Medicalodges Fort Scott
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Scott, Kansas.
- Location
- 915 S Horton, Fort Scott, Kansas 66701
- CMS Provider Number
- 175258
- Inspections on file
- 21
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Medicalodges Fort Scott during CMS and state inspections, most recent first.
Surveyors found that the facility did not complete required annual performance evaluations for two of five reviewed direct care staff. Record review showed that two CNAs had outdated evaluations, despite the expectation that evaluations be done annually. An administrative staff member confirmed that annual evaluations were required, and the facility was unable to provide a policy governing completion of these evaluations.
Surveyors identified multiple failures to maintain a clean, safe, and homelike environment, including a resident’s room with persistent strong urine odor, sticky and dirty flooring, and excessively loud television and gaming volume that disturbed other residents. Another resident reported needing to keep her door closed due to noise, while additional rooms had missing paint, dirty and scuffed floors, and damaged or missing threshold strips. An air conditioning unit lacked its front cover, and a hallway floor drain cover was loose and exposed the drain when stepped on. Staff interviews confirmed frequent urine on the floor, ongoing odor issues, repeated noise complaints, and awareness of the environmental problems.
Surveyors found the facility exceeded the acceptable medication error rate when two errors were identified during 30 observed medication administrations. In one case, a resident did not receive an ordered phenazopyridine dose because it had not been available from the pharmacy since admission and the omission was not reported as required by policy. In the same pass, a CMA administered Protonix after the resident had just eaten, contrary to the order specifying it be given 30–60 minutes before meals, and the administrative nurse was unaware of the unavailable medication.
A resident with DM, major depressive disorder, and a developmental disorder was hospitalized, and staff obtained a verbal bed-hold consent from the resident’s DPOA but did not provide or document provision of a written bed-hold policy including duration. Nursing staff reported they only obtained verbal bed holds and did not send forms with residents to the hospital, while administrative staff stated they completed the bed hold verbally and intended to mail the form but kept no record of doing so. The social services designee documented only verbal consent and was unaware that a paper copy had to be given, and another administrator confirmed there was no system to verify that a written bed-hold notice was provided when consent was obtained verbally, despite existing instructions requiring documentation of how the form would be delivered.
A resident with multiple complex conditions, including hemiplegia, seizures, major depressive disorder, severe protein-calorie malnutrition, and anemia, was admitted to hospice, and the care plan documented hospice services related to a terminal diagnosis. The earlier quarterly MDS did not show hospice or a prognosis of less than six months to live, while the later quarterly MDS did, but no Significant Change MDS was completed in the interval to capture the initiation of hospice services. Administrative nursing staff acknowledged that a Significant Change MDS should have been done, and the facility reported relying on CMS RAI guidelines, which require submission of an MDS within 14 days of determining a significant change in status.
A resident with multiple comorbidities, intact cognition, and total dependence for toileting had PRN orders for polyethylene glycol and bisacodyl suppositories for constipation, with care plan instructions for hospice aides to document bowel movements and notify nursing after three days without a BM. Over a seven‑day period, the EMR showed no documented bowel movement while staff administered ondansetron for nausea and repeated PRN polyethylene glycol doses that were documented as ineffective, yet no bowel or abdominal assessments were recorded in the progress notes. CNAs reported documenting BMs in the EMR, and an LPN described relying on a dashboard alert that only flagged three days without a BM and not reviewing the full bowel record, despite stating that providers should be contacted and daily assessments documented after day four. The administrative nurse expected daily bowel monitoring, use of EMR reports, and documented assessments and notifications, expressed concern about the seven‑day gap without a BM, and confirmed there was no bowel monitoring policy.
Surveyors found that the facility failed to ensure physicians reviewed and acted on consultant pharmacist medication regimen review (MRR) recommendations for two residents. For a resident with hypothyroidism on levothyroxine, the pharmacist requested lab monitoring, including TSH, but there was no documented physician response and no TSH labs completed over an extended period, despite facility policy requiring action and documentation within a set timeframe. For another resident on multiple psychotropic meds (risperidone, alprazolam, citalopram), the pharmacist recommended a gradual dose reduction of risperidone, yet the facility could not produce any provider response, and the dose was later increased without documented rationale tied to the pharmacist’s recommendation. Facility policy required that physicians accept or reject pharmacist recommendations and document their rationale, but this did not occur for these cases.
A resident with hypothyroidism was prescribed levothyroxine 50 mcg by mouth every other day, but the facility did not obtain thyroid-stimulating hormone (TSH) labs to monitor the effectiveness of this therapy over an extended period. The care plan and facility policy called for medication regimen review and monitoring of labs and diagnostic tests as ordered, and an administrative nurse reported expecting labs for residents on levothyroxine. However, review of the EMR showed no TSH orders or completed TSH labs, resulting in a failure to ensure the resident’s drug regimen was free from unnecessary drugs.
The facility did not ensure proper monitoring and reconciliation of narcotic medications in e-kits, as lock-out tag numbers on kits containing controlled substances did not match documentation, and staff failed to check and document these tags at each shift change as required by policy.
A resident with multiple psychiatric and cognitive diagnoses made an allegation of sexual abuse by staff during toileting. The facility did not remove the accused staff member from resident care during the investigation, and staff were unaware of the care plan requirement for two-person assistance. Care continued to be provided by a single CNA, and administrative staff did not implement the facility's policy for immediate staff removal following abuse allegations.
A resident with multiple mental health diagnoses and moderate cognitive impairment did not have their care plan updated in a timely manner after an incident involving increased behavioral symptoms. Staff were inconsistently informed about the need to provide care in pairs, and care was observed being provided by a single staff member despite the care plan's directive. The care plan was not revised to include this intervention until several days after the incident, contrary to facility policy.
A resident with severe cognitive impairment and swallowing disorders was neglected when a CMA continued administering medications despite the resident's requests to slow down. Witnesses observed the resident's distress and the CMA's dismissive behavior, which violated the facility's abuse and neglect policy.
A resident with severe cognitive impairment and swallowing difficulties experienced neglect when a CMA continued administering medications despite the resident's distress and requests to slow down. The incident, witnessed by other staff, was not reported immediately, violating the facility's policy on reporting abuse and neglect.
The facility failed to ensure adequate staffing levels on weekends, placing residents at risk for impaired mental and physical well-being. Resident Council members reported a lack of weekend activities due to low staffing, and staff confirmed the issue, with some shifts having only one CNA. The facility did not provide a policy related to weekend staffing.
The facility failed to ensure that five CNAs had the required yearly performance evaluations completed. No performance evaluations or in-service training records were found for these CNAs, who had been employed for more than 12 months. Administrative staff confirmed the absence of these records and the lack of a policy related to staff competency, training, or performance evaluation.
The facility failed to ensure that five CNAs had the required 12 hours of in-service education, placing residents at risk for inadequate care. Administrative staff confirmed the absence of performance evaluations and required in-service records for these CNAs, and the facility did not provide a policy related to staff competency, staff training, or performance evaluation.
The facility failed to post the State Survey Agency (SSA) contact information in a manner accessible to residents and their representatives. Small posters with SSA contact information were placed in locations that were not easily visible or readable, and residents reported being unaware of or unable to read the information. Staff confirmed that the posters should be more visible and readable.
The facility failed to provide a system for residents and their representatives to file grievances anonymously, as required by its policy. There were no designated grievance drop boxes, and staff and residents were unaware of any means to file anonymous grievances. This placed residents at risk for decreased psychosocial well-being and unresolved grievances.
The facility failed to review and revise care plans with resident-specific interventions, leading to impaired care for multiple residents. Issues included incorrect mattress settings for a resident at risk for pressure ulcers, lack of splint application for a resident with contractures, missing instructions for hearing aid use, and unrecorded daily weights for a resident with CHF.
The facility failed to provide consistent weekend activities, leaving residents with limited options like watching TV, reading books, or using coloring pages. This deficiency was confirmed by Resident Council members, a CNA, and Activities Staff, and was attributed to low staffing levels.
The facility failed to ensure a safe environment free from hazardous materials for eight cognitively impaired residents and did not properly assess and maintain a resident's siderails, placing them at risk for preventable accidents and injuries.
