Medicalodges Iola
Inspection history, citations, penalties and survey trends for this long-term care facility in Iola, Kansas.
- Location
- 600 E Garfield Street, Iola, Kansas 66749
- CMS Provider Number
- 175226
- Inspections on file
- 21
- Latest survey
- August 12, 2025
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Medicalodges Iola during CMS and state inspections, most recent first.
Annual performance evaluations were not completed for five CNAs and CMAs who had been employed for over a year, despite facility policy requiring formal, written evaluations for all staff. Administrative staff confirmed that these evaluations were not conducted as required.
Surveyors identified unsanitary conditions in the kitchens, including dirty equipment, food debris, sticky floors, and improper hand hygiene by dietary staff. Staff interviews confirmed a lack of regular cleaning schedules and inconsistent adherence to facility policies for cleaning and sanitation.
The facility did not have a certified Infection Preventionist (IP) overseeing the infection prevention and control program. After the previous certified IP left, the current staff member assigned as IP was not certified, contrary to facility policy requiring certification for this role.
A Certified Medication Aide did not complete the required 12 hours of annual education, and administrative staff confirmed the absence of a facility policy on education. The aide verified not having completed the mandatory training, and no policy was provided by the facility.
Residents were not fully informed about their health status, care, and treatments. The facility did not provide adequate communication to ensure that residents understood their medical conditions and the care or treatments being administered.
Multiple areas of the facility, including a resident's room and the dining area, were found to be unclean and in disrepair, with sticky food debris, missing floor tiles creating unmarked tripping hazards, and damaged door frames and doors. Staff interviews confirmed that these issues persisted for weeks without adequate cleaning or safety measures, contrary to facility policy.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
Two residents had inaccurate Minimum Data Set (MDS) assessments, including errors in documenting fall history and medication use. One resident’s MDS failed to record all recent falls, including one with injury, while another’s MDS incorrectly listed anticoagulant use instead of antiplatelet therapy. Staff confirmed these inaccuracies, which resulted in the residents’ care needs not being properly identified.
Two residents did not have complete care plans addressing their specific needs: one with trigeminal neuralgia lacked non-pharmacological pain interventions in the care plan despite documented pain and medication orders, and another with respiratory failure did not have care plan instructions for oxygen use, even though oxygen therapy was ordered and administered.
A resident with severe cognitive impairment and an indwelling Foley catheter was transferred using a full body lift, during which staff attached the catheter drainage bag above bladder level, contrary to care plan instructions and standard practice. Staff interviews confirmed knowledge of proper catheter bag positioning, but this was not followed during the transfer. The facility did not provide a catheter care policy when requested.
A resident with trigeminal neuralgia did not receive scheduled doses of carbamazepine and lidocaine viscous solution due to a failure to reorder medications in a timely manner, resulting in increased pain and observed facial grimacing. The care plan lacked non-pharmacological interventions, and the facility's pain management policy was not fully implemented.
Staff failed to maintain resident dignity and privacy by transporting a resident through common areas in a shower chair with exposed buttocks and by entering the rooms of three residents without knocking, introducing themselves, or waiting for acknowledgment. Staff interviews confirmed awareness of proper protocols, and facility policy emphasized residents' rights to dignity and privacy.
A resident reported being roughly handled by a CNA, causing dizziness, nausea, and difficulty breathing due to improper bed positioning and lack of oxygen. Despite activating her call light and yelling for help, she did not receive assistance for hours. The incident was not immediately reported to administrative staff, allowing the CNA to continue her shift, placing other residents at risk.
A resident reported that a CNA was rough during a transfer, causing dizziness and difficulty breathing. The resident's call for help was ignored, and the CNA responded rudely. The incident was not reported to administrative staff immediately, allowing the CNA to continue working for eight more hours, putting other residents at risk.
A resident experienced abuse and neglect when a CNA was rough during a transfer, causing dizziness and difficulty breathing. The resident's call light was ignored for hours, and staff failed to report the incident immediately, allowing the CNA to continue working and potentially placing other residents at risk.
A cognitively impaired resident with a history of elopement risk exited the facility unnoticed due to a deactivated door alarm. The resident was found outside by a visitor, highlighting lapses in supervision and safety protocols.
