Lincoln Care And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Wichita, Kansas.
- Location
- 4007 E Lincoln Street, Wichita, Kansas 67218
- CMS Provider Number
- 175273
- Inspections on file
- 20
- Latest survey
- June 30, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Lincoln Care And Rehab during CMS and state inspections, most recent first.
A CNA was found to be working without a current and valid certification, as confirmed by a review of personnel files and the Nurse Aide Registry. Administrative staff acknowledged the requirement for current certification, but the facility lacked a policy for CNA certificate renewal.
The facility did not complete required annual performance evaluations for two CNAs, as shown by missing documentation in their personnel files. Administrative staff confirmed that annual evaluations were expected, and facility policy supported this requirement.
Surveyors found that food items, including meat and bread, were not stored or dated properly in the kitchen. Open bags of meat were left unsealed, some food was stored on the floor, and several items lacked required date labeling. Moldy bread was also found past its expiration date, and food debris was present on the freezer floor.
A review of CNA training records found that some staff did not receive required in-service education, including dementia care, and lacked documentation of the mandated annual training hours. Facility policy required at least 12 hours of continuing education per year for nurse aides, but records and interviews confirmed this standard was not met.
Several residents were not invited to participate in their care plan meetings, and there was no documentation of such meetings in their records for the past six months. Staff interviews confirmed that care plan invitations had not been sent since the departure of the Clinical Reimbursement Coordinator, contrary to facility policy requiring resident and family involvement in care planning.
Surveyors observed multiple areas of disrepair and lack of cleanliness, including exposed concrete in a bathroom, missing vent covers, unmade beds stored in a resident's room, and missing tiles and baseboards throughout the facility. Staff interviews confirmed that these issues had persisted for weeks and that maintenance was unable to complete repairs due to shifting priorities and lack of clear direction. The facility did not provide a policy for maintaining a homelike environment.
The facility did not ensure that a CPR-certified staff member was present at all times for residents with Full Code status. A nurse held a CPR certificate without a hands-on component, and a CNA responsible for transporting a resident with Full Code status had an expired CPR card. The facility lacked a system to track and guarantee CPR-certified staff coverage on each shift, despite policy requirements.
Staff did not consistently follow Enhanced Barrier Precautions (EBP) and hand hygiene protocols during tube feeding care, resident transfers, and peri-care. A nurse and certified nurse aides failed to use gowns and did not disinfect equipment or perform proper hand hygiene between tasks, placing residents at risk for infection.
A resident with severe cognitive impairment and multiple diagnoses had a DNR order in the medical record that was only signed by a physician, lacking the required signature from the resident or their representative. Facility staff confirmed the DNR was incomplete and not valid, and no policy for advance directives was provided.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was given a PRN antianxiety medication repeatedly without a required 14-day stop date or documented physician rationale for extended use. Facility records and staff interviews confirmed the absence of a specified duration for the medication, in violation of facility policy for psychotropic drugs.
The facility did not consistently provide written bed hold policies or timely written notifications of transfer to residents or their representatives during hospitalizations. In several cases, required documentation was missing from the EHR, and staff reported that bed hold forms were sometimes sent unsigned or handled after the transfer, with forms kept outside the EHR.
Three residents had inaccurate MDS assessments, including failure to document CPAP use for a resident with sleep apnea, omission of dental and vision issues for a resident with a history of stroke and dental problems, and incorrect recording of insulin and ventilator use for a resident who did not receive these treatments. These discrepancies were confirmed through care plans, physician orders, staff interviews, and resident observations.
A resident with type 2 diabetes had blood glucose readings above 400 mg/dL on two occasions, but staff did not notify the physician as required by orders and facility policy. Interviews confirmed that nurses were expected to report such results, yet documentation and notification were lacking.
A resident with blindness and a history of schizophrenia did not receive consistent assistance with personal hygiene, specifically facial hair removal, as required by her care plan. Staff interviews revealed inconsistent practices, and documentation of personal hygiene was missing from the EHR. The facility lacked a policy on ADL assistance for dependent residents, resulting in unmet grooming needs.
A resident with a history of stroke and visual impairment did not receive or was not offered vision services, despite a physician's order and her own request for an eye exam. Facility staff could not provide documentation that services were offered or declined, and the resident reported never having received eyeglasses during her stay.
Staff did not properly clean and store respiratory care equipment for two residents, including a nebulizer and a CPAP mask. One resident's nebulizer was left uncleaned and not stored according to policy, while another resident's CPAP mask was left exposed to open air after use. Facility policies and care plans lacked necessary details or were not followed, resulting in unsanitary handling of respiratory devices.
