Medicalodges Leavenworth
Inspection history, citations, penalties and survey trends for this long-term care facility in Leavenworth, Kansas.
- Location
- 1503 Ohio Street, Leavenworth, Kansas 66048
- CMS Provider Number
- 175162
- Inspections on file
- 19
- Latest survey
- July 29, 2025
- Citations (last 12 mo.)
- 1 (1 serious)
Citation history
Health deficiencies cited at Medicalodges Leavenworth during CMS and state inspections, most recent first.
The facility did not ensure RN coverage for eight consecutive hours daily, as required, due to missing documentation and lack of policy. This affected 34 residents, placing them at risk of inadequate assessment and care.
The facility failed to complete the required yearly performance evaluations for three CNAs, placing residents at risk for inadequate care. The CNAs, employed for over 12 months, had no evaluations or in-service records available. Administrative Staff confirmed the absence of these records, and the facility lacked a policy on staff competency, training, or evaluations.
The facility did not employ a full-time certified dietary manager for its 34 residents, risking inadequate nutrition. Dietary Staff BB had not started classes to become certified, and the facility relied on a monthly visiting Registered Dietician. Administrative Staff B confirmed the absence of a Certified Dietary Manager, and no policy was in place for this role.
The facility did not designate a qualified Infection Preventionist (IP) employed at least part-time, as required. Administrative Staff C was acting as the IP, but it was revealed that a consultant, not directly employed by the facility, was performing IP duties. This deficiency placed all residents at risk due to the lack of proper infection identification, tracking, trending, and treatment.
The facility failed to ensure a CNA completed the required 12 hours of in-service education over the past year. This deficiency was confirmed by administrative staff, and the facility lacked a policy related to staff training, contributing to the issue.
The facility failed to ensure controlled substances were properly accounted for and reconciled between shifts, risking medication misappropriation and diversion. Missing signatures on Controlled Medication Shift Count Sheets for July, August, and September 2024 indicated non-compliance with procedures requiring narcotics to be counted at every shift change. Staff interviews confirmed the expectation for narcotics counting, but the facility did not ensure accurate reconciliation, violating federal and state regulations.
The facility failed to implement an effective infection prevention and control program, lacking signage for Enhanced Barrier Precautions (EBP) and PPE availability for residents with open wounds and catheters. Shared equipment was not sanitized between uses, and staff did not perform adequate hand hygiene. Respiratory equipment was improperly stored, increasing the risk of infectious diseases.
A resident with a history of COPD, CHF, myocardial infarction, and leukemia, and severely impaired cognition, was at risk for pressure ulcers and had existing ones. Despite the care plan requiring the resident's heels to be floated on a pillow, observations showed this was not done, and pressure-relieving boots were not used. Staff confirmed care plans were accessible, but the failure to follow them increased the risk of worsening the resident's condition.
A resident with a suprapubic catheter did not have a stat-lock properly placed, as required by their care plan, leading to a deficiency in catheter management. The resident reported issues with the stat-lock not staying in place due to pulling, and staff interviews revealed a lack of clarity on proper placement. The facility could not provide a catheter care policy, indicating a failure to follow standard practices, placing the resident at risk for complications.
A resident with sleep apnea and other medical conditions was found to have their CPAP mask stored unsanitarily on a bedside table, increasing the risk of respiratory infection. Despite staff acknowledging the need for sanitary storage in a plastic bag, the facility lacked a policy to ensure compliance, leading to this deficiency.
The facility failed to ensure comprehensive monthly drug regimen reviews for several residents, leading to deficiencies in medication management. A resident did not receive a recommended gradual dose reduction for Ambien, and the physician did not review the consultant pharmacist's recommendations. Another resident's medication regimen lacked physician documentation of the pharmacist's recommendations, and a third resident was prescribed an antipsychotic without a CMS-approved indication. These failures placed residents at risk for unnecessary medication use and adverse side effects.
A facility failed to ensure a CMS-approved indication or required physician documentation for the use of antipsychotic and hypnotic medications for two residents. One resident received Risperdal without a GDR attempt or documentation, while another received hypnotic medications without a GDR or drug regimen review. The facility's policy required monthly medication reviews, but these were not conducted, placing residents at risk for unnecessary medication use and adverse effects.