Failure to Complete Annual Performance Evaluations for CNAs and CMAs
Penalty
Summary
The facility failed to complete annual performance evaluations for five Certified Nurse Aides (CNAs) and Certified Medication Aides (CMAs) who had been employed for more than 12 months. Personnel records reviewed showed that these evaluations had not been conducted within the required timeframe, as outlined in the facility's Employee Handbook, which mandates formal, written evaluations for all full and part-time employees. During an interview, administrative staff confirmed awareness of the requirement but acknowledged that the evaluations were not completed for the selected staff members.
Unsanitary Food Storage and Preparation Conditions Identified
Penalty
Summary
Surveyors observed multiple unsanitary conditions in the facility's kitchens, including dried food debris on the automated dishwasher, food particles and storage bags on top of the ice maker, and dirty, dusty fans blowing into food preparation and dish cleaning areas. The kitchen floors were found to be sticky, slick, and littered with food items and trash, while trash cans and counters were visibly dirty. Seven plastic cutting boards were deeply grooved and marked, and three large baking sheets had baked-on grease and cut marks, all of which were acknowledged by the Dietary Manager as unsanitary and in need of replacement. Additionally, a broken tile was noted around a clean-out drain by the stove, and clean dishes were exposed to air from a dirty fan. Staff interviews revealed a lack of regular cleaning schedules for key equipment such as the automated dishwasher, and inconsistent cleaning practices throughout the kitchen. Dietary staff were observed failing to perform hand hygiene or wear gloves when handling resident cups and food, and continued food preparation without proper sanitation. Facility policies required routine cleaning and disinfection, as well as adherence to written cleaning schedules and staff training, but these were not followed as evidenced by the ongoing unsanitary conditions and staff admissions regarding lapses in cleaning and hand hygiene.
Lack of Certified Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) was trained and certified in infection prevention and control, as required by their own policy and regulatory standards. At the time of the survey, the facility had a census of 43 residents. Interviews with administrative staff revealed that the previous certified IP left the facility on 06/01/25, and the current staff member identified as the IP was not certified in infection control. The facility's Infection Control Surveillance policy, dated 11/2023, specifies that the IP is responsible for monitoring compliance with infection prevention and control standards, but this requirement was not met due to the lack of a certified IP.
Failure to Ensure Mandatory CNA Education Requirements Met
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) completed the mandatory 12 hours of education required within a 12-month period. Review of personnel and training records showed that a Certified Medication Aide (CMA) had not completed any of the required education hours in the last year. During interviews, administrative staff confirmed that there was no facility policy related to education and that the facility relied solely on regulations. The CMA also verified not having completed the mandatory education during the specified period. No policy was provided by the facility regarding staff education requirements.
Failure to Inform Residents of Health Status and Treatments
Penalty
Summary
Residents were not fully informed about their health status, care, and treatments. The facility failed to ensure that residents received adequate information and understanding regarding their medical conditions and the care or treatments being provided. This lack of communication resulted in residents not having the necessary knowledge to make informed decisions about their care. The deficiency was identified through observations and interviews, which revealed that residents did not consistently receive explanations or updates about their health status or the treatments they were receiving.
Failure to Maintain Safe and Clean Environment Creates Tripping Hazards and Discomfort
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations of uncleanliness and physical hazards throughout the building. One resident's fall mat and room floor were found to have sticky food particles and debris, and the mat was described as filthy by a licensed nurse. The dining room floor was missing 44 tiles, creating a tripping hazard that was not marked with any warning signs or barriers. Additionally, door frames and doors in several hallways were observed to have bubbled, chipped, and missing paint, with some doors showing veneer separation. These issues were present in multiple areas, including the 100, 300, and 400 halls. Staff interviews revealed that the missing dining room tiles had been removed three weeks prior due to a plumbing issue, but no temporary safety measures were put in place. Maintenance staff acknowledged ongoing issues with door frame and door repairs, including monthly repainting and attempts to re-glue bubbling laminate. Administrative staff confirmed that floors should be cleaned daily and that maintenance should be notified immediately for repairs, but these practices were not consistently followed. The facility's own policy states that residents have the right to dignity, respect, and proper living arrangements, which were not upheld in these instances.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, resulting in documentation errors regarding their clinical status and care needs. For one resident with Parkinson’s disease and dementia, the Significant Change MDS incorrectly recorded the number and type of falls, documenting only one non-injury fall when records showed two falls, one of which resulted in a minor injury. Observations confirmed the resident’s high level of dependency and fall risk, and staff interviews acknowledged the MDS inaccuracy. The facility’s own documentation and staff statements confirmed that the MDS did not accurately reflect the resident’s fall history as required by the Resident Assessment Instrument (RAI) manual. For another resident with dementia, the Quarterly MDS inaccurately indicated that the resident received an anticoagulant during the assessment period, when in fact the resident was only receiving an antiplatelet medication (aspirin). The resident’s cognitive status was also documented inconsistently between assessments. Staff interviews confirmed the MDS error, and facility policy required accurate and timely completion of the MDS. These inaccuracies in the MDS assessments placed the residents at risk for impaired care due to unidentified or misidentified care needs.
