Life Care Center Of Kansas City
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Kansas.
- Location
- 3231 N 61st Street, Kansas City, Kansas 66104
- CMS Provider Number
- 175281
- Inspections on file
- 16
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Life Care Center Of Kansas City during CMS and state inspections, most recent first.
Surveyors identified unsanitary conditions in the kitchen, including a sticky floor, overflowing and uncovered trash bins near the stove, and improperly stored food items that were unlabeled, undated, or left open. Dietary staff acknowledged these practices were not in line with facility policy, which requires proper labeling, dating, and sanitation.
The facility did not implement or document the core elements of an antibiotic stewardship program, as shown by missing and inconsistent tracking of infections and antibiotic use, and a lack of evidence for monitoring infection outbreaks. The Infection Preventionist could not confirm whether previous staff had tracked antibiotic administration or infection clusters, despite facility policy requiring such oversight.
The facility did not secure pressurized oxygen tanks in a locked area, leaving them accessible to cognitively impaired, mobile residents. Additionally, after a resident with severe cognitive impairment and a history of falls was moved to a new room, required fall prevention interventions such as non-skid tape and signage were not in place, contrary to the care plan and facility policy.
A bottle of ocular vitamins was found left unsecured on the counter at the nurse's station, contrary to facility policy requiring all medications to be locked. A licensed nurse later secured the medication, and both nursing staff confirmed that medications must be locked and out of resident reach at all times.
Two residents with significant cognitive and physical impairments were not provided with appropriate assistive device use and communication access. One was pushed in a wheelchair without foot pedals in use, contrary to care plan and policy, while another had her call light left out of reach, preventing her from communicating needs. Staff interviews confirmed these actions were not in line with facility expectations.
A resident's protected health information (PHI) was left visible on an unattended nursing cart across from the nurse's station. Staff interviews confirmed that computers should be locked when not attended to protect PHI, and facility policy requires resident privacy to be maintained.
The facility did not provide complete discharge summaries for two residents, omitting required recapitulations of their stays and failing to consistently provide written notifications about bed-hold policies to residents or their representatives at the time of transfer. Staff interviews and record reviews confirmed that documentation and notifications were incomplete or missing, contrary to facility policy.
A resident who was dependent on staff for all ADLs and received tube feeding was not provided with required mouth care, as observed by the presence of a thick yellow substance on her lips and in her mouth. Staff interviews revealed that while all nursing staff were responsible for resident hygiene, there was no documentation or clear accountability for providing oral care to residents with internal feedings, resulting in a failure to follow the care plan and facility policy.
A resident with multiple risk factors for pressure ulcers, including impaired mobility and cognition, was not provided with prescribed pressure-reducing boots while in bed, despite physician orders and care plan directives. Observations confirmed the resident's heels were directly on the mattress, and staff interviews indicated that ensuring the use of such devices was a nursing responsibility documented on the TAR.
A resident with hemiparesis and severe cognitive impairment did not receive prescribed range of motion (ROM) exercises as outlined in the care plan. The restorative aide responsible for these interventions was reassigned to CNA duties due to staffing shortages, resulting in the absence of documented ROM exercises and a failure to follow the facility's restorative nursing policy.
A resident with multiple diagnoses, including heart failure and hypertension, was prescribed Toprol XL but did not receive consistent heart monitoring as required. The Consultant Pharmacist did not identify or report this lack of monitoring in monthly medication reviews, and nursing staff confirmed that such monitoring should have been in place according to facility policy.
A resident with multiple diagnoses, including heart failure and hypertension, was prescribed Toprol XL, but the facility did not consistently document required heart monitoring for over three months. Nursing staff acknowledged the need for monitoring and clarification of orders, and the facility could not provide a policy for medication monitoring.
Several residents were not properly offered or had no documented declination or contraindication for the PCV20 pneumococcal vaccine, despite facility policy requiring this. Nursing staff reported that vaccines are offered at admission and documented if given, but records for some residents lacked evidence that the PCV20 was addressed as required.