A resident with severe dementia, depression, and anxiety exhibited aggressive and disruptive behaviors, required total assistance with daily living, and was prescribed multiple psychotropic medications. Despite these needs, the care plan lacked interventions for dementia care, and there was no documentation of nonpharmacological approaches or a facility policy for dementia care. Staff and administrative interviews confirmed the absence of appropriate care planning and interventions.
A resident with diabetes, end-stage renal disease, and anxiety did not have pharmacist-identified medication regimen irregularities or recommended lab work appropriately addressed. The facility lacked documentation of physician or nurse responses to the pharmacist's reports, and required lab monitoring for diabetes was not completed as ordered. Facility policy for handling medication review irregularities was not followed.
A resident with a history of depression and stroke, dependent on staff for daily care and with documented dental health problems, did not receive or was not offered dental services despite facility policy and care plan directives. Staff interviews and record review confirmed no evidence of dental care being arranged or declined, and the resident reported never being assessed for dental needs, resulting in ongoing dental decay.
A resident with dysphagia and dementia was served cut-up chicken instead of her prescribed mechanical soft diet, leading to a choking incident. Despite care plans and physician orders specifying a ground meat texture, staff failed to provide the correct diet, resulting in the resident being hospitalized for pneumonia and dehydration. Interviews revealed systemic issues in dietary practices and supervision during meals.
A resident with dementia and a history of homelessness was at risk for elopement, but the facility failed to include this risk in the care plan. Despite wearing a Wander Guard initially, the care plan lacked interventions for elopement, and the resident was able to leave the facility without staff knowledge. The facility's policy required a comprehensive care plan based on thorough assessments, which was not followed in this case.
A cognitively impaired resident at moderate risk for elopement exited a facility without staff knowledge when a CNA opened the door for another resident. The resident, who had a history of dementia and depression, refused to wear a Wander Guard, and the care plan lacked interventions for elopement risk. Staff had to retrieve the resident using a vehicle after he left the facility.
Failure to Ensure CNA Maintained Current Certification
Penalty
Summary
The facility failed to ensure that one Certified Nurse Aide (CNA) maintained a current and valid certification. Review of personnel files showed that the CNA was hired in May 2022, but there was no evidence of a current CNA certificate in the file. Further review of the Nurse Aide Registry confirmed that the CNA's status had been inactive since June 2023. During an interview, administrative staff acknowledged the expectation that all CNAs should have current certification. The facility was unable to provide a policy regarding the renewal of CNA certification.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for two Certified Nurse Aides (CNAs) within the required 12-month period. Specifically, a review of personnel files showed that one CNA, hired in May 2022, and another CNA, hired in February 2020, did not have documentation of a performance evaluation conducted in the last 12 months. During an interview, administrative staff confirmed the expectation that all CNA staff should have annual performance evaluations completed. The facility's employee handbook also documented the importance of regular performance reviews as part of their performance management process.
Failure to Store and Date Food Items Properly in Kitchen
Penalty
Summary
Surveyors observed that food items in the facility's kitchen were not stored in a sanitary manner. Specifically, a bag of beef patties was found in the freezer with the plastic bag left open, and two bags of chicken in a store bag were placed on the floor of the refrigerator. The freezer floor had visible food debris, and numerous bags of vegetables and sandwich meat lacked a date received. Additionally, nine loaves of bread with an expiration date of 02/22/25 were found with mold growing on them. The Dietary Manager confirmed that staff were expected to date all food items with the open date, expiration date, and date received, and to rotate stock using the first-in, first-out method, but these procedures were not followed as observed.
Failure to Provide Required In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required in-service training, including education on dementia care and abuse prevention, as mandated by facility policy and regulatory requirements. A review of training records for five CNAs revealed that at least two CNAs did not have documentation of dementia training, and one CNA's file lacked evidence of the total number of in-service hours completed. The facility's policy required all nurse aides to participate in at least 12 hours of continuing education annually, including dementia management. During an interview, administrative staff confirmed the expectation for staff to complete the required education and annual training hours.
Failure to Involve Residents in Care Plan Development
Penalty
Summary
The facility failed to ensure that residents were given the opportunity to participate in the development and implementation of their person-centered care plans. Multiple residents reported during interviews that they had never been invited to a care plan meeting and were unaware of what such meetings entailed. Review of the electronic health records for these residents confirmed the absence of documentation indicating that care plan meetings had been conducted in the past six months. Further investigation revealed that the staff member responsible for sending care plan meeting invitations had not done so since the departure of the Clinical Reimbursement Coordinator in October 2024. The Social Service Designee acknowledged that no invitations had been sent to residents or their responsible parties since that time. Facility policy requires that residents and their families be encouraged to participate in care planning, but this was not followed, as confirmed by both staff interviews and record review.
