Logan Manor Community Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in Logan, Kansas.
- Location
- 415 N Washington St, Logan, Kansas 67646
- CMS Provider Number
- 175480
- Inspections on file
- 14
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Logan Manor Community Health Services during CMS and state inspections, most recent first.
Surveyors found that food items in multiple kitchenettes and a pantry were not labeled or dated, and daily temperature logs for dishwashers were not maintained. Administrative staff confirmed that these practices did not align with facility policies requiring proper labeling, dating, and documentation for food safety and sanitation.
The facility did not ensure RN coverage for at least eight consecutive hours each day, as required, on multiple occasions. Staffing records and schedules confirmed repeated days without an RN present, and administrative staff acknowledged the ongoing difficulty in maintaining RN staffing levels.
Staff did not date an opened insulin pen and failed to remove an expired bottle of stock medication from the medication cart. A nurse and administrative staff confirmed that medications should be dated and expired items discarded, in accordance with facility policy.
A resident's blood sugar was checked by a nurse in a common dining area, and the result was announced aloud in front of other residents and staff, violating the facility's policy on privacy and dignity.
A resident with anxiety, dementia, and major depressive disorder received PRN Ativan cream for agitation without a 14-day stop date or documented physician rationale for ongoing use. Staff administered the medication in response to agitation, but the order and medical record lacked required documentation, contrary to facility policy.
A resident with impaired mobility and multiple diagnoses experienced a fall while being loaded into a facility van without foot pedals on her wheelchair, resulting in minor injuries. The facility did not complete an investigation or root cause analysis of the incident, despite policy requirements and staff acknowledgment that these steps were not taken.
The facility did not provide a resident with written information about the bed-hold policy when transferred to the hospital, and failed to complete a required recapitulation in the discharge summary for another resident discharged home. Both deficiencies were confirmed through record review and staff interviews, with missing documentation and notifications as required by facility policy.
Three residents experienced falls due to the facility's failure to provide adequate supervision, ensure the use of required safety devices such as alarms and wheelchair foot pedals, and complete required fall risk assessments and investigations. In each case, staff did not follow individualized care plans or facility policy, resulting in preventable accidents and injuries.
A resident with anxiety, dementia, and major depressive disorder received PRN Ativan cream without a 14-day stop date or specified duration, as required by policy. The Consultant Pharmacist did not identify or report the missing stop date or rationale for continued use during monthly drug regimen reviews, and administrative staff confirmed the oversight. Facility policies requiring periodic reassessment and documentation for such medications were not followed.
The facility did not accurately submit direct care staffing information through PBJ, as required, resulting in reported gaps in licensed nurse coverage that did not reflect actual staffing. The issue was attributed to incomplete documentation of agency nurse hours, despite facility policy requiring all staffing, including agency and contract staff, to be reported.
A resident with cognitive impairment and a history of confusion was able to exit the facility unsupervised on two occasions by using unlocked doors, despite being identified as a fall risk. The care plan did not include interventions for wandering or elopement, and staff were unaware of the resident's absence until after the events. The facility's elopement policy was not followed for this individual prior to the incidents.
Failure to Properly Label, Date, and Store Food Items and Maintain Dishwasher Temperature Logs
Penalty
Summary
Surveyors observed that the facility failed to store food according to professional food service safety standards in two kitchenettes and one pantry room. Multiple food items, including potato salad, chicken patties, pancakes, vegetable beef soup, cranberries, strawberry yogurt, shredded American cheese, sliced Swiss cheese, chicken tenders, and diced chicken, were found in refrigerators and were not labeled or dated. Additionally, the facility did not maintain daily temperature logs for dishwashers in the kitchenettes since moving into the new facility, as staff believed that the use of low temperature dishwasher detergent eliminated the need for temperature documentation. Administrative staff confirmed these findings and acknowledged that food items should be labeled and dated before refrigeration or freezing. The facility's own policies required all products to be labeled with the date received and for food to be rotated appropriately, as well as for dishwashing and food storage practices to meet sanitary standards. However, these procedures were not followed, resulting in the cited deficiencies.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for at least eight consecutive hours a day, seven days a week, as required by regulation and the facility's own policy. Payroll Based Journal (PBJ) records and nursing schedules documented multiple days across several months when there was no RN present in the building for the required duration. Administrative staff confirmed these absences and attributed the issue to difficulty in recruiting RNs due to the facility's rural location. The deficiency affected all residents in the facility, which had a census of 32, and was identified through interviews and record reviews, including a sample of 12 residents.
