Legacy At Herington
Inspection history, citations, penalties and survey trends for this long-term care facility in Herington, Kansas.
- Location
- 2 E Ash Street, Herington, Kansas 67449
- CMS Provider Number
- 175490
- Inspections on file
- 22
- Latest survey
- March 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Legacy At Herington during CMS and state inspections, most recent first.
The facility did not employ a full-time certified dietary manager, placing 31 residents at risk for inadequate nutrition. Dietary Staff BB, who was not certified, was managing the kitchen operations. This was against the facility's policy, which required a certified dietary manager to oversee food and nutrition services.
The facility was found to have unsanitary kitchen conditions, including a greasy air vent grill and disrepair of fluorescent light fixtures, posing a risk for food-borne illness among 31 residents. Maintenance staff confirmed these issues, which violated the facility's sanitization policy.
The facility failed to submit accurate staffing information through PBJ, with reports indicating no licensed nurse coverage on several days across different fiscal quarters. Despite payroll data showing 24/7 licensed nurse coverage, discrepancies were acknowledged by administrative staff, highlighting a failure to adhere to reporting requirements and placing residents at risk for inadequate staffing.
The facility failed to maintain the dignity of two residents. A resident received a blood sugar check and insulin injection in a common area, violating privacy policies. Another resident, with cognitive impairments, was repeatedly observed with unkempt hair and clothing, despite needing assistance with grooming. These actions did not align with the facility's dignity policy.
A facility failed to notify the State Long Term Care Ombudsman of a resident's discharge to the hospital. The resident, with a history of dementia and major depressive disorder, was sent to the emergency department after an incident involving self-harm behavior. The facility's Social Services staff were unaware of the requirement to notify the Ombudsman for hospital discharges, and the facility lacked a policy on this matter, leading to the oversight.
A resident with Alzheimer's and severely impaired cognition was frequently incontinent, yet her care plan lacked instructions for toileting assistance after meals. Despite staff awareness of her needs, the care plan was not updated, leading to an incontinent episode and placing her at risk for impaired care.
A resident with severe cognitive impairment did not receive consistent bathing and toileting assistance, as required by their care plan. Despite the resident's refusal of showers due to feeling cold, the facility did not offer alternative bathing methods. Additionally, the resident was not assisted with toileting after meals, leading to incontinence. These failures placed the resident at risk for poor hygiene and related complications.
A resident with Alzheimer's and thoracic spine pain experienced inadequate pain management due to staff's failure to communicate and administer prescribed medications. Despite frequent complaints of back pain, the resident's pain was not effectively addressed, as CNAs did not report the pain to the nurse or CMA, and the scheduled acetaminophen was not administered as required.
A facility failed to ensure the Consultant Pharmacist identified and reported the lack of appropriate indication for antipsychotic medication use in a resident with MDD and irregularities in blood sugar monitoring for a diabetic resident. The pharmacist's monthly reviews did not address these issues, placing residents at risk for ineffective medication regimens and side effects.
The facility failed to monitor and provide necessary interventions for bowel management for a resident with impaired cognition, leading to extended periods without bowel movements. Additionally, the facility did not notify a physician when another resident's blood sugar levels exceeded ordered parameters, risking unnecessary medication side effects. These deficiencies highlight a lack of adherence to physician orders and protocols.
A resident with dementia and major depressive disorder was administered Seroquel, an antipsychotic medication, without appropriate indication or documented physician rationale. The facility's policy required addressing various causes of behavioral symptoms before considering antipsychotic use, but this was not followed, placing the resident at risk for adverse side effects.
A facility failed to label insulin flex pens for three residents with the dates they were opened and the discard dates, as observed during a treatment cart inspection. Both a licensed nurse and an administrative nurse confirmed the requirement for such labeling. The facility's policy and Medlineplus.gov guidelines state that open, unrefrigerated insulin must be used within 28 days. This oversight risked the residents receiving ineffective medication.
The facility failed to properly prepare pureed diets for three residents, compromising the meals' nutritive value and palatability. A dietary staff member did not include bread or rolls in the pureed meals, as required by the facility's policy, resulting in residents not receiving the same nutritional value as those on the general diet.
The facility did not display current daily nursing staff hours as required by policy. On two consecutive days, the posted hours were outdated, showing information from a previous date. An administrative nurse confirmed that the night shift nurse responsible for updating the staffing hours had not posted the correct information. The facility's policy mandates daily posting of nursing personnel numbers for each shift.
