Logan County Senior Living Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Oakley, Kansas.
- Location
- 615 Price Ave, Oakley, Kansas 67748
- CMS Provider Number
- 175567
- Inspections on file
- 18
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Logan County Senior Living Inc during CMS and state inspections, most recent first.
A resident with Alzheimer's and severe cognitive impairment was forcibly administered medications by an LN, despite her refusal. The LN used physical force, including holding the resident's shoulders and head, to make her swallow the medications. A CNA intervened, and the incident was reported, leading to the LN's suspension. The facility's failure to adhere to the resident's care plan and abuse prevention policy resulted in psychosocial harm to the resident.
The facility failed to submit complete and accurate staffing information through the PBJ as required by CMS. PBJ reports indicated multiple days without 24-hour licensed nurse coverage, but a review of payroll data showed that a licensed nurse was on duty. Administrative Staff A confirmed that the corporate staff failed to document the correct hours, and a new employee is now handling data submission.
The facility failed to provide three residents with the correct CMS Skilled Nursing Facility ABN Form 10055, instead giving them form CMS-R-131. This error, verified by Social Services and Administrative Staff, was due to the facility's recent change in ownership and Medicare certification status, putting residents at risk of making uninformed decisions about their skilled services.
The facility failed to develop and implement an individualized dementia treatment plan for a resident with dementia and behaviors. Despite having a care plan, it lacked specific guidance for managing the resident's inappropriate physical and verbal actions. Staff confirmed the absence of person-centered interventions, placing the resident at risk for decreased quality of life.
A facility failed to follow acceptable standards of practice related to wound care for a resident with an infected wound. An administrative nurse did not sanitize the bedside table before placing clean supplies, did not change gloves after cleansing the wound, and improperly stored wound care items without sanitizing them. These actions violated the facility's wound care policy and placed the resident at risk for delayed healing and other complications.
The facility failed to ensure safety assessments for two residents using an electric wheelchair and smoking. One resident, with multiple diagnoses, used an electric wheelchair without a proper safety assessment, leading to several incidents of unsafe operation. Another resident, with nicotine dependence and other conditions, was not assessed for safe smoking practices, despite documented incidents of anger when unable to smoke. These failures placed both residents at risk for preventable accidents and injuries.
The facility failed to provide necessary behavioral health care for a resident diagnosed with schizophrenia, bipolar disorder, and depression. Despite documented thoughts of self-harm, the resident's clinical record lacked evidence of follow-up mental health services. Administrative staff confirmed that the required reporting and assessment procedures were not followed, placing the resident at risk for impaired quality of life.
The facility failed to develop and implement an individualized dementia treatment plan for a resident with dementia and behaviors. The care plan lacked specific interventions for managing the resident's inappropriate behaviors, which included physical contact and verbal aggression. Staff responses were limited to redirection and informing the charge nurse, without individualized interventions in place.
The facility failed to notify the physician of out-of-parameter blood sugars for a resident with diabetes mellitus type two. Despite physician's orders to report blood sugar levels outside specified parameters, multiple instances were documented where the physician was not informed. This oversight was confirmed by staff and placed the resident at risk for unnecessary medication side effects and other complications.
The facility failed to date a resident's Levemir insulin flex pen, which was confirmed by both a licensed nurse and an administrative nurse. The facility's policy requires dating and discarding expired insulin pens, and the failure to do so placed the resident at risk for ineffective medication.
A facility failed to ensure a coordinated plan of care for a resident receiving hospice services. The resident, with multiple diagnoses including heart failure and dementia, was admitted to hospice care but lacked a coordinated care plan between the hospice and the facility. This deficiency was confirmed by staff and placed the resident at risk for inappropriate end-of-life care.
A nurse failed to follow proper infection control measures during wound care for a resident with an infected wound. The nurse did not sanitize the bedside table, change gloves after cleansing the wound, or sanitize the scissors before use. These actions were against the facility's Wound Care policy and placed the resident at risk for further infection and cross-contamination.
The facility failed to ensure residents received their mail on Saturdays. During a resident council meeting, residents reported no mail delivery on Saturdays. Staff confirmed that mail was collected and delivered during the week but were unsure if weekend staff were aware of their responsibilities. The facility's policy required mail delivery within 24 hours, including Saturdays, but this was not followed.