A facility failed to ensure proper collaboration and communication with a hospice provider for a resident with chronic obstructive pulmonary disease and severely impaired cognition. The care plan lacked documentation of hospice-covered medications, personal care items, and medical equipment. Staff interviews revealed uncertainty about hospice services, and the facility lacked a policy for hospice care collaboration.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week, as required by regulations. This deficiency was identified through a review of the facility's nursing schedules for January, February, March, and April 2024, which lacked evidence of RN coverage on specific dates. The facility's census at the time was 34 residents. Administrative Staff C indicated that the previous Director of Nursing, a salaried employee, was supposed to provide RN coverage on those dates, but there was no documentation to verify her working the required hours. Additionally, the facility did not have a policy related to RN coverage. This lack of RN coverage placed all residents at risk of lack of assessment and inappropriate care.
Deficiency in CNA Performance Evaluations
Penalty
Summary
The facility, with a census of 34 residents, was found to have deficiencies in the performance evaluations and in-service training of its Certified Nurse Aides (CNAs). A sample review of 12 residents and three CNAs revealed that the facility failed to complete the required yearly performance evaluations for all three CNAs reviewed. Specifically, CNA Q, hired on June 30, 2022, CNA R, hired on March 22, 2019, and CNA MM, hired on February 8, 2022, had no performance evaluations available upon request. Administrative Staff C confirmed the absence of these evaluations and the required in-service records. Additionally, the facility did not provide a policy related to staff competency, training, or performance evaluation. This lack of evaluations placed residents at risk for inadequate care.
Lack of Certified Dietary Manager Puts Residents at Nutritional Risk
Penalty
Summary
The facility failed to employ a full-time certified dietary manager for its 34 residents, which placed them at risk for inadequate nutrition. Dietary Staff BB, who was responsible for dietary management, had not yet started classes to become a Certified Dietary Manager and was attempting to enroll in such a class. The facility relied on a Registered Dietician who visited monthly and could be contacted via email for changes to diets or menus. Administrative Staff B confirmed the absence of a Certified Dietary Manager and noted that the dietary manager was enrolled in a class. The facility did not have a policy in place for a Certified Dietary Manager, contributing to the deficiency in nutritional oversight and management.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) who was employed by the facility at least part-time, as required for the Infection Prevention and Control Program. During the entrance conference, Administrative Staff C stated she was acting as the IP and had been onsite for 45 days. However, it was later revealed by Administrative Nurse A that the facility did not have a designated IP at that time. Instead, Administrative Nurse C, a consultant not directly employed by the facility, was performing the IP duties. This lack of a qualified and certified IP employed by the facility placed all residents at risk due to the absence of proper identification, tracking, trending, and treatment of infections.
Deficiency in CNA In-Service Training
Penalty
Summary
The facility failed to ensure that one of the three Certified Nurse Aides (CNAs) reviewed had completed the required 12 hours of in-service education, which is necessary for maintaining the skills needed to care for residents. Specifically, CNA Q, who was hired on June 30, 2022, had not completed any of the required in-services in the past 12 months. This deficiency was confirmed by Administrative Staff C on September 24, 2024, and further acknowledged by Administrative Staff B on September 25, 2024, who mentioned that improving the process of yearly performance reviews was a focus for the new management team. Additionally, the facility was unable to provide a policy related to staff training, which contributed to the deficiency.
