room had numerous streaks of grayish-black areas. Further issues in the dining room included missing mopboard below the window air conditioner and around the floor air vents, as well as a section of mopboard sticking out from the wall below the shelf where iced tea was kept. These environmental deficiencies were verified by Administrating Staff A, who acknowledged the lack of maintenance staff and stated that he was responsible for addressing these issues. The facility's Quality of Life-Homelike Environment Policy, revised in May 2017, emphasized the importance of maintaining a clean, sanitary, and orderly environment, which the facility failed to uphold, placing residents at risk for impaired health and well-being and falls.
Deficient Food Safety Practices in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations in the kitchen. During an inspection, it was noted that the walk-in refrigerator contained a box of uncovered bacon and a box of roasted turkey breast stored above a box of bulk pork sausage, which violates proper food storage protocols. The Dietary Manager confirmed these findings and acknowledged that staff should cover food items before refrigeration and store thawing meat on the bottom shelf. Additionally, the outside of the ice machine had streaks of a whitish substance, and the drainage pipe from the dishwasher was improperly positioned, touching the floor drainage area. Further inspection revealed multiple maintenance issues in the kitchen area, including missing tiles under the sinks and dishwasher, grayish-black substances on pipes, peeling sheetrock in a storage closet, and expired sanitizer test strips. The ceiling vent and lights were also found to have grayish and black substances, respectively, and the window above the steam table had streaks of a grayish substance. These deficiencies in food storage, preparation, and kitchen maintenance placed the 65 residents who received meals from the facility's kitchen at risk for foodborne illness.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer or obtain informed declination or physician-documented contraindication for the pneumococcal PCV20 vaccination for several residents, as per the latest CDC guidance. The review of clinical medical records for five residents revealed a lack of evidence that the facility or the resident representative received or signed a consent or informed declination for the pneumococcal vaccine PCV20. This oversight placed the residents at risk for pneumococcal infection and related complications. Interviews with facility staff, including Administrative Nurses E and D, confirmed the absence of a systematic approach to determine residents' eligibility for the PCV20 vaccination. The facility relied on the medical director or clinic physician's office to determine eligibility but lacked a definitive system to track who was eligible, when they were eligible, and whether they had been offered or declined the vaccinations. The facility's existing policy required assessment of pneumococcal vaccination status within five working days of admission, but this was not effectively implemented, leading to the deficiency.
Failure to Provide Bed Hold Policy Documentation
Penalty
Summary
The facility failed to provide Resident 18 with written information regarding the bed hold policy when she was transferred to the hospital. Resident 18, who had a range of serious medical conditions including Influenza A, acute respiratory failure, hypoxia, cerebrovascular accident, dementia, and diabetes mellitus, was transferred to the hospital due to a significant decline in her health. The nurse's notes indicated that the resident was unresponsive, had a high temperature, and low oxygen saturation levels, prompting the nurse practitioner to order her transfer to the hospital. However, the facility did not provide the resident or her representative with a signed copy of the bed hold policy, which is required to ensure the resident's right to return to the facility. The facility's bed hold policy mandates that residents and their representatives be informed in writing about the facility and state bed hold policies, both in advance of any transfer and at the time of transfer. In this case, the facility's records showed that the bed hold policy document was signed by an administrative nurse rather than the resident's representative, and there was no evidence of a signed acknowledgment by the representative. The administrative nurse confirmed that the representative had not signed the document and that the facility could not provide written evidence of the representative's acknowledgment of the bed hold policy. This deficiency placed Resident 18 at risk of not being permitted to return and resume residence in the nursing facility. The facility's failure to provide the necessary documentation and obtain the representative's acknowledgment of the bed hold policy violated the established procedures and policies, which are designed to protect residents' rights during hospital transfers.
