Legacy On 10th Avenue
Inspection history, citations, penalties and survey trends for this long-term care facility in Topeka, Kansas.
- Location
- 2015 Se 10th Avenue, Topeka, Kansas 66607
- CMS Provider Number
- 175113
- Inspections on file
- 29
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Legacy On 10th Avenue during CMS and state inspections, most recent first.
The facility failed to maintain sufficient weekend nursing staff to meet residents’ basic and individual needs, as defined in its facility assessment. The assessment set minimum/optimal staffing for day and evening shifts at two licensed nurses, two CMAs, and four CNAs, and for nights at two licensed nurses and two CNAs, with weekend requirements matching weekdays. CMS PBJ CASPER data showed excessively low weekend staffing, and schedule reviews over several months revealed that all or most weekends were staffed below these minimums. An LN and administrative staff confirmed that weekends were expected to be staffed the same as weekdays but were difficult to cover due to frequent call-ins, despite having an on-call list and occasional management coverage.
The facility did not ensure nurse aides received the required 12 hours of annual in-service training, including dementia care and abuse prevention, for a census of 54 residents and a sample of 14 residents. When surveyors requested documentation of in-service training for the past year, the facility could not locate the binder containing sign-in sheets and training records. Administrative staff reported that staff turnover, including in the position responsible for overseeing nurse aide in-services and documentation, contributed to missing or incomplete records. The written policy on nurse aide qualifications and training did not address the requirement for 12 hours of annual in-service education.
Surveyors found that the facility failed to maintain sanitary conditions and proper food storage in the kitchen and serving areas. The dietary manager was observed in the kitchen without a hair net, floors were dirty with missing tiles, and multiple trays with dried leftover food were left from the previous day. The steam table, counters, and trays had dried food and residue, and the kitchen door was propped open. An opened, undated bag of sliced turkey was dripping juices in a refrigerator, and various food items, including pudding and fruit, were unlabeled and undated in refrigerators and a freezer. An ice scoop was stored on top of the ice machine instead of in a container, and there was no thermometer in the milk cooler, contrary to facility policies requiring safe food handling and sanitation.
The facility failed to ensure that an LN maintained a valid, active nursing license while providing care. One LN’s license had lapsed, as confirmed through Nursys and the state board verification system, yet the LN continued working for an extended period. Interviews with administrative and nursing leadership revealed that HR was responsible for license verification and tracking expirations, but due to multiple HR staff turnovers, required checks of nursing licenses and the nurse aide registry had not been kept current, contrary to the facility’s own background screening policy.
The facility did not follow a pest control contractor’s high-priority recommendation to patch a hole under a bathroom sink that was large enough for rodent entry in a resident’s room. A maintenance supervisor acknowledged the hole remained unrepaired due to competing project deadlines, despite staff reporting rodent sightings in two residents’ rooms through the work order system and nursing staff indicating they would notify maintenance of such issues. Administrative staff reported that rooms were checked weekly and that pest control recommendations were expected to be addressed immediately, and the facility’s pest control policy required an ongoing program to keep the building free of insects and rodents, but the identified structural entry point was not corrected.
Surveyors found that the facility did not consistently reconcile and document controlled drug counts between nursing shifts. Review of narcotic shift count sheets for one hall over an extended period showed that on most days there was a missing signature from either the on‑coming or off‑going nurse, indicating that required shift‑to‑shift narcotic counts were not reliably completed. An administrative nurse confirmed that facility policy required narcotic counts to be reconciled every shift, and the written pharmacy services policy required accurate and safe provision of medications, but documentation showed this process was not consistently followed.
Surveyors found that a medication cart on a resident hall was left unlocked with the keys in the lock and no staff present, despite facility policy that carts not be left unattended and unlocked. In the medication room, an opened vial of tuberculin lacked a date of opening and an expired bottle of latanoprost eye drops labeled for a resident remained in stock instead of being removed or returned to the pharmacy, contrary to the facility’s medication storage policy requiring locked storage and prompt disposal of outdated drugs.
Surveyors identified multiple infection control lapses, including several residents’ nebulizer masks and a nasal cannula left on surfaces or wrapped around oxygen equipment instead of being stored in sanitary containers, an uncovered clean-laundry cart with exposed linens, and an ice scoop resting directly on a metal cart rather than in a designated holder. A nurse was observed preparing and administering medications to multiple residents without performing hand hygiene between rooms, after touching trash can lids, linens, personal clothing, and her face, and after removing gloves, despite a facility policy emphasizing hand hygiene as the primary means to prevent infection. Staff interviews confirmed that respiratory equipment should be bagged when not in use, laundry carts should be covered, and the ice scoop should be stored in a container, and the facility was unable to provide a policy for clean laundry storage.
Surveyors found that the facility did not maintain a clean, odor-free, and homelike environment, as strong urine odors were present in multiple halls and at the dining room entry, and several urinals without lids were left on bedside tables and floors near beds. The dining room floor was sticky and dirty with dried spills, and laundry was stacked in large tubs in the laundry room near the kitchen foyer. Staff acknowledged ongoing odor issues, including a person who urinates outside the bathroom, and indicated that urinals were not always lidded or emptied frequently, contrary to the facility’s policy requiring a clean, sanitary environment with pleasant, neutral scents.
A resident was transferred to an acute hospital without receiving the required written notice detailing where and why the transfer occurred, their appeal rights, and state ombudsman contact information. The Nursing Home to Hospital Transfer Form lacked the transfer location, documentation that the resident or representative was notified, and the reason for transfer, as well as any statement of appeal rights or ombudsman details. Staff reported relying on EMR documentation and stated that written notices were not provided when a resident was their own legal representative or had an intact BIMS score, and the facility’s policy referenced written notice but did not ensure these elements were included for this unplanned hospital transfer.
A resident with hemiparesis, hemiplegia, dementia, and a history of falls was care planned for multiple fall-prevention interventions, including ensuring the call light was within reach and encouraging its use, keeping the chair reclined when not eating, and providing lateral support. Despite this, staff did not consistently keep the call light within the resident’s reach, and a fall was witnessed in which the resident fell from a wheelchair and sustained skin tears. Subsequent observations found the resident reclined in a Broda chair with the call light behind the bed and out of reach, even though staff acknowledged that fall interventions are listed in care plans and that call lights should be accessible to residents, in accordance with the facility’s falls management policy.