Resident Forced to Take Medications Against Will
Penalty
Summary
The facility failed to prevent a staff member from physically forcing a resident to take her medications against her will. On the morning of December 15, 2024, a Licensed Nurse (LN) attempted to administer medications to a resident diagnosed with Alzheimer's Disease, anxiety, and major depressive disorder. The resident, who had severely impaired cognition and a history of depression, refused the medications by swatting the nurse's hand away. Despite this clear refusal, the nurse pushed the resident's hands into her lap, removed her coffee cup, and replaced it with a cup of water. The nurse then held the resident's shoulders and attempted to spoon the medications into her mouth, which the resident spit out. The nurse further escalated the situation by grabbing the back of the resident's head, pushing it forward, and pouring water into her mouth in an attempt to force her to swallow the medications. The incident was witnessed by a Certified Nurse's Aide (CNA) who intervened by sitting beside the resident and encouraging her to take her medications, which she eventually did. The CNA and another staff member reported the incident to the Administrative Nurse, who suspended the nurse involved pending an investigation. The facility's review of the incident, including camera footage, confirmed the nurse's inappropriate actions and failure to respect the resident's rights and refusal to take medications. The nurse's behavior was characterized by frustration and a lack of adherence to appropriate care protocols, resulting in the resident experiencing fear and potential psychosocial harm. The resident's care plan highlighted her communication problems and potential for sadness, directing staff to allow her time to respond and not to rush her. Despite these directives, the nurse's actions directly contradicted the care plan's guidelines, leading to the deficiency. The facility's policy on abuse prevention emphasizes the residents' right to be free from abuse and neglect, which was violated in this instance. The incident underscores a significant lapse in following established protocols to protect residents from harm.
Failure to Submit Accurate PBJ Data
Penalty
Summary
The facility failed to submit complete and accurate staffing information through the Payroll Based Journal (PBJ) as required by CMS. The PBJ reports for Fiscal Year 2023 Quarters 2, 3, and 4 indicated multiple days where there was no licensed nurse coverage for 24 hours a day, seven days a week. However, a review of the facility's licensed nurse payroll data for the specified dates revealed that a licensed nurse was indeed on duty for the required hours. This discrepancy was confirmed by Administrative Staff A, who acknowledged that the corporate staff responsible for inputting the data failed to document the correct hours, and a new employee is currently handling the data submission process. The facility's policy on staffing, dated August 2022, states that the facility provides enough nursing staff with the appropriate skills and competency necessary to care for all residents in accordance with their care plans and the facility assessment. The policy also specifies that licensed nurses and certified assistants are available 24 hours a day, seven days a week, and that a registered nurse provides services for at least eight consecutive hours every 24 hours. Despite this policy, the facility's failure to submit accurate PBJ data placed the residents at risk for unidentified and ongoing inadequate staffing.
Failure to Provide Correct Medicare ABN Forms
Penalty
Summary
The facility failed to provide three residents or their representatives with the correct Centers for Medicare and Medicaid (CMS) Skilled Nursing Facility Advanced Beneficiary Notices (ABN) Form 10055. Instead, the residents received form CMS-R-131, which did not include the necessary information about potential liability for services not covered by Medicare. This error was identified through a review of the records for the three residents, whose skilled services had ended on various dates. The incorrect forms were verified by Social Services and Administrative Staff, who acknowledged the mistake and attributed it to the facility's recent change in ownership and Medicare certification status. The facility's policy, dated September 2022, required that residents be informed in advance of any changes to their bills using the correct ABN form. However, the facility did not adhere to this policy, resulting in the residents being at risk of making uninformed decisions about their skilled services. The failure to provide the correct form meant that the residents did not receive an estimated cost of continued services when discharged from skilled care, which is a critical component of the decision-making process for their ongoing care needs.
Failure to Develop Individualized Dementia Treatment Plan
Penalty
Summary
The facility failed to develop and implement an individualized dementia treatment plan for Resident 22, who had dementia and exhibited behaviors. Despite having a care plan that directed staff to administer medications, communicate capabilities, and document changes in cognitive function, the plan lacked specific guidance for managing R22's behaviors. The resident's medical records documented diagnoses of dementia, mood disorder, depression, and pain, and noted the use of antipsychotic and antidepressant medications. However, the care plan did not include person-centered interventions for R22's dementia-related behaviors, which included inappropriate physical and verbal actions towards staff and other residents. Observations and interviews with staff confirmed that R22 continued to exhibit sexually inappropriate behaviors and verbal aggression, and that staff redirected the resident without a formalized plan in place. The facility's policy required a comprehensive, person-centered care plan to be developed and updated to meet the resident's needs, but this was not done for R22. The care plan was not revised to include specific interventions for the resident's behaviors, despite multiple incidents of inappropriate conduct documented in the nurse's notes. Interviews with staff and administrative personnel verified the absence of person-centered interventions in the care plan, highlighting a failure to address the resident's dementia-related behaviors adequately. This deficiency placed R22 at risk for decreased quality of life due to uncommunicated care needs.