Failure to Implement Person-Centered Care Plan for PTSD
Penalty
Summary
The facility failed to implement a person-centered care plan for a resident diagnosed with PTSD, major depressive disorder, and traumatic brain injury. The resident's care plan, last revised on 10/23/24, did not include a specific care area to address PTSD, its triggers, or interventions to prevent re-traumatization. Despite the resident's documented diagnosis of PTSD since 09/09/22, the care plan lacked individualized interventions to manage the condition effectively. This oversight was identified during a survey, where it was noted that the resident had a severely impaired cognition with a BIMS score of six and had displayed behaviors such as rejecting care. Interviews with administrative nurses revealed a lack of awareness regarding the absence of a PTSD care area in the resident's care plan. The facility's policy, revised in March 2022, mandates that care plans should be comprehensive and person-centered, including measurable objectives and timeframes. However, the facility did not adhere to this policy, as the resident's PTSD was not addressed at admission or upon diagnosis. This deficiency placed the resident at risk for decreased psychosocial well-being and ineffective treatment.
Failure to Supervise Resident Smoking Leads to Injury
Penalty
Summary
The facility failed to maintain a safe environment for a resident, identified as R21, who was assessed to require supervision while smoking due to cognitive and physical impairments. Despite being educated on the need for supervision and the use of a protective smoking apron, R21 continued to smoke unsupervised, which led to a cigarette burn on her left iliac crest. The resident's medical history included conditions such as cerebral infarction, major depressive disorder, acute respiratory failure with hypoxia, and pneumonia, which necessitated staff assistance for activities of daily living and supervision for safety. R21's care plan and smoking policy indicated that she was a supervised smoker due to her impaired dexterity and history of smoking inside the facility. The facility's smoking assessment documented that R21 had no cognitive loss but had visual defects and dexterity problems, which increased her risk of injury from smoking. Despite these assessments, R21 was able to obtain cigarettes from family or other residents and smoked without supervision, leading to the burn injury. The facility's smoking policy required that all residents be informed of smoking limitations and that those requiring supervision be directly monitored by staff, family, or volunteers. However, the facility did not enforce these policies effectively, allowing R21 to smoke unsupervised, which placed her and other residents at risk for smoke or fire-related hazards.
Inadequate Dialysis Care Plan Documentation for Resident
Penalty
Summary
The facility failed to provide ongoing care plan communication and documentation for a resident, identified as R70, who required dialysis treatment. R70 had a diagnosis of end-stage renal disease and was admitted to the facility with a physician's order for dialysis three times a week. However, the care plan for R70 lacked essential documentation regarding the dialysis treatment, including the dialysis center, the schedule for dialysis sessions, and the care required for the dialysis site. This lack of documentation was confirmed by Administrative Nurse D, who acknowledged that the care plans were completed by a corporate nurse off-site and updated in-house as needed. The facility's policy on the care of residents with end-stage renal disease outlined the need for staff training and comprehensive care plans reflecting the resident's needs related to dialysis care. Despite this policy, the facility did not ensure that R70's care plan included necessary information about his dialysis treatment, placing him at risk for inadequate care and potential health decline. The deficiency was observed during an interview with R70, who expressed concerns about the timing of his meals in relation to his dialysis schedule, and was further verified by the administrative nurse.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, major depressive disorder, and traumatic brain injury. The resident's electronic medical record documented these diagnoses, and the resident exhibited behaviors such as rejecting care and had a severely impaired cognition score. Despite these indicators, the resident's care plan lacked specific interventions to address PTSD triggers or prevent re-traumatization. The facility's failure to include a PTSD care area in the resident's care plan was noted, and staff were unaware of this omission. Interviews with administrative nurses revealed that there was an expectation for staff to have directions on managing PTSD triggers and interventions, but this was not implemented for the resident. The facility did not provide a policy regarding PTSD care when requested, indicating a lack of structured guidance for managing such cases. This deficiency placed the resident at risk for decreased psychosocial well-being and ineffective treatment, as the facility did not identify trauma-based triggers or implement individualized interventions to prevent re-traumatization.
Failure to Identify and Report Missed Insulin Administration
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported missed insulin administrations and blood sugar readings for Resident 25. The resident had multiple diagnoses, including diabetes mellitus, and was prescribed both fast-acting and long-acting insulin. However, there were numerous instances where the administration of these medications and the required blood sugar readings were not documented in the resident's medical records over several months. Resident 25's medical records revealed a lack of staff sign-off on insulin administration and blood sugar readings across multiple months. Specifically, there were missing sign-offs for Lantus and Humalog insulin administrations and blood sugar readings in November and December 2024, as well as January and February 2025. Despite the facility's policy requiring the CP to perform monthly medication regimen reviews, these omissions were not identified or reported by the CP. Interviews with facility staff indicated an expectation that the CP would identify and report missed medication administrations. However, the CP did not fulfill this responsibility, and there was no documentation explaining why the insulin was not administered as ordered. This oversight placed Resident 25 at risk for unnecessary medication administration and related complications.