The facility failed to ensure adequate infection control standards, including enhanced barrier precautions, proper storage of clean linen, and sanitary care practices. Multiple residents with medical devices were not placed on enhanced barrier precautions, and staff lacked training on these new requirements. Observations revealed improper storage of clean linen and oxygen tubing, and staff did not perform hand hygiene between glove changes.
The facility failed to provide effective pest control, resulting in a significant cockroach infestation. Despite monthly treatments, the last recorded treatment was in March 2024. A walkthrough revealed a large number of cockroaches in the north hall Handicapped Women's Bathroom. Staff confirmed awareness of the infestation, which had persisted for seven years. The facility lacked a pest control policy, placing residents at increased risk for impaired comfort and disease.
The facility failed to issue the CMS Notification of Medicare Non-Coverage Form 10123 (NOMNC) to two residents at the end of their Medicare Part A episodes. The facility was unable to provide documentation that the NOMNC was issued, and Administrative Staff A could not locate the forms. Additionally, the facility did not provide a policy for beneficiary notification.
The facility failed to provide written notice of transfer or discharge for a resident's facility-initiated transfers to the hospital. Despite multiple hospitalizations, no written notices were given to the resident's legal representative, placing the resident at risk of uninformed choices and miscommunication regarding care needs.
The facility failed to provide a bed hold notice when a resident with congestive heart failure, hypertension, and a contracture was hospitalized multiple times. Despite the resident's moderately impaired cognition and extensive assistance needs, the facility did not inform the resident or his legal representative about the bed hold policy, placing the resident at risk of uninformed choices. Administrative staff confirmed the oversight, and the facility lacked a policy on transfers and discharges.
The facility failed to ensure a resident received necessary assistance with his hearing aids, leading to communication difficulties and inability to participate in ADLs. The care plan lacked specific instructions for staff, and multiple observations noted the resident without his hearing aids. Staff interviews revealed a lack of awareness and responsibility for managing the resident's hearing aids, placing him at risk for increased confusion and decreased dignity.
The facility failed to follow a physician's order for daily weights to monitor for fluid overload for a resident with congestive heart failure. The resident's care plan lacked directions for weight monitoring, and multiple instances of missed weight recordings were noted. Staff interviews revealed awareness of the issue but inconsistent actions to notify the physician or correct the deficiency.
A resident's low air-loss mattress pump was set incorrectly for his weight, despite his care plan indicating a risk for skin breakdown and pressure ulcers. The care plan and EMR lacked specific instructions for the mattress settings, and staff were unclear on who was responsible for checking and setting the pump.
The facility failed to ensure that a resident received appropriate services and treatment to prevent the worsening of contractures in his left hand. Despite the resident's medical record indicating the need for a splint, washcloth, or carrot in his left hand, these measures were not consistently applied, leading to a risk of further decline and discomfort.
The facility failed to ensure a resident received sanitary catheter care by not providing education on performing sanitary catheter care and not assessing the resident's ability to self-perform catheter care. The resident, with multiple diagnoses and an indwelling catheter, reported performing her own catheter care without any education or evaluation from the staff. Staff were unaware of the resident's self-performance of catheter care and did not monitor it, and the facility did not provide a policy on request.
The facility failed to obtain accurate weights for a resident with multiple medical conditions, including an enteral feeding tube, as ordered by the medical provider. Despite the physician's order for weekly weights, the facility did not document any weights after a certain date, placing the resident at risk for complications related to weight loss.
The facility failed to ensure appropriate respiratory care for two residents, placing them at risk for complications. One resident's oxygen cannula was improperly stored, and another resident used supplemental oxygen without a current physician's order. The facility lacked policies for oxygen use and physician orders.
The facility failed to document consent for the use of siderails, did not attempt alternative methods, and did not inform a resident and/or their representative of the risks and benefits. The resident had severe cognitive impairment and was dependent on staff for all activities of daily living. Observations revealed a loose siderail, and staff interviews indicated frequent issues with the siderail's stability. The facility lacked a policy on siderail use and did not document safety checks, placing the resident at risk.
The facility failed to ensure staff had the appropriate skills and knowledge to administer Midodrine to a resident with hypotension, resulting in the medication being given outside the prescribed parameters on multiple occasions. The facility lacked recent medication-based training and did not provide a policy related to staff competency or training.
The facility failed to ensure the CP identified and reported the need for physician-documented rationale for the continued use of antipsychotic medication for a resident with dementia. Additionally, the facility did not follow the CP's recommendations regarding another resident's Midodrine administration, which was given outside of the physician-provided parameters repeatedly. These deficiencies placed the residents at risk for adverse medication effects and unnecessary psychotropic medication use.
The facility failed to adequately monitor a resident's pulse before administering metoprolol and did not conduct ordered laboratory tests for another resident, placing both at risk for adverse medication effects and unnecessary medications.
The facility failed to ensure an appropriate indication or documented physician rationale for the continued use of the antipsychotic medication olanzapine for a resident with multiple diagnoses, including dementia. Staff were unclear about appropriate indications for antipsychotic medication use, and the facility's policy requiring assessments for appropriate diagnoses and target behaviors was not followed.
A resident with hypotension received Midodrine outside of physician-provided parameters on 37 occasions, with one nurse responsible for 20 errors. Despite recommendations from the consulting pharmacist for staff education, no recent training was documented, leading to repeated medication errors and placing the resident at risk.
The facility failed to ensure a communication process with the hospice provider, leading to a lack of documentation of services and equipment for a resident with severe cognitive impairment and multiple diagnoses. Observations and interviews revealed lapses in care coordination, with staff unsure about the documentation process and the inclusion of hospice services in the care plan.
The facility failed to provide consent, declination, or documentation of ineligibility for pneumococcal vaccinations for three residents. The residents' EMRs lacked necessary documentation, and the facility's vaccination policy was not followed, placing the residents at risk for complications related to pneumococcal diseases.
The facility failed to document a resident's COVID-19 immunizations, including consent, declination, or ineligibility, due to staffing changes and being behind on vaccinations. This placed the resident at risk for complications related to infectious diseases.
The facility failed to ensure residents received their mail services on Saturdays. Resident Council members and staff confirmed that mail was only delivered from Monday to Friday, with no one available to handle mail on Saturdays. The facility did not provide a policy related to mail delivery.
The facility failed to post the previous state inspection survey results in a location accessible to residents and visitors. A sign indicating 'Survey Results' was found in the main lobby, but no survey results were visible. The resident council was unaware of the survey book's location, and an inspection revealed no accessible survey results. The Administrator stated the survey binder had been in the Administrative Nurse's office and was later moved back to the main lobby. The facility did not provide a policy regarding the posting of survey results.
The facility failed to retain daily posted nursing staffing data for the required 18 months, missing data for January and February 2023. Administrative Nurse D confirmed that all available data had been provided, but the facility's policy to file the previous day's staffing form in the business office was not followed.
Failure to Complete Annual Performance Evaluations for Direct Care Staff
Penalty
Summary
The facility failed to conduct annual performance reviews for two of five direct care staff whose records were reviewed. The facility had a census of 33 residents at the time of survey. Review of employment records showed that one CNA, hired on 11/01/22, did not have an up-to-date annual performance evaluation, with the last evaluation dated 10/03/24. Another CNA, hired on 08/06/03, also lacked a current annual performance evaluation, with the last evaluation dated 10/08/24. During an interview on 02/18/2026 at 12:48 PM, an administrative staff member confirmed these findings and stated that performance evaluations were expected to be completed annually. The facility did not provide a policy related to the completion of annual performance evaluations. No resident-specific medical histories or conditions were described in the report, and the deficiency centered on incomplete and outdated performance evaluations for direct care staff as identified through record review and staff interview.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean, safe, and homelike environment in multiple resident rooms and common areas. One resident’s room repeatedly had a strong urine odor, with surveyors noting the smell both inside the room and in the hallway on several days, as well as a sticky floor and ground-in dirt near the head of the bed. This resident’s television and gaming system were consistently played at a very loud volume, disturbing other residents, and the resident stated he could not hear if the volume was turned down. Staff interviews confirmed that this resident frequently urinated on the floor, that his room often smelled of urine, and that his floor was generally sticky. Staff also reported that other residents had complained about the noise from his television. Additional environmental issues were observed in other areas of the facility. One resident’s room had multiple areas of missing paint on the wall near the bed, and another resident reported needing to keep her door closed due to noise from other residents’ televisions. The air conditioning unit in one resident’s room was missing its front cover, and several rooms had thresholds with missing black strips and ground-in dirt, with floors described as dirty, dull, and marked with black scuffs. In a common hallway, a floor drain cover was not secured and exposed the drain when stepped on. The housekeeping supervisor acknowledged that the broken thresholds, dirty floors, missing air conditioner cover, and loose floor drain cover were ongoing concerns and not acceptable. The facility did not provide a policy on maintaining a clean, safe, comfortable, and homelike environment.
