Medicalodges Columbus
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Kansas.
- Location
- 101 Lee Avenue, Columbus, Kansas 66725
- CMS Provider Number
- 175264
- Inspections on file
- 15
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 1 (1 serious)
Citation history
Health deficiencies cited at Medicalodges Columbus during CMS and state inspections, most recent first.
A resident with dysphagia, oropharyngeal dysphagia, Alzheimer’s disease, and severe cognitive impairment had clear EMR orders and care plan directives for a mechanical soft diet with ground meat and specific food restrictions. Despite this, dietary staff served the resident a whole chicken strip instead of ground meat, contrary to both the physician’s orders and facility policies requiring meat on mechanical soft diets to be chopped, flaked, or ground. During the meal, the resident choked on the chicken, and staff in the dining room performed the Heimlich maneuver, dislodging the food. Staff interviews revealed that the facility had a diet-card and multi-step verification process for ensuring correct diet texture, but this process was not properly followed for the resident’s meal, leading to the choking incident that surveyors cited as Immediate Jeopardy.
The facility did not conduct annual performance reviews for two CNAs, employed for over a year, as required by the Employee Handbook. This was confirmed by an administrative nurse and could affect the quality of care provided to residents.
The facility failed to maintain an effective infection control program, with staff not performing proper hand hygiene and failing to use appropriate PPE during care activities. Instances included improper glove use during catheter and wound care, and lack of PPE during bed sheet changes. Interviews revealed non-adherence to infection control policies, posing potential cross-contamination risks.
The facility failed to maintain a functional emergency call system, with multiple instances of call lights being out of reach or malfunctioning. Staff interviews revealed inconsistent use of pagers, and maintenance checks showed persistent issues despite regular audits. Administrative staff were unaware of these problems, and the facility lacked a policy for emergency call light use.
The facility failed to accurately complete the MDS for several residents, leading to uncommunicated care needs. A resident with cognitive and physical impairments experienced falls that were not accurately documented, while another resident's continence status and restorative care were misrepresented. Additionally, a resident's antidepressant medication was not properly recorded, and another resident's fall history was inaccurately documented. These inaccuracies were confirmed by the administrative nurse, highlighting significant deficiencies in resident assessments.
The facility failed to implement and maintain fall prevention measures for several residents, leading to multiple falls. A resident with cognitive impairment was found without a call light within reach, and a transfer pole was missing. Another resident's call light system was non-functional, leaving them unable to request assistance. Additionally, a resident dependent on staff for transfers was not safely transferred, and their electric recliner was improperly managed. These deficiencies highlight the facility's failure to adhere to fall prevention protocols.
The facility failed to obtain informed consent for psychotropic medications for four residents with severe cognitive impairments, violating their policy. Despite receiving medications like Prozac, Xanax, Venlafaxine, Seroquel, Fluoxetine, Lorazepam, and Mirtazapine, the facility did not have signed consent forms. This oversight was confirmed by an administrative nurse, indicating a systemic issue in medication management.
A facility failed to implement a comprehensive care plan for a resident with Parkinson's disease, who was dependent on staff for transfers and had severe cognitive impairment. The care plan lacked instructions for the use of an electric recliner, despite the resident's fall risk and inability to operate it safely. Staff inconsistently followed the intervention to keep the recliner unplugged, leading to a fall incident. Additionally, the facility did not complete required assessments for the recliner's use, contributing to the deficiency.
The facility failed to update care plans for two residents after significant changes in their conditions. One resident experienced multiple falls, yet the care plan lacked consistent updates with necessary interventions, such as ensuring the call light was within reach and completing a CT scan. Another resident developed a stage two pressure ulcer, but the care plan inaccurately documented the use of a cushion, which was not present in the resident's seating. These deficiencies in care planning risked uncommunicated care needs.
A resident with Alzheimer's and peripheral vascular disease had toe abrasions and was instructed to wear non-skid socks until healed. Despite this, the resident was observed wearing shoes multiple times. Staff interviews confirmed the resident wore shoes daily, contrary to the care plan and physician's orders. The facility's policy required addressing footwear for residents with skin issues, but this was not followed, leading to a deficiency.
The facility failed to provide adequate care for two residents with pressure ulcers. One resident with Alzheimer's disease developed a stage II ulcer behind the left ear, and the required padding was often not in place. Another resident with multiple health issues had a stage II ulcer on the buttock, but did not have the necessary pressure-reducing cushion in their seating arrangements. The facility's policies on wound prevention and management were not effectively implemented, leading to these deficiencies.
