Lincoln Park Manor Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lincoln, Kansas.
- Location
- 922 N 5th St, Lincoln, Kansas 67455
- CMS Provider Number
- 175419
- Inspections on file
- 14
- Latest survey
- September 8, 2025
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Lincoln Park Manor Inc during CMS and state inspections, most recent first.
The facility did not ensure that the director of food and nutrition services had the required certification as a CDM, as both the dietary manager and administrator were still in the process of obtaining certification. The registered dietician visited only twice a month, and the facility's policy requiring specific qualifications for this role was not met.
Staff did not consistently follow Enhanced Barrier Precautions or proper hand hygiene during wound care for two residents with pressure ulcers, including not wearing gowns, not changing gloves at appropriate times, and not performing hand hygiene between glove changes. Additionally, a resident's oxygen and nebulizer equipment was not properly stored when not in use, contrary to facility policy.
The consultant pharmacist did not provide the required monthly drug regimen review, resulting in missed communication of medication recommendations for several residents, including those prescribed antipsychotic and antidepressant medications. As a result, necessary recommendations for gradual dose reduction or physician rationale were not relayed to prescribers, and medication irregularities were not addressed in a timely manner.
Surveyors found that medication carts were left unlocked and unattended, insulin pens were not labeled or dated when opened, and expired medications were present in both medication carts and the emergency medication kit. Staff confirmed these deficiencies, which were not in accordance with facility policy requiring secure storage and proper labeling of all medications.
A resident with COPD and moderately impaired cognition was allowed to keep and self-administer an inhaler at bedside without a physician's order or documented assessment of self-administration ability. The resident's care plan required staff to administer medications, and facility policy mandated an IDT assessment and order before permitting self-administration, but these were not completed.
Staff left a resident's electronic medical record open and visible on a medication cart laptop, failing to secure protected health information. A CMA and a nurse both confirmed that screens and carts should be locked when unattended, in accordance with facility policy.
The facility did not ensure proper management and documentation of psychotropic medications for several residents, including missing stop dates for PRN antianxiety medication, lack of appropriate indications and risk/benefit documentation for antipsychotic use, and failure to obtain or document physician responses to pharmacist recommendations for gradual dose reduction of antidepressants. Required policies for psychotropic and antipsychotic medication use were not provided when requested.
Two residents with complex medical needs did not have their care plans updated after significant changes in condition, including hospital readmission and the need for Enhanced Barrier Precautions. Staff were not provided with current guidance on required care interventions or PPE use, leading to care being delivered without appropriate infection control measures and without reflecting the residents' increased need for assistance.
A resident with COPD and other conditions did not have their oxygen tubing, cannula, and nebulizer mask stored in a sanitary manner as required by facility policy. Staff left these respiratory devices unbagged and exposed in the resident's room, despite being aware of the need to keep them bagged when not in use.
Two residents receiving hospice care did not have their care plans updated to include specific details about hospice services, such as the frequency of visits, supplies, medications, and equipment provided by hospice. Although hospice documentation was present in the medical records and staff confirmed regular hospice involvement, the care plans lacked this essential information, resulting in incomplete coordination of care as required by facility policy.
Unqualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the director of food and nutrition services possessed the required qualifications, specifically the certification as a certified dietary manager (CDM). Observations and interviews revealed that the current dietary manager and the administrator were both enrolled in classes to obtain CDM certification but had not yet completed them. The facility's policy required the director of food and nutrition services to be a CDM, a certified food service manager, be nationally certified in food service management and safety, have an associate's degree in food service management or hospitality, or have two or more years of experience in the position along with a completed course in food safety and management. At the time of the survey, these requirements were not met, and the registered dietician was only present twice a month, though available by phone.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols during wound care for two residents. In one instance, two licensed nurses provided wound care to a resident with a Stage 2 pressure ulcer without following EBP guidelines, such as wearing gowns and changing gloves at appropriate times. The care plan for this resident did not include specific instructions for EBP or the required personal protective equipment (PPE), and a certified nurse aide was unaware that EBP was necessary for this resident. The resident had multiple diagnoses, including Alzheimer's disease, COPD, hemiparesis, and was dependent on staff for all activities of daily living. In another case, wound care for a resident with a Stage 4 pressure ulcer was performed without the use of protective gowns, and hand hygiene was not consistently performed between glove changes or after glove removal. One nurse applied clean gloves without performing hand hygiene, failed to don a gown, and did not sanitize hands after removing gloves or handling trash. The facility's policies required the use of gowns and gloves for high-contact care activities and specified hand hygiene before and after glove use, but these protocols were not followed during the observed care. Additionally, the facility failed to ensure that a resident's nasal cannula and nebulizer mask were properly stored when not in use, which could contribute to infection risk. The facility's own policies on EBP and hand hygiene were not adhered to during these care activities, as evidenced by staff statements and direct observation.