Failure to Maintain Acceptable Medication Error Rate and Follow Medication Timing Orders
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, with surveyors observing 30 medication administrations and identifying two errors, resulting in a 6.67 percent error rate. One identified error involved a resident whose physician orders included phenazopyridine HCL 200 mg by mouth three times a day after meals, and Protonix 40 mg delayed-release tablet to be given twice a day, 30 minutes to one hour before meals. During a morning medication pass, the certified medication aide (CMA) prepared the resident's medications but omitted the ordered phenazopyridine, stating that this medication had not been available from the pharmacy since it was ordered on the resident's admission date. The facility's policy on medication ordering and receiving from the pharmacy required timely delivery of new orders so that medication administration is not delayed and directed staff to promptly report omissions to the pharmacy and the charge nurse or supervisor. In the same medication pass, the CMA added the prescribed Protonix 40 mg and administered it to the resident after the resident reported having just finished eating, despite the physician's order specifying that Protonix be given 30 minutes to one hour before meals. The CMA later verified that medications should be administered as ordered by the physician. The administrative nurse also confirmed that she had not been informed about the unavailability of the phenazopyridine and stated that residents should receive medications as ordered. The facility's liberalized medication administration policy specified that medications with a specified time in the order are to be scheduled at that specific time and noted that some medications must be taken before, after, or with meals, which was not followed in this instance.
Failure to Provide Written Bed-Hold Policy and Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to provide a written bed-hold policy, including duration, to a resident who was hospitalized. The resident had diagnoses of diabetes mellitus, major depressive disorder, and a developmental disorder of scholastic skills, and had an MDS BIMS score indicating intact cognition. The resident’s EMR documented admission to the hospital, and a progress note showed that verbal consent for a bed hold was obtained from the resident’s durable power of attorney the following day. However, there was no documentation that a written bed-hold notice, including the policy and duration, was provided to the resident or the DPOA. Staff interviews revealed that nurses obtained verbal bed-hold consents but did not send a bed-hold form with residents when they went to the hospital. Administrative staff reported completing the bed hold verbally with the family member and stated that the form would be sent to the family, but there was no documentation or record that it was actually sent. The social services designee documented only that verbal consent was received and was not aware that a paper copy of the bed-hold notice should be given to the resident or family. Another administrative staff member confirmed the facility had no way to show that a resident or DPOA received a written bed-hold form when the consent was obtained verbally, despite facility instructions stating that the resident or responsible party should be asked whether they wanted to come in to sign or have the bed hold mailed, with the response documented on the form and in the census comments.
Failure to Complete Significant Change MDS After Hospice Initiation
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment after a resident experienced a decline in status and was initiated on hospice services. The resident had multiple diagnoses including hemiplegia, seizures, major depressive disorder, severe protein-calorie malnutrition, and anemia. A Quarterly MDS dated 07/05/24 showed a BIMS score of 5, indicating severely impaired cognition, and did not indicate that the resident had less than six months to live or that hospice services were being received. The resident’s physician orders documented admission to hospice services on 08/14/24, and the care plan initiated on 09/25/24 documented that the resident received hospice services related to a terminal diagnosis. The subsequent Quarterly MDS dated 10/04/24 documented a BIMS score of 10, indicating moderately impaired cognition, and reflected that the resident had less than six months to live and was receiving hospice services. However, the electronic medical record lacked a Significant Change MDS to identify the initiation of hospice services between 07/05/24 and 10/04/24. Administrative nursing staff acknowledged that a Significant Change MDS should have been completed when the resident was placed on hospice services. The facility reported that it did not have a specific policy and relied on CMS RAI guidelines, which require that an MDS be submitted within 14 days after determining that a significant change in a resident’s status has occurred.
Failure to Monitor and Intervene for Prolonged Absence of Bowel Movements
Penalty
Summary
The deficiency involves the facility’s failure to monitor and respond appropriately to a resident’s lack of bowel movements in accordance with physician orders and the resident’s care plan. The resident had diagnoses including diabetes mellitus, major depressive disorder, and a developmental disorder, with an MDS indicating intact cognition, total assistance needed for toileting hygiene, and frequent bowel incontinence. The care plan and physician orders included PRN polyethylene glycol 3350 by mouth every 24 hours for constipation and a PRN bisacodyl 10 mg rectal suppository every 24 hours for constipation, with instructions to call hospice before administering the suppository. The care plan also directed that the hospice aide would document bowel movements and report to the nurse if three or more days passed without a bowel movement. Review of the EMR showed that over a seven‑day period the resident had no documented bowel movement, exceeding the three‑day/72‑hour threshold. During this time, the EMAR documented administration of ondansetron for nausea and multiple administrations of PRN polyethylene glycol 3350 for constipation when no bowel movement had occurred for three days, with subsequent documentation that these interventions were ineffective and the resident still had no bowel movement. Despite the ongoing absence of bowel movements and ineffective PRN laxative use, there was no documentation that a bowel or abdominal assessment was completed in the progress notes from 01/30/26 through 02/04/26. Staff interviews revealed that CNAs were responsible for documenting bowel movements in the EMR and that nurses relied on an EMR dashboard alert that triggered when no bowel movement was documented for three days. The licensed nurse reported that the dashboard only alerted at three days and did not escalate for longer durations, and that she did not pull a full bowel movement record from the EMR. She stated that the provider should be called on day four and bowel assessments documented daily until a bowel movement occurred, but this was not reflected in the resident’s record. The administrative nurse stated she expected charge nurses to monitor bowel movements daily, use the dashboard and printed bowel movement lists, administer PRN constipation medications as ordered, and document bowel assessments and provider notifications, and acknowledged concern that the resident had no bowel movement for seven days. The facility did not have, and did not provide, a policy for bowel monitoring.
Failure to Ensure Physician Follow-Up on Consultant Pharmacist Medication Review Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that consultant pharmacist (CP) recommendations from monthly medication regimen reviews (MMR) were reviewed and addressed by the attending physicians, as required by facility policy. For one resident with hypothyroidism, the CP’s MMR dated 09/24/25 identified that the resident was receiving medications requiring routine lab work and specifically requested the physician to indicate which labs, including thyroid-stimulating hormone (TSH), should be ordered. Although the MMR was stamped as faxed, the electronic medical record contained no evidence of any physician follow-up or response to this recommendation. Review of the resident’s record from January 2025 through February 2026 showed no TSH lab had been completed during that period, despite the resident having an active order for levothyroxine for hypothyroidism. The resident with hypothyroidism had an annual MDS showing intact cognition and was largely independent in activities of daily living, with a care plan stating that the pharmacist reviewed medications monthly and as needed, and that staff were to monitor labs and diagnostic tests as ordered by the physician. The facility’s Medication Monitoring Medication Regimen Review and Reporting policy required that recommendations be acted upon within 30 calendar days or per facility-specific protocols, and that physicians either accept or reject recommendations and document their rationale in the medical record. However, the administrative nurse reported that she could not locate any physician follow-up to the 09/24/25 MMR for this resident and acknowledged that the facility had been experiencing a lack of physician response to MMRs. For a second resident receiving multiple psychotropic medications, including risperidone, alprazolam, and citalopram, the consultant pharmacist conducted an MRR on 07/03/25 and documented that the resident was taking risperidone 0.5 mg three times daily along with other psychotropics, and suggested the physician consider a dose reduction. The facility was unable to provide any copy of the provider or facility’s response to this recommendation. The care plan for this resident documented long-standing use of psychotropic medications for anxiety, wandering, exit-seeking, tearfulness, and a history of behaviors, and indicated that staff were to monitor effectiveness and side effects and consult with the pharmacist and physician to adjust dosages when clinically appropriate. The consultant pharmacist later reported that he did not receive a response to the gradual dose reduction request and observed that the physician had instead increased the risperidone dose from 0.5 mg to 1 mg, after which he did not repeat the request in subsequent MRRs. The facility’s policy again required that physician interventions be documented, including acceptance or rejection of recommendations and the rationale, but no such documentation was found for this resident. Across both residents, surveyors identified that the facility did not ensure that CP recommendations were acted upon and documented by the physicians within the time frames and processes outlined in the facility’s own Medication Monitoring Medication Regimen Review and Reporting policy. Administrative nursing staff acknowledged that physician responses to pharmacy recommendations were missing and that the facility did not receive the expected follow-up to the pharmacist’s MRRs. This lack of documented physician review and action on the CP’s recommendations for necessary lab monitoring and psychotropic dose reduction constituted the cited deficiency.