A resident with severely impaired cognition and a history of elopement risk exited a facility without staff knowledge, reaching the parking lot. Despite having a WanderGuard, the resident was not adequately supervised, and the incident was not documented. Staff interviews revealed frequent door alarms and an unsecured gate, contributing to the elopement.
The facility failed to accurately complete the MDS for a resident, leading to unidentified care needs. The resident had multiple diagnoses and frequent complaints of tooth pain, which were not properly documented in the MDS assessments. An administrative nurse admitted to not thoroughly reviewing the resident's oral assessment, resulting in incomplete and inaccurate MDS documentation.
A resident with a history of serious medical conditions experienced untreated dental issues and pain due to the facility's failure to follow up on dental assessments and complaints. Despite an oral assessment indicating probable extensive decay and moderate inflammation, the resident's care plan lacked dental care interventions, and staff were unaware of the resident's pain and the emergency nature of a scheduled dental appointment.
Sanitary Violations in Kitchen Food Storage and Waste Management
Penalty
Summary
Surveyors observed multiple sanitary violations in the facility's kitchen, including a sticky floor, overflowing and uncovered trash bins next to the stove, and improper food storage practices. Specifically, food items such as fish wrapped in plastic wrap were found in the freezer without labels or dates, and other items like a bottle of pink Minute Maid lemonade, a tub of ice cream, and a bag of cookie dough were opened and undated. Dietary staff confirmed that all foods should be labeled and dated, the kitchen floor should be clean, and trash bins should not be overflowing or uncovered. The facility's Food Safety policy requires food to be stored and maintained in a clean, safe, and sanitary manner in accordance with federal, state, and local guidelines.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement the core elements of an antibiotic stewardship program as part of its infection prevention and control efforts. A review of the infection control log from August 2024 through July 2025 revealed a lack of evidence for tracking and identifying possible infection outbreaks, as well as inconsistent identification of infections and antibiotic administration. The facility was unable to provide documentation of consistent infection control surveillance for the period from August 2024 through March 2025. During an interview, the current Infection Preventionist, who started in April 2025, was unable to confirm whether the previous Infection Preventionist had tracked antibiotic administration or monitored clusters of infections or organisms. The facility's antibiotic stewardship policy stated that the program should promote appropriate antibiotic use and include a monitoring system, but there was no evidence that these practices were being followed.
Failure to Secure Oxygen Tanks and Implement Fall Interventions
Penalty
Summary
The facility failed to secure 44 full E-pressurized medical oxygen tanks in a locked area, leaving them accessible in an unlocked storage room despite the presence of eight cognitively impaired, independently mobile residents. Multiple inspections over several days found the oxygen storage room door with a keypad that did not lock when shut, and staff interviews revealed confusion about whether the room should be locked. Facility policy required oxygen to be stored safely, but this was not followed, as confirmed by both direct observation and staff statements. Additionally, the facility did not ensure that fall prevention interventions for a resident with severe cognitive impairment, muscle weakness, and a history of falls were in place after she was moved to a new room. The resident's care plan required non-skid traction tape and signage to be present in her room, but an inspection found these interventions missing. Staff interviews confirmed that these fall interventions should have been transferred to the new room, and facility policy required staff to ensure interventions were implemented after a room change.
Unsecured Medication at Nurse's Station
Penalty
Summary
A bottle of ocular vitamins dated 07/07/25 was found unsecured on the counter at the nurse's station during an inspection of the 200 Hall. The bottle was labeled with a warning to keep out of reach of children and included instructions for accidental overdose. The medication was not locked in the medication cart as required by facility policy. A licensed nurse subsequently secured the vitamins after the observation. Both a licensed nurse and an administrative nurse confirmed that medications are required to be locked at all times and out of resident reach, in accordance with the facility's Medication Access and Storage policy revised in 09/2024.