Failure to Reconcile Controlled Substances
Penalty
Summary
The facility failed to ensure that controlled substances were properly accounted for and reconciled between shifts, which placed residents at risk for misappropriation and/or diversion of these medications. The facility had a census of 34 residents and utilized one medication room and two medication carts, one for scheduled medications and another for narcotics and treatments. Upon review of the Controlled Medication Shift Count Sheets for July, August, and September 2024, it was found that there were missing signatures for both on-coming and off-going nurses on multiple dates, indicating a failure to follow the established procedure for counting narcotics at every shift change. Interviews with staff revealed that the procedure required nurses to count narcotics with every shift change, as confirmed by Licensed Nurse G and Administrative Nurse D. The facility's policy on Medication Storage Controlled Medication Storage, dated January 2024, required special handling, storage, disposal, and record-keeping for controlled substances in compliance with federal, state, and other applicable laws and regulations. Despite these requirements, the facility did not ensure accurate reconciliation of controlled medications, thereby placing residents at risk of medication misappropriation and diversion.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by several deficiencies observed during a survey. The survey revealed that the facility did not have appropriate signage or indicators to alert staff and visitors of residents on Enhanced Barrier Precautions (EBP). Additionally, personal protective equipment (PPE) was not readily available in the rooms of residents who required EBP due to conditions such as open wounds and catheters. This lack of signage and PPE availability was noted in the rooms of multiple residents, including those with wound vacs, suprapubic catheters, and Foley catheters. Further deficiencies were observed in the facility's failure to sanitize shared equipment between uses and ensure adequate hand hygiene by staff. For instance, a Certified Nurse Aide (CNA) did not perform hand hygiene after providing peri care and handling a Hoyer lift, which was then not disinfected before being moved to the hallway. Additionally, respiratory equipment was not stored in a sanitary manner, as evidenced by an oxygen nasal cannula being draped over a bed rail instead of being contained in a sanitary container. These practices placed residents at risk for infectious diseases.
Failure to Implement Pressure-Reducing Interventions for a Resident
Penalty
Summary
The facility failed to implement pressure-reducing interventions for a resident identified as R16, who was at risk for pressure ulcer development and had existing pressure ulcers. R16's medical history included chronic obstructive pulmonary disease, congestive heart failure, myocardial infarction, and leukemia, with severely impaired cognition and mobility issues. The Minimum Data Set (MDS) indicated that R16 was at risk for pressure ulcers and required pressure-reducing devices for both the chair and bed. The care plan specified that R16's heels should be floated on a pillow while in bed to prevent further skin breakdown. Despite these documented needs, observations revealed that R16's heels were not floated on a pillow as required, and the blue foam boots intended for pressure relief were found on the bedside table instead of being used. Interviews with staff, including a CNA and a licensed nurse, confirmed that care plans were accessible and that important information was communicated during daily reports. However, the failure to ensure R16's heels were properly supported as per the care plan increased the risk of pressure ulcer development and worsening of the existing left heel wound.
Deficiency in Catheter Care for Resident with Suprapubic Catheter
Penalty
Summary
The facility failed to ensure proper care for a resident with a suprapubic catheter, leading to a deficiency in catheter management. The resident, identified as R26, had a history of urinary retention, Parkinson's disease, and diabetes mellitus, and required assistance with personal care. The resident's care plan specified that a catheter stat-lock should be used to prevent injury or pulling of the catheter. However, during an observation, it was noted that the resident did not have a stat-lock in place, and the resident reported that the stat-lock was usually placed on his inner left leg but would not stay in place due to the catheter tubing pulling it loose. Further interviews with staff revealed a lack of clarity and adherence to the standard of practice for the placement of the stat-lock. A CNA mentioned the need to clarify the placement with the charge nurse, while a licensed nurse and an administrative nurse both stated that the stat-lock should be placed on the abdomen to prevent pulling on the catheter tube. The facility was unable to provide a policy related to catheter care, indicating a gap in ensuring the standard of practice was followed. This deficiency placed the resident at risk for catheter-related complications.
Failure to Maintain Sanitary Storage of CPAP Equipment
Penalty
Summary
The facility failed to ensure the sanitary storage of a CPAP mask and nasal cannula for a resident, identified as R27, who was at increased risk for respiratory infection and complications. R27's medical history included conditions such as sleep apnea, hypertension, obesity, and osteomyelitis, among others. The resident was dependent on staff for all activities of daily living except eating and required a non-invasive mechanical ventilator. Observations revealed that R27's CPAP mask was repeatedly left on the bedside table without being stored in a sanitary container, contrary to the care plan and physician orders that specified regular cleaning and proper storage of the respiratory equipment. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that respiratory equipment should be stored in a plastic bag with the date on it and changed weekly. However, the facility did not provide a policy related to the care and sanitary storage of respiratory equipment. This oversight in maintaining sanitary conditions for R27's CPAP mask and nasal cannula was identified as a deficiency, as it placed the resident at an increased risk for respiratory infection and complications.