Failure to Monitor Thyroid Function for Resident on Levothyroxine
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was monitored appropriately by not obtaining thyroid function labs for a resident receiving levothyroxine for hypothyroidism. The resident had a documented diagnosis of hypothyroidism and an order for levothyroxine 50 mcg by mouth once daily every other day, revised on 05/06/24. Review of the electronic medical record from January 2025 through February 2026 showed no evidence that a thyroid-stimulating hormone (TSH) lab was ordered or completed to monitor the effectiveness of the thyroid hormone replacement therapy. The resident’s care plan indicated that the pharmacist would review medications monthly and as needed, and that staff were to monitor labs and diagnostic tests as ordered by the physician, but there was no corresponding TSH order in the physician’s orders. The resident’s Annual MDS documented a BIMS score of 15, indicating intact cognition, and showed that the resident required only setup or clean-up assistance with bathing and was independent with other activities of daily living. During observation, the resident was seen lying in bed on his left side with covers pulled up to his chest. In an interview, an administrative nurse stated she expected labs to be ordered for residents on levothyroxine. The facility’s Medication Monitoring Medication Regimen Review and Reporting policy stated that the goal of the medication regimen review was to promote positive outcomes and minimize adverse consequences and potential risks associated with medication, but the lack of TSH monitoring for this resident’s levothyroxine therapy demonstrated a failure to follow through with appropriate lab monitoring for an unnecessary drug review.
Failure to Accurately Monitor and Reconcile Narcotic Medications in Emergency Kits
Penalty
Summary
The facility failed to maintain an accurate and adequate system for monitoring and reconciling narcotic medications stored in emergency kits (e-kits). During a tour of the medication room, it was observed that the lock-out tag numbers on two e-kits containing controlled substances, including hydrocodone-acetaminophen, morphine sulfate, alprazolam, APAP-Codeine #3, clonazepam, lorazepam, zolpidem, and tramadol, did not match the numbers documented on the Controlled Medication Shift Count sheet. A review of the shift count sheet revealed that staff had signed off on the count and reconciliation of the e-kits only three times over a one-month period, rather than at every shift change as required by facility policy. Interviews with nursing staff confirmed that the lock-out tags on the e-kits were not being checked and documented by oncoming and off-going nurses at shift change. The administrative nurse stated that it was the facility's expectation for nurses to verify the lock-out tag numbers and sign the reconciliation form at the beginning and end of each shift, in accordance with the facility's Controlled Medication Reconciliation policy. The failure to follow these procedures resulted in a lack of proper monitoring and reconciliation of controlled medications in the facility's emergency kits.
Failure to Implement Protective Measures Following Abuse Allegation
Penalty
Summary
The facility failed to implement protective measures for a resident following an allegation of sexual abuse by staff during toileting assistance. The resident, who had a history of schizophrenia, bipolar disorder, major depressive disorder, intellectual disability, anxiety, and hallucinations, made an accusation of sexual abuse. Despite the facility's policy requiring immediate suspension and removal of the accused staff member pending investigation, there was no evidence that the alleged perpetrator was removed from the facility or denied access to residents during the investigation. Staff continued to provide care to the resident without following the care plan directive to use two staff members during care, and some staff were unaware of this requirement. The resident's care plan indicated a need for close monitoring and the use of two staff members during care due to behavioral issues and a history of making false accusations. However, observations and staff interviews revealed that care was provided by a single CNA and that both direct care staff and licensed nursing staff were unaware of the two-person care requirement. Administrative staff also reported being unaware of the need to suspend or remove the accused staff member during the investigation, despite being notified of the allegation and initiating an investigation promptly.
Failure to Timely Update and Communicate Care Plan Interventions
Penalty
Summary
The facility failed to update and communicate a resident's care plan following an incident involving increased behavioral symptoms and rejection of care. The resident, who had multiple mental health diagnoses including schizophrenia, bipolar disorder, major depressive disorder, intellectual disability, anxiety, and hallucinations, exhibited moderate cognitive impairment and required extensive assistance with toileting due to frequent incontinence. The care plan, which was not revised until several days after the incident, instructed staff to provide care in pairs due to the resident's tendency to make false accusations and behavioral issues. However, staff interviews revealed inconsistent awareness and implementation of this intervention, with some staff unaware of the requirement to provide care in pairs and others stating it was not always practiced. Observations confirmed that care was provided by a single staff member despite the care plan's directive. The administrative nurse acknowledged that the care plan had not been reviewed and revised to include the paired care instruction until after the incident occurred. The facility's policy required care plans to be reviewed and revised with any new interventions, but this was not followed in a timely manner, resulting in uncommunicated care needs and a risk for inadequate care.
Neglect in Medication Administration for Cognitively Impaired Resident
Penalty
Summary
The facility failed to protect a dependent and cognitively impaired resident, identified as R1, from neglect. R1, who had a diagnosis of dysphagia, oropharyngeal phage, and ileus, experienced difficulty swallowing medications. Despite R1's request to slow down due to swallowing difficulties, Certified Medication Aide (CMA) S continued to administer the medications without pausing. This incident was witnessed by Housekeeping/CNA U and Outside Resource Staff EE, who observed R1's distress and CMA S's dismissive behavior. R1's medical records indicated severe cognitive impairment and a history of swallowing disorders, requiring a mechanically altered diet and crushed medications mixed with applesauce. On the morning of the incident, CMA S administered R1's medications in applesauce, ignoring R1's requests to slow down. Witnesses reported that R1 was coughing and choking, and CMA S continued administering the medications without allowing R1 time to swallow properly. After completing the medication administration, CMA S made an inappropriate comment to R1, dismissing her distress. The facility's policy on abuse and neglect, revised in October 2022, mandates ensuring residents are free from neglect and taking precautions for their safety and well-being. However, the incident was not reported immediately by the witnesses, delaying the facility's awareness and response. The failure to adhere to the resident's care plan and the neglectful administration of medications resulted in a deficiency in the facility's care standards.
Failure to Report and Address Medication Administration Neglect
Penalty
Summary
The facility failed to ensure the safety and well-being of a dependent and cognitively impaired resident, identified as R1, who had a diagnosis of dysphagia, oropharyngeal phase, and ileus. The deficiency occurred when Certified Medication Aide (CMA) S continued to administer R1's morning medications despite R1's request to slow down due to difficulty swallowing. R1, who had a severely impaired cognition with a BIMS score of three, required a mechanically altered diet and had swallowing disorders that included coughing and choking during meals and swallowing medications. The care plan instructed staff to be patient and take time when administering medications, as R1 would become anxious and choke easily. On the morning of the incident, CMA S administered medications to R1, who was talking and screaming between bites of applesauce with her crushed medications. Despite R1's requests to stop and her visible distress, CMA S continued to administer the medications. Housekeeping/CNA U and Outside Resource Staff EE were present during the incident. Housekeeping/CNA U attempted to intervene by suggesting that CMA S wait before giving more medication and allow R1 to swallow and drink water. However, CMA S ignored these suggestions and continued administering the medications, later dismissing R1's distress by calling her a crybaby. The incident was not reported immediately to the administrative staff. Outside Resource Staff EE and Housekeeping/CNA U failed to report the incident to Administrative Staff A and Administrative Nurse D until five days later. The facility's Abuse and Neglect Policy requires all employees to report any abuse or neglect immediately to ensure residents' safety. The delay in reporting the incident contributed to the facility's failure to protect R1 from neglect, as the staff did not take timely action to address the inappropriate medication administration by CMA S.