Surveyors found that two residents did not have required documentation showing they were offered or declined influenza and pneumococcal (PCV20) vaccines, nor any record of prior vaccination or MD-documented contraindications. EMR immunization sections were incomplete, and staff could not locate consent or declination forms, while also indicating uncertainty or shifting responsibility regarding who tracks and documents immunizations, despite facility policies requiring that all eligible residents be offered these vaccines and be given information on their risks and benefits.
Surveyors determined that the facility did not use the correct CMS-10055 SNF Advance Beneficiary Notice of Non-Coverage (SNF ABN) when notifying two residents or their representatives that Medicare-covered services were ending. For each resident, a NOMNC was issued with the appropriate end date of covered services, but the accompanying ABN was an outdated version lacking the proper CMS identification number. A social services staff member reported relying on the facility’s master forms list and, at times, insurance company forms, and was unaware the ABN was incorrect. The administrator was not aware the wrong ABN had been used, and the facility did not have a policy on beneficiary notice.
Surveyors found that daily nurse staffing information was not consistently posted or retained as required. Over an 18‑month review period, multiple days of staffing records were missing, and the sheet displayed during observation was not for the current date. Staff interviews showed that an administrative staff member was responsible for weekday postings and record retention, while charge nurses were expected to post and update prefilled sheets on weekends. A changeover in the personnel responsible for maintaining these records contributed to the inability to locate all required historical staffing sheets, despite a written policy requiring timely posting and 18‑month retention of nurse and CNA staffing data.
The facility did not keep an area free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors. Staff did not implement sufficient monitoring or protective measures to address environmental risks.
The facility did not conduct a thorough facility-wide assessment, missing critical details such as specific staffing needs for each unit and contingency plans for non-emergency events. This oversight placed all residents at risk for unidentified care needs and inadequate care.
The facility failed to provide same-day access to funds for 29 residents with facility-managed trust accounts, as the facility's bank was only open for two hours on weekdays. Residents reported being unable to access their money on weekends or outside these hours, which was confirmed by staff. This practice placed residents at risk for decreased psychosocial well-being and impaired their rights.
The facility failed to maintain a sanitary and homelike environment, with observations of strong urine odors, food left out overnight attracting flies, and unsanitary dining conditions. Residents were affected, with flies landing on them and their meals. The Resident Council noted issues with open patio doors and food being left out, contributing to the fly problem.
The facility failed to provide a system for residents to file grievances anonymously, as observed during an inspection. Resident Council members and staff confirmed that grievances must be submitted through staff, lacking anonymity. This practice does not align with the facility's policy and risks unresolved grievances and decreased psychosocial well-being.
The facility failed to provide consistent activities for residents due to the absence of an Activity Director. Scheduled staff-led activities were not conducted, and outdated calendars were still posted. Interviews revealed that activities were inconsistent, especially on weekends, and self-directed activities were insufficient. The facility's policy required a qualified staff member to ensure the program met residents' needs, which was not being fulfilled.
The facility failed to provide a certified activity professional to direct the activities program, leading to inconsistent scheduling and a lack of staff-led activities. Observations and interviews revealed that the activities coordinator was let go weeks prior, and the facility resorted to providing independent activities like coloring pages. This deficiency placed residents at risk for impaired quality of life.
The facility failed to secure hazardous equipment, oxygen tanks, and chemicals, placing eleven cognitively impaired residents at risk. Observations revealed unsecured oxygen cylinders, furnace closets, and cleaning supplies, along with an open electrical panel. Staff confirmed these items should be locked, aligning with the facility's policy.
The facility failed to ensure proper infection control practices, with observations of unsanitary storage of respiratory equipment and linens, and inadequate hand hygiene by staff. A resident's nebulizer mask was improperly stored, and oxygen tubing was left unbagged. Staff did not perform hand hygiene before and after resident care, despite facility policies emphasizing its importance.
The facility failed to maintain effective pest control, leading to a significant presence of flies in the dining hall. Observations showed that food trays with exposed meals were left out overnight, attracting flies that landed on residents and their meals. Staff interviews revealed a lack of adherence to proper food handling and disposal procedures, and the facility did not provide a pest control policy.
A facility failed to include a resident's representative in care planning, risking impaired care and decreased autonomy. The resident had severe cognitive impairment and multiple medical conditions, yet their representative was only invited to one care conference. The administrative nurse was unaware of the invitation process, and the facility's policy to involve family and representatives was not followed.
A resident with multiple medical conditions and severely impaired cognition was found with their call light out of reach, contrary to their care plan and facility policy. Staff interviews confirmed that call lights should be accessible to residents, highlighting a deficiency in accommodating resident needs.
A resident with multiple health conditions and severely impaired cognition experienced two non-injury falls, but the facility failed to notify the resident's legal representative as required by policy. Staff interviews revealed inconsistencies in the notification process, placing the resident at risk for uninformed treatment decisions.
A facility failed to ensure a Consulting Pharmacist identified and reported the inappropriate indication for a resident's use of Risperdal, an antipsychotic medication. The resident's EMR lacked a specific diagnosis justifying the medication, despite the facility's policy requiring appropriate use and indications for all medications. Interviews confirmed that 'antipsychotic' is not an acceptable indication, placing the resident at risk for unnecessary medications and side effects.
A facility failed to monitor a resident's psychotropic medication use by not obtaining physician-ordered EKGs, placing the resident at risk for adverse effects. Another resident received antipsychotic medication without a CMS-approved indication, contrary to facility policy. These deficiencies highlight lapses in medication monitoring and appropriate use, risking unnecessary medication and side effects.
A resident receiving hospice services at the facility had a care plan that lacked coordination between the facility and the hospice provider. The resident, who had multiple diagnoses and a terminal prognosis, did not have a care plan detailing the frequency of hospice staff visits or the medications, equipment, and supplies provided by hospice. Facility staff were unsure about the specifics of hospice provisions, and the facility failed to ensure collaboration with the hospice provider, risking missed or delayed services.
The facility failed to provide mail delivery services on Saturdays for its residents. Resident Council members reported that mail was stored over the weekend and distributed on Monday, following the departure of the weekend activity staff who previously handled mail distribution. A CNA and an Administrative Nurse were unsure about the current mail delivery process, and the facility lacked a policy on residents' rights to mail delivery on Saturdays.
The facility did not maintain 18 months of daily posted nurse staffing records as required. An inspection found that staffing sheets were missing from May to November of the previous year. Administrative Nurse D indicated that the previous management team failed to file these records, leaving only those from December onwards available. The facility's policy requires these records to be kept for 18 months and accessible upon request.
