Medicalodges Pittsburg
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburg, Kansas.
- Location
- 2520 S Rouse Street, Pittsburg, Kansas 66762
- CMS Provider Number
- 175070
- Inspections on file
- 13
- Latest survey
- July 24, 2025
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Medicalodges Pittsburg during CMS and state inspections, most recent first.
A large rug at the facility entrance concealed a hole in the cement, creating a tripping hazard, while black, white, yellow, and green substances consistent with mold were observed throughout multiple areas, including resident rooms, laundry, and service areas. Staff reported ongoing symptoms such as headaches and sore throats, and a musty odor was noted. Despite widespread contamination, the facility did not test for mold or address the environmental hazards as the infection management policy lacked guidance on mold removal.
A cognitively impaired resident at high risk for elopement exited a facility unsupervised, crossing a lawn, parking lots, and a street before reaching a dentist office. The resident's care plan included monitoring for exit-seeking behaviors, but no alarm sounded when the resident left. Maintenance checks revealed a delay in the alarm on a frequently used exit door, contributing to the resident's unsupervised departure.
The facility failed to conduct annual performance reviews for CNAs and CMAs, with several employees lacking signed evaluations in their records. An interview with an administrative nurse confirmed the absence of these evaluations, and the facility did not provide a policy for completing them, resulting in a failure to ensure staff competency and training needs.
The facility failed to maintain sanitary conditions in food preparation, storage, and serving. Observations revealed dirty shelving in the ice room and dietary supplies stored on the floor. Staff had conflicting responsibilities for cleaning, and the facility's policy lacked guidance on proper storage practices.
The facility failed to submit accurate staffing data to CMS, missing 24-hour Licensed Nurse coverage on multiple dates. Despite having a policy for posting actual hours worked, the facility lacked a specific policy for PBJ submission, leading to discrepancies in reported staffing information.
The facility failed to track and trend infections effectively, with missing data in the Infection Control logbook and a lack of culture reports for infections. Administrative Nurse E was unaware of how to use the electronic monitoring program, and a COVID outbreak occurred in July 2024. The facility's policies required monitoring infections, but the facility did not determine trends to prevent their spread.
The facility failed to adhere to antibiotic stewardship principles, leading to a deficiency in monitoring antibiotic use. A resident was prescribed Cefdinir for health maintenance, but interviews with administrative nurses revealed a lack of training and completion of the computerized infection monitoring system. The resident had been hospitalized for pneumonia and returned with an antibiotic order, yet the facility's policy on antibiotic use was not followed.
The facility failed to maintain a sanitary environment in the ice room, with black grime on the floor, dirty shelving, and unclear cleaning responsibilities. Administrative and dietary staff were unsure who was responsible for cleaning, and no policy existed for maintaining the area.
A facility with 29 residents failed to maintain a clean and homelike environment on four of five resident halls. Issues included a strong urine odor in a resident room, rust and loose hair in a shower room, uncovered clean linen, loose handrails, and poor maintenance in various areas. These deficiencies were confirmed by staff, indicating a failure to follow housekeeping and maintenance policies.
A resident with schizoaffective disorder, diabetes, and severe cognitive impairment required assistance with personal hygiene but was observed with overgrown facial hair and long fingernails. Grooming was typically done on bath days, but the resident had issues with his electric razor and fingernail clippers. Staff interviews revealed a lack of awareness about the last grooming service, and the facility did not have a grooming policy, leading to the resident not being maintained in a dignified manner.
A resident with multiple medical conditions, including cerebral palsy and diabetes, experienced a skin tear after hitting their hand on a dining room table. The care plan was not updated to address this injury or prevent further incidents, and the table remained in use despite posing a risk. The facility's wound prevention policy was not followed, leading to a deficiency in care.
A resident with multiple health conditions, including cerebral palsy and diabetes, experienced repeated skin tears due to inadequate care and monitoring. The facility failed to update the care plan with necessary interventions and did not have a physician's order for the existing skin tear. The resident sustained injuries from a dining room table with a metal edge, which was not removed despite being identified as a hazard.
A facility failed to monitor a resident receiving antipsychotic medication for schizophrenia. Despite recommendations to conduct DISCUS assessments every six months, the last assessment was over eight months ago. The facility lacked a policy for these assessments, leading to a deficiency in care practices.
A facility failed to accurately complete a Significant Change MDS for a resident with dementia and severe cognitive impairment, who had multiple falls, including an injury fall. The Fall CAA lacked necessary fall information, and the care plan required specific interventions to prevent falls. An administrative nurse confirmed the documentation did not accurately reflect the resident's fall history and risk.