Failure to Complete Comprehensive Care Plans for Pain and Oxygen Use
Penalty
Summary
The facility failed to complete comprehensive care plans for two residents, resulting in unaddressed care needs. One resident with a diagnosis of trigeminal neuralgia had a care plan that did not include staff instructions for non-pharmacological pain interventions, despite receiving both scheduled and PRN pain medications and reporting pain levels ranging from zero to nine on a one to ten scale. The resident's medical record included physician orders for pain management medications, and staff observed the resident experiencing pain, as evidenced by facial grimacing. The facility's pain management policy required individualized interventions for residents with pain to be documented in the care plan, but this was not done for this resident. Another resident with a diagnosis of respiratory failure and receiving oxygen therapy did not have staff instructions regarding oxygen use included in the care plan. The resident's medical record documented ongoing oxygen use per nasal cannula, as ordered by the physician, and staff observed the resident using oxygen during multiple visits. The facility's policy required the development of a care plan to address each resident's needs, but the omission of oxygen use instructions in the care plan represented a failure to communicate essential care requirements.
Failure to Maintain Proper Catheter Bag Position During Resident Transfer
Penalty
Summary
Staff failed to provide appropriate catheter care for a resident with an indwelling Foley catheter, as observed during a transfer from wheelchair to bed. The resident, who had diagnoses including urinary tract infection, Parkinson's disease, and dementia with severe cognitive impairment, required total assistance and was transferred using a full body lift. During the transfer, staff attached the Foley catheter drainage bag to the sling at the resident's shoulder level, which was above the level of the bladder, contrary to care plan instructions and standard catheter care practices. The bag was later placed level with the bladder and then attached to the bed frame. Interviews with staff confirmed awareness that the catheter drainage bag should remain below the level of the bladder at all times to prevent urine backflow. However, staff admitted to not considering this during the transfer. The facility did not provide a policy for catheter care when requested. This failure to maintain the catheter bag below bladder level during resident transfer constituted a deficiency in providing appropriate catheter care and services.
Failure to Administer Prescribed Pain Medications for Resident with Trigeminal Neuralgia
Penalty
Summary
A resident with a diagnosis of trigeminal neuralgia, a chronic and painful nerve condition, did not receive scheduled pain medications, including carbamazepine and lidocaine viscous solution, as ordered by the physician. The medication administration record showed missed doses over several days, and progress notes indicated that the pharmacy was notified of the need for refills, but the medications were not available or administered during this period. The resident reported increased pain and facial grimacing was observed by staff, with a pain score of nine out of ten documented on the morning following the missed doses. Staff interviews confirmed that the medications were not reordered in a timely manner, resulting in the resident not having access to her prescribed pain management regimen over the weekend. The resident's care plan included pharmacological interventions for pain but lacked direction for non-pharmacological interventions. The facility's pain management policy required individualized treatment plans with both pharmacologic and non-pharmacologic interventions for residents experiencing pain. Despite this, the resident's care plan was incomplete, and the failure to ensure timely medication refills and administration led to unmanaged pain for the resident.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
Staff failed to protect the dignity and privacy of three residents through several observed actions. One resident was transported from his room to the shower room in a shower chair covered only with a white sheet, leaving his buttocks exposed as he was wheeled past the dining area where other residents were present. Staff interviews confirmed that this method of transport was not appropriate or dignified, and that residents were typically moved in their wheelchairs, fully clothed or covered. Additionally, staff repeatedly entered the rooms of three residents without knocking, introducing themselves, or waiting for acknowledgment. Observations showed staff opening closed doors and entering rooms while residents were present, sometimes during interviews, without following proper protocols for privacy and respect. Multiple staff members, including CNAs and nurses, acknowledged in interviews that the expected practice was to knock, introduce themselves, and await acknowledgment before entering a resident's room. The facility's policy also documented residents' rights to dignity, respect, and privacy.