Failure to Administer and Document Insulin for Resident
Penalty
Summary
The facility failed to ensure that Resident 25's physician-ordered insulin and finger stick blood sugars were administered and documented as required. The resident, who had a range of medical conditions including diabetes mellitus, hypertension, and major depressive disorder, was prescribed both fast-acting and long-acting insulin. However, there were multiple instances over several months where the Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked staff sign-off for the administration of these medications and the completion of blood sugar readings. Specifically, the MAR and TAR for November 2024 through February 2025 showed numerous missed sign-offs for both Lantus and Humalog insulin, as well as for blood sugar readings. Despite the facility's policy requiring documentation when medications are not administered, there was no documentation in the resident's progress notes explaining why the insulin doses were missed. This lack of documentation and adherence to physician orders placed the resident at risk for unnecessary medication administration and related complications. Interviews with administrative nurses confirmed the expectation that nursing staff should administer insulin as ordered and document any reasons for not doing so. The facility's policy, revised in April 2019, emphasized the importance of administering medications safely and timely, and documenting any deviations. The failure to follow these protocols resulted in a deficiency related to the administration and documentation of medications for Resident 25.
Inadequate Indication for Antipsychotic Use in Residents
Penalty
Summary
The facility failed to ensure that three residents had a CMS-approved indication for the use of antipsychotic medications, leading to the risk of unnecessary medication administration and related complications. Resident 25, who had multiple diagnoses including hallucinations and major depressive disorder, was prescribed Vraylar for hallucinations without a documented physician response to a pharmacist's request for an appropriate indication. Despite a recommendation for a gradual dose reduction, the physician maintained the current dosage, citing a history of hallucinations and potential increased symptoms with a decrease. Resident 38, diagnosed with Alzheimer's disease and dementia, was prescribed risperidone for dementia with psychotic disturbances. However, a pharmacist noted that risperidone was listed for anxiety, which is not an approved indication. Although a gradual dose reduction was attempted, the facility did not ensure a CMS-approved indication for the medication, placing the resident at risk for unnecessary use. Resident 22, with severe cognitive impairment and a diagnosis of dementia, was prescribed Seroquel for major neurocognitive disorder. The clinical record lacked physician documentation of the rationale and risks versus benefits for the continued use of Seroquel. The facility's failure to ensure an appropriate indication for the use of Seroquel placed the resident at risk for unnecessary psychotropic medication administration.
Failure to Properly Label and Discard Insulin Medications
Penalty
Summary
The facility failed to properly label and discard insulin medications, which placed residents at risk for receiving ineffective medications. Observations revealed that several insulin flex pens and vials were not labeled with the date they were opened or their expiration dates. Specifically, a Glargine flex pen and a Levemir vial were found without these labels, and two other flex pens had incorrect expiration dates. Licensed nurses verified that the insulin should have been labeled and discarded according to the facility's policy and professional guidelines. Additionally, another resident's lispro insulin pen was found without an open date, which was confirmed by a licensed nurse. The facility's policy requires that insulin pens be labeled with the resident's name and the date opened. The failure to adhere to these labeling and storage policies resulted in a risk of administering ineffective insulin doses to the residents involved.