A resident with dementia and bipolar disorder was transferred to the hospital due to increased agitation, but the facility failed to provide a written notification of the transfer to the resident or their representative. Although verbal communication was made, the facility's policy did not require written notifications, leading to a risk of miscommunication.
A resident with dementia and bipolar disorder was transferred to the hospital without receiving the required bed hold policy notice. The facility's policy mandates providing written information about bed hold rights and limitations at the time of transfer, but this was not done, posing a risk to the resident's ability to return to the facility.
The facility failed to ensure accurate and consistent reconciliation of controlled substances on medication carts, with numerous missed opportunities for narcotic counts and improper signing procedures by staff, despite recent training.
Persistent Weekend Understaffing Below Facility-Defined Minimums
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on weekends to meet residents’ basic and individual needs, as required by its own facility assessment and CMS PBJ staffing expectations. The facility had a census of 54 residents and a capacity of 60, with a facility assessment (last reviewed 03/19/26) that established minimum/optimal staffing levels for weekdays and weekends: for day and evening shifts, two licensed nurses, two CMAs, and four direct care staff (CNAs); and for night shift, two licensed nurses and two direct care staff. A review of the CMS PBJ CASPER 1705D report for FY 2026 Q1 showed the facility triggered for excessively low weekend staffing. Review of actual nursing schedules from 10/01/25 to 02/28/26 showed weekend staffing below the facility’s own minimum/optimal levels on all weekends in October, November, December, and February, and on two of four weekends in January. Staff interviews confirmed that weekend staffing was expected to be the same as weekday staffing but was difficult to maintain. A licensed nurse stated that the typical goal for day and evening shifts was two nurses, four aides, and two medication aides, and for nights two nurses and two aides, and that weekends should be staffed the same way. Administrative nursing staff reported that an on-call schedule existed for weekends and that on-call staff and management were contacted to cover open slots, but also acknowledged that weekends had the most call-ins and were hard to cover. Administrative staff further confirmed that weekend staffing requirements were the same as during the week and were based on the facility assessment’s determination of the minimal number of staff needed to meet residents’ needs, yet the documented schedules showed repeated weekend shifts staffed below those minimums.
Failure to Ensure Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure nurse aides received the required 12 hours of annual in-service training, including dementia care and abuse prevention, for a census of 54 residents and a sample of 14 residents. During the survey, when records of required nurse aide in-service training for the past year were requested, the facility was unable to locate the binder containing sign-in sheets and documentation of education and training provided to nurse aide staff. Administrative Staff A reported she could not find the in-service binder and noted there had been staff turnover in the past year, including the staff member responsible for ensuring completion of in-services and maintenance of documentation. Administrative Nurse D stated that the director of nurse aides was responsible for ensuring nurse aides completed the required in-services and maintained documentation, but that turnover in this position resulted in some required in-service documentation not being completed or retained. Additionally, the facility’s “Nurse Aide Qualifications and Training Requirements” policy dated 08/10/21 did not include information about the requirement for nurse aides to receive 12 hours of in-service training/education annually. No specific resident medical histories or conditions related to this deficiency were described in the report.
Failure to Maintain Sanitary Kitchen Conditions and Proper Food Storage
Penalty
Summary
Surveyors identified a failure to maintain sanitary dietary conditions and proper food storage and handling in the facility’s kitchen and dining service areas. During an initial tour, the dietary manager was observed in the kitchen without a hair net. The kitchen floor was sticky and dirty, with missing tiles near the dishwasher. A tall cart held 17 trays with dried chili, cinnamon rolls, and other foods left from the previous day, and the dishwasher sink contained standing water due to a backed-up garbage disposal. Bowls and plates were not stored inverted. The steam table had dried food on the top and dried dark brown food particles running down the front, with grease and food residue underneath. A nearby stainless-steel counter had dried food spilled down the side, and brown serving trays stored underneath were covered in dried white substance. The ovens on the stove were not working, and staff were using only the convection oven. The kitchen door was propped open. Food storage practices were also deficient. In the two-door refrigerator in the kitchen prep area, an opened, undated bag of sliced turkey was observed dripping juices onto the bottom shelves. In a single-door freezer, a box of chocolate chip cookie dough was opened and exposed to air. In a double refrigerator in the serving area, chocolate pudding, a bag of canned fruit, and small bowls of fruit were all unlabeled and undated. On a later recheck, the ice scoop was found resting on top of the ice machine rather than in a container, and there was no thermometer in the milk cooler. Dietary staff acknowledged that all foods should be dated and labeled, dishes should be inverted and not left overnight, and that the steam table and counters should be cleaned often and after each meal. Administrative staff reported being unaware that the kitchen was not clean, despite facility policies stating that foods must be received and stored in compliance with safe food handling practices and that the food service area must be maintained in a clean and sanitary manner.
Failure to Ensure Licensed Nurse Maintained Active Nursing License
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed nurse maintained a valid, active nursing license while working. The facility had a census of 54 residents with a sample of 14 residents. Facility documentation dated 02/17/26 showed that an administrative staff member identified that one licensed nurse’s (LN H’s) nursing license had lapsed on 11/30/25. The facility verified the lapse through searches on the Nursys national nurse licensure database and the Kansas State Board of Nursing (KSBN) verification website. On 03/23/26, surveyors independently confirmed via Nursys and KSBN that LN H’s license had lapsed on 11/30/25, yet LN H continued to work at the facility with the lapsed license until 02/17/26. Administrative staff interviews revealed that human resources (HR) staff were responsible for verifying valid licenses and tracking expiration dates, but this process had not been maintained. An administrative nurse stated that recent turnover in HR staff contributed to nursing license and nurse aide registry checks not being kept up to date. Another administrative staff member reported that, after turnover of three different HR staff in the prior six months, she discovered that nursing license verifications had not been completed for some time. The facility’s Background Screening Investigations policy, dated November 2023, documented that for any licensed professional applying for a position involving direct resident contact, the respective licensing board is to be contacted to determine if any sanctions have been assessed against the applicant’s license.