The facility failed to notify providers when medications were held for two residents, leading to a deficiency. One resident with hypertension had multiple antihypertensive medications held without provider notification, while another resident with diabetes had insulin doses held without consistent notification. This lack of communication placed both residents at risk for adverse complications.
A resident with cerebral palsy and osteoporosis was injured during a mechanical lift transfer when a CNA attempted the transfer alone, contrary to facility protocol requiring two staff members. The CNA failed to secure a leg strap, causing the resident to fall and sustain a laceration, hematoma, and hip fracture.
Failure to Follow Mechanical Soft Diet Orders Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident with food in the physician-ordered mechanical soft, ground meat form. The resident had diagnoses of dysphagia, oropharyngeal phase dysphagia, and Alzheimer’s disease, with a BIMS score of four indicating severe cognitive impairment. Her MDS and CAAs documented that she coughed or choked during meals or when swallowing medications and that she required a mechanically altered diet. The care plan and EMR orders specified a regular diet with mechanical soft texture, ground meat with gravy or sauce (no dry meat), and multiple restrictions including no soft tortilla shells, no salad, no raw onions, no raw vegetables, and tortilla chips to be crushed or broken. An intervention also directed staff to cut up her food and remind her to take only one bite at a time. Despite these documented needs and orders, on the day of the incident the resident was served a whole chicken strip instead of ground meat. A nurse’s note recorded that the resident received a whole chicken strip for lunch and choked on a bite of chicken. Staff statements confirmed that dietary staff provided a whole chicken strip, and one dietary staff member stated he had chopped one up but then set it aside and gave her a whole chicken strip because he could not remember if they were supposed to be chopped for her. This action directly conflicted with the resident’s ordered mechanical soft diet with ground meat and the facility’s own policies requiring foods to be cut, chopped, or ground to meet individual needs and specifying that meat, fish, and poultry on mechanical soft diets should be chopped, flaked, or ground. When the resident began choking, another resident alerted staff in the dining room. Staff observed the resident choking, and a CNA and another staff member attempted and then performed the Heimlich maneuver, resulting in the resident expelling a chunk of food onto the floor and stating she felt better. A prior progress note also documented that the resident had experienced a possible choking episode in the dining room on an earlier date, during which she was observed coughing with blue lips, encouraged to cough up a moderate amount of mushy substance, and suctioned for a moderate amount of thick, clear mucus. The facility’s dietary and nursing staff interviews described an established process using diet cards and multiple verification steps to ensure correct diet texture and consistency, but staff acknowledged that this process was not thoroughly followed for this resident’s meal, resulting in her receiving a full chicken strip instead of the ordered mechanical soft, ground meat diet. This failure led to a choking episode that surveyors determined constituted Immediate Jeopardy.
Removal Plan
- Provide in-service education for dietary monitoring and ensuring proper diets are served to each resident for direct-care staff and kitchen staff
- Provide 1:1 education with the cook and dietary aide
- Implement disciplinary action for the cook and dietary aide
- Provide 1:1 in-service education with all staff who serve in the dining room
- Revise the dining room monitoring schedule to include manager coverage for all meals
- Verify all at-risk residents to ensure diets match their diet cards
- Provide RELIAS educational training for the cook
- Hold a QAPI meeting with the Director of Nursing, Administrator, and Medical Director
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to conduct annual performance reviews for two Certified Nurse Aides (CNAs), identified as CNA M and CNA O, who had been employed for more than one year. This deficiency was identified during a review of five employee personnel files, which revealed that CNA M, hired on November 4, 2022, and CNA O, hired on November 27, 2023, did not have documented annual performance evaluations in their personnel files. This oversight was confirmed by Administrative Nurse D on February 10, 2025. The facility's Employee Handbook mandates that supervisors conduct performance evaluations for all full-time and part-time employees annually, a requirement that was not met for these two CNAs, potentially impacting the quality of care and services provided to the residents.
Infection Control Deficiency Due to Improper Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by improper hand hygiene and failure to follow enhanced barrier precautions (EBP) during care activities. On multiple occasions, staff members, including a Certified Medication Aide (CMA), Certified Nurse Aide (CNA), and Licensed Nurse (LN), did not perform proper hand hygiene after removing gloves and before putting on new ones. Specifically, during a catheter bag change for a resident, staff removed their gloves but did not sanitize their hands before continuing care. Additionally, a Licensed Nurse failed to perform hand hygiene and change gloves before placing a clean dressing on a resident's wound. The report also highlights instances where staff did not wear the appropriate personal protective equipment (PPE) when caring for residents requiring EBP. For example, a CNA did not wear the proper PPE while changing bed sheets after giving a resident a bed bath. Interviews with staff members revealed a lack of adherence to the facility's infection control policies, including the use of gowns and gloves for residents with catheters or wounds. The facility's Administrative Nurse confirmed the expectation for staff to follow EBP and perform hand hygiene as per policy, but these practices were not consistently followed, leading to potential cross-contamination risks.