Failure to Provide Timely Monthly Drug Regimen Review and Communicate Medication Irregularities
Penalty
Summary
The facility's consultant pharmacist failed to provide a monthly Drug Regimen Review (MRR) for February 2025, as required by facility policy and federal guidelines. This omission resulted in the facility and physicians not receiving timely recommendations regarding residents' medication regimens. Specifically, the pharmacist did not communicate recommendations for gradual dose reduction (GDR) or request a physician's rationale and risk versus benefit analysis for certain psychotropic medications prescribed to residents. The absence of the February 2025 MRR meant that medication irregularities were not identified or addressed in a timely manner. For one resident with diagnoses including Alzheimer's disease, hypertension, anxiety, and depression, the medical record showed ongoing use of antipsychotic, antidepressant, and antianxiety medications. The pharmacist's review noted the lack of an allowable diagnosis for the antipsychotic medication and requested a risk versus benefit statement or discontinuation, but this recommendation was not sent to the facility or physician, resulting in no physician response. The resident's care plan required quarterly consultation with pharmacy and physician to consider dosage reduction, but this process was not followed due to the missing review. Another resident with diabetes and major depressive disorder was prescribed sertraline, an antidepressant. The pharmacist had previously recommended a GDR or rationale for continued use, but no physician response was documented. The February 2025 MRR, which reiterated this recommendation, was not sent to the facility until months later, and the physician did not receive it. Facility policy required the consultant pharmacist to review each resident's medication regimen monthly and communicate any irregularities to prescribers and facility leadership, but this was not done for the month in question.
Failure to Secure, Label, and Remove Expired Medications
Penalty
Summary
Surveyors observed multiple instances where the facility failed to ensure the proper labeling, dating, and secure storage of medications and biologicals. On several occasions, medication carts were found unlocked and unattended, and medications such as insulin pens were not labeled with resident names or dates of opening. Additionally, expired medications, including aspirin, Systane eye drops, Dulcolax pills, melatonin, artificial tears, lidocaine jelly, and epinephrine auto-injectors, were found in both medication carts and the emergency medication kit. These findings were verified by various staff members, including a Certified Medication Aide, a Licensed Nurse, and an Administrative Nurse, who acknowledged the presence of expired and unlabeled medications and the failure to secure medication carts as required by facility policy. The facility's policies, dated February 2023, required that all medication storage areas be locked when not in use, that medication labels include the resident's name and expiration date, and that insulin pens be labeled and dated when opened. Despite these policies, staff did not consistently follow procedures for medication security and labeling, resulting in the presence of expired and improperly labeled medications accessible in the facility. No specific residents were identified as directly affected in the report, but the deficiencies were confirmed through direct observation and staff interviews.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including COPD, edema, chronic pain, anxiety, hypertension, and atrial fibrillation, was allowed to keep and self-administer a Breztri inhaler at her bedside without a physician's order or a documented assessment of her ability to safely self-administer medications. The resident's medical record indicated moderately impaired cognition and a care plan that directed staff to administer medications as ordered. The self-administration assessment documented that the resident required assistance for all medications, including inhalants, and there was no order permitting self-administration or bedside storage of the inhaler. During medication administration, a licensed nurse discovered the inhaler was not in its box and found it on the resident's bedside table. The resident self-administered the inhaler in the nurse's presence. Facility policy required an interdisciplinary team assessment and a physician's order before allowing self-administration or bedside storage of medications, but these steps were not completed for this resident.
Failure to Secure Resident Medical Record on Medication Cart Laptop
Penalty
Summary
Facility staff failed to secure and protect the privacy and confidentiality of a resident's medical record. On one occasion, staff left a resident's point of care information open and visible on the electronic medical record system at the medication cart laptop, making the information accessible to unauthorized individuals. A certified medication aide acknowledged that the screen should not be left unlocked with resident information displayed. A licensed nurse confirmed that both the medication cart and the laptop screen should always be locked when unattended, and an administrative nurse stated that nursing staff are expected to lock any screen on the laptop and secure the medication cart when not in direct sight. The facility's policy requires that protected health information not be used or disclosed except as permitted by law.