Failure to Ensure Proper Use of Assistive Devices and Call Light Accessibility
Penalty
Summary
The facility failed to ensure proper use of assistive devices and communication tools for two residents, resulting in deficiencies related to accident prevention and resident safety. One resident, who had diagnoses including cognitive communication deficit, dementia, muscle weakness, and a history of falls, was observed being pushed in a wheelchair without the use of foot pedals. The resident's care plan and facility policy required the use of foot pedals to prevent feet from dragging and reduce fall risk, but staff did not follow this protocol. Staff interviews confirmed that the expectation was to use foot pedals when transporting residents in wheelchairs. Another resident, with severe cognitive impairment, Parkinson's disease, muscle weakness, and total dependence on staff for activities of daily living, was found with her call light out of reach on the floor. The care plan for this resident required that the call light be kept within reach at all times to allow communication of needs. Staff interviews and facility policy confirmed that call lights should be accessible to residents during each encounter, but this was not adhered to, leaving the resident unable to call for assistance.
Failure to Secure Resident PHI on Unattended Nursing Cart
Penalty
Summary
The facility failed to secure protected health information (PHI) for one resident, as evidenced by an unattended nursing cart left across the hallway from the nurse's station with a resident's PHI displayed on it. During a walkthrough, surveyors observed the cart unattended and the PHI visible. Shortly after, a licensed nurse exited a nearby room and locked the computer screen. Interviews with nursing staff and administration confirmed that the expectation was for computer screens to be locked when not attended to protect residents' PHI. A review of the facility's Resident Rights policy indicated that the facility is responsible for ensuring each resident's privacy and educating residents about their rights.
Failure to Provide Complete Discharge Summaries and Bed-Hold Notifications
Penalty
Summary
The facility failed to provide a final summary of the resident's status at discharge for two residents, resulting in incomplete documentation of their care and discharge process. For one resident with multiple complex diagnoses, including malnutrition, cerebral palsy, rectal cancer, muscle weakness, depression, dysphagia, and anemia, the records showed that although the discharge plan indicated a comprehensive summary would be developed, the actual discharge charge summary was undated and lacked a recapitulation of the resident's stay. Nursing notes documented the resident's departure, refusal of medication, and that paperwork was sent with the resident, but did not include a comprehensive summary as required by facility policy. For another resident with diagnoses such as respiratory failure with hypoxia, dyspnea, insomnia, anxiety, and COPD, the records indicated that the resident was transferred to the hospital. Staff interviews revealed that while the bed-hold policy was verbally communicated and sent with the resident, written notification to the resident's legal representative was not consistently provided at the time of transfer. The facility's policy required that written information about the bed-hold policy be given upon admission and upon transfer, but this was not always documented as completed. Facility policies specified that both nursing and social services staff are responsible for developing a discharge summary that recapitulates the resident's stay and status at discharge to ensure continuity of care. However, in these cases, the required documentation was either incomplete or missing, and written notifications regarding bed-hold policies were not always provided as required. These deficiencies were confirmed through record review and staff interviews.
Failure to Provide Required Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary oral care for a resident who was dependent on staff for all activities of daily living and required tube feeding. The resident had multiple diagnoses, including hypothyroidism, anxiety, major depressive disorder, muscle weakness, Parkinson's disease, and hypoxia, and was documented as having severely impaired cognition and being rarely or never understood. The care plan specified that mouth care was to be provided at least daily due to oral/dental health problems, including inflamed gums, and that the resident was nothing by mouth (NPO) and received continuous tube feeding. During observation, the resident was found in bed with a thick yellow substance on her lips and in her mouth, indicating that mouth care had not been performed as required. Interviews with staff revealed a lack of clear documentation and accountability regarding the provision of mouth care for residents with internal feedings. The licensed nurse acknowledged that cleaning of the mouth for residents with internal feedings was not documented, although staff were aware it should be done at least every shift. Certified nurse aides and administrative nursing staff stated that it was the responsibility of all nursing staff to ensure residents remained clean, but there was no evidence that mouth care had been provided for this resident as directed by the care plan and facility policy.
