Medicalodges Coffeyville On Midland
Inspection history, citations, penalties and survey trends for this long-term care facility in Coffeyville, Kansas.
- Location
- 2921 W 1st Street, Coffeyville, Kansas 67337
- CMS Provider Number
- 175290
- Inspections on file
- 24
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Medicalodges Coffeyville On Midland during CMS and state inspections, most recent first.
The facility did not complete required annual performance evaluations or skills check-offs for two CNAs, as confirmed through employee file review and staff interviews. Administrative staff acknowledged that annual evaluations were expected but could not produce any evaluation documents for these CNAs, nor could the facility provide a policy outlining annual performance evaluation requirements when requested by surveyors.
Surveyors found multiple unsanitary food storage and preparation practices in both the South and North kitchens, including grime on handwashing areas, dirty floors and equipment, a freezer without an internal thermometer with temperatures incorrectly logged from another unit, and numerous open, unlabeled, and undated food items such as bread, ham spread sandwiches, pancake batter, chips, and salad dressings. Plate covers were stored upright, a can opener and fryer equipment were dirty or rusty, and an ice machine and a cart used with an ice chest for resident service were soiled with debris and unsheathed straws. In the North kitchen, a dietary staff member with facial hair repeatedly entered and worked in the food prep area and over the steam table without a beard guard, while grease and food debris were observed on and around the deep fat fryer, steamer, sink, and surrounding counters. Dietary staff acknowledged that these conditions and practices did not comply with facility policies requiring sealed, labeled, and dated food, proper temperature monitoring with internal thermometers, and mandatory hair restraints in food preparation and serving areas.
Surveyors found that several cognitively impaired, fully dependent residents did not receive basic ADL care, including shaving, nail care, face cleansing, and clean clothing. Residents were repeatedly observed with long facial whiskers, jagged and dirty fingernails, dried food on their faces, and soiled shirts, despite EMR, MDS, and care plans documenting the need for substantial to maximal staff assistance with personal hygiene. CNAs, an LPN, and administrative nursing staff all stated that residents were to be shaved on shower days, have nails trimmed and filed at least weekly, faces cleaned after meals, and clothing changed when dirty, but acknowledged these tasks did not always occur. These failures were inconsistent with the facility’s stated expectation and policy that residents be treated with dignity and respect.
Multiple residents with dementia and severe cognitive impairment did not receive individualized activity programming despite documented preferences for music, religious services, social events, outdoor time, and specific leisure interests. MDS assessments and activity assessments identified what was very important to these residents, but CAAs did not trigger, care plans lacked instructions for preferred activities, and EMR review showed only a single documented group music activity over a month. A scheduled hand and nail spa activity on the memory unit did not occur as posted; instead, residents were observed resting, sitting, or wandering without the planned activity, while staff reported that there were few activities on the unit and that turning on the TV or passing out snacks was treated as activity. This practice conflicted with the facility’s policy that the Activity Department provide a program supporting residents’ self-esteem, well-being, and satisfaction with an active lifestyle.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and a neurogenic bladder had an indwelling catheter ordered with a Stat-lock securement device and shift-by-shift monitoring of urine output. Surveyors observed the resident self-propelling a wheelchair while leaving a stream of apparent urine on the floor and later noted the resident sitting with a very full catheter bag hanging under the wheelchair. During observed catheter care, CNAs emptied the bag and checked the insertion site but did not use a Stat-lock, and one CNA reported they usually emptied catheter bags only at the end of their shift and did not apply a Stat-lock because the resident removed it. A nurse confirmed that all catheterized residents should have a Stat-lock and that supplies were available, while an administrative nurse stated expectations that Stat-lock use follow the care plan and that there was no written catheter care policy, with the facility instead relying on standards of practice.
A resident with a lumbar wedge compression fracture and cognitive impairment experienced significant pain, at times rated as high as eight out of ten, and was observed tearful, grimacing, and vocalizing pain during routine activities and transfers. Although PRN ibuprofen and hydrocodone-acetaminophen were ordered and administered with documented effect, the care plan also called for non-pharmacologic pain interventions such as massage, aromatherapy, warm packs, and distraction, which staff did not implement. CNAs reported the resident frequently complained of pain and confirmed they were unaware of any non-pharmacologic pain measures being used, while an administrative nurse stated staff were expected to use such interventions despite the absence of a formal pain management policy.
Surveyors identified that staff failed to follow EBP and proper infection control practices during catheter care and respiratory treatments. During observed catheter care, two CNAs assisted a resident with toileting and catheter bag emptying while only wearing gloves, did not use the EBP gowns posted on the door, and one CNA left the room and escorted the resident to the dining room without performing hand hygiene. In separate observations, two residents’ nebulizer equipment and oxygen tubing were stored with residual fluid in the medication bowls, left attached to machines, and placed on furniture with other items on top. A nurse and an administrative nurse described cleaning and drying processes for nebulizer components and placing them in plastic bags, which did not align with the unsanitary storage practices observed.
A resident with dementia, severe cognitive impairment, and total dependence for ADLs was resting in bed with her door open when another resident wandered into the room and began moving the blankets covering her. Staff, including an LPN and CNAs, reported that residents on the memory care unit were allowed to wander without boundaries, including entering other residents’ rooms. This practice conflicted with the facility’s policy requiring respect for resident dignity and privacy, resulting in a failure to protect the resident’s privacy while she was in bed.
Two residents with dementia and other comorbidities were transferred to the hospital for acute conditions such as hip fracture, pneumonia, shortness of breath, chest pain, hypotension, and brief unresponsiveness, but the facility failed to provide required written notifications of transfer, reasons for transfer, and bed-hold rights to the residents and/or their representatives, and did not send copies to the ombudsman as required. Documentation in the EHR lacked evidence of bed-hold notices, and staff interviews revealed confusion about who was responsible for issuing and obtaining signatures on bed-hold forms, with one staff member describing a practice of completing and signing bed-hold forms after the resident’s return or mailing them days later. This practice conflicted with the facility’s own bed-hold policy, which required written notice at admission and at the time of transfer, and administrative staff acknowledged that the facility did not provide written discharge or transfer notices and did not have a discharge policy.