Failure to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment for its residents, as evidenced by multiple observations of disrepair and lack of cleanliness throughout the building. Surveyors noted several patches of white plaster on hallway walls and entrance doors, chipped floor tiles in resident hallways, and holes in the bathroom flooring of a resident's room exposing the concrete underneath. Additionally, a grab bar in the same bathroom was covered with frayed, worn duct tape. In another room, an air conditioning vent cover was missing from the ceiling and was found on a nightstand, and three beds were present, two of which were unmade and had a rolled-up air mattress on them. Staff interviews confirmed that the vent cover had been off for about a month and that the beds had recently been placed in the room for storage due to ongoing repairs elsewhere in the facility. Further observations revealed missing tiles and baseboards in the beauty shop and adjacent hallway, as well as partially painted bathroom floors and missing door trim in other rooms. Maintenance staff acknowledged awareness of these issues but reported difficulty completing repairs due to being redirected to other tasks and uncertainty about required materials. Housekeeping and medication aide staff confirmed the ongoing nature of these environmental concerns. The facility did not provide a policy regarding the maintenance of a homelike environment.
Failure to Ensure Presence of CPR-Certified Staff for Full Code Residents
Penalty
Summary
The facility failed to ensure that at least one staff member certified in cardiopulmonary resuscitation (CPR) was present at all times for residents who had chosen Full Code status. Review of staff records showed that one licensed nurse held a CPR certification from an online provider that did not include a hands-on skills component, contrary to facility policy. Additionally, the staff schedule did not identify which staff were CPR-certified for each shift, and there was no system in place to guarantee that a CPR-certified staff member was always present. A certified nurse aide responsible for transporting a resident with Full Code status to and from dialysis appointments did not have a current CPR certification, as her card had expired. Interviews with administrative staff confirmed that the facility did not track or ensure the presence of CPR-certified staff on each shift, and that some staff may not have completed the required hands-on component of CPR training. The facility's policy required staff to maintain current CPR certifications with a hands-on session and to have CPR-certified staff available 24 hours a day.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
Staff failed to maintain effective infection control practices, specifically regarding Enhanced Barrier Precautions (EBP) and hand hygiene. During tube feeding care for a resident who had pulled out their feeding tube, a licensed nurse did not wear a gown as required by EBP protocols. In another instance, two certified nurse aides transferred a resident using a mechanical lift and provided a shower without donning gowns for EBP. After using the Hoyer lift, staff did not disinfect the equipment before moving it into the hallway. Additionally, a certified nurse aide provided peri-care to a resident and changed their brief while wearing the same soiled gloves, then handled the bedpan and continued care without performing hand hygiene between glove changes. The aide later acknowledged that handwashing should have occurred after glove removal and before continuing care. The facility's policy required appropriate precautions for residents with multidrug-resistant organisms (MDROs) and adherence to EBP, but these protocols were not consistently followed during observed care activities.
Incomplete DNR Documentation for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a resident's advance directive, specifically a Do Not Resuscitate (DNR) order, was thoroughly completed and valid. The resident in question had diagnoses of dementia, depression, and anxiety, with severely impaired cognition as documented by low BIMS scores on multiple Minimum Data Set (MDS) assessments. The resident was dependent on staff for all activities of daily living and was receiving hospice services. The resident's care plan and physician orders documented a DNR, but the only DNR form available in the electronic health record was a hospice-based form signed solely by the physician, lacking the required signature from the resident or the resident's representative. Interviews with facility staff confirmed that the DNR form in the record was incomplete and not valid, as it did not include the necessary signature from the resident or their durable power of attorney (DPOA), nor was it witnessed. The facility was unable to provide a policy for advance directives. This incomplete documentation resulted in the resident's advance directive not being properly honored according to regulatory requirements.
