Medicalodges Frontenac
Inspection history, citations, penalties and survey trends for this long-term care facility in Frontenac, Kansas.
- Location
- 206 S Dittman Street, Frontenac, Kansas 66763
- CMS Provider Number
- 175363
- Inspections on file
- 21
- Latest survey
- March 20, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Medicalodges Frontenac during CMS and state inspections, most recent first.
A resident with depression, limited mobility, and a history of impaired safety awareness exited the facility unattended in a motorized wheelchair. The care plan and elopement risk assessments did not initially identify the resident as at risk, and staff were unaware of the exit when a family member deactivated the door alarm without notification. The resident was found and returned without injury after being outside for approximately 20 minutes.
The facility did not accurately post daily nurse staffing information, as required, by failing to record the actual hours worked by licensed and unlicensed nursing staff on the daily staffing sheets. This deficiency was confirmed by an administrative nurse and was not in accordance with the facility's policy.
The facility did not conduct annual performance reviews for three CNAs employed for over a year, as required by their Employee Handbook. The CNAs lacked documented evaluations in their personnel files, and Administrative Nurse D acknowledged that the evaluations were not current.
The facility failed to submit accurate direct care staffing information to CMS for Quarters 1, 2, and 3 of 2024. The PBJ Staffing Data Report showed low weekend staffing levels, despite schedules indicating similar staffing to weekdays. Administrative Staff A confirmed the inaccuracy, and the facility lacked a policy for PBJ reporting.
A facility failed to provide a sanitary dressing change for a resident with a stage three pressure ulcer, as a nurse placed supplies on an unsanitized surface. The facility also inadequately tracked infections, lacking culture results and compliance with McGeers criteria. Additionally, PPE and COVID-19 testing supplies were improperly stored on the floor, with no policy in place for storage.
The facility failed to ensure safe transfer practices for two residents with severe cognitive impairment, leading to unsafe transfers due to inadequate weight-bearing and improper use of assistive devices. Additionally, an unlocked janitor's closet containing harmful chemicals was found in a resident hall with confused residents, posing a safety risk. The facility lacked policies for safe transfers and chemical security.
The facility failed to maintain a safe, sanitary, and homelike environment in two resident rooms and one hallway. A strong urine odor was detected in the west hallway and inside a resident room. Black streaks were observed on a wall beside a resident's bed, caused by a positioning bar scraping against it. Another room had yellow-brown stains on the ceiling. These issues were confirmed by staff during an environmental tour, indicating a lapse in following the facility's housekeeping policy.
A facility failed to obtain a signed bed hold for a resident admitted to a hospital with a UTI and sepsis. The resident's EMR lacked documentation of a signed bed hold, which was confirmed by an administrative nurse. The facility's policy requires a written notice of bed hold policies at the time of transfer to a hospital.
A facility failed to create a comprehensive care plan for a resident with incontinence issues, leading to frequent urine saturation of the bed and a strong urine odor in the room. The resident, who requires maximum assistance and often refuses care, was not provided with specific instructions for check and change frequency or interventions for care refusal. Staff were unaware of the resident's care refusals, and the facility lacked a policy for care plan development.
A resident with dementia, dependent on staff for personal hygiene, was not regularly shaved, despite being unable to communicate his needs. Observations showed the resident with long, unshaven facial hair, and interviews revealed staff only shaved residents on shower days. The facility lacked a specific ADL policy, contributing to this oversight.
A resident with a history of urinary tract infections and incontinence was not provided adequate toileting opportunities, leading to frequent incontinence episodes and a strong urine odor in the room. Despite being able to communicate needs, the resident often refused care, and staff were not fully informed or equipped to manage the situation effectively. The facility failed to conduct a thorough assessment and develop an optimal toileting plan, increasing the risk of further infections.
A facility failed to follow antibiotic stewardship principles, leading to inappropriate antibiotic use for a resident with a history of UTIs. Despite a physician's order for cefdinir based on a culture report, a subsequent urine sample showed no UTI. Macrodantin was later prescribed without a supporting culture report, and cefuroxime axetil was administered based on susceptibility to proteus mirabilis. The facility did not adhere to its policy requiring review of lab results to support antibiotic use.
The facility failed to ensure adequate staff for safe mechanical lift transfers, leading to single-staff transfers for 12 residents, contrary to professional standards and safety guidelines. This practice placed the residents in immediate jeopardy.
The facility failed to ensure nursing personnel had the necessary competencies to safely transfer residents using mechanical lifts, often conducting transfers with only one staff member instead of the required two. This practice was against professional standards, OSHA guidelines, FDA guidelines, and manufacturers' recommendations, posing a significant safety risk to the residents.