Deficiency in Emergency Call System Functionality
Penalty
Summary
The facility failed to maintain a functional emergency call system, which is essential for residents to call for staff assistance from their rooms, bedside, bathroom areas, and bathing facilities. Observations revealed multiple instances where the emergency call lights were either out of reach for residents or malfunctioned. For example, one resident had their call light on the floor behind a table, making it inaccessible, while another resident's call light was placed on an over-bed table, out of reach. Additionally, a resident reported that the emergency call system did not always work, leading them to use their phone to call for assistance. Maintenance checks revealed that some call lights required multiple attempts to activate, and others in the shower room did not work at all. Staff interviews indicated a lack of consistent use of pagers, which are supposed to alert staff when a call light is activated. Some staff members admitted to not carrying pagers, and it was noted that the computer monitor displaying call light alerts was concealed by a curtain, limiting its visibility. Maintenance staff reported conducting monthly checks and random weekly audits of the call lights, but issues persisted, with staff sometimes removing pager batteries to avoid carrying them. Administrative staff were unaware of the ongoing issues with the call light system and the staff's reluctance to use pagers. The facility also failed to provide a policy for the use of emergency call lights.
Inaccurate MDS Completion Leads to Uncommunicated Care Needs
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for several residents, leading to uncommunicated care needs. Resident 15, who had a history of cognitive communication deficit, diabetes mellitus, coronary artery disease, hypertension, muscle weakness, and depression, was inaccurately assessed in relation to falls. Despite having experienced falls, the MDS did not reflect these incidents accurately, as confirmed by Administrative Nurse D. Observations revealed that R15 was found on the floor on multiple occasions, and during one observation, the resident was without a call light within reach, indicating a lack of proper fall prevention measures. Resident 1's MDS was also inaccurately completed concerning continence status and restorative care. The resident, diagnosed with spastic hemiplegia, bipolar disorder, and seizures, was documented as always incontinent, although records showed instances of continence. Additionally, the resident's care plan included a restorative program for an ankle-foot orthotic (AFO) and splint care, but observations and interviews revealed that the AFO was too small and not being used, contradicting the documented care plan. Administrative Nurse D confirmed these inaccuracies and noted that the program could not be completed as documented. Resident 18's MDS inaccurately documented the administration of antidepressant medication. Despite having a diagnosis of major depressive disorder and receiving venlafaxine, the MDS lacked documentation of this medication during the assessment period. Similarly, Resident 20's MDS inaccurately recorded a fall that did not occur after a specific date, as confirmed by Administrative Nurse D. The resident, diagnosed with Alzheimer's and Parkinson's disease, was at a high risk for falls, yet the MDS did not accurately reflect the resident's fall history, leading to potential uncommunicated care needs.
Failure to Implement and Maintain Fall Prevention Measures
Penalty
Summary
The facility failed to adequately implement and reevaluate fall prevention interventions for several residents, leading to multiple falls and placing residents at risk for injury. Resident 15, who had a history of cognitive impairment and multiple falls, was observed without a call light within reach on several occasions, and the transfer pole intended to assist him was not present in his room. Despite documented interventions in his care plan, such as ensuring the call light was within reach and moving his room closer to the nurse's station, these measures were not consistently followed, and new interventions were not implemented after each fall. Resident 17, who had severe cognitive impairment and a history of falls, was found to have a non-functioning call light system, which did not alert staff when activated. Despite the facility's policy to ensure call lights were within reach and functioning, the call light in Resident 17's room was not operational, and staff did not respond to the call light when it was activated. This failure to maintain a working call light system left Resident 17 without a reliable means to request assistance, increasing the risk of falls. Resident 20, who had severe cognitive impairment and was dependent on staff for transfers, was not safely transferred according to her care plan. The care plan required the use of a gait belt and specified that her electric recliner should remain unplugged to prevent her from operating it unsafely. However, staff left the recliner plugged in, and the resident was transferred without proper weight-bearing support. Additionally, the facility failed to complete necessary assessments for the resident's ability to safely use the electric recliner, further compromising her safety. Resident 18, also with severe cognitive impairment, was observed without a call light within reach, contrary to the care plan's instructions, which further exemplifies the facility's failure to adhere to fall prevention protocols.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the use of psychotropic medications for four residents, which is a violation of their policy for Behavior Management and Psychotropic Medications. The policy, revised in November 2024, mandates that informed consent must be completed for the use of psychotropic medications that affect brain activity prior to their initial administration. Despite this requirement, the facility did not have signed and dated informed consent forms for Residents 12, 17, 18, and 30, all of whom were receiving psychotropic medications. Resident 12, who has severe cognitive impairment with a BIMS score of two, was receiving Prozac for depression and Xanax for anxiety. The resident's care plan required monitoring for side effects and notifying the physician of any adverse reactions. However, the facility did not have a signed informed consent for these medications. Similarly, Resident 18, with a BIMS score of four indicating severe cognitive impairment, was receiving Venlafaxine and Seroquel for depression and agitation, respectively, without a signed informed consent. Resident 17, also with severe cognitive impairment and a BIMS score of five, was receiving Fluoxetine for major depressive disorder without informed consent documentation. Resident 30, with diagnoses of anxiety, major depressive disorder, and insomnia, was receiving Lorazepam and Mirtazapine. The facility failed to document behaviors at the time of Lorazepam administration and did not have a signed informed consent for the use of these medications. Administrative Nurse D confirmed that informed consent forms were not completed and signed for these residents, highlighting a systemic issue in the facility's medication management practices.