Failure to Properly Label and Remove Expired Medications
Penalty
Summary
Staff failed to properly label and store medications and biologicals as required by facility policy and professional standards. During an observation of the medication room refrigerator, an opened insulin glargine pen belonging to a resident was found without an open date or discard date. Additionally, a medication cart inspection revealed a bottle of Thera High Potency Vitamin Dietary Supplement that had expired, yet remained in use. The bottle had been dated when placed in the cart, but the expiration date had passed. Licensed nursing staff confirmed that insulin pens are to be dated when opened and expired medications are to be discarded. Administrative staff also verified that medications should be removed once expired and that insulin pens require both an open date and an expiration date. Facility policies on medication administration and pharmacy services require all drugs and biologicals to be labeled according to accepted professional principles, including expiration dates, and to be stored and administered safely.
Failure to Protect Resident Dignity During Blood Glucose Testing
Penalty
Summary
A deficiency occurred when a licensed nurse checked a resident's blood sugar using a glucometer in a common dining area, rather than in a private setting. The nurse announced the resident's blood sugar result aloud in the presence of other residents who were seated at the dining table and in adjacent hallways. This action was observed by surveyors and was later confirmed by administrative staff to be contrary to facility policy, which requires such procedures to be conducted in private to protect residents' dignity, privacy, and confidentiality. The facility's policy specifically states that residents have the right to a dignified existence and privacy, which was not upheld in this instance.
Failure to Specify Duration and Rationale for PRN Antianxiety Medication
Penalty
Summary
The facility failed to ensure that a resident's as-needed (PRN) antianxiety medication, Ativan (lorazepam) cream, had a 14-day stop date or a specified duration with a physician's rationale for ongoing use. The resident, who had diagnoses of anxiety, dementia, and major depressive disorder, was noted to have severely impaired cognition and required extensive assistance with activities of daily living. The care plan indicated the resident received antianxiety medication and mental health consults, but the physician's order for Ativan cream lacked a stop date or documented rationale for continued PRN use. Observations showed the resident exhibiting agitation and resistance to redirection, leading to the administration of Ativan cream by staff. Review of the electronic medical record confirmed the absence of a specified duration or physician rationale for the extended use of the PRN medication. Administrative staff verified that the required stop date or justification for continued use was not obtained, which was inconsistent with the facility's policy on antipsychotic medication use that requires periodic reassessment and documentation.
Failure to Investigate and Analyze Resident Fall Incident
Penalty
Summary
The facility failed to complete an investigation, including a root cause analysis, after a resident experienced a fall while being loaded into a facility van. The resident, who had diagnoses of hypertension, transient ischemic attack, and chronic kidney disease, was documented as having impaired mobility and required substantial staff assistance for transfers and ambulation. On the day of the incident, the resident was being assisted by a licensed nurse and the activity director, but did not have foot pedals on her wheelchair, which made it more difficult to push her. As the staff attempted to pull the resident up the ramp, she slid forward out of the wheelchair and onto the ramp, resulting in two small skin tears on her left elbow. The incident was documented in the nurse's note, and the resident was treated for her injuries. Despite the fall and resulting injury, the electronic medical record lacked documentation that an investigation or root cause analysis was completed for the incident. Interviews with staff confirmed that a full investigation was not conducted, and administrative staff acknowledged the absence of a root cause analysis. The facility's policy required that investigations begin immediately and include a root cause analysis, but this was not followed in this case. The failure to investigate the fall and analyze its causes constituted a deficiency in responding appropriately to an alleged violation.
Failure to Provide Bed-Hold Policy Notification and Discharge Recapitulation
Penalty
Summary
The facility failed to provide a resident with written information regarding the bed-hold policy when the resident was transferred to the hospital. The resident in question had multiple diagnoses, including congestive heart failure, edema, GERD, and anxiety, and was noted to have moderately impaired cognition and required staff assistance with activities of daily living. During an acute episode involving fever and respiratory distress, the resident was transferred to the hospital, but the clinical record did not contain documentation that the bed-hold policy was provided to the resident or their representative, as required by facility policy. Administrative staff confirmed that there was no evidence of a signed bed-hold policy being given or acknowledged at the time of transfer. Additionally, the facility failed to complete a required recapitulation as part of the comprehensive discharge summary for another resident who was discharged home. This resident had a history of a femur fracture, anxiety, major depressive disorder, and hypertension, and required significant staff assistance with daily care. The care plan included arrangements for community resources and home health services upon discharge. However, review of the electronic medical record revealed that a discharge summary, including a recapitulation of the resident's stay, was not completed as required by facility policy. Administrative staff were unable to locate the required documentation. Both deficiencies were identified through record review and staff interviews, which confirmed the absence of required documentation and notifications related to resident needs, appeal rights, and bed-hold policies. The facility's own policies specify the need for written information and documentation in these situations, but these procedures were not followed in the cases reviewed.