Failure to Ensure Required Stop Date for PRN Antianxiety Medication
Penalty
Summary
A deficiency was identified when a resident with diagnoses of dementia, depression, and anxiety was administered a PRN (as-needed) antianxiety medication without a required 14-day stop date or a specified duration, and without documentation of the physician's rationale for extended use. The resident's electronic health record showed severely impaired cognition and dependence on staff for activities of daily living. The resident's care plan included directions for medication administration and monitoring, but the PRN order for Ativan lacked a stop date as required by facility policy. Review of the resident's records revealed that the PRN Ativan was ordered and administered multiple times over a period exceeding 14 days, with no evidence in the electronic health record of a specified duration or physician's rationale for continued use. The medication regimen review initially did not identify irregularities, but a subsequent review noted the missing stop date. Despite this, the medication continued to be administered without the required documentation. Interviews with nursing staff indicated a lack of clarity regarding which PRN medications required stop dates. The facility's policies specified that as-needed psychotropic medications should be limited to 14 days unless a longer duration is justified and documented by the physician. The failure to include a stop date or physician's rationale for the extended use of the PRN antianxiety medication constituted the deficiency.
Failure to Provide Timely Bed Hold Policy and Transfer Notification
Penalty
Summary
The facility failed to provide written bed hold policies and timely written notifications of transfers for three residents who were hospitalized. Review of the electronic health records (EHR) for these residents showed no evidence that bed hold notices or written notifications of transfer were provided to the residents or their representatives at the time of transfer. Specifically, one resident was transferred to the hospital on multiple occasions without documentation of the required notifications, and another resident's transfer lacked a signed bed hold form for one of the hospitalizations. Staff interviews revealed that, in practice, bed hold forms were sometimes sent unsigned with residents during emergency transfers, and follow-up for signatures was handled later, with forms kept in a separate folder rather than uploaded to the EHR. The facility's policy required informing residents of the bed hold policy upon admission and prior to transfer, including any charges and Medicaid time limits. However, the process described by staff did not consistently ensure that residents or their representatives received or signed the bed hold forms at the time of transfer, particularly during emergencies. Additionally, the required information was not always documented in the EHR as expected by facility leadership, resulting in incomplete records of notification and policy provision.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for three residents, resulting in discrepancies between the residents' actual care needs and what was documented. For one resident with a diagnosis of obstructive sleep apnea, the MDS did not indicate the use of a CPAP machine, despite physician orders, care plan documentation, and staff confirmation that the resident used a CPAP at night. The facility did not provide a policy on accurate MDS assessment. Another resident with major depressive disorder and a history of stroke had inconsistencies in the MDS regarding oral and vision care. The MDS documented no dental or vision issues, while the care plan and resident interview revealed significant dental problems, a need for mouth care assistance, and a visual deficit. The resident reported never being assessed by a dentist and not having eyeglasses, despite needing them, and observations confirmed broken teeth and visual impairment. A third resident with schizophrenia and anxiety was incorrectly documented in the MDS as receiving insulin, hypoglycemic medication, and using a non-invasive mechanical ventilator. However, the care plan, physician orders, and resident interview confirmed that the resident had never received insulin, was not diabetic, and had only used oxygen via nasal cannula. The facility did not provide a policy on accurate MDS assessment for any of the cases.
Failure to Notify Physician of Critical Blood Glucose Levels
Penalty
Summary
Staff failed to follow physician orders and facility policy regarding the notification of blood glucose levels for a resident with type 2 diabetes mellitus. The resident's care plan and physician orders required staff to notify the physician if blood sugar readings were greater than 400 mg/dL or less than 60 mg/dL. Despite this, the electronic medical record showed that on two separate occasions, the resident's blood glucose levels exceeded 400 mg/dL (418 mg/dL and 409 mg/dL), and there was no documentation that the physician was notified as required. Interviews with licensed nurses and the administrative nurse confirmed that the standard practice and expectation was to contact the physician for blood sugars above 400 mg/dL, in accordance with the orders. The facility's policy also emphasized timely and effective communication of significant changes in resident status to the medical staff. However, the lack of documentation and notification in these instances demonstrated a failure to meet professional standards of care for the resident.
Failure to Provide Consistent ADL Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide appropriate assistance with activities of daily living (ADLs), specifically grooming of facial hair, for a resident who was blind and required help with personal care. The resident had diagnoses including blindness in both eyes and paranoid schizophrenia, and her care plan directed staff to provide cueing and set-up assistance with personal hygiene. Observations over several days revealed that the resident had prominent beard stubble and yellow crusty drainage on her eyes, and she reported that staff only cleaned her face during showers. Documentation of personal hygiene tasks was missing from the electronic health record. Interviews with staff indicated inconsistent practices regarding facial hair removal, with some staff performing the task and others not. Staff reported that facial hair should be removed on shower days or when requested, but the resident, due to her blindness, did not typically request this care. The facility did not provide a policy on ADL assistance for dependent residents. These actions and omissions resulted in the resident not receiving grooming care in accordance with her needs and preferences.