Inadequate Weekend Staffing
Penalty
Summary
The facility failed to ensure adequate staffing levels on the weekends to meet the needs of the residents, which placed them at risk for impaired mental and physical well-being. The facility had a census of 37 residents, and the sample included 12 residents. A review of the CMS Payroll-Based Journal for FY 2023 Quarter 4 and FY 2024 Quarter 1 revealed excessively low weekend staffing. Resident Council members reported that activities rarely occurred on weekends compared to weekdays due to low staffing, and there was no activity person available on weekends. They expressed a desire for activities such as bingo or interactive groups on weekends. Administrative Staff A acknowledged that weekend staffing was low at times due to call-ins and lack of staff, although they stated it had improved. Activities Staff Z confirmed that there were no activities on weekends. CNA Q mentioned that previously there were activities on weekends, but now only church services were available on Sundays, leaving most residents to watch TV. CNA O and LN G both reported low staffing on weekends, with CNA O sometimes being the only CNA on the 2-10 shift, making it difficult to complete all duties. The facility did not provide a policy related to weekend staffing, leading to the deficiency in ensuring adequate staffing levels on weekends.
Failure to Conduct Yearly Performance Evaluations for CNAs
Penalty
Summary
The facility failed to ensure that five Certified Nurse Aides (CNAs) had the required yearly performance evaluations completed. The CNAs in question had been employed for more than 12 months, with hire dates ranging from 1997 to 2022. Upon request, no performance evaluations or in-service training records were found for these CNAs. Administrative Staff A confirmed the absence of these records and stated that going forward, each department head would conduct yearly performance evaluations. Administrative Nurse D also confirmed that no performance evaluations had been conducted since she assumed her position. The facility did not provide a policy related to staff competency, training, or performance evaluation, placing residents at risk for inadequate care.
Failure to Provide Required In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that five Certified Nurse Aides (CNAs) had the required 12 hours of in-service education, placing residents at risk for inadequate care. The facility had a census of 37 residents, and the sample included 12 residents and five CNAs. A review of the staffing list revealed that CNAs employed for more than 12 months had no recorded hours of in-service training. Specifically, CNA Q, CNA M, CNA BB, CNA R, and CNA S had no hours of in-service training recorded. Administrative Staff A and Administrative Nurse D confirmed the absence of performance evaluations and required in-service records for these CNAs. The facility did not provide a policy related to staff competency, staff training, or performance evaluation.
Failure to Post Accessible SSA Contact Information
Penalty
Summary
The facility failed to post the State Survey Agency (SSA) contact information in a manner accessible to residents and their representatives. During a walkthrough, it was observed that the SSA contact information was displayed on small 8x10 posters with small black writing, placed in locations that were not easily visible or readable. One poster was located by the main entry door to the television area, four feet high on the wall, and another was placed behind two Hoyer lifts in the center hall, six feet away from the view of the hall. Resident Council members and a cognitively intact resident reported they were not aware of the location of the SSA contact information or were unable to read the posters due to their small size and poor placement. A Licensed Nurse and an Administrative Nurse confirmed that the posters should be placed in highly visible areas and be large enough for residents to read, especially considering many residents have difficulty seeing small letters. The facility's policy on
Failure to Implement Anonymous Grievance System
Penalty
Summary
The facility failed to implement a system to allow residents and/or their representatives to file grievances anonymously. During an inspection, it was observed that there were no designated grievance drop boxes or systems available in areas accessible to residents and visitors. Interviews with Resident Council members revealed that they were unaware of any means to file anonymous grievances, and Social Services staff also confirmed the lack of such a system. The facility's grievance policy indicated that residents should be able to file grievances anonymously, but this was not being practiced. The Administrator stated that grievances could be filed through a corporate complaint line or by staff on behalf of residents, but acknowledged the absence of a posted grievance dropbox. This deficiency placed residents at risk for decreased psychosocial well-being and unresolved grievances. The facility's failure to provide a system for anonymous grievance filing was inconsistent with its own policy, which required documentation and prompt resolution of grievances, including anonymous submissions.
Failure to Update and Communicate Care Plans
Penalty
Summary
The facility failed to review and revise the care plan with resident-specific interventions for multiple residents, leading to impaired care due to uncommunicated care needs. For Resident 7, the care plan did not include instructions related to the low air-loss mattress or pump settings, despite the resident's significant risk for pressure ulcers. Observations revealed that the mattress pump was set incorrectly, and staff were unaware of the proper settings, which were not documented in the care plan or orders. This oversight placed the resident at risk for skin breakdown and discomfort. Resident 10's care plan lacked direction for a left-hand splint, despite documentation indicating the need for a splint/brace and a washcloth in the resident's hand to protect against contractures. Observations and interviews confirmed that the splint and washcloth were not being applied, and staff were unaware of these requirements. This failure to update and communicate the care plan interventions compromised the resident's care and increased the risk of further contracture development. Resident 25's care plan did not provide specific instructions for the application of hearing aids, which were essential for the resident's ability to participate in activities of daily living. Observations showed that the resident often did not have hearing aids in place, and staff were not consistently ensuring their use. Similarly, Resident 14's care plan lacked direction for weight monitoring related to congestive heart failure, and there were numerous instances where daily weights were not recorded or communicated to the physician. These deficiencies in care planning and communication placed the residents at risk for impaired care and unaddressed medical needs.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility failed to provide consistent weekend activities for its residents, which placed them at risk for decreased psychosocial well-being. A review of the facility's Activity Calendar for January, February, and March 2024 revealed no scheduled activities on Saturdays and Sundays, except for church services on Sunday afternoons. Resident Council members reported that activities rarely occurred on weekends compared to weekdays, attributing this to low staffing levels. They expressed a desire for more engaging activities such as bingo or interactive groups on weekends. Certified Nurses Aid (CNA) Q confirmed that activities used to be held on weekends but now were limited to church services, leaving residents with limited options like watching TV. Activities Staff Z corroborated the lack of weekend activities, stating that residents could read books or use coloring pages left out for them. The facility's Activities and Resident Rights policy, revised in October 2019, indicated that the facility would promote and advocate for residents' rights in the provision of recreation services and promote self-determination. However, the facility failed to adhere to this policy, resulting in a lack of consistent activities for residents during weekends, thereby affecting their psychosocial well-being.
Failure to Ensure Safe Environment and Proper Siderail Assessment
Penalty
Summary
The facility failed to ensure a safe environment free from hazardous materials for eight cognitively impaired independently mobile residents. During a walkthrough, an unlocked oxygen storage room containing 25 pressurized supplemental oxygen cylinders and an unsecured beauty shop with sanitizing chemical wipes were found. Staff confirmed that these areas should be secured to prevent accidents or injuries, but the facility lacked policies related to safe chemical and oxygen storage, placing residents at risk for preventable accidents. Additionally, the facility failed to assess and ensure Resident 25's siderails were mounted safely. Resident 25, who had severe cognitive impairment and a history of falls, was observed with a loose left half siderail that created a significant gap between the rail and the bed frame. Despite staff attempts to tighten the siderail, it remained loose, and there was no evidence of alternatives tried before the use of siderails or documentation of risk versus benefits explained to the resident or their legal representative. The facility's failure to secure hazardous materials and properly assess and maintain siderails placed the affected residents at risk for preventable accidents and injuries. The lack of policies and proper documentation further contributed to the unsafe environment, highlighting significant deficiencies in the facility's safety protocols.