Failure to Follow Wound Care Protocols
Penalty
Summary
The facility failed to follow acceptable standards of practice related to wound care for a resident with an infected wound. The resident, who had multiple diagnoses including diabetes mellitus, Charcot arthropathy, MRSA, neuropathy, chronic kidney disease, and vascular insufficiency, required specific wound care procedures as per physician's orders. However, during an observation, an administrative nurse did not sanitize the bedside table before placing clean supplies on it, did not change gloves after cleansing the wound, and placed the wound cleanser bottle directly on the resident's bed. Additionally, the nurse did not sanitize the scissors before cutting the foam for the wound vacuum and improperly stored the wound cleanser and scissors in the resident's dresser drawer without sanitizing them first. These actions were in direct violation of the facility's wound care policy, which mandates proper sanitization and use of disposable cloths to prevent cross-contamination. The resident's care plan included directives to float the resident's heels on a pillow, use caution during transfers, and monitor the wound for infection. Despite these directives, the administrative nurse's failure to adhere to proper wound care procedures placed the resident at risk for delayed healing and other complications. The nurse acknowledged the potential for cross-contamination and verified the lapses in following the wound care policy, which further highlights the deficiency in providing appropriate treatment and care according to the resident's needs and physician's orders.
Failure to Ensure Safety Assessments for Electric Wheelchair and Smoking Practices
Penalty
Summary
The facility failed to ensure the environment was free of accident hazards for two residents, R9 and R18. R9, who had diagnoses including diabetes mellitus type two, COPD, CHF, hypertension, and weakness, was using an electric wheelchair without a proper safety assessment. Despite multiple incidents of confusion and unsafe operation of the wheelchair, including running over another resident's feet and bumping into furniture and doorways, the facility did not document an assessment of R9's ability to safely use the electric wheelchair. The facility's policy required such an assessment, but it was not conducted, placing R9 at risk for injury. R18, who had diagnoses including nicotine dependence, diabetes mellitus type two, mood disorder, edema, and COPD, was also not properly assessed for safe smoking practices. Although R18's care plan required supervision while smoking and documented that her smoking supplies were stored in the medication cart, there was no evidence in the EMR that the facility assessed her ability to smoke safely. R18 had several documented incidents of becoming upset and angry when staff could not take her outside to smoke, but the facility did not complete a smoking safety assessment as required by their policy. The facility's failure to conduct necessary safety assessments for both the use of an electric wheelchair and smoking practices resulted in an environment with accident hazards, placing both residents at risk for preventable accidents and injuries. The facility's policies on assistive devices and smoking required comprehensive assessments, which were not followed in these cases.
Failure to Provide Necessary Behavioral Health Care
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident diagnosed with schizophrenia, bipolar disorder, and depression. The resident's Admission Minimum Data Set (MDS) indicated a mood score of 16, suggesting moderate to severe depression, and documented thoughts of self-harm. Despite these indicators, the resident's clinical record lacked evidence of follow-up mental health services, psychotherapy notes, or documentation from social service staff regarding the resident's statements or behaviors. Observations revealed the resident in a state of neglect, with unkempt hair and dressed in a nightgown, indicating a lack of proper care and attention to her mental health needs. Administrative staff confirmed that the Social Service Designee (SSD) did not inform the Director of Nursing (DON) or other relevant staff about the resident's suicidal thoughts, as required by the facility's Suicide Threats policy. This policy mandates immediate reporting and assessment of any suicide threats, followed by appropriate actions such as notifying the attending physician and monitoring the resident's mood and behavior. The facility's failure to adhere to this policy and provide timely mental health interventions placed the resident at risk for impaired quality of life due to untreated and ongoing mental health concerns.
Failure to Implement Individualized Dementia Treatment Plan
Penalty
Summary
The facility failed to develop and implement an individualized dementia treatment plan for a resident (R22) who had dementia and exhibited behaviors. R22's medical records documented diagnoses of dementia, mood disorder, depression, and pain. Despite these diagnoses, the care plan lacked specific interventions for managing R22's dementia-related behaviors. The resident's behaviors included inappropriate physical contact and verbal aggression towards staff and other residents. The care plan only directed staff to administer medications, communicate with the resident and family, and document changes in cognitive function, without providing specific guidance for handling the resident's behaviors. Observations and interviews with staff revealed that R22 continued to exhibit inappropriate behaviors, such as smacking a CNA's buttocks and making inappropriate remarks. Staff responses to these behaviors were limited to redirecting the resident and informing the charge nurse, without any individualized interventions in place. The facility's dementia policy required a resident-centered care plan and appropriate interventions for behavioral and psychiatric symptoms, but this was not implemented for R22. This deficiency placed the resident at risk for abuse and decreased quality of life.