Failure to Implement High-Priority Pest Control Recommendation for Rodent Entry Point
Penalty
Summary
The facility failed to follow its pest control program and the pest control contractor’s high-priority recommendations regarding a structural opening that could allow rodent entry. A Pest Control Monthly Report dated 02/24/26 documented a high-priority recommendation to patch a hole in the wall under a bathroom sink, near the floor, that was large enough for rodent entry. On 03/24/26 at 11:32 AM, an observation of Resident 5’s room showed that the hole under the sink was still present. On 03/24/26 at 12:05 PM, the Maintenance Supervisor confirmed that the hole remained and stated he had not had time to fix it due to other assigned projects and deadlines. On 03/31/26, a CNA reported that when staff see mice or rodents in Resident 5’s room or Resident 18’s room, they enter this information into the facility’s work order system (TELS) so maintenance can address it. A licensed nurse stated she would call the Maintenance Supervisor immediately if there was a problem. An administrative nurse stated the facility had a program to ensure all rooms and equipment were kept in good condition and that rooms were checked weekly. Administrative Staff A stated she expected any pest control recommendations to be followed up on immediately. The facility’s undated Pest Control policy documented that the facility maintains an ongoing pest control program to keep the building free of insects and rodents, with maintenance services assisting as appropriate, but the documented high-priority recommendation to patch the hole in Resident 5’s room had not been implemented.
Failure to Consistently Reconcile and Document Controlled Drug Counts Between Shifts
Penalty
Summary
Surveyors identified that the facility failed to ensure accurate reconciliation of controlled drugs at the end of daily work shifts. The facility had a census of 54 residents and a sample of 14 residents, with four medication carts and two medication rooms reviewed. On review of the Narcotic Shift Count Sheet for the west hall covering an 88‑day period from 01/01/26 to 03/29/26, surveyors found that on 59 of those days there was a missing signature from either the on‑coming nurse or the off‑going nurse, indicating that the required shift‑to‑shift narcotic count reconciliation was not consistently completed. Specific dates with missing signatures included multiple days in January, February, and March. An administrative nurse confirmed that facility policy and expectations required the narcotic count to be reconciled between shift changes daily and every shift, and the written Pharmacy Services Overview policy stated the facility would accurately and safely provide pharmaceutical services, including medications and the services of a licensed consultant pharmacist. These observations and record reviews demonstrated that the facility did not consistently follow its own policy and expectations for controlled drug reconciliation, as evidenced by the frequent absence of required nursing signatures on narcotic shift count sheets over the reviewed period.
Unlocked Med Cart and Expired Medications in Drug Room
Penalty
Summary
Surveyors identified that medication security and storage practices did not follow facility policy or professional standards. During observation of the west hall, a medication cart assigned to a certified medication aide was found unlocked with the keys left in the lock, and no staff present near the cart. An administrative nurse then approached, locked the cart, and removed the keys while waiting for the medication aide to return. The administrative nurse later stated that medication carts should never be left unlocked or have keys left in them when staff are away, and the medication aide acknowledged she had stepped away briefly to assist another staff member and should have locked the cart and removed the keys. In a separate observation of the west medication storage room, surveyors found an opened vial of tuberculin without a date of opening and an expired bottle of latanoprost ophthalmic solution labeled for a specific resident, with an expiration date of 10/15/24. The administrative nurse reported that another administrative nurse was responsible for ensuring medications were returned to the pharmacy as needed and that no outdated medications remained in the medication room. The facility’s Storage of Medications policy documented that drugs and biologicals must be stored in locked compartments, that discontinued, outdated, or deteriorated drugs or biologicals are to be returned to the dispensing pharmacy or destroyed, and that unlocked medication carts are not to be left unattended.
Infection Control Lapses in Respiratory Equipment Storage, Laundry Handling, Ice Service, and Hand Hygiene
Penalty
Summary
The deficiency involves multiple failures in infection prevention and control practices related to the storage and handling of resident respiratory equipment, clean laundry, and ice service items, as well as inadequate hand hygiene during medication administration. During an initial walk-through, surveyors observed several residents’ nebulizer masks not stored in sanitary containers when not in use: one mask was lying next to an oxygen canister, another on a blue tote by a doorway, another at the bottom of a bed, and another on a bedside table. A resident’s nasal cannula was also found wrapped around the handle of an oxygen canister rather than contained in a sanitary manner. Staff later stated that respiratory equipment should be cleaned and placed in plastic bags when not in use. Surveyors also observed that a green cart containing clean laundry on one hall was uncovered, exposing blue chucks, brown blankets, and white sheets, despite staff statements that such carts should always be covered. In a day room, an ice scoop was found lying directly on a metal cart next to an ice chest instead of being stored in a designated container. Staff interviews confirmed that the ice scoop should have a container or holder and that the clean laundry cart should be covered, indicating a discrepancy between facility expectations and actual practice. In addition, there were repeated lapses in hand hygiene by a nurse during medication passes. The nurse prepared and administered medications to multiple residents in succession without performing hand hygiene after exiting resident rooms, after touching potentially contaminated items such as trash can lids, blankets, her own clothing, and her face, and after doffing gloves. She also handled a resident’s drinking cup, filled it with ice, and returned it to the resident without performing hand hygiene between tasks. The facility’s hand hygiene policy stated that hand hygiene is the primary means to prevent the spread of infections and that personnel should follow handwashing/hand hygiene procedures, but the observed practices did not align with these requirements. The facility did not provide a policy for clean laundry storage when requested.
Failure to Maintain Clean, Odor-Free, and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its Quality of Life-Home Environment policy. During a walkthrough of the East and West halls, surveyors noted a distinct smell of urine throughout the halls and at the foyer entry into the dining room. Multiple urinals were observed on bedside tables and on the floors by residents’ beds, and some of these urinals did not have lids. The dining area floor was described as sticky and dirty, with multiple dried spills present. An inspection of the laundry service room revealed stacked laundry and four large grey tubs of laundry in a room located in the hall next to the kitchen foyer entry. Administrative staff acknowledged awareness of the odor issues and the presence of a person in the facility who urinates in places other than the bathroom. Staff interviews indicated that the source of the odor had not been clearly identified at the time of the observations, and that urinals without lids and infrequent emptying of urinals contributed to the problem. The facility’s own policy stated that residents were to be provided with a clean, sanitary, and orderly environment with pleasant, neutral scents, but the observed urine odors, improperly managed urinals, unclean dining room floor, and accumulated laundry demonstrated that this standard was not being met.