Failure to Prevent Unattended Exit of Resident at Risk for Elopement
Penalty
Summary
A resident with a diagnosis of depression, limited range of motion in one upper extremity, and who used a motorized wheelchair, exited the facility unattended. The resident was assessed as having intact cognition but required substantial to maximal assistance for transfers. The care plan was not updated to reflect the resident's risk for elopement until after an incident where the resident attempted to exit the facility. Prior to this, the resident's elopement assessment did not indicate risk, and there was no documentation of wandering behavior. On the day of the incident, the resident was last seen in the dining room awaiting dinner. Video surveillance showed the resident leaving through the front doors in his wheelchair, triggering the door alarm. A family member of another resident deactivated the alarm and did not notify staff. Staff were unaware of the resident's exit until notified by an external party, and the resident was retrieved approximately 20 minutes later without injury. The facility's elopement book, which contained information on at-risk residents, did not include this resident at the time of the incident.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to display accurate, publicly accessible, and identifiable daily nurse staffing information for its 38 residents. Review of the Daily Staffing Sheets from 01/01/25 through 03/19/25 showed that the actual hours worked by nursing staff were not completed on the forms as required. On 03/20/25, an administrative nurse confirmed that the forms did not include the actual hours worked. The facility's policy, revised in 12/19, requires that the actual hours worked by licensed and unlicensed nursing staff responsible for resident care be recorded on the Daily Staff Posting form.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to conduct annual performance reviews for three Certified Nurse Aides (CNAs) who had been employed for over a year. Specifically, CNA R, hired on October 18, 2019, CNA MM, hired on December 15, 2022, and CNA NN, hired on May 17, 2022, did not have documented annual performance evaluations in their personnel files. The facility's Employee Handbook states that annual performance evaluations are necessary to assist employees in improving their performance and identifying areas of excellence and improvement. On November 18, 2024, Administrative Nurse D confirmed that the staff's annual evaluations were not up to date.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to electronically submit accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for Quarters 1, 2, and 3 of 2024. The deficiency was identified through interviews and record reviews, revealing that the facility's Payroll Base Journal (PBJ) Staffing Data Report showed excessively low weekend staffing levels. Despite the staffing schedules indicating that weekend staffing was the same as during weekdays, the PBJ reporting was found to be inaccurate. Administrative Staff A acknowledged the inaccuracy of the PBJ reporting, and it was noted that the facility lacked a policy for reporting PBJ hours. This failure to report accurate staffing information occurred from January 1, 2024, through December 31, 2024.
Infection Control and Sanitation Deficiencies
Penalty
Summary
The facility failed to provide a sanitary dressing change for a resident with a stage three pressure ulcer. During an observation, a licensed nurse placed dressing supplies directly onto the resident's overbed table without sanitizing it first. The nurse confirmed the oversight during an interview, acknowledging that the supplies should have been placed on a sanitized surface. The facility's policy required staff to clean a surface and provide a clean field for dressing supplies, which was not followed in this instance. The facility also failed to adequately track and trend infections and causative organisms. The Infection Surveillance Monthly Reports from May to October 2024 documented multiple residents with urinary tract infections (UTIs) but lacked culture results and compliance with McGeers criteria. Interviews revealed that the facility had three different infection preventionists over the past year, and the current one was new to the role. The facility's policy required staff to analyze infection data routinely and base antibiotic initiation on specific organisms identified in lab results, which was not consistently done. Additionally, the facility did not store personal protective equipment (PPE) and COVID-19 testing supplies in a sanitary manner. During an environmental tour, several open and unopened boxes of PPE and COVID-19 tests were found resting directly on the floor in the utility room. Administrative staff confirmed that the boxes should not be stored on the floor, but the facility lacked a policy regarding the storage of supply boxes.
Unsafe Transfer Practices and Unsecured Chemicals in LTC Facility
Penalty
Summary
The facility failed to ensure safe transfer practices for two residents, leading to potential safety hazards. Resident 15, who had severe cognitive impairment and required maximum assistance for transfers, was observed being transferred without non-skid footwear, contrary to her care plan. Despite the use of a gait belt and assistance from two CNAs, the resident's inability to bear weight fully during transfers was not adequately addressed, as confirmed by the CNAs and the administrative nurse. The facility did not provide a policy regarding safe transfers, contributing to the unsafe transfer of this resident. Similarly, Resident 32, who also had severe cognitive impairment and required maximum assistance for transfers, was transferred using a sit-to-stand lift. However, the resident was unable to hold onto the lift handles properly, causing the lift belt to slide up into her armpits, placing her in a precarious position. This issue was noted during multiple transfers, and staff confirmed the resident's inability to bear full weight or hold onto the handles consistently. The facility again failed to provide a policy regarding safe transfers, resulting in unsafe transfer practices for this resident. Additionally, during an environmental tour, it was observed that a janitor's closet on the East Hall was unlocked, containing harmful cleaning chemicals. This area housed eight confused residents, posing a significant risk due to the accessibility of these chemicals. The facility did not provide a policy for managing unlocked chemicals, failing to ensure the safety of these residents by leaving potentially dangerous substances unsecured.