Failure to Facilitate Access to Vision Services for Resident with Visual Impairment
Penalty
Summary
A deficiency was identified when the facility failed to provide or facilitate access to visual services for a resident with impaired visual function. The resident had a history of major depressive disorder and cerebrovascular accident, resulting in a left-sided visual deficit. Despite having a physician's order allowing for specialist visits, including an eye doctor, there was no evidence in the electronic health record (EHR) that visual services were offered or facilitated, nor was there documentation that the resident declined such services. The resident reported requesting an eye exam and stated she could not read without glasses, yet had never received eyeglasses during her stay at the facility. Interviews with facility staff revealed that when a resident requested vision services, the process involved documenting the request in the EHR or informing the Social Services Designee (SSD). However, the SSD could not locate any documentation of a declined consent or progress note regarding visual services for this resident. The facility's policy required the provision of necessary care and services, including assistance with making vision appointments, but this was not followed in the resident's case. The lack of action placed the resident at risk for further deterioration of vision.
Failure to Maintain Sanitary Respiratory Care Equipment
Penalty
Summary
Staff failed to provide sanitary respiratory care for two residents requiring respiratory devices. For one resident with a history of pneumonia and moderate cognitive impairment, the nebulizer was observed attached to tubing on the bedside table with liquid remaining in the chamber and had not been separated or rinsed after use. Staff interviews confirmed that the nebulizer should have been cleaned after each treatment, and facility policy required washing, rinsing, disinfecting, and proper storage of the nebulizer equipment after each use. However, these procedures were not followed, and the resident's care plan did not include information regarding nebulizer use. For another resident diagnosed with obstructive sleep apnea and using a CPAP device, the CPAP mask was observed left attached to the tubing and exposed to open air on the bedside table after use on multiple occasions. The resident's care plan documented CPAP use, but the facility's policy did not address cleaning and storage procedures for the CPAP mask. Staff interviews indicated that the expectation was for the mask to be cleaned and stored in a bag after each use, but this was not done.
Failure to Provide Nonpharmacological Dementia Care and Services
Penalty
Summary
The facility failed to provide appropriate nonpharmacological dementia care and services to a resident diagnosed with dementia, depression, and anxiety. The resident had severely impaired cognition, as evidenced by low BIMS scores, and required total dependence for activities of daily living such as toileting, personal hygiene, and footwear. The resident also exhibited fluctuating behaviors, disorganized thinking, and frequent rejection of care. Despite these needs, the resident's care plan lacked specific interventions to address dementia care, and there was no facility policy provided for dementia care. The resident was prescribed multiple psychotropic medications, including antipsychotics, antidepressants, and antianxiety agents, and was monitored for behavioral symptoms. However, the Medication Administration Records for April and May did not document occurrences of behavioral symptoms or the use of nonpharmacological interventions, despite the resident displaying frequent crying, repetitive movements, yelling, aggression, and resistance to care. Progress notes indicated that the resident had difficulty participating in activities, was not easily redirected, and sometimes became aggressive during care, requiring staff intervention and medication administration. Observations and staff interviews confirmed that the resident engaged in aggressive and disruptive behaviors, such as attempting to slap a surveyor, grabbing another resident's walker, and self-transferring, which required frequent staff redirection. Staff reported that care plans typically guide interventions, but in this case, the care plan did not address the resident's dementia needs. Administrative staff acknowledged the omission, and the facility did not provide a policy for dementia care when requested.
Failure to Act on Pharmacist Medication Review and Lab Orders
Penalty
Summary
The facility failed to act upon the pharmacist's monthly medication regimen review (MRR) for a resident with diagnoses including diabetes mellitus, end-stage renal disease, and anxiety. The resident's care plan included the use of antidepressant and antianxiety medications, but lacked documentation of non-pharmacological interventions. The MRRs for multiple months indicated irregularities and referenced reports, but the electronic health record (EHR) did not contain the actual reports or any documented responses from the physician or nursing staff. Additionally, the pharmacist requested a hemoglobin A1c (HbA1c) lab draw to monitor diabetes management, but the lab was not completed as ordered, and the last available result was outdated. Interviews with administrative nursing staff revealed that the resident refused lab draws at the facility, expecting them to be completed at the dialysis center, which did not occur. The administrative nurse was unable to locate the missing MRRs and confirmed that follow-up on the pharmacist's recommendations was not documented. Facility policy required that irregularity reports be provided to the physician for review and that any actions or rationale for no change be documented, but this process was not followed for the resident in question.