Failure to Provide Required Written Transfer Notice and Appeal Rights
Penalty
Summary
The facility failed to provide a resident and their representative with the required written notification of transfer when the resident was sent to the hospital. The electronic medical record documented that the resident had an unplanned discharge to an acute hospital with return anticipated, and a Discharge MDS was completed. The facility’s Nursing Home to Hospital Transfer Form for this resident did not include the transfer location, did not document that the resident or legal representative was notified of the transfer, and did not state the reason for the transfer. The form also lacked any written information about the resident’s appeal rights, including the name, address, and telephone number of the entity that receives appeal requests, how to obtain and complete an appeal form, and how to submit an appeal hearing request. Surveyor interviews further showed that staff practice did not ensure written notification of transfer and appeal rights. A licensed nurse reported that she would document in the EMR who was notified of the transfer, where the resident was transferred, and what information was sent regarding the resident’s medical condition, but this documentation did not appear on the written transfer form. An administrative nurse stated that the facility would not provide written notification if the resident was their own legal representative or had a BIMS score of 12 or greater, indicating intact cognition. The facility’s written Transfer or Discharge Notice policy stated that a 30‑day written notice would be provided for impending transfers or discharges and that, in a medical emergency, the resident would be transferred to an acute care setting and a determination made regarding the need for a formal notice of discharge, but the required written notice elements were not provided for this resident’s hospital transfer.
Failure to Implement Care-Planned Fall Interventions Related to Call Light Access
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to implement fall-prevention interventions as care planned for a resident with significant neurological and mobility impairments. The resident’s diagnoses included hemiparesis, hemiplegia, dementia, and cerebrovascular accident, and a recent MDS documented intact cognition with a history of one non-injury fall. A Falls CAA identified the resident as at risk for falls due to unsteady balance, history of falls, and psychotropic medications. The care plan included interventions such as anticipating and meeting needs, following the facility’s fall protocol, educating the resident and family about safety, providing prompt response to requests for assistance, ensuring the call light was within reach and encouraging its use, keeping the resident’s chair reclined when not eating, and ensuring right lateral support was in place. Despite these care-planned interventions, the facility did not consistently ensure the resident’s call light was within reach. A Fall Note documented that dietary staff witnessed the resident fall over the side of his wheelchair to the floor, resulting in skin tears to the left knee, right ankle, and left thumb, and a Fall Risk Assessment on the same date identified the resident as a high fall risk. On two separate observations later in the month, the resident was seen reclined in a Broda chair in his room with the call light lying behind the bed and not within his reach. During interviews, a CNA, a licensed nurse, and an administrative nurse all stated that staff had access to care plans, that fall interventions were found in those care plans, and that call lights should be within reach of residents, including this resident. The facility’s Managing Falls and Fall Risk policy stated that staff would identify and implement interventions based on evaluations and current data to try to prevent falls and minimize complications, but the call light intervention was not implemented as planned.
Failure to Offer and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to follow its policies for offering and documenting influenza and pneumococcal vaccinations for two residents. For one resident, admitted on an unspecified date, review of the EMR under the Immunization tab on 03/30/26 showed no documentation that the influenza vaccine had been offered or declined, and there was no record of prior influenza vaccination or a physician-documented contraindication. The facility was unable to provide any declination form for this resident’s annual influenza vaccination. For another resident, also admitted on an unspecified date, the EMR Immunization tab on 03/30/26 lacked documentation that either the influenza vaccine or the PCV20 pneumococcal vaccine had been offered or declined, and there was no record of historical administration or physician-documented contraindications for either vaccine. The facility could not produce declination forms for this resident’s annual influenza or PCV20 vaccinations. During interviews, a licensed nurse stated she was not responsible for tracking resident immunization history or vaccine administration, and an administrative nurse reported she could not locate the consent or declination forms and indicated the infection preventionist was responsible for tracking and documenting immunizations. The facility’s written policies stated that all residents without medical contraindications would be offered influenza and pneumococcal vaccines and that pertinent information about vaccine risks and benefits would be provided to residents or their legal representatives.
Failure to Use Correct CMS SNF ABN Form for Medicare Beneficiary Notices
Penalty
Summary
Surveyors found that the facility failed to provide the correct CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) to two Medicare beneficiaries, identified as R56 and R57, or their representatives. Record review showed that for R56, the facility issued a Notice of Medicare Non-Coverage (NOMNC) indicating covered services would end on 11/19/25, with the NOMNC and ABN received on 11/17/25; however, the ABN used was not the most current version of the CMS-10055 form. Similarly, for R57, the facility issued a NOMNC documenting that covered services would end on 11/04/25, with the NOMNC and ABN received on 11/02/25, but again the ABN provided was not the current CMS-10055 version. During interviews, the social services staff member responsible for issuing the notices stated she obtained and used ABN forms from the facility’s master list of forms and sometimes used ABN forms supplied by insurance companies, and she was unaware that the ABN form she used lacked an identification number. The administrator reported not being aware that the incorrect ABN form had been issued. The facility was unable to provide a policy on beneficiary notice, and the census at the time of survey was 54 residents, with 14 residents sampled and four reviewed for beneficiary notification.
Failure to Post and Retain Required Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to consistently post and retain daily nurse staffing information as required by regulation and facility policy. Surveyors reviewing 18 months of records on 03/24/26 found that the facility lacked any posted staffing information from 08/01/25 through 11/14/25, as well as additional specific missing days in November and December 2025, January and February 2026, and March 2026. On 03/24/26 at 1:49 PM, observation showed that the daily posted staffing sheet on display was dated 03/23/26 instead of the current date. The facility’s written policy from October 2021 required that within two hours of the beginning of each shift, the numbers of licensed nurses and CNAs directly responsible for resident care be posted in a prominent, accessible location in a clear and readable format, and that records of staffing information for each shift be kept for at least 18 months or longer if required by state law. Interviews with staff clarified how the posting process was intended to work and revealed gaps in implementation. On 03/31/26, an LN stated that an administrative staff member was responsible for posting the daily staffing sheets during the week, and that on weekends the sheets were prefilled and posted by the charge nurse, who would adjust them if needed. An administrative nurse confirmed that the same administrative staff member was in charge of both posting and retaining the daily staffing information, and that on weekends the charge nurse was responsible for posting and updating the prefilled sheets. Another administrative staff member reported there had been a changeover in the staff responsible for maintaining the daily posted staffing sheets and acknowledged she had not been able to locate all of the required records from the past 18 months. At the time of the survey, the facility had a census of 54 residents and a sample of 12 residents, but the deficiency centered on the facility’s failure to post and retain required staffing information rather than on specific resident clinical issues.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Inadequate Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment, dated [DATE], was found lacking in several critical areas. It did not specify the staffing requirements for each unit, including nights and weekends, and omitted the number of RNs, LPNs/LVNs, CMAs, and CNAs needed per unit. Additionally, the assessment did not include a contingency plan for events that could impact resident care but did not necessitate the activation of the facility's emergency plan. Furthermore, there was no plan outlined to enhance the recruitment and retention of direct care staff. During the inspection, Administrative Staff A acknowledged reviewing updated CMS requirements related to facility assessments but noted that some information might not have been incorporated into the facility's documentation. The facility's policy, revised in July 2024, mandates an annual assessment to thoroughly review services, care, equipment, and staffing needs. However, the failure to conduct a thorough assessment placed all residents at risk for unidentified care needs and inadequate care.