Inadequate Infection Control Standards
Penalty
Summary
The facility failed to ensure adequate infection control standards related to enhanced barrier precautions, laundry services, and sanitary care practices. Multiple residents with medical devices such as Foley catheters, PEG tubes, and surgical wounds were not placed on enhanced barrier precautions, as indicated by the lack of documentation in their electronic medical records (EMRs) and the absence of necessary signage and personal protective equipment (PPE) outside their rooms. Additionally, observations revealed that clean linen was improperly stored, with sheets touching the floor and clean clothing transported uncovered in the hallway. Oxygen tubing was also found improperly stored, either on the floor or wrapped around oxygen canisters, increasing the risk of contamination. Housekeeping staff were observed transporting clean linen and clothing on uncovered carts, and soiled incontinence briefs were left in the hallway, further compromising sanitary conditions. Interviews with staff, including CNAs and licensed nurses, indicated a lack of training and awareness regarding enhanced barrier precautions. Staff members admitted to not performing hand hygiene between glove changes and were unaware of the new requirements for enhanced barrier precautions. The facility's Infection Management Process policy, revised in November 2023, did not include information on enhanced barrier precautions, highlighting a gap in the facility's infection control education and practices. This deficiency placed residents at risk for infectious diseases due to inadequate infection control measures and staff training.
Failure to Provide Effective Pest Control
Penalty
Summary
The facility failed to provide effective pest control, resulting in a significant cockroach infestation. An inspection of the facility's pest sighting log revealed that cockroaches were last seen on 07/07/23 in the north hall soiled utility room. Despite contracting a pest control company to spray monthly, the last recorded treatment was in March 2024. During a walkthrough on 04/01/24, a large number of cockroaches were observed in the north hall Handicapped Women's Bathroom. Interviews with staff confirmed awareness of the infestation, with reports indicating the problem had persisted for seven years. The facility lacked a policy related to pest control, contributing to the ongoing issue and placing residents at increased risk for impaired comfort and disease.
Failure to Issue Medicare Non-Coverage Notification
Penalty
Summary
The facility failed to issue the CMS Notification of Medicare Non-Coverage Form 10123 (NOMNC) to two residents, R88 and R89, at the end of their Medicare Part A episodes. R88's Medicare Part A episode began on 12/09/23 and ended on 12/21/23, while R89's episode began on 9/27/23 and ended on 11/03/24. Both residents did not remain in the facility for custodial care. The facility was unable to provide documentation that the NOMNC was issued for either resident. Administrative Staff A was unable to locate the forms or any documentation indicating that the residents had received the NOMNC. Additionally, the facility did not provide a policy for beneficiary notification. This failure placed the residents at risk for decreased autonomy and impaired decision-making.
Failure to Provide Written Notice of Transfer or Discharge
Penalty
Summary
The facility failed to provide written notice of transfer or discharge for a resident's facility-initiated transfers to the hospital. The resident, who had diagnoses of congestive heart failure, hypertension, and a contracture, was documented to have moderately impaired cognition and required extensive assistance for transfers. Despite multiple hospitalizations, the facility did not provide evidence of written notice to the resident's legal representative for any of these transfers. The resident's care plan indicated that staff should assist in maintaining his level of care and prevent a decline in his ability to participate in his care. However, the facility was unable to provide a policy related to transfers and discharges and admitted that no written notices were given for the resident's hospitalizations. This failure placed the resident at risk of uninformed choices and miscommunication regarding care needs.
Failure to Provide Bed Hold Notice for Hospitalized Resident
Penalty
Summary
The facility failed to provide a bed hold notice when Resident 10 was hospitalized. This deficiency was identified through observation, record review, and interviews. Resident 10, who had diagnoses of congestive heart failure, hypertension, and a contracture, was hospitalized multiple times. Despite these hospitalizations, the facility did not provide a bed hold notice to the resident or his legal representative. This failure was confirmed by Administrative Staff A, who acknowledged that no bed hold notice had been given for any of Resident 10's hospitalizations. Additionally, the facility was unable to provide a policy related to transfers and discharges upon request. Resident 10's medical records indicated moderately impaired cognition and required extensive assistance for transfers. The resident's care plan aimed to maintain his level of care and prevent a decline in his ability to participate in his care. Despite these documented needs, the facility's failure to provide a bed hold notice placed Resident 10 at risk of uninformed choices. The lack of a bed hold notice was observed on multiple occasions, and the facility did not have a policy in place to address this issue.
Failure to Assist Resident with Hearing Aids
Penalty
Summary
The facility failed to ensure that a resident, identified as R25, received the necessary assistance with his hearing aids, which are crucial for his ability to communicate and participate in activities of daily living (ADLs). R25's medical records indicated diagnoses of congestive heart failure, hypertension, depression, and cognitive communication deficit. The Minimum Data Set (MDS) documented that R25 had severely impaired cognition and required substantial to maximum assistance with personal hygiene. Despite this, the care plan lacked specific instructions for staff regarding the application of R25's hearing aids. Multiple observations noted that R25 was without his hearing aids, leading to difficulties in communication with peers and staff. On one occasion, a staff member mistakenly instructed R25 to discard his hearing aids, which were wrapped in a Kleenex, resulting in their loss. Although an old pair of hearing aids was found and used, there was no designated staff responsible for ensuring R25 wore his hearing aids regularly. The facility also lacked a policy related to maintaining a resident's hearing aids. The deficiency was highlighted through several incidents where R25 was observed without his hearing aids, leading to his inability to hear and communicate effectively. Staff interviews revealed a lack of awareness and responsibility regarding the management of R25's hearing aids. The administrative nurse acknowledged the loss of the hearing aids but was unaware of any specific staff assigned to assist R25 with them. This oversight placed R25 at risk for increased confusion, negative psychosocial outcomes, and decreased dignity, as he was unable to participate fully in ADLs and communicate with others.
Failure to Follow Physician's Order for Daily Weights
Penalty
Summary
The facility failed to follow a physician's order for daily weights to monitor for fluid overload for Resident 14, who had diagnoses including congestive heart failure (CHF), neuromuscular dysfunction of the bladder, dysphagia, and aphasia. The resident's care plan, revised on 08/25/22, did not include directions related to weight monitoring for CHF, despite a physician's order dated 04/27/21 for daily weights. A review of the Medication Administration Record (MAR) from 02/17/24 to 04/03/24 showed multiple instances where the resident's weight was not recorded, and there was no documentation of physician notification or evidence that the resident refused to be weighed. Observations and interviews revealed that the facility staff were aware of the missed weights but did not consistently notify the physician or take corrective actions. Certified Nursing Aide (CNA) O mentioned that nurses usually informed CNA staff if residents needed to be weighed, while Licensed Nurse (LN) G admitted to occasionally not having time to obtain weights or notify the physician. Administrative Nurse D acknowledged that staff were behind on obtaining weights and mentioned plans to have the restorative aide or herself complete the task. The facility did not provide a policy for quality of care or following physician orders, contributing to the deficiency and placing Resident 14 at risk for delayed treatment related to fluid overload and untreated illness.
Incorrect Low Air-Loss Mattress Settings
Penalty
Summary
The facility failed to ensure that a resident's pressure-reducing interventions were implemented correctly. Specifically, the low air-loss mattress pump for a resident with morbid obesity, COPD, muscle weakness, and respiratory failure was set incorrectly for his weight. The resident's care plan and electronic medical records lacked documentation and instructions related to the correct settings for the low air-loss mattress. Observations revealed that the pump was set for a weight range of 400-450 lbs, while the resident weighed 338 lbs. Interviews with staff indicated a lack of clarity on who was responsible for checking and setting the pump, and there was no evidence of in-service training related to the use of low air-loss beds. The resident's care plan indicated he was at risk for skin breakdown and pressure ulcers and required repositioning every two hours. Despite this, the care plan did not include specific instructions for the low air-loss mattress settings. The facility's Wound Prevention and Management policy stated that pressure redistribution mattresses and devices should be used appropriately and assessed regularly. However, the facility did not ensure that the mattress pump was set correctly, placing the resident at risk for complications related to skin breakdown and pressure ulcers.
