Linn Community Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Linn, Kansas.
- Location
- 612 Third St, Linn, Kansas 66953
- CMS Provider Number
- 175494
- Inspections on file
- 16
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Linn Community Nursing Home during CMS and state inspections, most recent first.
A resident with multiple health conditions, who primarily used a wheelchair, was pushed by a maintenance staff member despite her repeated requests to stop and her wish to go to the activity room. Several staff witnessed the incident, filed grievances, and reported it to a nurse and administrator, but no formal investigation was conducted, staff were not interviewed, and the incident was not reported to the State Agency as required by facility policy.
A resident with multiple health conditions, who primarily used a wheelchair and required staff assistance, was observed by several staff being pushed by a maintenance staff member despite her objections. Staff filed grievances, but they were not individually interviewed, and the administrator did not conduct a formal investigation or report the incident to the State Agency, contrary to facility policy.
A facility failed to prevent accidents and falls for two residents. One resident, with severe cognitive impairment, was allowed to exit unsupervised through an unlocked gate, remaining outside for hours before being noticed. Another resident, with a history of falls and high fall risk, lacked adequate care plan interventions for multiple falls. These deficiencies highlighted failures in maintaining a safe environment, placing residents at risk for injury.
The facility failed to store food properly and ensure effective dishwashing, risking foodborne illness for residents. Observations revealed missing thermometers, unsealed and expired food, and inadequate dishwashing logs. Dietary staff confirmed these deficiencies, highlighting lapses in food safety protocols.
The facility failed to implement a water management program to prevent Legionella disease, placing 38 residents at risk. Interviews and record reviews revealed a lack of documentation for Legionella preventative measures, such as risk area identification and disinfection procedures. Maintenance staff confirmed the absence of a water distribution map, and the Infection Control Preventionist noted missing documentation for the water management plan, despite policy requirements.
The facility failed to ensure the Consultant Pharmacist identified and reported unapproved indications and inadequate monitoring for psychotropic medications for several residents. This oversight placed the residents at risk for unnecessary medication use and side effects.
The facility failed to ensure approved indications and adequate monitoring for psychotropic medications for several residents, placing them at risk of unnecessary medication use. Residents were administered psychotropic drugs without specific targeted behaviors or side effect monitoring documented, and physicians declined GDR recommendations without providing specific rationales. The facility's policy on psychotropic medication use was not adequately implemented, leading to deficiencies in monitoring and documentation.
The facility failed to offer pneumococcal immunizations to four residents, despite physician orders and facility policy. The residents had received a previous Pneumovax dose but lacked documentation of being offered further vaccinations. Interviews revealed a lack of systematic tracking and offering of the vaccine, with staff confirming the absence of a list of eligible residents. This oversight placed the residents at risk for complications related to pneumococcal pneumonia.
A resident with severe cognitive impairment and multiple health issues was transferred to a hospital without being provided the required bed hold policy information. An administrative nurse confirmed the lack of documentation, which is against the facility's revised policy. This oversight placed the resident at risk of not being able to return to the facility.
A facility failed to complete a discharge summary for a resident, omitting a recapitulation of the resident's stay and treatment. The resident, who had multiple medical conditions, was discharged without this essential documentation, contrary to the facility's policy. This oversight was confirmed by an administrative nurse, highlighting a risk for unmet care needs.
A resident with multiple diagnoses, including dementia and psychotic disturbance, was not assessed for trauma-informed care needs, contrary to the facility's policy. Despite documented behavioral issues and high-alert medications, neither the administrative nurse nor social services completed the required assessment, placing the resident at risk for unmet emotional and psychosocial needs.