Limited Access to Resident Funds
Penalty
Summary
The facility failed to ensure that residents had same-day access to their funds for amounts less than $100.00, affecting 29 residents with facility-managed trust accounts. Observations and interviews revealed that the facility's bank was only open from 3 PM to 5 PM on weekdays, limiting residents' access to their money. Residents reported that they could not access their funds on weekends or outside of these hours, which was confirmed by Administrative Staff B, who stated she was the only one with access to the funds during these limited hours. The facility's policy indicated that residents should have access to manage their funds in a safe and confidential manner, but it did not specify the need for same-day access. The lack of access to funds outside of the specified hours placed 29 residents at risk for decreased psychosocial well-being and impaired their rights to manage their financial affairs. The facility had previously allowed access through a cashbox with the nurses, but this practice was discontinued a year ago, further restricting residents' access to their money.
Unsanitary Conditions and Pest Issues in Facility
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment, as evidenced by multiple observations of unsanitary conditions and pest issues. Upon entrance to the facility, a strong urine odor was detected in the west and central hallways. Inspections of the dining hall area revealed multiple food trays with partially eaten meals left out overnight, attracting flies. Flies were observed landing on the exposed food and were present throughout the dining room and vending machine area. Additionally, dried food particles and residue were found on the dining room floor. Residents were directly affected by these conditions, as evidenced by one resident sleeping in her wheelchair in the dining room while flies landed on her. During meal times, numerous residents were seen swatting flies away from their meals. The Resident Council acknowledged the fly issues, attributing them to the dining room patio doors being left open and food being left out. Administrative staff confirmed that the facility was working with a pest control company to address the fly problem and acknowledged that food should not be left out for extended periods. The facility's policy emphasizes providing a safe, clean, and comfortable environment, which was not upheld in this instance.
Lack of Anonymous Grievance System
Penalty
Summary
The facility failed to implement a system that allows residents and their representatives to file grievances anonymously. During an inspection, it was observed that there were no designated grievance drop boxes or systems available in areas accessible to residents and visitors. Interviews with Resident Council members revealed that they were unaware of any method to submit grievances anonymously, indicating that grievances had to be taken directly to a staff member. The staff would then either slide the grievance under the administrator's door or hand it directly to the administrator. Further interviews with facility staff, including a Licensed Nurse and the Administrator, confirmed the absence of an anonymous reporting system for grievances. The facility's policy states that residents have the right to file grievances orally or in writing, but the current practice requires residents to submit grievances through staff members, which does not ensure anonymity. This deficiency placed residents at risk for decreased psychosocial well-being and unresolved grievances.
Inconsistent Resident Activities Due to Lack of Activity Director
Penalty
Summary
The facility failed to provide consistent activities for its residents, as observed during a survey. The activity calendar for September 2024 indicated that residents were supposed to have four scheduled staff-led activities each day, including events like coffee chat, crafts, social hours, Bingo, and trivia. However, observations on October 8, 2024, revealed that no staff-led morning or afternoon activities were conducted. Additionally, outdated September activity calendars were still posted throughout the facility, indicating a lack of current planning and execution of activities. Interviews with Resident Council members and staff revealed that the facility's Activity Director had been let go three weeks prior, and no replacement had been hired. The Resident Council reported that while some activities were held sporadically, they were inconsistent, especially on weekends. The facility attempted to provide self-directed activities like coloring pages and games, but these were not sufficient to meet the residents' needs. The facility's Activities policy, revised in October 2022, stated that a qualified staff member should ensure the program meets the residents' emotional, social, physical, and psycho-social needs, which was not being fulfilled at the time of the survey.
Deficiency in Activities Program Due to Lack of Certified Coordinator
Penalty
Summary
The facility failed to provide a certified activity professional to direct the activities program, which is a requirement to ensure the emotional, social, physical, and psycho-social well-being of the residents. The facility had a census of 55 residents, with a sample of 15 residents, and was unable to provide evidence of an activity coordinator during the survey conducted on October 7 and 8, 2024. Observations during these dates revealed that no staff-led activities were conducted in the morning or afternoon, despite the activity calendar indicating scheduled activities. The September 2024 activity calendar was still posted throughout the facility, indicating a lack of updates and organization in the activities program. Interviews with Resident Council members and staff confirmed the absence of a certified activity professional. The Resident Council reported that the activities coordinator was let go three weeks prior, leading to inconsistent activity scheduling, especially on weekends. Administrative Nurse D and Licensed Nurse G corroborated this, stating that the front office attempted to organize activities, but they were often inconsistent. The facility resorted to providing coloring pages and games for residents to engage in independently. The facility's activities policy, revised in October 2022, mandates the employment of a qualified staff member to lead the activities program, which was not adhered to, placing residents at risk for impaired quality of life.
Failure to Secure Hazardous Materials and Equipment
Penalty
Summary
The facility failed to secure potentially hazardous equipment, oxygen tanks, and chemicals in a safe, locked area, placing eleven cognitively impaired independently mobile residents at risk for preventable accidents and injuries. During a walkthrough, it was observed that an unsecured oxygen storage room contained 40 pressurized supplemental oxygen cylinders. Additionally, unsecured furnace closets were found in the central and west hallways, and a storage room in the west hallway had multiple bottles of bleach wipes with the door propped open. These bottles contained warnings about potential hazards to humans. Further observations revealed an unsecured cleaning closet in the central hallway with multipurpose floor cleaners, and an unsecured beauty shop in the east hallway with a bottle of super-strength bleach and an open high-voltage electrical panel. Interviews with staff confirmed that oxygen should be locked at all times and that potentially hazardous chemicals and equipment should be secured and locked out of reach from residents. The facility's policy on accident storage areas, revised in October 2024, indicated that potentially hazardous materials should remain in locked and staff-controlled areas at all times.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, as evidenced by several observations during a survey. A resident's nebulizer mask was found unsanitarily placed directly on a bedside table without being stored in a sanitary container. Additionally, oxygen tubing was observed unbagged and coiled around a wheelchair, indicating improper storage of respiratory equipment. Furthermore, clean linens were stored next to a soiled linen bin with the cover left open, compromising their sanitary condition. Staff members were observed not adhering to hand hygiene protocols. Certified Nurse's Aides (CNAs) were seen donning gloves without performing hand hygiene and failing to wash their hands after removing gloves and leaving a resident's room. Interviews with staff, including a Licensed Nurse and an Administrative Nurse, revealed inconsistencies in understanding and implementing the facility's policies on hand hygiene and the storage of respiratory equipment and linens. These practices placed residents at risk for infectious diseases, as the facility's policies emphasize hand hygiene as a primary means to prevent infection spread.