Failure to Provide or Facilitate Dental Services for Resident with Dental Decay
Penalty
Summary
The facility failed to provide or facilitate access to dental services for a resident with widespread dental decay. The resident had a history of major depressive disorder, cerebrovascular accident, and was dependent on staff for several activities of daily living, including requiring set-up assistance for oral care. Despite care plan documentation indicating oral and dental health problems and directing staff to coordinate dental care, there was no evidence in the electronic health record that dental services were offered or facilitated, nor that the resident had declined such services. The resident reported that no staff had asked about dental assessment since admission and described having several broken teeth, which was confirmed by observation. Interviews with facility staff revealed that the process for arranging dental appointments involved documentation in the EHR or verbal communication with social services, but there was no record of this occurring for the resident in question. The social services designee stated that residents must sign a consent or declination for dental services, but no such documentation could be found for this resident. The facility's policy required an initial dental evaluation upon admission, but this was not completed for the resident, resulting in a lack of dental care despite clear need.
Failure to Provide Prescribed Diet Leads to Choking Incident
Penalty
Summary
The facility failed to provide a cognitively impaired resident, identified as R2, with her prescribed mechanical soft diet, which led to a choking incident. R2, who had diagnoses of dysphagia and dementia, was served cut-up chicken instead of the required ground meat texture. This error occurred despite R2's care plan and physician orders specifying a mechanical soft diet with ground meat due to her swallowing difficulties. On the day of the incident, R2 began to cough and choke on her food, requiring staff intervention to clear her airway. The resident was subsequently transferred to the hospital and admitted for fever, pneumonia, and dehydration. Interviews with staff revealed that dietary and nursing staff were not consistently present in the dining room to ensure residents received the correct diet consistency. Dietary Staff F and Dietary Staff I admitted to serving R2 cut-up meat instead of ground meat, as they were instructed to do so based on previous practices. It was noted that R2 had been receiving chopped meat for her meals many times prior to the choking episode, indicating a systemic issue in adhering to prescribed dietary orders. The facility's policies on therapeutic diets and tray identification were not followed, as nursing staff failed to verify the correct diet before serving the resident. The lack of oversight and communication between dietary and nursing staff contributed to the incident, placing R2 and potentially other residents at risk. The deficiency was identified as an immediate jeopardy situation, highlighting the critical need for adherence to dietary orders and proper supervision during meal times.
Failure to Develop Comprehensive Care Plan for Elopement Risk
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as R3, who was at risk for elopement. R3 had a history of dementia and depression, with a moderately impaired cognition score. Despite wearing a Wander Guard initially, the care plan did not include interventions for elopement risk, and there were no physician orders for the Wander Guard at the time of R3's elopement. The resident had previously expressed a desire to leave the facility and had a history of homelessness, which was documented in the progress notes. The facility's records showed that R3's Wander Guard was discontinued after he was no longer exit-seeking, but later progress notes indicated that R3 expressed a desire to leave again. Despite these indications, the care plan was not updated to reflect the elopement risk until after R3 had already left the facility. Staff interviews revealed that the care plan lacked documentation of elopement risk and Wander Guard use until after the incident occurred. The facility's policy required a comprehensive care plan based on thorough assessments, including the MDS and physician orders, but this was not adhered to in R3's case. The failure to include elopement risk in the care plan placed R3 at risk for inadequate care and services, as evidenced by the resident's ability to leave the facility without staff knowledge or supervision.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to a cognitively impaired, independently mobile resident identified as a moderate risk for elopement. The resident, who had a history of dementia and depression, exited the facility without staff knowledge when a Certified Nurse Aide (CNA) opened the exit door for another resident. The resident was previously assessed as having a low risk for elopement, and the care plan lacked interventions related to the resident's elopement risk. The resident had a history of refusing to wear a Wander Guard, a bracelet that sets off an alarm when residents attempt to exit the building without an escort. Despite previous incidents where the resident expressed a desire to leave the facility, the Wander Guard was not consistently used or documented in the resident's care plan. On the day of the incident, the resident exited the facility, and staff had to retrieve him using a vehicle. Interviews with staff revealed that the resident had made comments about wanting to leave the facility and had previously removed the Wander Guard. The facility's policy on elopement was not effectively implemented, as the resident's risk was not adequately assessed or documented, and the necessary precautions were not taken to prevent the elopement.
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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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