Failure to Prevent Worsening of Contractures
Penalty
Summary
The facility failed to ensure that Resident 10 received appropriate services and treatment to prevent the worsening of contractures in his left hand. Despite the resident's medical record indicating the need for a splint, washcloth, or carrot in his left hand to prevent contractures, these measures were not consistently applied. Observations over several days revealed that the resident's left hand was not equipped with the necessary splint or washcloth, and staff interviews confirmed a lack of awareness and inconsistent application of the prescribed interventions. The resident's care plan and electronic medical record documented the need for these interventions, but there was no evidence that they were being followed, leading to a risk of further decline and discomfort for the resident. The resident's medical history included diagnoses of congestive heart failure, hypertension, and a contracture in his left hand. The resident had moderately impaired cognition and required extensive assistance for most activities of daily living. Despite these needs, the facility's staff, including CNAs and licensed nurses, were not consistently implementing the restorative program as outlined in the resident's care plan. The facility's policy on restorative programs emphasized the importance of maintaining residents' functional abilities, but this was not reflected in the care provided to Resident 10, resulting in a deficiency in care and an increased risk of further impairment for the resident.
Failure to Ensure Sanitary Catheter Care for Resident
Penalty
Summary
The facility failed to ensure a resident received sanitary catheter care by not providing education on performing sanitary catheter care and not assessing the resident's ability to self-perform catheter care. The resident, who had diagnoses including weakness, acute respiratory failure with hypoxia, diabetes mellitus, and neuromuscular dysfunction of the bladder, was documented to have an indwelling catheter and required extensive assistance for toileting. Despite this, the resident reported performing her own catheter care without any education or evaluation from the staff, and staff confirmed they did not perform catheter care for the resident, only perineal care. Observations and interviews revealed that the resident's catheter care was not being monitored or documented properly. The resident's urine collection bag was hung on the back of her wheelchair, and she stated she used personal wet wipes for catheter care. Staff, including a CNA and a licensed nurse, were unaware of the resident's self-performance of catheter care and did not monitor it. The administrative nurse also did not know how the resident's self-performance was being monitored and stated she would clarify if education was needed. The facility did not provide a policy on request, indicating a lack of proper protocol and oversight in ensuring sanitary catheter care for the resident.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to obtain accurate weights as ordered by the medical provider for a resident (R4) who had multiple medical conditions, including cognitive communication deficit, dysphagia, COPD, muscle weakness, and abnormal weight loss. R4 was admitted with a weight of 143.8 lbs. and had an order for weekly weights due to his enteral feeding tube. However, the facility did not document any weights after 03/04/24, despite the physician's order for weekly monitoring. This lack of documentation and monitoring placed R4 at risk for complications related to weight loss. Observations and interviews with staff revealed that the facility's policy required weights to be taken and documented per physician orders, and any missed weights or refusals should be reported and re-attempted. Despite this policy, R4's weights were not consistently monitored or documented, and staff interviews indicated a lack of adherence to the weight monitoring protocol. The facility's failure to follow the physician's orders and its own policy for weight monitoring led to the deficiency, putting R4 at risk for further health complications.
Failure to Ensure Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care and services for two residents, R33 and R2, placing them at risk for respiratory complications. R33, who had severe cognitive impairment and required assistance with activities of daily living, was observed without his oxygen cannula in place, and the cannula was improperly stored wrapped around the handle of the oxygen canister. Staff acknowledged that this was an inappropriate storage method and that the facility lacked a policy for oxygen use, leading to unsanitary conditions for R33's oxygen equipment. R2, who had intact cognition and a history of acute respiratory failure with hypoxia, was observed using supplemental oxygen without a current physician's order. Although R2 was able to apply her oxygen independently, the facility failed to ensure that her oxygen use was documented in her Electronic Medical Record (EMR) with a valid physician's order. Staff were unsure if the order needed to be in the EMR, and it was revealed that the previous order had been discontinued. The facility also lacked a policy for physician orders, contributing to the oversight in R2's care.
Failure to Document Consent and Ensure Safety of Siderails
Penalty
Summary
The facility failed to ensure that a resident (R25) had documented consent for the use of siderails, did not show that alternative methods were attempted, and did not inform the resident and/or their representative of the risks and benefits associated with the use of siderails. R25's electronic medical record (EMR) documented diagnoses of congestive heart failure, hypertension, depression, and cognitive communication deficit. The resident had severe cognitive impairment and was dependent on staff for all activities of daily living. Despite these conditions, the facility did not provide evidence of documented consent for the use of siderails, nor did it show that alternative methods were tried before resorting to siderails. Additionally, there was no documentation that the risks and benefits of siderail use were explained to the resident or their legal representative. Observations revealed that R25's left half siderail was loose and created a significant gap between the rail and the bed frame, posing a safety risk. Staff interviews indicated that the siderail frequently came loose and was manually tightened by CNAs. The facility was unable to provide a policy related to the use of siderails and did not have documentation of safety checks being performed on the siderails. This lack of documentation and failure to follow proper procedures placed the resident at risk for uninformed decisions regarding siderail use and potential safety hazards due to the loose siderail.
Failure to Ensure Staff Competency in Medication Administration
Penalty
Summary
The facility failed to ensure that staff possessed the appropriate skills and knowledge to administer Midodrine to a resident (R30) with hypotension, muscle weakness, major depressive disorder, and aphasia. The resident's Electronic Medical Records (EMR) included a physician's order to administer ten milligrams of Midodrine three times daily, with instructions to hold the medication if the systolic blood pressure (SBP) was greater than 100 mmHg. However, the Medication Administration Report (MAR) for March 2024 indicated that the medication was given outside of the provided parameters on 37 occasions, with one Licensed Nurse (LN) administering it incorrectly on 20 of those occasions. The nurse admitted to not understanding the medication order or its indication before administering it outside the parameters. The facility's in-service schedule showed no recent medication-based training in February or March of 2024, and the facility did not provide a policy related to staff competency, training, or performance evaluation. Interviews with the nursing staff revealed a lack of understanding and training regarding the medication orders. The Administrative Nurse confirmed that no in-service training related to physician orders or medications had been provided since the previous year. This deficiency placed the resident at risk for impaired quality of care due to the improper administration of medication.
Failure to Follow Consultant Pharmacist Recommendations and Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure the Consultant Pharmacist (CP) identified and reported the need for physician-documented rationale for the continued use of antipsychotic medication for a resident diagnosed with dementia. The resident's electronic medical record (EMR) showed diagnoses including diabetes mellitus, congestive heart failure, dementia, hallucinations, and edema. Despite the resident's severely impaired cognition and dependence on staff for most activities of daily living, the monthly medication reviews from April 2023 to March 2024 lacked evidence of recommendations for physician documentation for the continued use of the antipsychotic medication. This oversight placed the resident at risk for unnecessary psychotropic medication and related complications. Additionally, the facility failed to follow the CP's recommendations regarding another resident's Midodrine administration, which was given outside of the physician-provided parameters repeatedly. The resident's EMR included diagnoses of hypotension, muscle weakness, major depressive disorder, and aphasia. The medication administration report for March 2024 indicated that the medication was given outside the parameters on 37 occasions, with one licensed nurse responsible for 20 of these instances. Despite the CP identifying these occurrences and instructing the facility to educate staff on medication administration, no facility response was noted, and no recent medication-based training had occurred. The facility's Medication Regimen Review and Reporting policy indicated that the CP would complete monthly medication reviews and provide appropriate recommendations for identified medication concerns. However, the facility failed to ensure the CP identified and reported an inappropriate indication for the antipsychotic medication and did not follow the CP's recommendations regarding the Midodrine administration. These deficiencies placed the residents at risk for adverse medication effects and unnecessary psychotropic medication use.