Failure to Maintain a Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, sanitary, and homelike environment in two resident rooms and one hallway. During an observation, a strong urine odor was detected in the west hallway near a resident room and inside the room itself. Additionally, there were multiple arched black streaks on the wall beside a resident's bed, caused by the positioning bar scraping against the wall. Another resident room on the west hall had two yellow-brown irregular circle-like stains on the ceiling, each measuring approximately 10 inches. These findings were confirmed by Administrative Staff A and Housekeeping Staff V during an environmental tour. The facility's policy on housekeeping, laundry, and maintenance, reviewed in February 2024, instructed staff to provide basic housekeeping services to resident living areas and utility and public areas, which was not adequately followed.
Failure to Obtain Signed Bed Hold for Hospitalized Resident
Penalty
Summary
The facility failed to provide a signed bed hold for Resident 14 upon their admission to an acute care hospital. The resident was admitted to the hospital with a diagnosis of a urinary tract infection and sepsis. Upon review of the resident's electronic medical record, it was found that there was no signed bed hold related to the hospitalization. Administrative Nurse D confirmed that the facility did not obtain a signed bed hold for the resident, despite the facility's policy requiring a written notice of bed hold policies to be provided to residents, family members, or legal representatives at the time of transfer to a hospital.
Failure to Develop Comprehensive Care Plan for Incontinent Resident
Penalty
Summary
The facility failed to develop a personalized comprehensive care plan for Resident 22, who has a history of cardiomyopathy, depression, and urinary tract infections. The resident, who is always incontinent of bowel and bladder, requires maximum assistance for care and often refuses incontinence care. Despite being able to communicate her needs, the care plan lacked specific instructions on the frequency of check and change programs, interventions for refusal of care, and enhancements to incontinence products to prevent frequent urine saturation of the bed. Observations revealed that the resident's room consistently had a strong urine odor, and the resident was often found in a slumped position in bed. The call light was out of reach and disconnected, which hindered the resident's ability to request assistance. Certified Nurse Aides reported that the resident's bed was frequently soaked with urine, and the resident did not always notify staff of the need for incontinence care. The resident was cooperative with care but often reported not needing to be changed when she was incontinent. Interviews with staff indicated a lack of awareness regarding the resident's refusal of incontinence care and the adequacy of the current check and change schedule. The facility did not provide a policy for the development of a comprehensive care plan, and there was no assessment of the urinary incontinence pattern or the effectiveness of the incontinence products used. This deficiency in care planning and execution compromised the resident's well-being and comfort.
Failure to Provide Regular Shaving for Dependent Resident
Penalty
Summary
The facility failed to provide regular shaving for a resident diagnosed with dementia, who was dependent on staff for personal hygiene. The resident's electronic medical record indicated moderate cognitive impairment and a need for substantial to maximum assistance with activities of daily living (ADLs), including facial shaving. Despite the resident's inability to communicate his needs, observations on multiple occasions revealed that the resident had long, unshaven facial hair, indicating a lack of regular shaving. Interviews with Certified Nurse Aides (CNAs) and an Administrative Nurse revealed that the facility's practice was to shave residents on their shower days. However, the resident in question was unable to request additional shaving due to his cognitive impairment. The facility did not have a specific policy for ADLs, which contributed to the oversight in ensuring the resident was shaven regularly, as he did not refuse care and was dependent on staff for his personal hygiene needs.
Inadequate Toileting Opportunities for Resident with Incontinence
Penalty
Summary
The facility failed to provide adequate toileting opportunities for a resident, identified as R22, who was always incontinent of bowel and bladder. R22 had a history of urinary tract infections and was on diuretics, which increased urine production. Despite being able to communicate her needs, R22 often refused incontinence care and was assessed to require maximum assistance from two staff members. Observations revealed that the resident's room frequently had a strong urine odor, and the resident was often found in a slumped position in bed, with the call light out of reach and disconnected. The facility's care plan instructed staff to encourage R22 to allow incontinence care and to notify the nurse if care was declined. However, staff interviews indicated that the resident did not consistently use the call light and often reported not needing to be changed, even when incontinent. Staff were instructed to check and change the resident every two hours, but observations showed that the resident's brief was often saturated, and urine had soaked through to the mattress. The facility's policy required a thorough assessment of the resident's urinary incontinence, including a three-day toileting diary, but it was unclear if this was completed. The facility's failure to conduct a thorough assessment of R22's urinary incontinence and to develop an optimal toileting plan contributed to the resident's frequent incontinence episodes and the strong urine odor in the room. The lack of a proper assessment and individualized care plan increased the risk of urinary tract infections, as evidenced by the resident's history of infections and recent antibiotic treatments. The facility did not ensure that staff were adequately informed or equipped to manage the resident's incontinence effectively.