Lack of Coordination with Hospice Services
Penalty
Summary
The facility failed to ensure proper collaboration of care between a resident's hospice provider and the facility, which placed the resident at risk of inadequate end-of-life care. The resident, who had been recently admitted to hospice services, had a significant medical history including Alzheimer's disease, dementia, hemiplegia, heart failure, and cerebral infarction. The resident's care plan was lacking in specific directions for staff on how to contact the hospice provider, details of the medical supplies and equipment provided by hospice, and a schedule of hospice staff visits. The resident's electronic medical record and hospice provider book were missing critical information, such as the hospice plan of care, a list of medications, and other services provided by hospice. Interviews with facility staff revealed that there was an expectation for the hospice plan of care to be included in the hospice book, and for the care plan to reflect all necessary hospice information. However, this information was not present, indicating a lack of coordination and communication between the facility and the hospice provider. The facility's Hospice Program policy outlined the responsibilities of both the hospice and the facility in managing the resident's care, emphasizing the need for coordinated care plans. Despite this policy, the facility did not ensure that the hospice plan of care was integrated into the resident's care plan, nor did it provide staff with the necessary information to effectively coordinate care with the hospice provider. This oversight resulted in a deficiency that compromised the resident's end-of-life care.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide timely and adequate care for a resident, R1, who was at high risk for pressure ulcers due to his medical conditions, including Alzheimer's disease, Down's Syndrome, and muscle weakness. R1 was totally dependent on staff for mobility, transfers, and toileting, and was always incontinent of bowel and bladder. Despite these needs, the facility did not implement a turning/repositioning program and failed to monitor R1's skin weekly, conduct weekly wound assessments, and provide wound treatments as ordered. As a result, R1 developed an unstageable pressure ulcer on his upper medial buttocks, which was not identified by the facility until two weeks after its onset, and it progressed to a stage four pressure ulcer. The facility's inaction and lack of communication contributed to the deterioration of R1's condition. Hospice staff repeatedly found R1 in saturated briefs and linens, indicating a failure to change and reposition him every two hours as required. Despite hospice staff educating facility staff on the importance of repositioning and providing peri-care, the facility continued to fail in these duties. The facility also failed to document wound characteristics and did not have treatment orders in place for R1's pressure area until 15 days after its onset. Additionally, the facility did not notify the dietary staff of R1's pressure area, which could have impacted his nutritional interventions for skin healing. The facility's documentation was inconsistent and incomplete, with missing entries for wound care and repositioning checks. The facility failed to perform weekly skin assessments as ordered and did not document current wound characteristics. R1's condition worsened with the development of additional skin issues, including new pressure ulcers on his left outer ankle, left ear, upper right abdomen, and fingers. The facility's lack of timely intervention and inadequate care led to the progression of R1's pressure ulcers and further skin breakdown.
Failure to Update Care Plans for Residents with Pressure Ulcers and Catheter Management
Penalty
Summary
The facility failed to revise the care plans for three residents, leading to deficiencies in their care. Resident 1, diagnosed with Alzheimer's disease, Down's Syndrome, and muscle weakness, had a significant decline in his pressure ulcer from stage two to stage four, and a urinary catheter was inserted to assist with wound healing. Despite these changes, the care plan was not updated to reflect the new stage of the pressure ulcer or the presence of the urinary catheter, which was a requirement according to the facility's policy. Resident 2, who had diabetes mellitus with neuropathy, hemiplegia, and dementia, developed an arterial wound on her right foot. The care plan did not include this wound or provide guidance for its care, despite multiple assessments and treatments being documented. The facility's failure to update the care plan with the presence of the wound and the necessary care instructions was a clear oversight. Resident 5, who required assistance with personal care and had an indwelling urinary catheter, had a care plan that did not reflect his ability to empty his catheter bag independently. Observations showed improper management of the catheter tubing and drainage bag, which was not addressed in the care plan. The facility's policy required care plans to be revised as residents' conditions changed, but this was not done for Resident 5, leading to a deficiency in his care management.
Failure to Provide Ordered Wound Care and Pressure Relief
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, identified as R2, who had an ulcer on her right foot. R2 had a medical history that included diabetes mellitus with neuropathy, hemiplegia affecting the right side, dementia, muscle weakness, and osteoarthritis. Despite being at risk for pressure ulcers, the facility did not ensure that R2 received the necessary treatments as ordered, including the use of pressure-relieving boots while in bed. Observations revealed that R2's pressure-relieving boot was often found on the floor rather than on her foot, and staff failed to change her dressing as scheduled. The facility's records showed inconsistencies and omissions in the documentation of R2's wound care. The Treatment Administration Record for June 2024 lacked any treatment interventions for R2's right foot, and there was a significant delay in implementing treatment orders for the wound. The Weekly Non-Pressure Wound assessments were incomplete, lacking measurements and descriptions of the wound area. Additionally, the facility's staff did not consistently monitor R2's wound status weekly, as required. Interviews with staff members revealed a lack of clarity and adherence to the care plan for R2. Licensed nurses and certified nurse aides were unsure about the specific requirements for R2's wound care and the use of pressure-relieving boots. The facility's policy on pressure ulcers and skin breakdown did not specify the frequency of assessments, contributing to the inadequate monitoring and treatment of R2's condition. These deficiencies highlight the facility's failure to ensure that R2 received the necessary care and treatment for her ulcer, as ordered by her physician.