Failure to Prevent Abuse and Neglect of Resident
Penalty
Summary
The facility failed to prevent the physical abuse and neglect of a resident (R2) by a Certified Nurse Aide (CNA M). On the evening in question, R2 reported that CNA M was rough while assisting her to bed, throwing her into bed by holding her legs and swinging her while in the lift sling. This improper handling caused R2 to experience dizziness, nausea, and difficulty breathing due to the bed being left flat and the lack of supplemental oxygen. Despite activating her call light and yelling for help, R2 did not receive assistance for 3 to 3.5 hours until another CNA (CNA N) arrived for the night shift. When CNA N responded, she found R2 crying and upset, and CNA M yelled at R2 from the hallway, further exacerbating the situation. CNA N reported the incident to Licensed Nurse (LN G), who also failed to report the abuse and neglect to the administrative staff immediately, allowing CNA M to continue her shift for eight more hours, placing other residents at risk for abuse and neglect. R2's medical records indicated she had muscle weakness, anxiety disorder, and chronic obstructive pulmonary disease (COPD), requiring oxygen at night to maintain oxygen saturations above 90 percent. R2 was assessed with intact cognition and required extensive assistance from two staff members for bed mobility and transfers with a full-body lift. The facility's investigation revealed that R2 had been left in a flat position without oxygen, causing her significant distress. Multiple staff members, including CNA N and LN G, witnessed R2's distress and reported the incident, but the reports were not immediately escalated to the administrative staff as required by the facility's policy. The facility's policy for Abuse, Neglect, and Exploitation mandates immediate reporting of any alleged violations involving abuse, neglect, exploitation, or mistreatment to the Administrator or their designated representative. However, this policy was not followed, as evidenced by the delayed reporting and the continued presence of CNA M in the facility. The failure to adhere to the policy and the improper handling of R2 by CNA M resulted in immediate jeopardy for R2 and other residents in the facility.
Removal Plan
- Administrative Staff A and Administrative Nurse D interviewed R2. R2 confirmed the allegations.
- CNA M interviewed by Administrative Staff A and Administrative Nurse D and asked if she had done all the things reported and CNA M responded yes and began crying. CNA M suspended.
- CNA M interviewed by Administrative Staff A regarding the allegations against CNA N to R2.
- The LN completed an assessment.
- Verbal discipline and education given to LN G for not reporting immediately.
- All staff training initiated immediately on reporting allegations of abuse and completed at the start of each shift.
- Written discipline given to LN G.
- QAPI meeting held with the medical director.
- CNA M terminated.
Failure to Report Abuse and Neglect Immediately
Penalty
Summary
The facility failed to report abuse and neglect of a resident immediately. On the evening of 03/21/24, a resident reported that a Certified Nurse Aide (CNA) was rough with her during a transfer from her wheelchair to her bed, causing her to feel dizzy, nauseous, and have difficulty breathing. The resident activated her call light and yelled for help, but the CNA responded by yelling back from the hallway and did not assist her. The resident remained in an uncomfortable and unsafe position without her supplemental oxygen for several hours until another CNA arrived for the night shift and provided the necessary assistance. The incident was reported to a Licensed Nurse (LN) at 10:10 PM, but the LN and the CNA who discovered the resident's distress did not report the abuse and neglect to the administrative staff immediately. The administrator only became aware of the situation the following morning after reading the Report of Concern forms. The CNA involved in the incident continued to work her shift for eight more hours, potentially putting other residents at risk. The resident involved had a medical history of muscle weakness, anxiety disorder, and chronic obstructive pulmonary disease (COPD). She required oxygen at night and extensive assistance from staff for bed mobility and transfers. The facility's failure to report the abuse and neglect immediately allowed the CNA to remain on duty, which placed the resident and potentially other residents in immediate jeopardy.
Removal Plan
- Administrative Staff A and Administrative Nurse D interviewed R2. R2 confirmed the allegations.
- CNA M interviewed by Administrative Staff A and Administrative Nurse D and admitted to the allegations. The facility suspended CNA M.