Failure to Maintain Effective Pest Control
Penalty
Summary
The facility failed to maintain effective pest control measures, resulting in a significant presence of flies in the dining hall area. Observations revealed that food trays with exposed and partially eaten meals were left out overnight, attracting flies. On multiple occasions, flies were seen landing on the food and around the dining area, including on residents and their meals. This was particularly evident when a resident was observed sleeping in her wheelchair at the dining table, with flies landing on her and her uncovered meal. Interviews with staff indicated a lack of adherence to proper food handling and disposal procedures. Dietary Staff BB acknowledged that old food and dirty dishes should not be left out overnight, and trash should be stored in closed containers. However, she noted that there was no designated area for disposing of old food and used dishes. Administrative Nurse D confirmed that staff were expected to discard old food and rinse dishes before placing them in the turn-in bin. The facility did not provide a policy for pest control, contributing to the ineffective management of the pest issue.
Failure to Include Resident's Representative in Care Planning
Penalty
Summary
The facility failed to include Resident 50's representative in the development and planning of the resident's care plan, which placed the resident at risk of impaired care and decreased autonomy. Resident 50 had a severely impaired cognition with a BIMS score of zero and was dependent on staff for daily activities. The resident's medical conditions included diabetes mellitus, congestive heart failure, depressive disorder, dysphagia following cerebral infarction, kidney disease, urinary retention, and aphasia. Despite these conditions, the facility did not document the involvement of the resident or their representative in care conferences held on two occasions. The resident's representative expressed a desire to attend each care conference but was only invited to one. The administrative nurse was unaware of the invitation process for care conferences, which were scheduled and conducted by the Social Service Designee. The facility's policy encouraged the participation of the resident, their family, and legal representatives in care planning, but this was not adhered to in the case of Resident 50. This oversight in involving the resident's representative in care planning was a deviation from the facility's policy and contributed to the deficiency.
Resident's Call Light Out of Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a deficiency in accommodating the needs and preferences of residents. The resident, identified as R50, had multiple medical conditions including diabetes mellitus, congestive heart failure, depressive disorder, dysphagia following a stroke, kidney disease, urinary retention, and aphasia. The resident's cognitive abilities were severely impaired, as indicated by a Brief Interview of Mental Status (BIMS) score of zero. The care plan for R50 specifically required staff to ensure the call light was within reach and to encourage the use of a pancake light, with prompt responses to requests for assistance. During an observation, it was noted that R50's call light was on the floor and out of reach while the resident lay in bed. Interviews with staff, including a licensed nurse, a certified nurse's aide, and an administrative nurse, confirmed that call lights should be within the resident's reach or beside them. The facility's policy on accommodation of needs emphasizes assisting residents in maintaining safe independent functioning, dignity, and well-being. The failure to keep the call light accessible left the resident vulnerable to unmet care needs.
Failure to Notify Resident's Representative of Falls
Penalty
Summary
The facility failed to notify the legal representative of a resident, identified as R50, about changes related to falls, which is a requirement under their policy. R50's medical history includes diabetes mellitus, congestive heart failure, depressive disorder, dysphagia following cerebral infarction, kidney disease, urinary retention, and aphasia. The resident has severely impaired cognition, as indicated by a BIMS score of zero, and is dependent on staff for daily activities. Despite these vulnerabilities, the facility did not document notification of R50's representative after two non-injury falls on separate occasions. Interviews with staff revealed inconsistencies in the notification process. R50's representative confirmed being informed of only one fall, while the facility's policy mandates prompt notification of any changes in a resident's condition, including falls. Licensed Nurse G and Administrative Nurse D both acknowledged the requirement to inform the resident's guardian or representative of any changes, yet there was uncertainty about whether this was consistently done. This oversight placed R50 at risk for uninformed treatment or care decisions.
Failure to Identify Inappropriate Indication for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that the Consulting Pharmacist (CP) identified and reported the inappropriate indication or lack of diagnosis for a resident's use of Risperdal, an antipsychotic medication. The resident's Electronic Medical Records (EMR) included diagnoses such as altered mental status, epilepsy, hemiparesis/hemiplegia, cerebral infarction, and heart failure. However, the records did not provide a specific diagnosis justifying the use of Risperdal. The resident's Minimum Data Set (MDS) indicated intact cognition and no observed behaviors since the last assessment, yet the resident was routinely administered antipsychotic medication. The Pharmacy Monthly Medication Review noted the resident was readmitted with the medication and reminded the medical provider to attempt a gradual dose reduction. However, the CP did not identify the inappropriate indication for Risperdal. Interviews with facility staff confirmed that antipsychotic medications should only be used for approved diagnoses, and 'antipsychotic' is not an acceptable indication. The facility's policy on psychotropic medication monitoring emphasized ensuring appropriate use and indications for all medications, but this was not adhered to in the case of the resident, placing them at risk for unnecessary medications and side effects.