A resident with intact cognition was taken outside for his scheduled vape time by an LPN. During this time, an administrative staff member confronted the LPN in front of the resident, stating that the resident's vaping was not a priority. This interaction made the resident feel insecure, unimportant, and belittled, violating the facility's dignity policy.
The facility failed to ensure that two residents were able to exercise their right to receive visitors of their choosing at the time of their choice. One resident was restricted from receiving visits from her representative without prior scheduling and supervision, while another resident's husband was barred from the dining room after an outburst. These actions were not in line with the facility's visitation policy, placing the residents at risk for impaired rights and social isolation.
The facility failed to inform two residents and/or their representatives of visitation restrictions, leading to emotional distress and impaired resident rights. One resident with severe cognitive impairment and another with intact cognition were affected, with no formal notices issued as required by the facility's visitation policy.
Lack of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to provide the services of a full-time certified dietary manager for its 31 residents, which placed them at risk for inadequate nutrition. During an observation, it was noted that the dietary staff in the kitchen were preparing meals without the oversight of a certified dietary manager. Dietary Staff BB, who was acting as the dietary manager, confirmed that she was not certified. This was further verified by Administrative Staff A, who acknowledged that the facility did not have a certified dietary manager. The facility's policy, dated 10/2017, required a qualified dietician to oversee food and nutrition services, and if a dietician was not employed full-time, a certified dietary manager should be designated. The policy outlined specific qualifications for this role, including certification in dietary or food service management. The absence of a certified dietary manager meant that the facility did not meet its own policy requirements, thereby failing to adequately evaluate residents' nutritional needs and oversee food-related operations.
Unsanitary Kitchen Conditions
Penalty
Summary
The facility, with a census of 31 residents, was found to have unsanitary conditions in its kitchen, which posed a risk for food-borne illness among the residents. During an initial tour, surveyors observed a three-foot by six-inch air vent grill above the North door entrance to the kitchen covered with a brownish grease/sticky substance and a gray fuzzy substance, which was blowing directly onto the food preparation area. Additionally, two fluorescent light fixtures located in the exhaust hood above the stovetop were found to be in disrepair; one cover was missing, exposing the fluorescent bulb, and the other cover was partially affixed. Further observations revealed nine ceiling-mounted fluorescent light fixtures with metal pull chains that had a brownish-gray fuzzy substance affixed to them, located directly above the food preparation and dishwashing areas. Maintenance staff confirmed the unsanitary conditions, including the dirty register grill, the dirty overhead fluorescent light pull chains, and the missing and partially affixed fluorescent light covers. The facility's Sanitization policy, dated October 2008, required the food service area to be maintained in a clean and sanitary manner, but the facility failed to adhere to these standards, placing residents at risk for food-borne illness.
Inaccurate PBJ Data Submission
Penalty
Summary
The facility failed to submit complete and accurate staffing information through Payroll-Based Journaling (PBJ) as required by CMS. The PBJ reports for various fiscal quarters indicated that there were days with no licensed nurse coverage, specifically on eight days in FY 2023 Q4, eight days in FY 2024 Q3, and six days in FY 2024 Q1. However, a review of the facility's licensed nurse payroll data for these dates revealed that a licensed nurse was on duty 24 hours a day, seven days a week. This discrepancy suggests that the facility did not accurately report its staffing data to CMS. Administrative Staff A acknowledged that there might have been instances where incorrect information was submitted, confirming the inaccuracies in the reported dates. Despite the facility's policy, which mandates the electronic reporting of direct care staffing information to CMS, including details about the category of work and hours worked, the facility failed to adhere to these requirements. This failure to submit accurate PBJ data placed the residents at risk for unidentified and ongoing inadequate staffing.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to provide care for two residents in a manner that protected and promoted their dignity. For one resident, a licensed nurse checked the resident's blood sugar and administered an insulin injection in a common area, where other residents and staff were present. This action was contrary to the facility's policy, which requires such procedures to be conducted in private to maintain the resident's dignity and respect. Another resident, who had a cognitive communication deficit and required assistance with personal care, was observed multiple times with disheveled and greasy hair, dried food on her clothing, and unshaven chin hair. Despite the care plan directing staff to assist with grooming, the resident was brought to common areas without adequate grooming, failing to uphold the dignity policy that mandates residents be groomed as they wish and treated with respect.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman (LTCO) of a facility-initiated discharge of a resident to the hospital. The resident, identified as R25, had a history of dementia, major depressive disorder (MDD), and a traumatic subdural hematoma. The resident's care plan included the administration of antipsychotic medication and monitoring for side effects. On a particular day, the resident was observed attempting to sharpen a shaving razor, which led to an assessment by the nurse and a subsequent decision to send the resident to the emergency department for evaluation. The resident was later transported to a behavioral health hospital for further psychiatric evaluation. The clinical record for the resident lacked documentation that the LTCO was notified of the discharge. Social Services staff stated that they were unaware of the requirement to notify the LTCO of discharges to the hospital, as they only reported residents discharged home. The facility did not provide a policy regarding the discharge of residents or the notification of the Ombudsman, which contributed to the oversight. This failure to notify the LTCO placed the resident at risk for impaired rights.