- CNA M interviewed by Administrative Staff A regarding the allegations against CNA N to R2.
- The LN completed an assessment.
- Verbal discipline and education given to LN G for not reporting immediately.
- All staff training initiated immediately on reporting allegations of abuse, and completed at the start of each shift.
- Written discipline given to LN G.
- QAPI meeting held with the medical director.
- CNA M terminated.
Failure to Protect Resident from Abuse and Neglect
Penalty
Summary
The facility failed to protect a resident from further abuse and neglect when staff did not immediately notify the administrator of an allegation of abuse. The incident occurred when a Certified Nurse Aide (CNA) was reported to have been rough with the resident during a transfer to bed, causing the resident to experience dizziness, nausea, and difficulty breathing. The resident's call light was not answered for several hours, and when another CNA arrived, the resident was found crying and upset. Despite being informed of the situation, the staff did not report the abuse immediately to the administrator, allowing the CNA to continue working for eight more hours, potentially placing other residents at risk. The resident involved had a medical history that included muscle weakness, anxiety disorder, and chronic obstructive pulmonary disease (COPD). The resident required oxygen and had limited use of her right arm, necessitating total assistance from staff for bed mobility and transfers. On the night of the incident, the resident was left in a flat position without her supplemental oxygen, which exacerbated her symptoms. The resident's oxygen saturation level was documented at 85 percent, significantly lower than her usual levels. The facility's policy required immediate reporting of any allegations of abuse, neglect, or exploitation to the administrator. However, the staff failed to follow this policy, resulting in a delay in addressing the resident's concerns and removing the CNA from duty. The failure to report the incident promptly and the continued presence of the CNA in the facility constituted a serious deficiency in the facility's duty to protect its residents from abuse and neglect.
Removal Plan
- Administrative Staff A and Administrative Nurse D interviewed R2. R2 confirmed the allegations.
- CNA M interviewed by Administrative Staff A and Administrative Nurse D and asked if she had done all the things reported and CNA M responded yes and began crying. CNA M suspended.
- CNA M interviewed by Administrative Staff A regarding the allegations against CNA N to R2.
- The LN completed an assessment.
- Verbal discipline and education given to LN G for not reporting immediately.
- All staff training initiated immediately on reporting allegations of abuse and completed at the start of each shift.
- Written discipline given to LN G.
- QAPI meeting held with the medical director.
- CNA M terminated.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for a cognitively impaired and independently mobile resident identified as an elopement risk. On one occasion, staff deactivated an exit door alarm due to a storm, which led to the resident exiting the facility without staff knowledge. The resident was found outside by a visitor, who then informed the facility staff. The resident had a history of Alzheimer's disease, dementia, and hallucinations, and was assessed with severe cognitive impairment and a high elopement risk level. Despite these known risks, the facility did not ensure that the exit door alarms were functioning, nor did they provide appropriate supervision for the resident, who had previously displayed exit-seeking behaviors. The resident's care plan included interventions such as structured activities, reorientation strategies, and monitoring for wandering patterns. However, these measures were not effectively implemented, as evidenced by the resident's ability to exit the facility unnoticed. Staff members who were present during the incident did not hear any door alarms, and the door that the resident exited from was found to be unlocked and unalarmed. Multiple staff members provided witness statements indicating that they were unaware of the resident's whereabouts until alerted by the visitor. The facility's failure to maintain functioning door alarms and provide adequate supervision placed the resident in immediate jeopardy. The incident highlighted significant lapses in the facility's safety protocols and staff awareness, which ultimately led to the resident's elopement. The facility's policies and procedures for monitoring and preventing elopement were not effectively followed, resulting in a serious deficiency in resident care and safety.
Removal Plan
- The facility immediately placed R1 on one-to-one supervision with staff, after the nurse assessed for injuries when he returned back inside the building.
- A facility wide door check completed by maintenance to ensure all alarmed doors were in proper working order.
- R1's elopement assessment updated, and all other residents has elopement assessment completed and care plan reviewed for accuracy and appropriateness.
- Stop signs placed on hallway exit doors to remind resident to turn around.
- The facility's Elopement book reviewed to ensure accurate content.
- The Administrator, Director of Nursing, and Medical Director held a QAPI (Quality Assurance Performance Improvement) meeting via phone.
- All staff educated on elopement policy and resident incident. Otherwise, employees were suspended pending required in-service.
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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