Failure to Ensure Proper Management and Documentation of Psychotropic Medications
Penalty
Summary
The facility failed to ensure appropriate management and documentation of psychotropic medications for multiple residents. For one resident with diagnoses including vascular dementia, anxiety, bipolar disorder, and major depressive disorder, the physician’s order for PRN Ativan lacked a required stop date, and the medication was administered without issue. The facility did not provide a policy for psychotropic medication use when requested, and the administrative nurse confirmed that the Ativan order should have included a stop date and reassessment by the physician. Another resident with Alzheimer’s disease, anxiety, and depression was prescribed Seroquel for anxiety and agitation, with the dose later increased. The care plan directed staff to consider dosage reduction quarterly, but the physician’s order did not include an appropriate indication or documentation of risk versus benefit for the antipsychotic use. The administrative nurse acknowledged that agitation was not an appropriate diagnosis for Seroquel and that the physician needed to provide ongoing justification for its use. The facility was unable to provide a policy for antipsychotic medication use upon request. A third resident with diabetes and major depressive disorder was prescribed sertraline, with the consultant pharmacist recommending a gradual dose reduction or rationale for continued use. There was no documented physician response to these recommendations, and the administrative nurse confirmed that the physician had not received or responded to the pharmacist’s recommendations. The facility’s pharmacy services policy required monthly medication regimen reviews and communication of recommendations, but the facility did not provide a specific policy for psychotropic drugs.
Failure to Update Care Plans After Significant Change in Condition
Penalty
Summary
The facility failed to ensure that care plans for two residents were updated to reflect their current care needs following significant changes in their conditions. One resident, who had diagnoses including Alzheimer's disease, COPD, hemiparesis, and anxiety, was dependent on staff for all activities of daily living and had a Stage 2 pressure ulcer. Despite being on hospice and requiring Enhanced Barrier Precautions (EBP) due to an open area, the care plan did not include interventions or directions for staff regarding the use of personal protective equipment (PPE) necessary for infection control. Staff interviews revealed a lack of awareness about the resident's EBP status, and care was provided without appropriate PPE, as confirmed by both nursing and administrative staff. Another resident, with diagnoses of paraplegia, hypertension, pressure ulcer, and osteomyelitis, experienced a significant change in condition after a hospital stay and was placed on hospice services. The resident's Minimum Data Set (MDS) indicated increased dependence on staff for activities of daily living, but the care plan was not revised to reflect these changes. The care plan continued to document previous levels of independence and did not address the resident's current needs for assistance, despite the resident now requiring more substantial support and the use of a mechanical lift with two staff members for transfers. Facility policy required that comprehensive, person-centered care plans be developed and updated within specific timeframes following significant changes in a resident's condition, including after hospital readmission and at least quarterly. In both cases, the care plans were not updated as required, resulting in a lack of clear guidance for staff and the potential for delayed or missed care.
Failure to Store Respiratory Equipment in a Sanitary Manner
Penalty
Summary
Staff failed to provide adequate respiratory care and services for a resident diagnosed with COPD, vascular dementia, anxiety, bipolar disorder, and major depressive disorder. The resident had physician orders for supplemental oxygen via nasal cannula and nebulizer treatments, with care plans and facility policy directing that oxygen tubing, cannula, and nebulizer mask be stored in a plastic bag when not in use to prevent infection. However, observations revealed that the resident's oxygen tubing and cannula were left unbagged and draped over a lamp, and the nebulizer mask was left unbagged on a table beside the resident's recliner on multiple occasions. Interviews with staff confirmed awareness of the policy requiring these respiratory devices to be bagged when not in use, and staff acknowledged that bags had been provided for this purpose. Despite this, the resident's preference to drape the tubing over the lamp was noted, and staff did not consistently ensure proper storage as required by facility policy. The facility's infection prevention policy specifically directed staff to keep these items in a plastic bag when not in use, but this was not followed, resulting in a failure to maintain sanitary storage of respiratory equipment.
Failure to Coordinate and Document Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure proper collaboration and communication between hospice providers and facility staff for two residents receiving hospice care. For one resident with Alzheimer's disease, COPD, hemiparesis, and anxiety, the care plan documented receipt of hospice services and provided general instructions for comfort and medication administration. However, it lacked specific details about the hospice services being provided, such as the frequency of support visits, supplies and medical equipment covered by hospice, medications provided, and the hospice provider's contact information. The resident's records confirmed hospice admission, and staff interviews indicated that hospice staff visited regularly, but the care plan was not updated to reflect these arrangements. For another resident with paraplegia, hypertension, a stage 4 pressure ulcer, and osteomyelitis, the care plan noted a terminal prognosis and receipt of hospice services. The plan included directions for comfort measures and collaboration with the hospice team but did not specify which durable medical equipment, supplies, or medications were provided by hospice, nor did it detail the hospice staff involved or the frequency of their visits. Although the resident's electronic medical record contained the hospice plan of care and related documentation, this information was not incorporated into the care plan used by facility staff. Facility policy required coordinated care plans for residents receiving hospice services, including the most recent hospice plan of care and details of care and services provided by both the hospice and the facility. Staff interviews confirmed that care plans should include all relevant hospice information, but this was not consistently done for the residents in question. As a result, the facility did not ensure comprehensive and coordinated care planning for residents on hospice, as required by its own policy.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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