Failure to Update Care Plan for Resident's Toileting Needs
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R2, to adequately address her toileting needs. R2, who has diagnoses including Alzheimer's disease and severely impaired cognition, was documented as frequently incontinent of bladder and bowel. Despite this, her care plan did not include specific instructions for staff to assist her with toileting after every meal. Observations and interviews revealed that R2 expressed a need to use the bathroom but was not assisted in time, resulting in an incontinent episode. Staff members, including CNAs and administrative nurses, acknowledged that R2 required assistance with toileting before and after meals, but this was not reflected in her care plan. The facility's policy mandates that care plans be individualized and updated to reflect the resident's needs, especially when there is a significant change or unmet desired outcomes. However, the care plan for R2 lacked the necessary updates to guide staff on her toileting schedule, placing her at risk for impaired care due to uncommunicated needs. The failure to revise the care plan as per the facility's policy led to the deficiency identified by the surveyors.
Failure to Provide Adequate Hygiene and Toileting Assistance
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for a resident, identified as R2, who had severe cognitive impairment due to Alzheimer's disease. R2 required supervision with activities of daily living, including bathing, dressing, and toileting. Despite the care plan directing staff to encourage bathing twice a week and provide peri-care with every incontinent episode, R2 did not receive a bath or shower for extended periods, specifically from late September to mid-October and again from mid to late October. The EMR noted that R2 refused showers on several occasions, and staff acknowledged that R2 often refused showers due to feeling cold and a possible past incident related to water. However, the facility did not offer alternative bathing methods to accommodate R2's needs and preferences. Additionally, the facility failed to assist R2 with toileting after meals, as required by her care plan. Observations revealed instances where R2 expressed the need to use the bathroom but was not assisted in time, resulting in incontinence. Staff interviews confirmed that R2 required assistance with toileting before and after meals, but the care plan did not reflect this need. The facility's policy on activities of daily living emphasized providing appropriate support to maintain personal hygiene and addressing cognitive impairments by identifying underlying causes of care resistance. However, the facility did not consistently apply these guidelines, placing R2 at risk for poor hygiene and related complications.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to adequately respond to a resident's complaints of pain, placing the resident at risk for unresolved pain and discomfort. The resident, who had diagnoses including Alzheimer's disease, thoracic spine pain, and hyperthyroidism, was documented to have severely impaired cognition and required supervision for various activities. Despite having physician orders for pain management, including scheduled and as-needed medications, the resident's pain was not effectively managed. Observations revealed that the resident frequently complained of back pain, yet the Certified Nurse Aide (CNA) did not report these complaints to the nurse or Certified Medication Aide (CMA). The facility's records showed that the resident had a care plan directing staff to administer pain medications as ordered and to document the effectiveness of interventions. However, the Medication Administration Record (MAR) indicated that the scheduled acetaminophen was not administered as required. Interviews with staff revealed a lack of communication regarding the resident's pain, with the CMA unaware of the resident's pain complaints and scheduled medication. The facility's Pain-Clinical Protocol required staff to assess and document pain, but these procedures were not followed, leading to inadequate pain management for the resident.
Consultant Pharmacist Fails to Identify Medication and Monitoring Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported the lack of an appropriate indication for the continued use of antipsychotic medication Seroquel for a resident diagnosed with Major Depressive Disorder (MDD). The resident's Electronic Medical Record (EMR) lacked documented physician rationale for the use of Seroquel, including unsuccessful attempts for non-pharmacological symptom management and risk versus benefits analysis. Despite monthly medication reviews by the CP, there was no evidence of a recommendation for an appropriate indication for the continued use of Seroquel over several months. Additionally, the facility did not ensure that the CP identified and reported irregularities in blood sugar monitoring for another resident diagnosed with diabetes mellitus. The resident's Diabetic Monitoring Record showed multiple instances where blood sugar levels were out of the physician-ordered parameters, yet the physician was not notified. The CP's Medication Regimen Review for the months of August and September lacked evidence of identifying and reporting these out-of-parameter blood sugars. These deficiencies placed the residents at risk for physical decline, ineffective medication regimens, and side effects from unnecessary medication. The facility's policies required the CP to review each resident's drug regimen monthly and report any irregularities, but these requirements were not met, leading to the identified deficiencies.