Failure to Report and Investigate Resident's Objection to Staff Handling
Penalty
Summary
The facility failed to report an incident involving a resident with multiple medical conditions, including hypertension, pain, muscle weakness, and major depressive disorder, who primarily used a wheelchair for mobility. On the date in question, multiple staff members witnessed a maintenance staff member pushing the resident in her wheelchair despite her repeated requests to stop and her desire to go to the activity room. Staff members, including a CNA and dietary staff, observed the resident expressing her wish for the maintenance staff to stop, and one staff member reported that the resident did not appear jovial about the interaction. Grievances were filed by staff who witnessed the event, but they were not interviewed about what they saw. The incident was reported up the chain to a licensed nurse and then to administrative staff, who acknowledged being informed that the resident was taken by the maintenance staff and that her whereabouts were temporarily unknown. Although the administrator later interviewed the resident, who downplayed the incident, no formal investigation was conducted, and the staff who filed grievances were not individually interviewed. The facility did not report the incident to the State Agency as required by its own abuse, neglect, and exploitation policy, nor did it complete a written investigation into the staff grievances related to the event.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to fully investigate an allegation of abuse involving a resident with multiple medical conditions, including hypertension, pain, generalized edema, and major depressive disorder. The resident, who primarily used a wheelchair and required staff assistance for mobility and activities of daily living, was observed by multiple staff members being pushed in her wheelchair by a maintenance staff member despite her objections and requests to stop. Staff members, including a CNA and dietary staff, witnessed the incident, noted the resident's distress, and filed grievances regarding the event. However, these staff members were not individually interviewed about what they witnessed. The licensed nurse reported the incident and submitted the grievances to administrative staff, who acknowledged being informed of the situation and seeing the resident and maintenance staff together. The administrator conducted only a brief, informal interview with the resident and did not conduct a written investigation or interview the involved staff individually. No report was made to the State Agency, and no formal investigation documentation was completed, despite the facility's policy requiring immediate investigation and reporting of all alleged or suspected abuse, neglect, or exploitation.
Failure to Prevent Accidents and Falls for Residents
Penalty
Summary
The facility failed to ensure an environment free from accident hazards for a cognitively impaired resident, identified as R35. On the morning of 05/23/24, a dietary staff member allowed R35 to exit through a door leading to the patio without ensuring additional supervision. The patio area had an unlocked gate, which R35 used to leave the facility unsupervised. It was not until approximately 3.5 hours later that staff realized R35 had been outside without supervision. R35 was found in her room, having returned on her own. The resident's medical records indicated severe cognitive impairment, a history of falling, and a need for supervision with ambulation. The facility also failed to provide adequate interventions to prevent falls for another resident, identified as R12. R12 had a history of multiple falls, with the care plan lacking interventions for several incidents. R12's medical records documented conditions such as spinal stenosis, cognitive-communication deficit, and Alzheimer's disease, which contributed to a high fall risk. Despite this, the care plan did not consistently address the falls, leaving R12 at risk for further incidents. The facility's policies on accident prevention and fall prevention were not effectively implemented, as evidenced by the incidents involving R35 and R12. The unlocked gate and lack of supervision for R35, along with the insufficient fall prevention measures for R12, highlighted deficiencies in maintaining a safe environment for residents. These failures placed both residents at risk for injury, with R35's situation being classified as immediate jeopardy.
Removal Plan
- Updated Elopement and Elopement Risk Policies
- The facility started a sign-off sheet to include charge nurses' verification that a resident was able to go outside the facility without staff or a family member.
- Staff participated in an elopement drill.
- R35's care plan was updated.
- Initiated daily maintenance checks of the patio gates to make sure they are secured.
- R35 received 15-minute checks.
- Updated R35's wander/elopement risk assessment which shows moderate risk for elopement.