Inadequate Incontinence Care for Residents
Penalty
Summary
The facility failed to provide timely incontinence care to two residents, resulting in saturated briefs and urine-soaked linens. Resident 1, diagnosed with Alzheimer's disease, Down's Syndrome, and muscle weakness, was always incontinent of bowel and bladder and dependent on staff for toileting. Despite a care plan requiring staff to check and change his brief every two hours, multiple hospice visit notes documented that Resident 1 was frequently found saturated with urine, indicating neglect in providing necessary care. Resident 2, diagnosed with hemiplegia, dementia, muscle weakness, and osteoarthritis, was also always incontinent of bowel and bladder and dependent on staff for toileting. Observations revealed that Resident 2 was not checked or changed for several hours, despite the care plan instructing staff to do so every two hours. The resident reported feeling wet and not being changed since early morning, and staff confirmed the delay in providing care. The facility's policy on urinary continence and incontinence management required scheduled toileting and interventions to manage incontinence. However, the facility's failure to adhere to these policies resulted in inadequate care for both residents, as evidenced by the repeated findings of saturated briefs and soiled linens.
Failure to Timely Reorder Pain Medications
Penalty
Summary
The facility failed to ensure timely reordering of medications for a resident, identified as R4, resulting in missed doses of critical pain management medications. R4, who had diagnoses of pain and restless leg syndrome, was assessed with intact cognition and required scheduled pain medication. The resident missed eight doses of Norco and one dose of a Fentanyl patch over a period from July 27 to July 29, 2024. The facility's Medication Administration Record (MAR) indicated that the medications were unavailable, and there was no documentation of attempts to notify the physician or pharmacy to obtain the medications. R4 reported experiencing significant pain, which affected her sleep and daily activities, with pain levels reaching up to eight or nine on a scale of ten. Despite the administration of PRN acetaminophen, which was sometimes ineffective, the facility did not document the use of other available pain management options, such as Voltaren gel. The resident expressed that the facility had run out of her medication in the past and noted that the medication aides did not reorder in a timely manner, leading to a delay in obtaining a new prescription over the weekend. Interviews with facility staff revealed a lack of awareness and communication regarding the medication shortage. Certified Medication Aide R and Administrative Nurse D described the process for reordering medications, which involved using the electronic system or faxing a request to the pharmacy. However, there was a failure to follow these procedures effectively, as evidenced by the lack of documentation and follow-up. The facility's policy on medication administration did not provide clear instructions for reordering medications, contributing to the oversight that led to R4's missed doses.
Infection Control Deficiencies in Glove Use and Catheter Positioning
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observations involving improper glove removal and hand hygiene practices. On one occasion, a Certified Nurse Aide (CNA) removed a resident's wet disposable brief with gloved hands and then handled a new brief without changing gloves. Additionally, a Licensed Nurse (LN) performed wound care on a resident's pressure ulcer without performing hand hygiene between glove changes, despite acknowledging the importance of doing so. The LN also used scissors to cut a foam piece and applied it to the resident's wound without proper hand hygiene, and the CNA assisted with the same gloves used to handle the wet brief and trash can. Another incident involved a CNA providing peri-care to a resident after incontinence and then placing clean bedding and a brief on the resident without changing gloves. The CNA later acknowledged the need to change gloves between tasks. Furthermore, a resident's pressure-reducing boot was stored directly on the floor, which is not in line with proper infection control practices. The facility also failed to ensure proper positioning of a resident's urinary catheter drainage bag. The catheter tubing was observed exiting from the bottom of the resident's pant leg and crossing a lap tray before reaching the drainage bag, which was positioned above the bladder. This improper positioning was noted on two separate occasions, and staff acknowledged that the drainage bag should be positioned lower than the bladder to prevent complications. The facility's policies on hand hygiene and catheter care were not adhered to, contributing to these deficiencies.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