Failure to Monitor Bowel Management and Blood Sugar Levels
Penalty
Summary
The facility failed to adequately monitor and provide necessary interventions for bowel management for a resident with severely impaired cognition and a history of constipation. Despite having a physician's order to administer Milk of Magnesia as needed for constipation, the resident's bowel monitoring records showed multiple instances of extended periods without bowel movements, ranging from four to eleven consecutive days. The Medication Administration Records lacked documentation of the administration of the ordered interventions during these periods. Staff interviews revealed that the resident was not a reliable historian due to cognitive impairment, and staff failed to perform bowel assessments or administer the prescribed laxatives, placing the resident at risk for impaction and physical decline. Another deficiency involved the failure to notify a physician when a resident's blood sugar levels were outside the physician-ordered parameters. The resident, who had diagnoses including diabetes mellitus and severely impaired cognition, had several instances where blood sugar levels exceeded the set threshold, yet the physician was not notified as required. The Diabetic Monitoring Records documented multiple occurrences of elevated blood sugar levels without physician notification, and there were also instances where blood sugar levels were not obtained as ordered. Staff interviews indicated a lack of awareness regarding the documentation of blood sugar levels and the necessity to follow physician orders. These deficiencies highlight the facility's failure to adhere to physician orders and protocols for monitoring and managing residents' medical conditions. The lack of appropriate interventions and communication with physicians placed the residents at risk for unnecessary medication side effects and other related complications.
Inappropriate Use of Antipsychotic Medication Without Proper Indication
Penalty
Summary
The facility failed to ensure an appropriate indication or a documented physician rationale for the continued use of antipsychotic medication for a resident diagnosed with major depressive disorder (MDD). The resident, who had a history of dementia, major depressive disorder, and a traumatic subdural hematoma, was receiving Seroquel, an antipsychotic medication, without documented unsuccessful attempts for nonpharmacological symptom management or a risk versus benefits analysis. The resident's care plan indicated that a gradual dose reduction review would be completed by the pharmacist and physician, but the electronic medical record lacked the necessary documentation to justify the continued use of the medication. Observations and interviews revealed that the resident was administered Seroquel despite the absence of an approved indication for its use in treating MDD. The facility's policy on antipsychotic medication use required that such medications be considered only after addressing medical, physical, functional, psychological, emotional, psychiatric, social, and environmental causes of behavioral symptoms. However, the facility did not adhere to this policy, as the resident continued to receive the medication without the required physician documentation, placing the resident at risk for adverse side effects.
Failure to Label Insulin Flex Pens with Opened and Discard Dates
Penalty
Summary
The facility failed to properly label insulin flex pens for three residents, identified as R6, R14, and R26, with the dates they were opened and the discard dates. This oversight was discovered during an observation of the facility's treatment cart, where it was noted that the Basaglar and Lantus insulin flex pens for these residents lacked the necessary labeling. Both a licensed nurse and an administrative nurse confirmed that the insulin pens should have been labeled with the date they were opened and the expiration date. According to Medlineplus.gov, open and unrefrigerated Lantus (including Basaglar and glargine) must be used within 28 days, after which it should be discarded. The facility's own medication storage policy, dated November 2020, mandates that all drugs and biologicals be stored safely and securely, and that outdated or deteriorated drugs should not be used. The failure to label the insulin flex pens with the opened and discard dates placed the residents at risk for receiving ineffective medication.
Failure to Properly Prepare Pureed Diets
Penalty
Summary
The facility failed to correctly prepare a pureed diet for three residents, which compromised the nutritive value and palatability of the meals provided. During an observation, it was noted that the dietary staff member, DS CC, prepared pureed meals by blending cheesy macaroni hamburger helper with beef base, resulting in a thin consistency. The pureed food was then placed in a hot water well for holding. Additionally, DS CC prepared pureed pears and carrots, but did not include bread or rolls in the pureed diet, which was part of the general diet menu. This omission was confirmed by another dietary staff member, DS BB, who acknowledged that DS CC forgot to include these items due to nervousness. The facility's Pureed Diet policy, dated January 2014, specifies that a pureed diet should be smooth in consistency and should include all components of the general diet, modified as necessary. The policy also states that bread or rolls should be pureed with the meal if they are part of the general diet. The failure to adhere to this policy resulted in the affected residents not receiving the same nutritional value as those on the general diet, placing them at risk for impaired nutrition. The deficiency was identified through observation, record review, and interviews, highlighting a lapse in the facility's dietary practices for residents requiring pureed diets.