Failure to Prevent Falls and Ensure Safe Environment
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent falls for three residents. One resident with a history of multiple fractures, severe cognitive impairment, and high fall risk was found on the floor in her room after a fall. Her care plan required the use of bed and chair alarms, but at the time of the incident, the alarm was not attached, and staff were unaware of the correct alarm type to use. The resident's environment also had poor lighting during the fall, and her medical record lacked a documented fall risk assessment. Another resident, who was dependent on staff for mobility and transfers and had a history of falls, slipped out of her wheelchair while being loaded into a facility van. Staff failed to ensure the use of foot pedals on the wheelchair, which contributed to the resident sliding forward and falling. The incident resulted in skin tears, and there was no documentation of a completed investigation or root cause analysis for the fall, despite facility policy requiring such actions after every fall. A third resident, with osteoarthritis and a moderate fall risk, experienced a fall when he was lowered to the floor by staff and subsequently dropped himself to the floor again. His care plan did not include new interventions after the fall, and there was no documentation of an investigation or root cause analysis. Staff interviews confirmed that the resident had a history of not using his call light and getting up on his own, which contributed to his fall risk. The facility's fall prevention policy required assessment and care plan review after each fall, which was not consistently followed.
Failure to Identify and Report Missing Stop Date for PRN Antianxiety Medication
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist identified and reported the absence of a 14-day stop date or specified duration for a resident's as-needed (PRN) antianxiety medication, as required by facility policy and federal regulations. The resident in question had diagnoses of anxiety, dementia, and major depressive disorder, with severely impaired cognition and required extensive assistance with activities of daily living. The physician's order for Ativan (lorazepam) cream, to be administered every six hours as needed for anxiety or aggression, did not include a stop date or documented rationale for continued use beyond 14 days. The resident's electronic medical record also lacked evidence of a specified duration or physician justification for the ongoing PRN use of lorazepam. During the monthly drug regimen review, the Consultant Pharmacist did not identify or report the missing stop date or rationale for the extended use of the PRN antianxiety medication to the Director of Nursing, medical director, or physician. Administrative staff confirmed that the facility did not obtain the required 14-day stop date or appropriate rationale for continued use, and that the pharmacist's monthly reviews did not include recommendations regarding this issue. Facility policies required that antipsychotic and antianxiety medications be prescribed for the shortest effective duration and reassessed periodically, but these procedures were not followed in this case.
Failure to Accurately Report Licensed Nurse Staffing in PBJ Submission
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information through Payroll Based Journaling (PBJ) as required. The PBJ report for a specific fiscal quarter indicated that there was no licensed nurse coverage on five dates. However, a review of the facility's licensed nurse payroll data for those dates showed that a licensed nurse was on duty 24 hours a day, seven days a week. Administrative staff confirmed that the discrepancies were likely due to the use of agency nurses whose hours were not properly documented in the PBJ system. The facility's policy required the submission of complete staffing information, including agency and contract staff, but this was not followed, resulting in inaccurate data being reported to CMS.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Lacking Care Plan Interventions
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent a resident from exiting the building unsupervised. The resident had a history of nontraumatic brain dysfunction, dementia, anxiety, depression, and psychotic disorder, and was assessed as having impaired decision-making skills and confusion, despite an MDS score indicating intact cognition. The care plan did not include interventions for wandering or elopement prior to the incident, although it did note the resident was a fall risk and required alarms for bed and chair mobility. On two separate occasions, the resident was able to leave the facility without staff awareness. In the first incident, the resident exited through unlocked double doors in a wheelchair while a maintenance staff member briefly left the room. The resident was later found outside on the sidewalk near a generator and was brought back inside by staff. In the second incident, the resident again exited the building, this time by kicking open a west door, and was found outside on the grass by a CNA taking out the trash. In both cases, the resident was unsupervised outside the facility for a period of time before being located and returned by staff. Observations and staff interviews confirmed that the doors used by the resident did not lock from the inside and that the resident's care plan lacked specific interventions for elopement risk prior to these events. The facility's elopement policy required identification and precautions for residents at risk, but these measures were not implemented for this resident before the incidents occurred.
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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