Surveyors found that the dumpster area was not properly maintained or kept free of refuse, with used gloves on the ground, multiple broken and stained recliners, a broken armchair, and a broken chest of drawers left around the dumpster for an extended period. A dietary staff member confirmed the debris and was unaware of how trash and garbage pickup was arranged, noting that maintenance handled disposal. A maintenance staff member stated that maintenance was responsible for cleaning the dumpster area, that he had placed the furniture there months earlier for disposal, and that the person who previously removed trash and debris had stopped doing so without a replacement being found. He acknowledged that the accumulated debris and used gloves created potential for rodent infestation and cross-contamination, contrary to facility policy requiring storage areas to be neat and free of refuse and discarded furniture.
A cognitively impaired resident with a history of dementia and anxiety was neglected by the facility, as staff failed to report blood observed during care. Hospital staff later discovered multiple bruises and genital trauma, indicating possible sexual assault, less than 17 hours after the facility documented no skin issues.
A cognitively impaired resident with Alzheimer's and dementia was verbally and physically abused by a CNA on two occasions. The abuse was witnessed by staff who failed to report it immediately, allowing the CNA to continue working. The resident required assistance with daily activities and had severe cognitive impairment, but the facility's policy on immediate reporting of abuse was not followed, placing the resident and others at risk.
A cognitively impaired resident in a memory care unit was subjected to verbal and physical abuse by a CNA on two occasions. The incidents were not reported immediately by the witnessing staff, allowing the CNA to continue working with residents. The resident had severe cognitive impairment and required assistance with daily activities. The facility's failure to adhere to its abuse reporting policy placed the resident and others at risk.
A resident with severe cognitive impairment was subjected to verbal and physical abuse by a CNA, who restrained and threatened her on two occasions. Despite witnessing the incidents, staff members failed to report them immediately, allowing the CNA to continue working with residents, thus placing them at risk.
A resident experienced significant weight loss due to the facility's failure to implement timely interventions and monitor their nutritional status. Despite being on a specialized diet and receiving supplements, the resident's weight was not consistently tracked, leading to a 29.64% weight loss over 182 days. Staff interviews revealed inconsistencies in obtaining weights and offering alternative food options, and the facility lacked a policy for weight monitoring.
The facility failed to maintain sanitary conditions in the kitchen and during food service. Observations included unlabeled and improperly stored food, grime on containers, and improper use of gloves and hairnets by dietary staff. The facility lacked a kitchen sanitation policy, contributing to these deficiencies.
The facility failed to ensure proper hand hygiene during meals and dressing changes, maintain sanitary conditions for oxygen concentrators and glucometers, and implement enhanced barrier precautions for residents with urinary catheters. Observations revealed staff did not perform hand hygiene between tasks, improperly stored oxygen equipment, and inadequately sanitized glucometers. Additionally, staff lacked understanding of enhanced barrier precautions, leading to improper handling of urinary catheters.
The facility failed to ensure residents could voice grievances about care and treatment, particularly regarding food quality, and did not make prompt efforts to resolve these issues. Despite residents voicing concerns during Resident Council meetings, the facility lacked action plans and follow-up, as confirmed by administrative staff. The grievance logs showed no tracking or resolution of recurring issues, and the facility's policy did not address grievances reported to the Resident Council.
The facility failed to provide timely and appropriate assistance with ADLs for several residents, particularly in personal grooming such as facial shaving and nail trimming. Residents with cognitive impairments and physical limitations were observed with long facial hair and fingernails, despite being dependent on staff for personal hygiene. The facility lacked a policy for ADLs, contributing to the deficiency.
The facility failed to address grievances raised by residents in the Resident Council, particularly concerning food quality and availability. Despite multiple residents voicing concerns about cold food and lack of variety, the facility did not document or implement an action plan to resolve these issues. Interviews with staff confirmed the absence of documented meetings and follow-up actions, highlighting a systemic failure to address residents' concerns.
The facility failed to provide quarterly statements for 31 residents with active trust accounts, as required by their policy. Administrative Staff O could not locate any copies of the statements, and Administrative Staff A confirmed that these should be sent to residents or their responsible parties. The facility's policy required maintaining a signed copy of the quarterly transactions for five years post-discharge, but the facility did not ensure a complete accounting of each resident's personal funds.
The facility failed to return personal funds within 30 days for two residents, one deceased and one discharged, despite federal requirements. Administrative staff were aware of the requirement, but the policy lacked documentation for timely fund return.
A resident's personal funds were inaccurately accounted for, resulting in a $51.00 overcharge. The facility's handling of trust accounts was inconsistent, with staff unsure of procedures and a lack of proper documentation. The facility's policy required quarterly trust statements and proper receipts for purchases, but these were not adequately maintained.
A resident with Parkinson's disease and severe cognitive impairment had oxygen tubing improperly stored, hanging uncovered over an oxygen concentrator. Despite a physician's order for oxygen use, the facility lacked a policy for storing the tubing when not in use, and the care plan did not include instructions for oxygen supply care. An administrative nurse confirmed the expectation to bag the tubing, but this was not followed.
A facility failed to develop a comprehensive care plan for a resident with Parkinson's disease, who required oxygen therapy. Despite a physician's order for oxygen to maintain saturation levels, the care plan lacked instructions for staff on managing the oxygen equipment. Observations showed the oxygen tubing was left uncovered, and the facility lacked a policy for care plans, leading to the deficiency.
The facility failed to document the daily resident census on the Daily Staff Postings for several months. Interviews with administrative staff confirmed the absence of this documentation and revealed that the facility lacked a policy for the required documentation on the form.
Missing Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance reviews at least once every 12 months for two CNAs, which is required to ensure adequate and appropriate care and services for residents. On 04/08/26 at 3:52 PM, review of employee files showed there were no performance evaluations or skills check-off documents for CNA OO, hired on 11/10/23, and CNA PP, hired on 07/29/24. Later that day, Administrative Staff A and Administrative Nurse D confirmed that the evaluation documents provided to the survey team did not include performance evaluations for these two CNAs, and Administrative Staff A stated she expected performance evaluations to be performed annually. The facility was unable to provide a policy related to annual performance evaluations when requested on 04/09/26, further demonstrating that there was no documented process in place to ensure that CNAs received regular performance reviews and skills assessments as expected.