Deficiencies in Medication Regimen Review and Physician Oversight
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a comprehensive monthly drug regimen review (MRR) for several residents, leading to deficiencies in medication management. For Resident 3, the facility did not ensure that the consultant pharmacist (CP) identified and recommended a gradual dose reduction (GDR) for the hypnotic medication Ambien. Additionally, there was no evidence that the physician reviewed or addressed the CP's recommendations for Resident 3's medication regimen from May to July 2024. This oversight placed Resident 3 at risk for unnecessary medication administration and potential adverse side effects. Resident 26 also experienced deficiencies in medication management, as the facility failed to ensure that the CP's monthly recommendations were reviewed or addressed by the physician. The MRRs for Resident 26 from February to June 2024 lacked evidence of physician documentation of the CP's recommendations. This failure to conduct a thorough MRR placed Resident 26 at risk for unnecessary medications and adverse side effects. For Resident 9, the facility did not ensure that the CP identified and reported the lack of a CMS-approved indication for the antipsychotic medication Risperdal. The clinical record lacked physician documentation of a rationale for the continued use of Risperdal without a GDR attempt. This deficiency placed Resident 9 at risk for unnecessary medication administration and possible adverse side effects. The facility's failure to adhere to its Medication Regimen Review and Reporting policy contributed to these deficiencies.
Failure to Ensure GDR and Documentation for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that Resident 9 had a CMS-approved indication for the use of an antipsychotic medication, Risperdal, or the required physician documentation. The resident's electronic medical record documented diagnoses of bipolar disorder, delusions, anxiety, and cognitive communication deficit, with severely impaired cognition as indicated by a BIMS score of one. Despite receiving antipsychotic and antidepressant medications, no gradual dose reduction (GDR) was attempted or documented as contraindicated by the physician. The facility's records lacked evidence of physician documentation for the continued use of Risperdal without a CMS-approved indication or GDR attempts, placing the resident at risk for unnecessary medication administration and adverse side effects. Additionally, the facility did not ensure that Resident 3 had a GDR or the required physician documentation for the use of hypnotic medications. The resident's electronic medical record showed diagnoses of paraplegia, mild cognitive impairment, depression, and anxiety, with intact cognition as indicated by a BIMS score of 15. The resident received antidepressant, antianxiety, hypnotic, and opioid medications, but no GDR or drug regimen review was completed during the observation period. The facility's records lacked evidence of a GDR attempt or documentation as contraindicated by the physician, placing the resident at risk for unnecessary medication administration and adverse side effects. The facility's policy on Behavior Management and Psychotropic Medications, last revised in December 2022, required the consultant pharmacist to complete a monthly Medication Regimen Review and provide information to the physician and facility regarding GDR or continued use when indicated. However, the facility failed to adhere to this policy for both residents, as evidenced by the lack of GDR attempts and necessary documentation. This oversight placed the residents at risk for unnecessary medication use and potential adverse effects.
Deficiency in Hospice Care Coordination for a Resident
Penalty
Summary
The facility failed to ensure proper collaboration and communication between the nursing home and the hospice provider for Resident 8, who was receiving hospice care. The resident's care plan lacked documentation regarding the medications covered by hospice, personal care items, and medical equipment provided by hospice. Despite the care plan indicating that the hospice provider's certified nurse aide would visit twice weekly and the hospice nurse would visit weekly, there was no clear documentation of these arrangements. This lack of documentation and communication created a risk of missed opportunities for services and delayed addressing the resident's physical, mental, and psychosocial needs. Resident 8 had a history of chronic obstructive pulmonary disease, depression, and altered mental status, with a BIMS score indicating severely impaired cognition. The resident reported constant pain and required assistance with activities of daily living. Interviews with facility staff revealed uncertainty about the hospice services provided, as the Kardex did not clearly list the medical equipment or the schedule of hospice CNA visits. The facility was also unable to provide a policy related to the collaboration of care with the hospice provider, further highlighting the deficiency in ensuring a collaborative process for the resident's care.
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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