Deficiencies in Psychotropic Medication Monitoring and Indication
Penalty
Summary
The facility failed to obtain physician-ordered tests to monitor for side effects related to the use of psychotropic medication for a resident identified as R21. The resident's electronic medical record documented diagnoses of anxiety, depression, and hypertension, with a significant change in cognitive status over time. Despite a physician order for an electrocardiogram (EKG) every three months due to psychotropic medication use, the facility did not provide evidence of EKG results for November 2023 and August 2024. This oversight was acknowledged by Administrative Nurse D, who noted that the EKG order should have been discontinued when the resident was admitted to hospice services. The facility's failure to conduct these tests placed the resident at risk for adverse medication effects. Another resident, identified as R4, was found to be receiving antipsychotic medication without a CMS-approved indication or appropriate diagnosis. The resident's medical records included diagnoses such as altered mental status, epilepsy, and heart failure, and noted the use of Risperdal for bipolar disorder. However, the facility's records did not provide an appropriate indication for the use of this antipsychotic medication. The facility's policy required that all medications have appropriate use and indications, but this was not adhered to in R4's case. Licensed Nurse G and Administrative Nurse D both confirmed that antipsychotic medications should only be used for approved diagnoses. The facility's failure to ensure appropriate monitoring and indications for psychotropic medication use resulted in deficiencies that placed residents at risk for unnecessary medications and potential side effects. The facility's policies on psychotropic medication monitoring were not effectively implemented, leading to these lapses in care for residents R21 and R4.
Lack of Coordinated Hospice Care for Resident
Penalty
Summary
The facility failed to ensure a collaborated plan of care for a resident, identified as R51, who was receiving hospice services. The deficiency was identified through observation, record review, and interviews. R51's electronic medical record documented multiple diagnoses, including diabetes mellitus, atrial fibrillation, cirrhosis, COPD, hypertension, dysphagia, and congestive heart failure. The resident was cognitively intact and had a terminal prognosis related to end-stage heart failure. Despite being admitted to hospice services, the care plan lacked essential information regarding the frequency of hospice staff visits and the medications, equipment, and supplies covered and provided by hospice. Interviews with facility staff revealed a lack of awareness and coordination regarding the hospice services provided to R51. A CNA was unsure about the specifics of hospice provisions and relied on the Kardex for information. The Administrative Nurse acknowledged that the facility should have collaborated with hospice to ensure that medication, supplies, and hospice staff visits were included in the care plan. The facility's hospice program policy indicated that hospice services were available to residents at the end of life, but the facility failed to ensure collaboration between the facility and the hospice provider for R51's end-of-life care, creating a risk for missed or delayed services and impaired care.
Failure to Provide Mail Delivery on Saturdays
Penalty
Summary
The facility, with a census of 55 residents, failed to provide mail delivery services on Saturdays, as identified in a sample of 15 residents. During an interview on October 8, 2024, Resident Council members reported that mail was not distributed on Saturdays and was instead stored over the weekend to be distributed on the following Monday. This issue arose after the weekend activity staff member, who previously handled mail distribution, was no longer employed at the facility. On October 9, 2024, a Certified Nurse Aide (CNA) expressed uncertainty about the mail delivery process on Saturdays, and an Administrative Nurse confirmed that the mail was previously distributed by the activities staff but was unsure of the current process. The facility did not provide a policy regarding residents' rights to mail delivery on Saturdays, leading to the deficiency of failing to provide mail delivery on Saturdays.
Failure to Maintain Required Nurse Staffing Records
Penalty
Summary
The facility failed to maintain 18 months of daily posted nurse staffing information as required by regulations. During an inspection on October 7, 2024, it was observed that the necessary daily posted staffing sheets were present on each unit. However, a review of the facility's records from May 1, 2023, to October 7, 2024, revealed that the daily posted staffing sheets were missing for the period from May 1, 2023, through November 30, 2023. Administrative Nurse D confirmed on September 8, 2024, that only the staffing sheets from December 2023 to the present were available, attributing the missing records to the previous management team's failure to file them. The facility's staffing policy, revised in August 2022, mandates that staffing hours be maintained for at least 18 months and be available upon request, which the facility did not comply with.
Failure to Provide Written Notification of Transfer
Penalty
Summary
The facility failed to provide a written notification of transfer to a resident or his representative, which is a deficiency in the facility's procedures. The resident, who had diagnoses of dementia and bipolar disorder, was admitted to the facility and later transferred to the hospital due to increased agitation and aggression. Although the resident's representative was verbally informed of the transfer, the facility did not provide a written notification as required. This oversight was confirmed through interviews with administrative staff, social services, and a licensed nurse, all of whom acknowledged that written notifications were not issued for transfers. The facility's policy on emergency transfers did not include a requirement for written notification, which contributed to the deficiency. The policy outlined steps such as notifying the resident's physician and the receiving facility, preparing the resident for transfer, and notifying the representative, but it lacked a directive for issuing written notifications. This gap in the policy and practice led to a risk of miscommunication between the facility and the resident or their representative, potentially resulting in missed opportunities for healthcare services.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a bed hold policy notice to Resident 1 or his representative when he was transferred to the hospital. Resident 1, who had diagnoses of dementia and bipolar disorder, was admitted to the facility and later transferred to the hospital due to increased agitation and aggression. Despite the facility's policy requiring written information about bed holds to be given to residents and their representatives at the time of transfer, this was not done for Resident 1. The facility's staff, including administrative and nursing personnel, acknowledged that the bed hold policy notice was not consistently provided as required. The facility's Bed-Holds and Returns policy, revised in October 2021, mandates that residents and their representatives receive detailed written information about bed hold rights and limitations, payment policies, and a copy of the bed hold agreement prior to or at the time of transfer. However, during the investigation, it was found that the facility did not provide such notice to Resident 1 or his representative. This oversight posed a risk to Resident 1's ability to return to the facility and to his previous room, as the necessary communication regarding the bed hold was not completed.
Failure to Reconcile Controlled Substances
Penalty
Summary
The facility failed to ensure an accurate and consistent reconciliation of all controlled substances on the medication carts, placing residents at risk for misappropriation and ineffective medication regimens. The review of various narcotic count sheets for April 2024 revealed numerous instances where the narcotic reconciliation was not performed or completed on multiple medication carts. Specifically, Medication Cart A had 17 out of 88 missed opportunities, Medication Cart B had 52 out of 88, Medication Cart C had 34 out of 132, and Medication Cart D had 22 out of 132. Additionally, several shift-to-shift sheets documented only one staff signature for reconciliation for entire days, and some dates had no reconciliation documentation at all. Interviews with staff members indicated a lack of adherence to proper procedures for counting and signing off on narcotic counts, despite recent training on the process. Staff members admitted to either forgetting to sign or signing both the oncoming and off-going shift opportunities at once, which is against the facility's policy. The facility's Controlled Substance policy, revised in October 2021, mandates that controlled medications be counted at the end of each shift by both the oncoming and off-going staff, but this was not consistently followed. The administrative nurse acknowledged the need for further demonstration training on counting narcotics to ensure compliance with the policy.
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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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