Unsanitary Food Storage, Preparation, and Staff Hygiene Practices in Facility Kitchens
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to store and prepare food under sanitary conditions in both the South and North kitchens. During an initial tour of the South kitchen, surveyors observed grime build-up on a handwashing sink and backsplash, grime along the baseboards in a kitchen alcove, and a freezer without an internal thermometer, despite a temperature log entry having been taken from another freezer. In dry storage, bread was found unsealed and unlabeled, and in the refrigerator there were unsealed and unlabeled ham spread sandwiches, unlabeled salad dressing bottles, an unlabeled container of pancake batter with congealed batter on the outside, and an unsealed, unlabeled bread/bun bag with buns missing. Additional issues included two unlabeled bags of potato chips, an open and undated bag of Cheetos, plate covers stored upright rather than inverted, and the absence of sanitizing strips in the South kitchen. Equipment and surfaces were also unclean: fryer baskets were dirty, fryer oil contained old food pieces across the surface and on the sides, the dipping spatula was greasy and dirty, the floor had dirt, grease, and food debris, and the spike can opener and mounting bracket had rust and debris. The ice machine had hard water and calcium build-up and holes on its outer surface, and a cart labeled as clean, used for an ice chest for resident ice service, had dirty lower shelves with food debris, dirty napkins, and unsheathed straws. In the North kitchen, surveyors observed a dietary staff member with a beard and no hair restraint entering the food preparation area and later standing over the steam table to check food temperatures without a beard guard, contrary to facility policy requiring hair restraints in food preparation and serving areas. Environmental and equipment sanitation issues were also noted, including grease build-up on the outside panel of a deep fat fryer, crumbs at the bottom of a food steamer door, food debris around and on the counter next to a sink near the puree area, and a dirty, stained, wet wooden board behind the sink faucet with a rusty garbage disposal tool lying on the sink. The counter around the large electric food steamer had food debris underneath, in front, to the sides, and behind the unit. Dietary staff interviewed acknowledged that food should be sealed, labeled, and dated; that each refrigerator and freezer should have an internal thermometer with temperatures checked and logged daily; that staff with facial hair should wear beard guards; and that the observed practices did not follow facility policies on food storage and hair restraints. These observations formed the basis of the deficiency for failure to procure, store, prepare, and serve food in accordance with professional standards and facility policy.
Failure to Provide Basic ADL Hygiene and Grooming for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate activities of daily living (ADL) care, including shaving, nail care, face cleansing, and clothing hygiene, for multiple residents who were cognitively impaired and dependent on staff. One resident with dementia, documented as requiring substantial to maximal assistance with personal hygiene on the MDS, CAA, care plan, and EMR, was repeatedly observed on multiple days with long facial whiskers. CNAs and a licensed nurse stated that residents were supposed to be shaved on shower days, but acknowledged that this did not always occur. Administrative nursing staff also stated residents were to be shaved on shower days and as needed, consistent with the facility’s policy that residents have the right to be treated with dignity and respect. Another resident with severe cognitive impairment and dependent on staff for personal hygiene had a care plan directing staff to trim her fingernails weekly. She was observed on consecutive days sitting in a recliner with jagged, dirty fingernails. CNAs, a licensed nurse, and an administrative nurse all stated that residents’ fingernails were to be kept clean, smooth, and trimmed at least weekly, confirming that the observed condition did not meet facility expectations. The same facility policy on resident rights and dignity applied to this resident’s care. Additional residents with dementia or Alzheimer’s disease, all with MDS and care plan documentation showing moderate to severe cognitive impairment and dependence on staff for ADLs and personal hygiene, were observed with unshaven faces, dirty clothing, jagged and dirty fingernails, and dried food on the face. One resident was seen twice in the same day with an unshaven face and dried-on food debris on the front of his t-shirt, and another was observed on two days unshaven with jagged, dirty fingernails and dried food on his face around his mouth. Staff interviews confirmed that residents were supposed to be shaved on shower days, have their clothes changed when dirty, have their fingernails trimmed and filed weekly, and have their faces cleaned after meals as needed, but staff acknowledged these tasks did not always get done. These observations and statements show the facility did not follow its own care expectations and resident rights policy regarding dignity and respect.
Failure to Provide Resident-Specific Activities on Memory Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide resident-specific activity programs for multiple residents with dementia or severe cognitive impairment on the memory unit. For several residents, including those with diagnoses of dementia and Alzheimer’s disease, the Minimum Data Set (MDS) assessments documented severe cognitive impairment, with Brief Interview for Mental Status (BIMS) scores of 99 or staff assessments indicating severe impairment. These assessments also documented that it was very important to the residents to listen to preferred music, participate in favorite activities and religious services, and go outside for fresh air when the weather was good. Despite these documented preferences, the Activity Care Area Assessments (CAAs) did not trigger for these residents, and their care plans lacked staff instructions regarding their preferred activities. For each of the identified residents, the facility’s records showed minimal or no documented participation in activities over a one-month review period. Electronic Medical Record (EMR) review for the residents showed that each participated in only one documented activity, a music program on a single date, with no other activities recorded from early March through early April. Activity Assessments completed for these residents identified specific interests such as church services, parties, visiting with others, watching westerns or baseball on TV, listening to country music or other music, going for walks, being around animals, and going outside in good weather. However, these preferences were not reflected in individualized care plan instructions, and there was no documentation that these preferred activities were being provided on an ongoing basis. Surveyor observations and staff interviews further demonstrated that scheduled activities on the memory unit were not carried out as planned. The posted Activity Calendar listed an "Afternoon Hand and Nail Spa" at a specified time, but at that time residents were observed resting in bed, sitting in recliners with eyes closed, sitting at the dining room table, or wandering the unit, with no hand and nail spa activity occurring. A CNA confirmed that the fingernail activity did not take place and that staff instead handed out snacks, and stated she did not know why the scheduled activity was not provided. Activity staff reported that unit staff were responsible for conducting activities on the memory unit, while CNAs and a nurse indicated that there were not many activities on the unit and that staff mainly ensured the TV was on or passed out snacks, which they considered “somewhat of an activity.” An administrative nurse stated that the activity staff planned the activities and that nurses on the memory unit were responsible for executing and documenting them, but the facility’s own policy required the Activity Department to provide an activity program that supports positive self-esteem, well-being, and satisfaction with the facility’s active lifestyle, which was not reflected in practice for these residents. Title: Failure to Provide Resident-Specific Activities on Memory Unit ShortSummary: Multiple residents with dementia and severe cognitive impairment did not receive individualized activity programming despite documented preferences for music, religious services, social events, outdoor time, and specific leisure interests. MDS assessments and activity assessments identified what was very important to these residents, but CAAs did not trigger, care plans lacked instructions for preferred activities, and EMR review showed only a single documented group music activity over a month. A scheduled hand and nail spa activity on the memory unit did not occur as posted; instead, residents were observed resting, sitting, or wandering without the planned activity, while staff reported that there were few activities on the unit and that turning on the TV or passing out snacks was treated as activity. This practice conflicted with the facility’s policy that the Activity Department provide a program supporting residents’ self-esteem, well-being, and satisfaction with an active lifestyle.