Failure to Implement Pressure-Reducing Measures for High-Risk Resident
Penalty
Summary
The facility failed to ensure that pressure-reducing measures were implemented for a resident with significant risk factors for pressure ulcer development. The resident had multiple diagnoses, including hypertension, diabetes mellitus, COPD, muscle weakness, communication deficit, hemiparesis following a stroke, and severely impaired cognition. The resident was identified as being at high risk for pressure ulcers, with a Braden Scale score of 12, and had a history of pressure injury. Physician orders and the care plan specified the use of bilateral boots to be worn even while in bed, with removal every shift for skin checks, and the application of skin prep to the heels. Despite these orders, observations showed that the resident's heels were directly on the mattress without the prescribed boots in place. Interviews with nursing staff and review of facility policy confirmed that ensuring the application of pressure-reducing boots was a nursing responsibility, documented on the Treatment Administration Record (TAR), and could be delegated to CNAs with follow-through required by the nurse. The facility's policy outlined procedures for managing skin integrity and preventing pressure ulcers. However, the lack of adherence to these procedures and physician orders resulted in the resident being left without the necessary pressure-reducing devices, placing them at increased risk for pressure ulcer development.
Failure to Provide Prescribed ROM Exercises Due to Staffing Issues
Penalty
Summary
A deficiency was identified when a resident with a history of cerebral infarction, hemiparesis affecting the left side, muscle weakness, and severely impaired cognition did not receive prescribed range of motion (ROM) exercises as documented in their care plan. The care plan specified that nursing and restorative aides were to perform active ROM to the resident's bilateral lower extremities for 20 minutes, and staff were to observe and report any immobility or contracture formation. However, review of the resident's electronic medical record (EMR) showed no documentation that ROM exercises were performed, nor were there any recorded refusals by the resident. Interviews with facility staff revealed that the restorative aide, who was responsible for carrying out these exercises, had been reassigned to regular CNA duties due to understaffing and was unable to perform restorative duties during that period. The facility's restorative nursing policy required proactive identification, care planning, and monitoring of residents' needs, as well as training for nursing assistants in restorative techniques. Despite these requirements, the resident did not receive the necessary ROM interventions, resulting in a failure to provide appropriate care to maintain or improve mobility and prevent contractures.
Failure to Identify and Report Irregularities in Antihypertensive Medication Monitoring
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities related to the monitoring of antihypertensive medication for a resident. The resident had diagnoses including adult failure to thrive, cognitive communication deficit, congestive heart failure, and hypertension, and required substantial to maximum assistance with activities of daily living. The resident was prescribed Toprol XL, an antihypertensive medication, but a review of the Medication Administration Record (MAR), Treatment Administration Record (TAR), and electronic medical record over a period of 111 days showed a lack of consistent heart monitoring associated with this medication. Additionally, the monthly medication reviews from August 2024 to July 2025 did not include documented recommendations for heart monitoring or instructions for hold parameters and physician notification related to the antihypertensive medication. Interviews with nursing staff confirmed that monitoring should occur for antihypertensive medications and that the CP is expected to identify any lack of appropriate monitoring. The facility's policy on Pharmacy Services and Medication Regimen Review requires oversight by a licensed pharmacist to maintain residents' well-being and prevent adverse medication consequences, but this oversight was not demonstrated in the case of the resident receiving Toprol XL.
Failure to Monitor Antihypertensive Medication as Recommended
Penalty
Summary
The facility failed to follow the pharmacist's recommendation for monitoring antihypertensive medication for a resident diagnosed with adult failure to thrive, cognitive communication deficit, congestive heart failure, and hypertension. The resident's medical record showed an order for Toprol XL, an antihypertensive medication, but there was no consistent documentation of heart monitoring in the Medication Administration Record, Treatment Administration Record, or electronic medical record over a period of 111 days. The care plan indicated that staff would administer medications as ordered, but did not address the lack of monitoring for the antihypertensive medication. Interviews with nursing staff confirmed that monitoring should occur when administering antihypertensive medications, and that clarification should be sought if physician orders lack specific parameters. The administrative nurse also acknowledged that the care plan should identify the need for correct medication monitoring. The facility was unable to provide a policy related to medication monitoring, further demonstrating the lack of appropriate oversight for residents receiving antihypertensive therapy.