Failure to Implement Comprehensive Care Plan for Resident Using Electric Recliner
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with Parkinson's disease, who was dependent on staff for transfers and had severe cognitive impairment. The resident's electronic medical record (EMR) indicated a history of falls and a moderate to high risk for future falls. Despite this, the care plan lacked specific instructions regarding the use of an electric recliner in the resident's room, which was a significant oversight given the resident's inability to safely operate the recliner due to physical and cognitive limitations. The deficiency was highlighted by an incident where the resident fell from the electric recliner, resulting in a reddened area on her spine. The interdisciplinary team had previously initiated an intervention to keep the recliner unplugged when the resident was seated to prevent her from raising the chair independently. However, observations revealed that staff frequently left the recliner plugged in, with the controller accessible to the resident, contrary to the intervention plan. This inconsistency in care practices contributed to the resident's fall risk. Interviews with staff members revealed a lack of clarity and adherence to the care plan regarding the recliner's use. Some staff members were unaware of the requirement to unplug the recliner, and there was no consistent practice in place. Additionally, the facility failed to complete an Electric Recliner Assessment upon the resident's admission and did not conduct regular assessments as required by their policy. This lack of assessment and clear guidance in the care plan contributed to the deficiency in providing safe and appropriate care for the resident.
Failure to Revise Care Plans for Falls and Pressure Ulcer Management
Penalty
Summary
The facility failed to accurately revise the care plans for two residents, R15 and R11, after significant changes in their conditions, leading to uncommunicated care needs. R15, who had a history of cognitive communication deficit, muscle weakness, diabetes mellitus, coronary artery disease, hypertension, and depression, experienced multiple non-injury falls. Despite these incidents, the care plan was not consistently updated with appropriate interventions. Observations revealed that R15's call light was often out of reach, and a transfer pole was missing from his room, which was confirmed to be on back order. Additionally, a CT scan ordered to check for suspected neurological deficits had not been completed, further indicating lapses in care plan updates. R11, diagnosed with diabetes mellitus, Parkinson's disease, morbid obesity, and chronic kidney disease, developed a stage two pressure ulcer. The care plan documented the use of a pressure-reducing mattress and a wheelchair cushion, but observations and interviews revealed that R11 did not have a cushion in his recliner, wheelchair, or motorized scooter. Despite the care plan's directives, R11 reported not using a cushion, and staff confirmed the absence of these essential items, indicating a failure to revise the care plan to reflect the resident's current needs. The facility's policies on falls management and wound prevention and management were not adhered to, as evidenced by the lack of appropriate interventions and updates to the care plans following the residents' falls and pressure ulcer development. This deficiency in care planning placed the residents at risk for uncommunicated care needs, potentially affecting their overall physical and psychosocial well-being.