Failure to Follow Catheter Care Standards and Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to provide catheter care in accordance with standards of practice and the resident’s care plan for a resident with an indwelling urinary catheter. The resident had Alzheimer’s disease, CKD stage 3, BPH, obstructive uropathy, neurogenic bladder, weakness, and minimally impaired cognition, and required staff assistance with ADLs due to physical limitations and decreased safety awareness. The care plan directed use of a 16Fr urinary catheter for acute urinary retention with obstruction, use of a Stat-lock device to secure the catheter and reduce tugging, and monitoring of catheter output every shift. The urinary incontinence CAA documented the need for a catheter to address obstructive uropathy and to help prevent skin breakdown and UTI. Despite these directives, the resident was observed self-propelling in a wheelchair with a steady stream of apparent urine on the floor along the hallway, which staff immediately recognized as belonging to this resident. Further observations and interviews showed that catheter care practices were inconsistent with the care plan and standards of practice. During catheter care, the CNAs emptied the catheter bag and assessed the insertion site but the resident did not have a Stat-lock on the thigh to anchor the catheter tubing. A CNA stated they were supposed to empty catheter bags at the end of their shift and that a Stat-lock was not used because the resident “just takes them off.” On another occasion, the resident was observed sitting in the dining room with a full, round catheter bag hanging under the wheelchair, and nursing staff were notified. A nurse stated that CNAs typically empty catheter bags at the end of their shift, while also acknowledging that all catheterized residents should have a Stat-lock and that multiple cases were in stock. The administrative nurse stated her expectation was that the Stat-lock be used unless not tolerated, with such intolerance documented in the care plan, and also reported that the facility had no written catheter care policy and instead followed standards of practice.
Failure to Implement Non-Pharmacologic Pain Interventions for Resident with Spinal Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide non-pharmacologic pain management interventions for a resident with acute pain related to a wedge compression fracture of the second lumbar vertebra. The resident’s MDS assessments documented moderately to severely impaired cognition, receipt of PRN pain medications, and use of non-medication pain interventions during one assessment period, but no scheduled or PRN pain medications and no non-medication pain interventions during a subsequent look-back period. The resident reported occasional pain with the worst pain rated as eight out of ten in the prior five days and received opioid medication during the seven-day look-back period. The care plan, revised 03/31/26, directed staff to use alternative pain management methods such as massage, aromatherapy, warm packs, and distraction, and the physician’s orders included PRN ibuprofen and hydrocodone-acetaminophen for pain. Despite these orders and care plan directions, observations showed the resident tearful, with clenched fists and facial grimacing while seated in the dining room, and again with facial grimacing and audible indicators of pain during a transfer from wheelchair to recliner requiring extensive assistance. The MAR documented pain scores ranging from one to seven, with staff administering ordered pain medications and documenting effective results, but there was no evidence that non-pharmacologic interventions were offered or implemented. CNAs interviewed stated the resident often complained of pain after a fall and had a lot of hip pain, and that nurses would give pain medication, but they were not aware of any non-pharmacologic pain interventions being used for this resident. An administrative nurse stated that, in addition to scheduled and PRN pain medications, staff were expected to attempt non-pharmacologic pain interventions and acknowledged the facility did not have an actual pain management policy, relying instead on a standard of care.
Failure to Follow Enhanced Barrier Precautions and Sanitary Nebulizer 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) and the sanitary handling and storage of respiratory treatment devices. Surveyors observed one resident’s oxygen tubing wound around a portable oxygen tank, and the nebulizer mouthpiece attached to a medication bowl that still contained a small amount of fluid and remained attached to the nebulizer machine. Another resident’s nebulizer machine was observed with the face mask and medication bowl still attached and containing fluid, lying on a chair beside the bed with the tubing wound up with a blanket and a back brace placed on top of the nebulizer. A licensed nurse reported that after completing breathing treatments, she rinsed the medication cup and mask, dried the mask with a paper towel, allowed the equipment to air dry, and then placed it in a plastic bag, and an administrative nurse confirmed that staff were expected to clean the mouthpiece and medication cup, allow them to dry, and place them in a bag for infection control. The deficiency also includes failure to follow EBP during catheter care for a resident with an indwelling catheter. During an observed toileting and catheter care episode, two CNAs entered the resident’s room, donned gloves, and assisted the resident with toileting and clothing changes after a bowel movement. The catheter bag was emptied into a plastic urinal and placed on the back of the toilet, then the urine was poured into the toilet. Afterward, both CNAs removed their gloves; only one washed her hands before leaving the room, and the other exited the room and escorted the resident to the dining room without hand hygiene. In interviews, both CNAs acknowledged they forgot to don the EBP gowns posted on the resident’s door, and one CNA stated that handwashing was supposed to be done before and after handling a patient or a catheter. The facility’s infection control surveillance policy documented that all staff are to be educated on infection control prevention practices as they relate to their job.
Failure to Protect Bedbound Resident’s Privacy on Memory Care Unit
Penalty
Summary
The facility failed to maintain privacy for a resident with dementia and severe cognitive impairment who was dependent on staff for all ADLs while she was in bed in her room. The resident’s EMR and MDS assessments documented severe cognitive impairment and total dependence for ADLs, and her care plan reflected this dependence. During observation, the resident was resting in bed covered with blankets, with her room door open to the hallway, when another resident wandered into the room and began moving the blankets covering her. A licensed nurse removed the wandering resident from the room after being informed of the incident. Staff interviews revealed that on the memory care unit residents were allowed to wander wherever they wanted, with no boundaries for wandering, including going into and out of other residents’ rooms, despite a facility policy stating that resident dignity and privacy are to be respected. This failure to provide privacy occurred in the context of a memory care unit practice that permitted unrestricted wandering into other residents’ rooms, including the room of a cognitively impaired, fully dependent resident who was in bed at the time.