Improper Food Storage and Dishwashing Practices
Penalty
Summary
The facility failed to adhere to proper food storage and dishwashing protocols, which placed residents at risk for foodborne illness. During an inspection, it was observed that the stainless-steel double-door refrigerator lacked a thermometer in the refrigerator section, and the freezer section contained seven opened, unsealed, and unlabeled bags of frozen foods. Additionally, the thermometer on the door shelf was not functioning. The walk-in freezer had boxes of various food items stored directly on the floor, and the white refrigerator in the hallway contained expired frozen products. Furthermore, the walk-in freezer lacked an independent backup thermometer, which is essential for monitoring temperature fluctuations. The dishwashing machine logs revealed inconsistencies in recording temperatures and sanitizer levels, with several days lacking documentation entirely. The facility's policy required daily checks for expired food and proper labeling and dating of opened food items, which were not followed. Dietary staff confirmed these deficiencies, acknowledging the lack of proper labeling, expired food, and inadequate monitoring of dishwashing temperatures and chemical sanitation. These oversights in food storage and dishwashing practices compromised the safety and well-being of the residents.
Failure to Implement Legionella Water Management Program
Penalty
Summary
The facility, with a census of 38 residents, failed to implement a comprehensive water management program to prevent Legionella disease, a bacterium that can cause pneumonia, particularly in adults over 50 and those with weakened immune systems. The deficiency was identified through interviews and record reviews, revealing that the facility did not have documentation of Legionella preventative measures, such as identifying risk areas and actions taken to mitigate risk. The Water Temperature Check Log documented weekly checks of various areas, but there was no evidence of a map of water distribution or documentation of disinfection of shower heads, especially in unused resident halls. During interviews, Maintenance Staff V confirmed the absence of a water distribution map and documentation of disinfection procedures, while the Infection Control Preventionist CC verified the lack of required documentation to show adherence to the water management plan. The facility's Water Management Policy outlined minimum standards, including risk assessments, system descriptions, and action plans for controlling Legionella, but these were not implemented. This failure placed residents at risk of contracting Legionella pneumonia due to inadequate management of waterborne pathogens.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported unapproved indications for the use of psychotropic medications, as well as the lack of monitoring for side effects and targeted behaviors for several residents. For Resident 6, the CP did not report the lack of side effects and targeted behavior monitoring, nor the unapproved indication for Zyprexa. The resident's care plan lacked specific targeted behaviors and monitoring related to high-alert medications, placing the resident at risk for unnecessary medication side effects. Resident 13's care plan also lacked specific targeted behaviors and side effect monitoring for high-alert medications. The CP failed to identify and report these inadequacies, and the physician's denial of a gradual dose reduction (GDR) lacked a patient-specific rationale. This oversight placed the resident at risk of unnecessary psychotropic medication use and related side effects. Similarly, for Residents 22 and 21, the CP did not report the unapproved indications for antipsychotic medications and failed to ensure adequate monitoring of targeted behaviors. The lack of documentation and communication regarding these issues placed the residents at risk for unnecessary psychotropic medication use and potential side effects.
Inadequate Monitoring and Indication for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that several residents had approved indications and adequate monitoring for the use of psychotropic medications, placing them at risk of receiving unnecessary medications. Resident 6, who had severe cognitive impairment and was dependent on staff for functional abilities, was administered multiple psychotropic medications without specific targeted behaviors or monitoring for side effects documented in the care plan. Despite recommendations for gradual dose reductions (GDR) for some medications, the physician declined these without providing a specific rationale, and the clinical record lacked evidence of a risk versus benefit analysis for the continued use of antipsychotic medication. Resident 13, who had intact cognition and no signs of delirium or psychosis, was also administered several psychotropic medications without specific targeted behaviors or side effect monitoring documented. The physician declined GDR recommendations without recording a patient-specific rationale, and the medication regimen reviews did not identify or report the lack of monitoring. Similarly, Resident 22, who had intact cognition but exhibited delusions and verbal behaviors, was administered an antipsychotic medication without an approved indication, and the consultant pharmacist's evaluation lacked information regarding this unapproved use. Resident 21, with moderate cognitive impairment, was administered psychotropic medications without evidence of targeted behavior monitoring. The physician declined GDR recommendations, citing clinical contraindications, but the clinical record lacked evidence of monitoring for targeted behaviors or adverse reactions. The facility's policy required monitoring for the need and benefits of psychotropic medications, but this was not adequately implemented, leading to the risk of unnecessary medication use and related side effects for the residents involved.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer pneumococcal immunizations to four residents, despite physician orders and facility policy requiring such vaccinations. The residents involved were R13, R25, R12, and R24, all of whom had received a previous dose of the Pneumovax vaccine but lacked documentation of being offered or refusing further vaccinations. The facility's policy, aligned with CDC recommendations, required offering two pneumococcal vaccines to adults aged 65 years or older, with specific intervals between doses. However, the facility did not adhere to this policy, as evidenced by the absence of documentation and the failure to screen residents for eligibility for a second dose. Interviews with facility staff revealed a lack of systematic tracking and offering of the pneumococcal vaccine. Administrative Nurse E confirmed that four of the six reviewed residents had not received a second pneumonia immunization since admission, and the facility had not screened them for eligibility. Administrative Nurse D acknowledged that the facility had not compiled a list of residents eligible for a second vaccination, despite the information being available in their EHR. The facility's reliance on the pharmacy to review and administer vaccinations further contributed to the oversight, as the pharmacy had not been provided with a list of eligible residents. This inaction placed the residents at risk for complications related to pneumococcal pneumonia.