Failure to Notify Physician of Out-of-Parameter Blood Sugars
Penalty
Summary
The facility failed to notify the physician of out-of-parameter blood sugars for one resident, identified as R18. R18 had a documented history of diabetes mellitus type two, mood disorder, edema, and chronic obstructive pulmonary disease (COPD). The resident's care plan directed staff to administer diabetes medication as ordered and to document side effects and effectiveness. Physician's orders specified that staff should notify the physician if R18's blood sugar was less than 70 ml/dL or greater than 170 ml/dL. However, the Treatment Administrative Record for February and March 2024 showed multiple instances where R18's blood sugar levels were out of the specified parameters, and the physician was not notified. This failure was confirmed by Administrative Nurse D and Licensed Nurse G, who verified that the physician was not informed of the out-of-parameter blood sugars and that the Treatment Administration Record did not indicate the blood sugar parameters for R18. The facility's Diabetes Clinical Protocol required the physician to order desired parameters for monitoring and reporting information related to blood sugar management. Despite this protocol, the facility did not adhere to the physician's orders, placing R18 at risk for unnecessary medication side effects and other related complications. Observations confirmed that R18 was ambulatory and had intact cognition, making the oversight particularly concerning. The deficiency was identified through a combination of record reviews, observations, and staff interviews, highlighting a significant lapse in the facility's adherence to prescribed medical protocols for managing diabetes in residents.
Failure to Date Insulin Pen
Penalty
Summary
The facility failed to date a resident's insulin flex pen, specifically Levemir, which is a long-acting insulin. During an observation, it was noted that the insulin pen for Resident 11 lacked an open date. Licensed Nurse H confirmed that nurses are required to date the flex pens when opened and discard them when expired. Administrative Nurse E also verified that the pens should be labeled with the resident's name and discarded if expired or outdated. According to Medlineplus.gov, Levemir pens must be discarded after 42 days of use. The facility's Insulin Administration policy mandates verifying the type of insulin, dosage, strength, method of administration, and expiration date before administration. The failure to date the insulin pen placed the resident at risk for ineffective medication.
Failure to Coordinate Hospice Care
Penalty
Summary
The facility failed to ensure a coordinated plan of care for a resident receiving hospice services. The resident, who had diagnoses including heart failure, stage 3 kidney disease, anxiety, and dementia with behavioral disturbance, was admitted to hospice care but lacked evidence of coordination between the hospice and the facility. The resident's care plan documented a holistic approach to care by collaboration between hospice and nursing facility staff, but the facility had not received the hospice care plan from the hospice provider, and there was no communication book or external document available for review in the Electronic Health Record (EHR). This lack of coordination was confirmed by Administrative Staff A, who verified that the facility lacked a hospice care plan for the resident since her admission to hospice. Observations revealed that the resident required extensive assistance with activities of daily living (ADL) and had severely impaired cognition. Despite the resident's significant needs, the facility did not have a coordinated care plan that included the hospice plan of care. The facility's policy required a written agreement with the hospice contractor outlining responsibilities and ensuring coordinated care, but this was not in place. This deficiency placed the resident at risk for inappropriate end-of-life care.
Inadequate Infection Control Measures During Wound Care
Penalty
Summary
The facility failed to ensure adequate infection control measures during wound care for Resident 79. During an observation, Administrative Nurse D did not sanitize the bedside table before placing clean supplies on it. The nurse also placed the wound cleanser bottle directly on the resident's bed and did not change gloves after cleansing the wound. Additionally, the nurse did not sanitize the scissors before cutting the foam for the wound vacuum and placed the used wound cleanser and scissors inside the resident's dresser drawer without proper sanitization. These actions were verified by the nurse, who acknowledged the potential for cross-contamination. The facility's Wound Care policy, dated October 2010, directed staff to establish a clean field using a disposable cloth, sanitize nozzles and bottle tops with alcohol, and wipe reusable supplies with alcohol before returning them to storage. The nurse's failure to follow these procedures placed Resident 79, who had an infection in a wound, at risk for continued wound infection, cross-contamination, and other infectious diseases.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure residents received their mail on Saturdays. During a resident council meeting, residents reported that there was no mail delivery on Saturdays. Activity Staff Z confirmed that administration staff retrieved the mail during the week from a mailbox outside the facility, with the key located in the nurse's station. Administrative Staff A verified that the mail was collected during the week and delivered to residents by Social Service staff but was unsure if weekend staff were aware of their responsibility to collect and deliver mail on Saturdays. The facility's policy, dated May 2017, stated that mail should be delivered to residents within 24 hours of delivery, including Saturdays. However, this policy was not followed, resulting in residents not receiving their mail on Saturdays.
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Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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