Failure to Provide Required Written Transfer and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notifications of transfer, discharge, and bed-hold rights to two residents and/or their representatives, and to send copies of such notifications to the ombudsman. One resident with dementia and anxiety had an unplanned discharge to the hospital for a right hip fracture, with progress notes documenting the hospital transfer and subsequent cancellation of a care plan meeting due to the hospitalization. However, the electronic record under the miscellaneous tab lacked evidence that written bed-hold documentation was provided to the resident or representative at the time of transfer. Staff interviews revealed confusion and inconsistency regarding responsibility for issuing bed-hold notices: nursing staff reported that social services handled bed-hold notices, social services and administrative staff identified a specific administrative staff member as responsible, and that staff member stated she completed bed-hold forms after being notified via the EHR dashboard and typically obtained signatures upon the resident’s return or by mailing the form days later. This practice conflicted with the facility’s own written bed-hold policy, which required written notice at admission and again at the time of transfer, with the charge nurse sending a blank notice with the resident at discharge and administration documenting attempts to contact the resident or representative within 24 hours. The deficiency also includes the facility’s failure to provide written notification of the reason for hospital transfers to another resident with dementia, Stage 2 skin breakdown, and CHF, who experienced multiple acute episodes requiring transfer to the hospital for pneumonia and other symptoms such as shortness of breath, chest pain, pallor, weakness, diaphoresis, brief unresponsiveness, drooling, and hypotension. Nursing notes documented the clinical events and physician orders to send the resident to the hospital, as well as the hospital admissions, but the electronic medical record lacked documentation of any written notification to the resident or representative explaining the reasons for these transfers. In interviews, social services staff stated that the business office manager obtained bed-hold signatures and acknowledged being unaware of the regulatory requirement to notify residents in writing of the reason for transfer, although they reported notifying the ombudsman of transfers. Administrative staff further stated that bed-hold forms should be completed and signed when a person was transferred out, but also stated that the facility did not notify residents’ representatives in writing of a discharge or transfer, and the administrative nurse reported that the facility did not have a discharge policy.
Improper Maintenance and Disposal of Garbage and Refuse in Dumpster Area
Penalty
Summary
Failure to properly maintain and dispose of garbage and refuse occurred in the facility’s dumpster area, as identified during an initial kitchen tour when surveyors, accompanied by a dietary staff member, observed multiple items of trash and discarded furniture around the dumpster. Specifically, two used gloves were lying on the ground beside the base of the dumpster, along with one broken metal and upholstered armchair, four cloth recliners with large black stains or substances on the fabric (including one red recliner with the back pulled or broken off), and a broken chest of drawers with broken shelving and top. The dietary staff member confirmed these observations, stated she had not been aware of the trash and garbage accumulation around the dumpster, and reported she did not know what arrangements were in place for trash and garbage pickup, indicating that maintenance was responsible for disposal. Further interview with a maintenance staff member revealed that maintenance staff were responsible for maintaining and cleaning the dumpster area and that he had placed the chairs by the dumpster for disposal several months earlier. He reported that the person who previously picked up and disposed of the garbage and trash around the dumpster had stopped performing this duty and that he had not found a replacement, resulting in the continued accumulation of debris. The maintenance staff member acknowledged that the condition of the dumpster area, with debris, trash, and used gloves, posed potential for rodent infestation and cross-contamination and spread of infection to residents and staff. The facility’s undated policy on Housekeeping, Laundry and Maintenance – Basic Services Provided stated that storage areas must be kept neat and free of extraneous material such as refuse and discarded furniture, which was not followed in this situation.
Neglect of Cognitively Impaired Resident Leading to Possible Sexual Assault
Penalty
Summary
The facility failed to prevent the neglect of a cognitively impaired resident, identified as R2, who exhibited a recent increase in behaviors. On the evening of August 26, a licensed nurse completed a skin assessment on R2 and documented her skin as clean, dry, intact, and without new skin conditions. However, the following morning, staff observed blood on a tissue after wiping R2 but failed to notify the licensed nurse in charge of her care. Later that day, when R2 was taken to a senior behavioral unit, hospital staff discovered multiple areas of bruising, bleeding, and genital trauma, which were possible indicators of sexual assault. R2 had a medical history that included dementia, cognitive communication deficit, muscle weakness, major depressive disorder, and anxiety. She was assessed with severe cognitive impairment and required assistance with activities of daily living. Despite her increased behaviors and the need for psychotropic medications, the facility's documentation and observations failed to identify any skin issues or signs of trauma until hospital staff conducted a thorough assessment. The facility's neglect was evident as the hospital staff's findings of bruising, bleeding, and genital trauma were made less than 17 hours after the facility's nurse documented no skin issues. The presence of these injuries prompted the completion of a sexual assault kit by the hospital staff, highlighting the facility's failure to protect R2 from neglect and potential abuse.
Removal Plan
- The facility contacted R2's physician.
- The facility began interviewing staff and residents for any indications of abuse and neglect.
- Staff in-service on abuse, neglect and exploitation and education completed.
- The facility held a quality assurance performance improvement (QAPI) meeting.
- The facility educated staff to provide care in pairs for all residents until further notice and initiated immediately.
- A skin sweep of all residents in the building initiated with care plans revised and physician and responsible party notified with any findings from assessments.
- The facility held a resident council meeting to review abuse, neglect, and exploitation.