Failure to Provide Bed Hold Policy Information
Penalty
Summary
The facility failed to provide a resident or their representative with written information regarding the bed hold policy when the resident was transferred to the hospital. The resident, identified as R17, had diagnoses of congestive heart failure and an acute upper respiratory infection, and was dependent on staff for most activities of daily living due to severely impaired cognition. The resident's care plan required oxygen at night due to breathing difficulties. Despite these needs, when R17 was admitted to the hospital, there was no evidence in the clinical record that the facility provided the required bed hold policy information. An administrative nurse confirmed the oversight, acknowledging the absence of documentation that the bed hold policy was given to R17 or their representative at the time of hospital transfer. The facility's bed hold policy, revised earlier in the year, mandates that such information be provided before a resident is transferred to a hospital or goes on therapeutic leave. This failure to communicate the bed hold policy placed the resident at risk of not being permitted to return and resume residence in the nursing facility.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to complete a discharge summary for a resident, identified as R39, which included a recapitulation of the resident's stay and course of treatment. This deficiency was identified during a review of the resident's electronic medical record (EMR) and through interviews. R39 was admitted to the facility with multiple diagnoses, including idiopathic peripheral neuropathy, enterocolitis due to clostridium, edema, vomiting, kidney calculus, anemia, urinary tract infection, abdominal pain, and leg pain. The resident's care plan indicated a desire to return to live in the community, and a physician's order was documented for discharge back to her apartment with the same medication orders. On the day of discharge, a progress note recorded that R39 left the facility with a family member, taking medications and instructions. However, the discharge summary in the EMR lacked a recapitulation of the resident's stay, which was confirmed by an administrative nurse. The facility's policy required documentation of the resident's clinical record, including medical treatment, care responses, and changes in condition, as well as the resident's functional status at admission and discharge. The absence of a recapitulation summary placed the resident at risk for unidentified and unmet care needs.
Failure to Conduct Trauma-Informed Care Assessment
Penalty
Summary
The facility failed to assess a resident, identified as R22, for trauma-informed care needs, which could have helped in eliminating or mitigating triggers that may cause re-traumatization. R22's electronic medical record documented diagnoses including hypertension, mild cognitive impairment, muscle weakness, chronic pain, and dementia with psychotic disturbance. Despite these conditions, the facility did not conduct a trauma-informed care assessment to identify potential mental health needs. The resident's care plan included high-alert medications such as valproate and olanzapine, and there were documented instances of behavioral issues, including conflict with another resident. Interviews with facility staff revealed that neither the administrative nurse nor the social services had completed a trauma-informed care assessment for R22. The facility's policy required an initial screening for a history of trauma within 48 hours of admission, but this was not done for R22. The lack of assessment placed the resident at risk for unmet emotional and psychosocial needs, as the care plan did not account for trauma-informed care strategies that could help manage the resident's behavioral symptoms.
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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