Failure to Post Current Daily Nursing Staff Hours
Penalty
Summary
The facility failed to display current daily nursing staff hours as required by their policy. On two consecutive days, the posted nurse staff hours were outdated, showing information from a previous date. This was observed on 10/29/24 and 10/30/24, where the posted hours were dated 10/28/24. An interview with Administrative Nurse E on 10/31/24 confirmed that the night shift nurse, who was responsible for updating the daily nurse staffing hours, had not posted the correct information for those days. The facility's policy, dated 07/16, mandates that the number of nursing personnel responsible for providing direct care to residents be posted daily for each shift. The failure to update the staffing information as required led to this deficiency.
Failure to Treat Resident with Dignity
Penalty
Summary
The facility failed to ensure that a resident, identified as R3, was treated with dignity. R3, who had a diagnosis of nontraumatic intracerebral hemorrhage and intact cognition, was taken outside by a Licensed Nurse (LN) H for his scheduled vape time. During this time, Administrative Staff A confronted LN H in front of R3, questioning why she was outside and stating that R3's vaping was not a priority. This interaction made R3 feel insecure, unimportant, and belittled. R3 expressed that the nurses were supposed to make residents a priority, and the comment from Administrative Staff A made him feel terrible and unwanted. The facility's Dignity policy, revised in February 2021, directed that residents be treated with respect and dignity at all times. However, the incident on 02/29/24, where Administrative Staff A confronted LN H in front of R3, violated this policy. The conversation, which R3 overheard, led to feelings of decreased dignity and self-worth for R3. The facility's failure to uphold its dignity policy placed R3 at risk for impaired psychosocial well-being.
Failure to Ensure Resident Visitation Rights
Penalty
Summary
The facility failed to ensure that two residents, R1 and R2, were able to exercise their right to receive visitors of their choosing at the time of their choice. R1, who had severe cognitive impairment due to a stroke, was restricted from receiving visits from her representative without prior scheduling and supervision. This restriction was based on an unverified email from the State Agency (SA) that mentioned substantiated neglect. The facility did not clarify the information with the SA before imposing the restriction, leading to an incident where law enforcement was called to remove R1's representative during an unscheduled visit. R2, who had intact cognition, was also restricted from receiving visits from her husband in the dining room. The restriction was imposed after a dietary staff member felt uncomfortable due to an outburst from R2's husband when he was denied seconds. The facility refunded the money R2's husband had paid for meals and told him he could no longer eat at the facility. R2 expressed that her husband made her feel comfortable and that the restriction made her feel uncomfortable and led to her crying during an interview with the surveyor. The facility's visitation policy, revised in September 2022, directed that residents were permitted to have visitors of their choosing at the time of their choosing and provided 24-hour access to visitors with the resident's consent. The facility's failure to adhere to this policy placed both R1 and R2 at risk for impaired resident rights, impaired psychosocial well-being, and social isolation.
Failure to Inform Residents of Visitation Restrictions
Penalty
Summary
The facility failed to inform two residents and/or their representatives of their visitation rights and any restrictions placed on them. Resident 1, who had severe cognitive impairment, was not provided with a notice regarding restricted visitation for her durable power of attorney (DPOA). The DPOA was told by the facility's administrative staff that she could only visit Resident 1 by appointment and under supervision, but no formal notice was issued. This led to a situation where law enforcement was called when the DPOA visited outside the scheduled time, causing distress to Resident 1 and her representative. Resident 2, who had intact cognition, was also not informed of visitation restrictions placed on her husband. The facility told Resident 2's husband that he could not eat in the dining room and had to wait until Resident 2 finished eating. This restriction was imposed after an incident where dietary staff felt uncomfortable due to an outburst by Resident 2's husband. Despite this, no formal notice was given to Resident 2 or her representative about the visitation restrictions, leading to emotional distress for Resident 2. The facility's visitation policy, revised in September 2022, stated that residents were permitted to have visitors of their choosing at any time, with 24-hour access provided. However, the facility failed to adhere to this policy by not issuing the required notices to the residents and their representatives, thereby impairing resident rights, psychosocial well-being, and increasing the risk of social isolation.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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