Failure to Prevent Abuse of Cognitively Impaired Resident
Penalty
Summary
The facility failed to prevent the verbal and physical abuse of a cognitively impaired resident, identified as R2, on two separate occasions. On the first incident, a Certified Nurse Aide (CNA) was observed by a non-certified staff member grabbing R2's arms and pushing them to her chest while verbally threatening her. The staff member did not report the incident immediately, allowing the CNA to continue working. On the second occasion, another CNA heard yelling and witnessed the same CNA grabbing R2's arms and forcefully pushing them against her chest, again accompanied by verbal threats. This incident was also not reported immediately, as the observing CNA chose to write a note and slide it under an administrative nurse's door, which was not discovered until days later. R2, who has Alzheimer's disease, dementia with behavioral disturbance, and major depressive disorder, was assessed with severe cognitive impairment and required assistance with activities of daily living. Despite her cognitive deficits, R2 did not reject care but exhibited behavioral symptoms. The care plan for R2 included staff assistance and specific instructions to explain activities to her before beginning. However, the incidents of abuse were not prevented, and the staff involved failed to follow the facility's policy on immediate reporting of abuse allegations. The facility's policy required immediate reporting of any alleged abuse, neglect, or mistreatment, but this was not adhered to by the staff who witnessed the incidents. The failure to report allowed the abusive CNA to continue working in the memory care unit, placing R2 and other residents at risk. The incidents caused a negative psychosocial impact on R2's safety and well-being, highlighting a significant deficiency in the facility's ability to protect residents from abuse.
Removal Plan
- The facility suspended CNA O.
- The facility conducted a skin assessment of R2.
- The facility notified the responsible party and left a voicemail.
- The facility provided additional education to CNA M and Non-Certified Staff N.
- The facility held a Quality Assurance and Performance Improvement meeting with the Medical Director.
- The facility began education with all staff and completed.
- The facility notified local law enforcement, interviewed three residents with intact cognition, and updated R2's care plan to include follow up with the social service designed post event weekly for four weeks.
Failure to Report Abuse in Memory Care Unit
Penalty
Summary
The facility failed to immediately report incidents of verbal and physical abuse involving a cognitively impaired resident, identified as R2, on two separate occasions. On the first occasion, a non-certified staff member observed a certified nurse aide (CNA) grab R2's arms and push them to her chest while verbally threatening her. The staff member did not report this incident immediately, allowing the CNA to continue working her scheduled shifts. On the second occasion, another CNA heard yelling and witnessed the same CNA grab R2's arms forcefully and verbally threaten her again. This CNA also failed to report the incident immediately, instead leaving a note for the administrative nurse, which was not discovered until several days later. R2, the resident involved, had a medical history of Alzheimer's disease, dementia with behavioral disturbance, and major depressive disorder. She was assessed with severe cognitive impairment and required assistance with activities of daily living. Despite her cognitive deficits, R2 did not reject care but exhibited behavioral symptoms. The incidents of abuse occurred in the memory care unit, where R2 resided, and were not reported in a timely manner, placing her and other residents at risk. The facility's policy required immediate reporting of any alleged abuse, neglect, or mistreatment, but this protocol was not followed. The failure to report these incidents allowed the abusive CNA to continue working with vulnerable residents, creating an environment where further abuse could occur. The lack of immediate action by the staff members who witnessed the abuse contributed to the deficiency, highlighting a significant lapse in the facility's duty to protect its residents.
Removal Plan
- The facility suspended CNA O.
- The facility conducted a skin assessment of R2.
- The facility notified the responsible party and left a voicemail.
- The facility provided additional education to CNA M and Non-Certified Staff N.
- The facility held a Quality Assurance and Performance Improvement meeting with the Medical Director.
- The facility began education with all staff and completed.
- The facility notified local law enforcement, interviewed three residents with intact cognition, and updated R2's care plan to include follow up with the social service designed post event weekly for four weeks.
Failure to Report Abuse in Memory Care Unit
Penalty
Summary
The facility failed to protect residents from abuse when staff did not immediately report incidents of verbal and physical abuse involving a cognitively impaired resident, R2. On two separate occasions, a Certified Nurse Aide (CNA O) was observed physically restraining R2 by grabbing her arms and pushing them against her chest while verbally threatening her with explicit language. These incidents occurred on 07/13/24 and 07/19/24, yet were not reported immediately by the witnessing staff members, Non-Certified Staff N and CNA M, allowing CNA O to continue working with residents. R2, who has a medical history of Alzheimer's disease, dementia with behavioral disturbance, and major depressive disorder, was assessed with severe cognitive impairment and required assistance with activities of daily living. Despite her cognitive deficits, R2 did not reject care but exhibited behavioral symptoms. During the incidents, R2 attempted to hit CNA O, who responded with physical restraint and verbal threats, causing a negative psychosocial impact on R2's safety and well-being. The failure to report these incidents immediately placed R2 and other residents in the memory care unit at risk for abuse. The facility's policy requires all alleged violations involving abuse to be reported immediately, yet this protocol was not followed. The delay in reporting allowed CNA O to continue working her scheduled shifts, further endangering the residents under her care.
Removal Plan
- The facility suspended CNA O.
- The facility conducted a skin assessment of R2.
- The facility notified the responsible party and left a voicemail.
- The facility provided additional education to CNA M and Non-Certified Staff N.
- The facility held a Quality Assurance and Performance Improvement meeting with the Medical Director.
- The facility began education with all staff and completed.
- The facility notified local law enforcement, interviewed three residents with intact cognition, and updated R2's care plan to include follow up with the social service designed post event weekly for four weeks.
Failure to Monitor and Address Resident's Weight Loss
Penalty
Summary
The facility failed to implement timely and pertinent interventions to prevent significant weight loss in Resident 13, who experienced a 25.11% weight loss over 141 days. The resident, diagnosed with diabetes mellitus type 2 and other conditions, was not weighed monthly as required, and the facility did not identify or assess the resident when meal intake consistently declined. This oversight resulted in a total weight loss of 40.6 lbs, or 29.64%, over 182 days, placing the resident at risk for further nutritional decline and life-threatening symptoms. Resident 13's care plan included interventions such as a low concentrated sweet diet with fortified foods, double proteins, and supplements. However, the facility did not consistently monitor the resident's weight or meal intake, as evidenced by missing weight records for several months. Despite recommendations from the dietary consultant to continue the current plan of care, the resident's weight continued to decline, indicating a lack of effective monitoring and intervention. Interviews with facility staff revealed inconsistencies in obtaining resident weights and offering alternative food selections when meals were refused. The facility did not provide a policy related to weight loss and monitoring, further highlighting the deficiency in care. The failure to monitor and address the resident's weight loss as ordered by the physician contributed to the resident's significant weight loss and potential negative impact on their well-being.