Failure to Document and Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer or obtain informed declinations or physician-documented contraindications for the Pneumococcal Conjugate Vaccine (PCV20) and pneumococcal vaccination for several residents. Specifically, record reviews showed that while the Pneumococcal Polysaccharide Vaccine (PPSV23) was offered and declined for some residents, there was no documentation that the PCV20 was offered, declined, or previously administered, nor was there a physician-documented contraindication. This lack of documentation was noted for multiple residents in the sample reviewed. Interviews with nursing staff revealed that vaccinations were typically offered at admission, and if consented, ordered from the pharmacy and documented in the electronic medical record. However, the records for certain residents did not reflect that the PCV20 vaccine was addressed according to policy. The facility's own policy required that each resident be offered pneumococcal immunization unless medically contraindicated or already immunized, with appropriate documentation in the medical record, but this was not consistently followed.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and appropriate interventions for a resident, identified as R1, who exited the building without staff knowledge. R1 had a history of attempting to leave the facility unattended and was identified as an elopement risk due to impaired safety awareness. Despite having a WanderGuard in place, R1 managed to exit the facility and was found outside in the courtyard and later in the back parking lot. The facility's records lacked documentation of this elopement incident, indicating a failure in monitoring and recording the resident's movements and behaviors. R1's medical history included diagnoses of metabolic encephalopathy, muscle weakness, gait abnormalities, and severely impaired cognition, as indicated by a BIMS score of six. The resident required supervision or touch assistance for mobility and had a care plan that included interventions for safe wandering and monitoring of the WanderGuard. However, staff failed to adequately supervise R1, as evidenced by the resident's ability to exit the building and reach the parking lot without staff intervention. Interviews with staff revealed that door alarms were frequently triggered, and the gate leading from the courtyard to the parking lot lacked a locking mechanism, allowing easy access to the outside. Staff members, including a Licensed Nurse and a Certified Medication Aide, were aware of the incident but did not take immediate action to prevent R1 from leaving the facility. The facility's elopement policy required staff to assess the resident's condition and notify the physician and responsible party, but these steps were not documented in R1's case.
Failure to Accurately Complete MDS for Resident
Penalty
Summary
The facility failed to accurately and thoroughly complete the Minimum Data Sets (MDS) for a resident, identified as R1, which placed the resident at risk for unidentified care needs. R1's Electronic Medical Record (EMR) documented several diagnoses, including traumatic subdural hemorrhage, respiratory failure, convulsions, and depression. Despite these conditions, the Annual MDS and subsequent Quarterly MDS assessments did not accurately reflect R1's oral and dental status. Specifically, the Dental Care Area Assessment (CAA) did not trigger, and the Quarterly MDS assessments lacked documentation of a Brief Interview for Mental Status (BIMS) or a staff assessment, and failed to address R1's oral and dental status. An oral assessment by a dental vendor noted probable extensive decay and moderate inflammation, with R1 frequently complaining of tooth pain. However, this information was not incorporated into the MDS assessments. During an interview, R1 confirmed ongoing tooth pain, which was known to the nurses. Administrative Nurse E admitted to not thoroughly reviewing R1's oral assessment in the EMR and acknowledged that the MDS should have been marked as not assessed instead of leaving the area blank or documenting no issues. This oversight in the MDS assessment process led to the deficiency in accurately identifying and addressing R1's care needs.
Failure to Address Resident's Dental Needs
Penalty
Summary
The facility failed to identify and respond to a resident's dental needs, resulting in tooth pain and untreated dental issues. The resident had a history of traumatic subdural hemorrhage, respiratory failure, convulsions, and depression, and was documented as having intact cognition. Despite an oral assessment by a dental vendor indicating probable extensive decay and moderate inflammation, and the resident's complaints of tooth pain, the facility did not follow up on these concerns. The resident's care plan lacked interventions related to dental care and monitoring, and there was no evidence of oral assessments from January 2023 to April 2024. On the day of the dental appointment, the resident was observed in bed with a flat affect and reported ongoing tooth pain. Interviews with staff revealed a lack of awareness of the resident's dental pain and the emergency nature of the dental appointment. The facility's policy stated that it was responsible for assisting residents in obtaining needed dental services, but this was not adhered to in the resident's case, leading to untreated dental issues and pain.
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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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