Failure to Monitor Medications and Follow Physician Orders
Penalty
Summary
The facility failed to provide adequate pulse monitoring for a resident (R4) who was prescribed metoprolol, an anti-hypertensive beta-blocker. Despite the physician's order to monitor the resident's pulse before administering the medication, the facility's records showed that pulse monitoring was only conducted in the morning and not for the evening dosage. This oversight was confirmed by both a licensed nurse and an administrative nurse, who acknowledged that pulse checks should be documented each time the medication was administered. The facility's medication administration policy also emphasized the importance of proper monitoring, but it was not followed in this case, placing the resident at risk for adverse medication effects and unnecessary medications. Another resident (R3) was also affected by the facility's failure to follow physician orders. R3, who had multiple diagnoses including diabetes mellitus, congestive heart failure, and dementia, was prescribed several medications, including insulin and an antipsychotic with a Black Box Warning. The physician had ordered a series of laboratory tests to be conducted every three months to monitor the resident's condition and medication effects. However, the facility was unable to provide evidence that these tests were completed as ordered. The administrative nurse confirmed that the tests had not been conducted as required, and the facility lacked a policy to ensure compliance with physician orders. These deficiencies highlight significant lapses in the facility's medication administration and monitoring processes. The failure to adequately monitor R4's pulse before administering metoprolol and the failure to conduct ordered laboratory tests for R3 placed both residents at risk for adverse medication effects and unnecessary medications. The facility's inability to adhere to its own policies and physician orders underscores the need for improved oversight and compliance in medication management.
Failure to Ensure Appropriate Indication for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure an appropriate indication or documented physician rationale for the continued use of the antipsychotic medication olanzapine for a resident (R3). R3's electronic medical record indicated diagnoses of diabetes mellitus, congestive heart failure, dementia, hallucinations, and edema. Despite these conditions, the clinical record lacked evidence of multiple unsuccessful attempts for nonpharmacological symptom management and a risk versus benefits analysis for the continued use of olanzapine. The resident's care plan noted the use of olanzapine for dementia, but there was no documented rationale from the physician to justify its continued use. Observations and interviews revealed that staff were unclear about appropriate indications for antipsychotic medication use. A licensed nurse believed that residents with dementia and behaviors should receive antipsychotic medication, while an administrative nurse stated that a diagnosis of schizophrenia would be an appropriate indication. The facility's policy required assessments for appropriate diagnoses and target behaviors related to psychotropic medication use, but this was not followed in R3's case. This placed the resident at risk for unnecessary psychotropic medication effects.
Failure to Prevent Significant Medication Error
Penalty
Summary
The facility failed to prevent a significant medication error for a resident diagnosed with hypotension, muscle weakness, major depressive disorder, and aphasia. The resident's physician had ordered Midodrine to be administered three times daily with specific parameters to hold the medication if the systolic blood pressure (SBP) was greater than 100 mmHg. However, the medication was administered outside of these parameters on 37 occasions, with one licensed nurse responsible for 20 of these errors. The consulting pharmacist had identified similar errors in the previous month and recommended staff education, but no facility response or in-service training was documented. Interviews with the licensed nurse revealed a lack of understanding of the medication's purpose and parameters. The administrative nurse confirmed that staff were expected to review orders before administering medications and that no recent training had been provided. The facility's medication administration policy emphasized proper training and consultation with medical providers, but this was not adhered to, leading to repeated medication errors and placing the resident at risk for adverse effects.
Failure to Implement Communication Process with Hospice Provider
Penalty
Summary
The facility failed to ensure a communication process was implemented between the facility and the hospice provider, leading to a lack of documentation of services and equipment provided to Resident 25 by hospice. Resident 25, who had diagnoses of congestive heart failure, hypertension, depression, and cognitive communication deficit, was dependent on staff for all activities of daily living and had severe cognitive impairment. The care plan indicated that hospice would provide certain services, but the hospice communication book lacked recent documentation of these services, with the last entry dated several months prior. This created a risk for missed or delayed services and impaired care for Resident 25. Observations and interviews revealed that Resident 25 was without his hearing aids and unable to hear conversations, indicating a lapse in care coordination. Licensed Nurse G and Certified Nurse Aide O were unsure about the documentation process and the inclusion of hospice services in the care plan. Administrative Nurse D confirmed that the care plan should include all services and equipment provided by hospice and that the hospice provider's visits should be documented for facility staff to review. The facility was unable to provide a policy related to hospice services, further highlighting the communication gap.
Failure to Document Pneumococcal Vaccination Status
Penalty
Summary
The facility failed to provide consent, declination, or documentation of ineligibility for pneumococcal vaccinations for three residents, identified as R2, R19, and R33. R2's electronic medical record (EMR) indicated she had previously refused the Prevnar 13 and Pneumovax 23 vaccinations and received an unidentified pneumococcal vaccination from the Kansas Department of Health and Environment. However, the EMR lacked documentation of consent, declination, or ineligibility for the offered pneumococcal vaccinations, as well as documentation related to the education provided and the risks associated with the vaccinations ordered. Similarly, R19's and R33's EMRs lacked documentation indicating their pneumococcal immunization status, consent, declination, or ineligibility for the vaccinations, and any related education or risk information provided to them. This deficiency was identified during a review conducted on 04/02/24 at 10:03 AM and was confirmed through interviews with the facility's administrator and administrative nurse, who acknowledged the missing documentation and the need for a better tracking system for immunizations. The facility's vaccination policy, revised in February 2023, indicated that the facility would screen and offer influenza and pneumococcal immunizations based on CDC recommendations and track each resident's immunization status in the EMR. Despite this policy, the facility failed to adhere to these guidelines, resulting in the lack of necessary documentation for the three residents. The administrator attributed the missing documentation to changes in staffing, while the administrative nurse admitted that the facility was behind on vaccinations and was in the process of developing a system to better track and audit immunization documentation. This failure to document consent, declination, or ineligibility for pneumococcal vaccinations placed the residents at risk for complications related to pneumococcal diseases.
Failure to Document COVID-19 Immunizations
Penalty
Summary
The facility failed to provide proper documentation for a resident's COVID-19 immunizations. Specifically, the electronic medical record (EMR) for one resident lacked documentation indicating whether she received or was offered COVID-19 immunizations. The EMR also did not include consent, declination, or documentation of ineligibility for the vaccinations, nor did it contain information about the education provided regarding the risks associated with the vaccinations. This deficiency was identified during a review of COVID-19 immunization records for five residents. Interviews with facility staff revealed that the missing documentation was due to changes in staffing and that the facility was behind on their vaccinations. The administrative nurse acknowledged the issue and mentioned that a system was being developed to better track and audit needed immunization documentation. The facility's policy indicates that they will follow CDC guidelines related to immunizations and document the offering, administration, and declination of vaccinations in the resident's EMR. However, this policy was not followed in the case of the resident in question, placing her at risk for complications related to infectious diseases.
Failure to Provide Mail Services on Saturdays
Penalty
Summary
The facility failed to ensure residents received their mail services on Saturdays. The deficiency was identified through observations, record reviews, and interviews with residents and staff. Resident Council members reported that mail services were not provided on Saturdays, with mail only being delivered from Monday to Friday. The Activities Coordinator confirmed that there was no one available to pick up and distribute mail on Saturdays. The Administrative Nurse also stated that she handled mail delivery during weekdays but was not present on Saturdays. The facility did not provide a policy related to mail delivery, leading to the failure in ensuring residents received their mail on Saturdays.
Failure to Post State Inspection Survey Results
Penalty
Summary
The facility failed to post the previous state inspection survey results in a location accessible to residents and visitors. During an initial walkthrough, a sign indicating 'Survey Results' was found in the main lobby, but no survey results were visible in the surrounding area. The resident council reported being unaware of the survey book's location, and an inspection revealed no posted survey results accessible to residents or their representatives. The Administrator stated that the survey binder had been in the Administrative Nurse's office and was later moved back to the main lobby. The facility did not provide a policy regarding the posting of survey results.
Failure to Retain Daily Nursing Staffing Data
Penalty
Summary
The facility failed to retain the daily posted nursing staffing data for the required 18 months. The facility identified a census of 37 residents. Upon review, it was found that the daily posted nursing staffing data for January 2023 (31 days) and February 2023 (28 days) was missing. Administrative Nurse D, who was responsible for maintaining and filing the posted staffing data, confirmed that all available data had been provided for review. The facility's policy, last reviewed in December 2019, required that the previous day's staffing form be removed and filed in the business office for an 18-month period. However, this procedure was not followed, resulting in the missing data for the specified months.
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Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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