Sanitation Deficiencies in Kitchen and Food Service
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and during food service, as observed during a survey. During an initial tour of the kitchen, several issues were noted, including an uncovered trashcan at the hand-washing sink, unlabeled food items such as dressing cups, gelatin parfaits, and baked potatoes, and improperly covered peach slices. Additionally, the refrigerator had racks with dried-on food substances and rust, and the outside dumpster was not closed. Containers of flour and dried milk were found with grime on their lids. The facility also lacked a policy for kitchen sanitation, which contributed to these deficiencies. During meal service in the memory care unit, a dietary staff member was observed with hair not fully covered by a hairnet, and she used the same pair of gloves throughout the service, touching the eating surfaces of plates and the food with her thumb. The staff member acknowledged her improper handling of plates and hair covering, attributing it to an old habit. The facility's policy on proper hand washing and glove use, dated 2020, was not adhered to, as gloves were not changed frequently, and proper hand washing procedures were not followed. These actions led to the failure to serve food in a sanitary manner.
Infection Control Deficiencies in Hand Hygiene and Equipment Sanitation
Penalty
Summary
The facility failed to ensure proper hand hygiene practices among staff during meal times and dressing changes, contributing to potential infection risks. Observations revealed that a Certified Nurse Aide (CNA) assisted residents with their meals without performing hand hygiene after handling various items and residents. Additionally, a Licensed Nurse (LN) did not perform hand hygiene between glove changes during a dressing change for a resident with a pressure ulcer, contrary to the facility's policy. The facility also did not maintain sanitary conditions for oxygen concentrators and glucometers. Observations showed unlabeled oxygen concentrators with tubing and cannulas stored improperly, with one cannula resting on the floor. Furthermore, glucometers used by multiple residents were not sanitized according to the manufacturer's instructions, with staff using alcohol wipes instead of the recommended Sani-wipes, and not adhering to the correct wet time for disinfection. Enhanced barrier precautions were not consistently implemented for residents with urinary catheters. A CNA was observed emptying a urine collection bag without knowledge of the necessary personal protective equipment, while another CNA did not follow proper procedures for rinsing and storing urinals. Interviews with staff indicated a lack of understanding and implementation of enhanced barrier precautions, despite recent efforts to introduce these measures based on CDC recommendations.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure that residents had the right to voice grievances regarding their care and treatment, as well as other concerns related to their long-term care stay. A resident reported dissatisfaction with the food quality, noting that it was often cold and that the facility sometimes ran out of food. Despite voicing these concerns to the Social Service Designee and during Resident Council meetings, no changes were made, and no action plans were communicated back to the residents. During a Resident Council meeting, multiple residents unanimously complained about the food temperature, variety, and lack of ethnic choices, yet these grievances were not addressed or resolved by the facility. The facility's grievance logs from February 2023 to May 2024 showed a lack of tracking and action plans for recurring grievances noted in Resident Council meetings. The logs did not document any action plans or reviews with residents regarding their concerns, particularly those related to food dissatisfaction. Administrative staff confirmed the absence of evidence for action plans and follow-up with residents, indicating that the facility did not provide a forum for residents to voice grievances or make prompt efforts to resolve them. The facility's grievance policy, dated March 2024, required follow-up within seven days but failed to address grievances reported to the Resident Council.
Failure to Provide Timely ADL Assistance
Penalty
Summary
The facility failed to provide appropriate and timely assistance with activities of daily living (ADLs) for several residents, specifically regarding personal grooming such as facial shaving and nail trimming. Resident 13, who has type II diabetes mellitus and moderate cognitive impairment, was observed with long facial hair over several days despite being dependent on staff for personal hygiene. The resident expressed discomfort with the facial hair and stated that staff did not shave her, although it was expected to be done on shower days or as needed. Resident 8, diagnosed with Parkinson's disease and severe cognitive impairment, also did not receive timely grooming care. The resident was dependent on staff for all ADLs, including shaving on shower days. However, records indicated missed showers on multiple occasions, and the resident was observed with long, unshaven facial hair. Staff interviews confirmed that residents should be groomed appropriately daily, but the facility lacked a policy for ADLs. Resident 46, with a diagnosis of weakness and severe cognitive impairment, required extensive assistance for personal hygiene. Despite receiving a shower, the resident was observed with long facial hair and expressed a desire for staff to shave her chin hairs. Similarly, Resident 49, who has dementia and intact cognition, required assistance with personal hygiene and was observed with long facial hair and fingernails. The resident preferred to have her facial hair shaved and fingernails kept short, but staff did not meet these preferences. The facility's lack of a policy for ADLs contributed to the failure to provide timely and appropriate care.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to uphold the residents' rights to organize and participate in resident groups, specifically the Resident Council, and to address grievances and recommendations from these groups. A resident reported issues with the quality and availability of food, noting that concerns raised in Resident Council meetings were not addressed with an action plan. The facility did not provide feedback or solutions to the residents' grievances, which included complaints about food temperature, variety, and availability. During a Resident Council meeting, multiple residents expressed dissatisfaction with the meals, citing issues such as cold food and lack of ethnic variety. Despite these concerns being voiced, the facility did not document a plan of action or follow-up to resolve these issues. The facility's records showed a lack of evidence of monthly Resident Council meetings and follow-up on grievances for several months, indicating a systemic failure to address residents' concerns. Interviews with facility staff confirmed the absence of documented Resident Council meetings and follow-up actions. The facility's grievance policy required prompt resolution of grievances, but it did not specifically address those reported to the Resident Council. This lack of response and documentation demonstrates the facility's failure to consider and act upon the views and grievances of resident groups, impacting the quality of care and life in the facility.
Failure to Provide Quarterly Trust Fund Statements
Penalty
Summary
The facility failed to provide quarterly statements for 31 residents with active trust accounts, as required by their policy. The trust transaction history review revealed that no copies of the quarterly statements were available for review. Administrative Staff O, who had been in her position for just over a week, was unable to locate any copies of the quarterly statements for the residents with trust funds managed by the facility. She mentioned that it was the facility's policy to offer trust statements quarterly and typically sent two copies to the resident's representative, requesting one signed copy to be returned to the facility. However, no such copies were found. Additionally, Administrative Staff A confirmed that quarterly statements should be sent to residents or their responsible parties, and a copy should be maintained in the resident's file. The facility's updated policy on Resident Funds Trust Account stated that the trust account should be maintained at a local bank in an interest-bearing checking account, and a signed copy of the quarterly transactions should be kept on file for five years post-discharge. The facility failed to establish and maintain a system that ensured a full and complete separate accounting of each resident's personal funds, according to generally accepted accounting principles.