Failure in Antibiotic Stewardship for UTI Treatment
Penalty
Summary
The facility failed to adhere to antibiotic stewardship principles, resulting in inappropriate antibiotic use for a resident with a history of urinary tract infections (UTIs). The resident, who had diagnoses including cardiomyopathy and depression, was assessed with no cognitive impairment and required significant assistance with incontinence care. Despite a physician's order for cefdinir based on a culture report showing susceptibility, a subsequent urine sample revealed no UTI. Later, Macrodantin was prescribed without a supporting culture report, and cefuroxime axetil was administered based on a culture report indicating susceptibility to proteus mirabilis. The facility's policy required staff to review clinical records for diagnostic or lab results supporting antibiotic use, but this was not followed for the Macrodantin order. An interview with the Administrative Nurse revealed that the antibiotic order came from an emergency room physician, and the facility did not receive the culture report. This oversight in obtaining culture results for the Macrodantin prescription compromised the facility's antibiotic stewardship efforts, potentially leading to multidrug-resistant bacterial infections.
Inadequate Staffing for Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure adequate staff to safely transfer residents using mechanical lifts, as required by professional standards, OSHA guidelines, FDA guidelines, and manufacturers' recommendations. The facility identified eight residents who required a full body mechanical lift and four residents who required a sit-to-stand mechanical lift for transfers. Nursing staff reported that they often performed these transfers without a second staff member due to a lack of available staff, which was confirmed by interviews with six residents who regularly experienced single-staff transfers. This practice placed the 12 residents in immediate jeopardy. During an onsite survey, it was observed that staff did not utilize two staff members for mechanical lift transfers, contrary to best practices and safety guidelines. Interviews with alert and oriented residents revealed that they were frequently transferred by a single staff member, despite their care plans specifying the need for two staff members. For example, one resident reported being transferred with one staff member for several months, and another resident confirmed that one staff member regularly transferred them using a full body mechanical lift. Interviews with various staff members, including CNAs and licensed nurses, indicated that the practice of single-staff transfers was common and had been ongoing for approximately three months. Some staff members admitted to transferring residents alone because it was quicker than waiting for assistance. The facility lacked a policy on mechanical lift transfers, and staff education on the requirement for two staff members during transfers was only provided during orientation. The facility's failure to ensure the safe transfer of residents using mechanical lifts with the required number of staff members led to the identification of immediate jeopardy for the 12 affected residents.
Removal Plan
- A Quality Assurance and Performance Improvement (QAPI) meeting held with the Medical Director.
- All nursing staff will receive education from the Director of Nursing or designee on the requirement to have two staff present for mechanical lift transfers and the resident transfer requirements to have two staff present for mechanical lift transfers and the resident transfer requirements located in the plan of care/Kardex.
- All nursing staff will complete a skills demonstration on mechanical lift transfers before their start of their next shift.
Failure to Ensure Safe Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that nursing personnel had the necessary knowledge, competencies, and skill sets to safely transfer residents using mechanical lifts, as per professional standards, OSHA guidelines, FDA guidelines, and manufacturers' recommendations. The facility identified twelve residents who required mechanical lifts for transfers, but staff frequently conducted these transfers with only one staff member present, contrary to the guidelines that mandate two staff members for safe operation. Interviews with six alert and oriented residents confirmed that staff regularly did not utilize two staff members for mechanical lift transfers, posing a significant safety risk to the residents involved. Resident 1, who required a sit-to-stand mechanical lift for transfers due to limited mobility, reported that nursing staff often transferred him with only one staff member. Similar reports were made by Residents 2 through 6, all of whom required either a full body or sit-to-stand mechanical lift and were supposed to be assisted by two staff members according to their care plans. These residents consistently reported that only one staff member was present during their transfers, which had been occurring for several months. Interviews with facility staff revealed a lack of awareness and adherence to the guidelines for mechanical lift transfers. Certified Nurse Aides (CNAs) admitted to transferring residents alone to save time, and there was no policy in place to ensure proper staffing for these transfers. Administrative and nursing staff were unaware of the single-staff transfers, and competencies for staff had not been updated for approximately a year. The facility lacked a staffing policy and failed to ensure staff competency and skill sets for the safe transfer of residents requiring mechanical lifts.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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