Failure to Follow Care Plan for Resident with Toe Abrasions
Penalty
Summary
The facility failed to adhere to the care plan and physician's orders for a resident with skin abrasions on the toes. The resident, diagnosed with Alzheimer's disease and peripheral vascular disease, had abrasions on the second toe of the right foot and the second and third toes of the left foot. The care plan, revised on 01/05/25, instructed staff to leave the resident's shoes off and only have him wear non-skid socks until the abrasions healed. Despite this, observations on multiple occasions revealed the resident wearing white Velcro tennis shoes, contrary to the care plan and physician's orders. Interviews with staff members, including a Certified Medication Aide, Certified Nurse Aide, and Licensed Nurse, confirmed that the resident was wearing shoes daily, despite the care plan's instructions. The facility's policy for wound prevention and management required addressing footwear appropriateness for residents with skin integrity issues. The administrative nurse acknowledged that the abrasions were caused by ill-fitting shoes, which had been removed by the family, and confirmed the expectation for staff to refrain from putting shoes on the resident until the abrasions healed. This failure to follow the care plan and physician's orders resulted in a deficiency related to the resident's care.
Inadequate Pressure Ulcer Care for Two Residents
Penalty
Summary
The facility failed to provide adequate care for two residents with pressure ulcers, leading to deficiencies in their treatment and prevention. Resident 13, diagnosed with Alzheimer's disease and moderately impaired cognition, developed a stage II pressure ulcer behind the left ear. Despite physician orders to pad the earpiece of the resident's glasses and oxygen tubing to prevent further irritation, observations revealed that the padding was frequently not in place. Staff interviews confirmed the inconsistency in following the care plan, which was expected to be adhered to until the wound healed. Resident 11, with diagnoses including diabetes mellitus, Parkinson's disease, morbid obesity, and chronic kidney disease, was identified as having a stage II pressure ulcer on the buttock. The care plan required the use of a pressure-reducing cushion in the resident's wheelchair, recliner, and motorized scooter. However, observations and interviews indicated that the resident did not have a cushion in any of these seating arrangements. The resident reported discomfort with a cushion previously tried, and staff confirmed the absence of a cushion, which was contrary to the care plan. The facility's policies on wound prevention and management, as well as electronic care plans, were not effectively implemented, resulting in inadequate care for the residents' pressure ulcers. The failure to consistently apply necessary interventions, such as padding and pressure-reducing cushions, contributed to the deficiencies observed in the care of these residents.
Failure to Notify Providers of Held Medications
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary drugs, as evidenced by the administration of excessive doses of antihypertensive medications without proper provider notification. Resident 17, who had diagnoses including hypertension and dementia, experienced multiple instances where medications such as Diltiazem, Lisinopril, Metoprolol, and Clonidine were held without notifying the provider. This lack of communication occurred despite the presence of specific instructions to hold medications under certain conditions, such as low systolic blood pressure or pulse. The facility's electronic medical administration records (EMAR) showed numerous instances of these medications being held over several months without provider notification, placing the resident at risk for adverse complications. Additionally, Resident 134, who had diabetes mellitus, was at risk due to the facility's failure to notify the provider when insulin doses were held. The resident's care plan included instructions to hold insulin if blood sugar levels were below a certain threshold or if the resident did not eat. Despite these instructions, the EMAR revealed that Novolog insulin was held multiple times over a short period without consistent provider notification. The lack of communication with the provider about these held doses posed a risk for adverse complications related to the resident's diabetes management. Interviews with facility staff, including administrative and licensed nurses, indicated an expectation that providers should be notified whenever a medication is held. However, the facility lacked a formal policy on physician notification, contributing to the oversight. The failure to notify providers about held medications for both residents resulted in a deficiency, as it placed the residents at risk for future adverse complications due to the potential for unnecessary drug administration.
Resident Injury Due to Improper Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure the safety of a dependent resident, identified as R1, during a mechanical lift transfer. Certified Nurse Aide (CNA) M attempted to transfer R1 without the assistance of a second staff member, which was against the facility's protocol for mechanical lift transfers. During the transfer, CNA M did not secure one of the leg straps to the mechanical lift, resulting in R1 falling from the lift and sustaining injuries. R1, who had a history of cerebral palsy, osteoarthritis, and osteoporosis, was totally dependent on staff for activities of daily living and required a mechanical lift for transfers. The resident's care plan indicated a moderate risk for falls and required the use of a mechanical lift with two staff members present. Despite these instructions, CNA M proceeded with the transfer alone, leading to R1 falling face forward onto the floor. As a result of the fall, R1 suffered a laceration to the left ear, a hematoma on the left temple, and an acute left hip fracture. The incident was witnessed by Licensed Nurse (LN) G and another CNA, who confirmed that the mechanical lift was not defective and that the failure was due to improper use by CNA M. The facility's expectation was for two staff members to be present during such transfers to ensure resident safety.
Removal Plan
- The facility suspended CNA N.
- The facility updated R1's care plan related to ADL.
- An immediate quality assurance and performance improvement (QAPI) meeting held.
- Nursing staff education provided related to mechanical lift skills check offs and training.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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