Failure to Convey Personal Funds Timely
Penalty
Summary
The facility failed to ensure the timely conveyance of personal funds for two residents, leading to a deficiency. The facility had a census of 81 residents, with 31 having active personal funds accounts. Upon review, it was found that two residents, who were no longer on the current resident census list, still had active personal funds accounts. One resident had expired, and the other had been discharged, both over 30 days prior. Despite the federal requirement to disperse personal funds within 30 days of discharge or death, the facility had not returned the funds. Administrative staff acknowledged awareness of this requirement, yet the policy for Resident Funds Trust Account lacked documentation for returning funds within the stipulated timeframe. Consequently, the facility did not convey personal funds within 30 days for the deceased resident and the discharged resident.
Inaccurate Accounting of Resident's Personal Funds
Penalty
Summary
The facility failed to provide a resident, identified as R13, with an accurate accounting of her personal funds, resulting in an overcharge of $51.00. The trust transaction fund review documented a closing balance of $11.01 for R13, which was disputed by R13's family member who believed there should have been more money in the account. Administrative Staff O, who had been employed at the facility for just over a week, was unsure of the previous business officer manager's actions and stated that the facility became the payee for R13 in May 2023. The facility received verbal permission from the responsible party to withhold extra funds, but a document showed a $51.00 overcharge dated May 2024. The facility's policy was to offer trust statements quarterly, and there were discrepancies in the handling of resident funds. Certified Medication Aide Q reported that if a resident requested money during off-hours, it would be taken from a bag in the medication cart, but there was no list of residents with trust accounts. Administrative Staff A mentioned a petty cash box in the medication cart with a list of available funds, but this was a new addition, and the staff was unsure when it was implemented. The facility's policy required a signed invoice or receipt for purchases, but the facility failed to maintain the correct trust balance for R13.
Failure to Store Oxygen Tubing Properly
Penalty
Summary
The facility failed to maintain a clean and sanitary storage method for oxygen tubing for a resident identified as R8. The resident, who has a diagnosis of Parkinson's disease and severe cognitive impairment, was observed with oxygen tubing hanging uncovered over an oxygen concentrator. Despite a physician's order for oxygen administration to maintain blood oxygen saturation above 90%, the facility did not have a policy in place for storing oxygen tubing when not in use. The resident's care plan also lacked specific instructions for the care of the oxygen tank or supplies. An administrative nurse confirmed that the expectation was for staff to place the oxygen tubing in a bag when not in use, but this was not adhered to, leading to the deficiency.
Incomplete Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to complete a comprehensive care plan for a resident with Parkinson's disease, who was prescribed oxygen therapy. The resident's electronic medical record indicated a severe cognitive impairment with a BIMS score of zero and did not initially utilize oxygen. Despite a physician's order for oxygen therapy to maintain saturation above 90%, the care plan lacked specific staff instructions for managing the oxygen tank and supplies. Observations revealed that the resident's oxygen tubing was left uncovered, contrary to the facility's expectation to store it in a bag when not in use. Additionally, the facility did not have a policy in place for care plans, contributing to the deficiency.
Failure to Document Daily Resident Census
Penalty
Summary
The facility failed to ensure that the daily resident census was recorded on the Daily Staff Postings as required. During a review of the Daily Staff Posting for February, March, and April 2024, it was found that there was a lack of documentation of the resident census for each day. An interview with Administrative Staff HH on May 13, 2024, revealed that she did not document the daily resident census on the Daily Staff Postings. Another interview with Administrative Staff A confirmed the absence of the resident census on the Daily Staff Postings and highlighted that the facility lacked a policy for the documentation required on the form.
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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.
The facility failed to coordinate hospice services within the care plans for two residents receiving hospice. Both residents had severe cognitive impairment and extensive ADL needs, and their MDS assessments documented hospice care. Their care plans included general directions about ADL assistance, pain monitoring, and consulting with hospice or the physician, but omitted key hospice-specific details such as hospice contact information, visit schedules, services to be provided, and what supplies, equipment, and medications hospice would furnish. Clinical record review and interviews with an administrative nurse confirmed that there was no documented coordination between hospice and facility care plans, contrary to the facility’s hospice policy requiring an interdisciplinary plan integrating hospice and facility services.
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 Coordinate Hospice Services in Resident Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain a coordinated hospice plan of care that integrated hospice services with facility services for two residents receiving hospice. For one resident with Alzheimer’s disease, CAD, and atrial fibrillation, the Significant Change MDS documented severely impaired cognition and extensive assistance needs for bed mobility and transfers, and indicated the resident was receiving hospice services. The resident’s care plan noted a terminal prognosis due to Alzheimer’s, directed staff to adjust ADL care, consult the physician for hospice care in the facility, and monitor and treat pain, but it did not include instructions on hospice services such as hospice staff visit schedules, supplies, medical equipment, or medications covered by hospice. The clinical record showed the resident had been admitted to hospice care months earlier, yet there was no documented evidence of coordination of care between hospice and the facility. For the second resident, diagnosed with PVD, DM, HTN, and atherosclerotic heart disease, the Significant Change MDS showed severe cognitive impairment with a BIMS score of two and dependence on staff for most ADLs, and documented that the resident received hospice services. The resident’s care plan recorded admission to hospice and directed staff to adjust ADL provision, encourage participation as desired, assess coping, respect wishes, and consult with the physician and hospice for continuing hospice care, as well as monitor for pain and notify the physician and hospice for breakthrough pain. However, the care plan lacked a hospice contact number, information on what supplies, equipment, and medications hospice would provide, and details on when hospice staff would be in the building and what care they would deliver. Observations and staff interviews confirmed these omissions. One resident was observed in bed receiving eye drops from a CMA, and during record review, the Administrative Nurse acknowledged that the facility care plan lacked specific information coordinating with the hospice care plan. For the second resident, the Administrative Nurse verified that the care plan did not contain information regarding hospice visits, phone numbers, or medical supplies provided by hospice, and stated that such information should be on the resident’s care plan. These findings were inconsistent with the facility’s Hospice Services policy, which required an interdisciplinary care plan integrating facility and hospice services, including coordination of services and supplies provided by the hospice provider.
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