The facility failed to complete the Daily Staff Posting by not including the total and actual hours worked by direct care staff. A review of the Daily Staffing Sheet revealed missing actual hours for nursing staff. Interviews indicated that the business office was responsible for logging these hours but had not done so since June. The facility's policy required the charge nurse to fill in total hours and the business office to verify actual hours using payroll data.
Unsafe Entrance and Widespread Mold Contamination
Penalty
Summary
The facility failed to ensure a safe and sanitary environment for residents, staff, and visitors. Observations revealed a large rubberized rug covering a sloped walkway at the front entrance, which concealed a large hole in the underlying cement. This rug created a tripping hazard, as evidenced when a surveyor stumbled on it. Multiple areas throughout the facility, including public restrooms, laundry areas, corridors, the kitchen, smoking lounge, medical records storage, boiler room, and HVAC room, were found to have black, white, yellow, and/or green substances on walls, floors, and ceilings. Staff interviews confirmed that these substances had been present for months, with reports of a musty smell and a recent ceiling leak that required a bucket to catch water. Several staff members reported headaches and sore throats in the weeks leading up to the discovery of the mold-like substances. Administrative staff confirmed that nearly all rooms in several hallways were contaminated with mold, and that the facility's infection management policy did not address mold treatment or removal. Despite the leadership team's identification of the need to evacuate residents due to the environmental concern, instructions from a consultant directed staff to resume their regular duties and to spray visible surfaces with a disinfectant. The facility did not test the substance to confirm the presence of mold, following consultant advice, and did not take immediate action to address the environmental hazards identified.
Resident Elopement Due to Inadequate Supervision and Alarm Delay
Penalty
Summary
The facility failed to ensure adequate supervision and a safe environment for a cognitively impaired resident, identified as R31, who was at high risk for elopement. On the morning of 08/29/24, R31, who had been assessed with severe cognitive impairment and daily wandering behaviors, exited the facility unsupervised and without staff knowledge. The resident managed to walk approximately 248 feet, crossing a lawn, two parking lots, and a two-way street, before arriving at a nearby dentist office. The facility was unaware of the resident's absence until the dentist office contacted them about the resident's presence. R31's medical records indicated diagnoses of Alzheimer's disease and major depressive disorder, with a history of wandering and poor safety awareness. The resident's care plan included instructions for staff to monitor for exit-seeking behaviors and to redirect the resident as needed. Despite these measures, the resident was able to leave the facility without triggering any alarms, as staff did not hear any alarm sound when the resident exited. Interviews with staff revealed that the resident often sat near the front door but had not previously exited the facility. Maintenance checks revealed that the alarm on the exit door by the staff break room had a delay of approximately one minute before sounding, which may have allowed the resident to exit unnoticed. This door was frequently used by staff for taking out trash and led to an area with grass and a parking lot. The facility's elopement policy required staff to identify at-risk residents and develop individualized care plans, but the failure to ensure the security of the premises resulted in the resident's unsupervised departure, placing them in immediate jeopardy.
Removal Plan
- LN G completed a full body assessment of R31 upon return to facility.
- Resident placed on 1:1 monitoring for the remainder of the investigation.
- Maintenance and door alarm company provide door alarm testing.
- LN G notified R31's responsible party and his physician of his elopement.
- Administrative Nurse D documented an alert in the electronic software of any care plan changes.
- Administrative Nurse D notified the State Agency via email of the elopement.
- Administrative Nurse D reviewed the Medication Administration Record and progress notes that led up to R31 leaving unsupervised and without staff knowledge, to determine if other risk factors were present.
- Administrative Nurse D reviewed all residents for elopement risk, for accuracy, and updated the elopement book and care plans as needed.
- The facility provided Mandatory Elopement Policy training to all staff.
- Quality Assurance Performance Improvement (QAPI) meeting held with the medical director regarding the elopement.
- All staff completed the mandatory Elopement Policy Training.
Failure to Conduct Annual Evaluations for CNAs and CMAs
Penalty
Summary
The facility failed to conduct annual performance reviews for certified nurse aides (CNAs) and certified medication aides (CMAs) as required. The review of employee records revealed that several CNAs and CMAs, with hire dates ranging from 1999 to 2023, lacked signed evaluations. Specifically, CNA Q, CNA O, CNA/CMA NN, CNA P, and CNA MM did not have documented evaluations in their records. An interview with Administrative Nurse D confirmed the absence of these evaluations and indicated that annual evaluations were expected to be completed in a timely manner. The facility did not provide a policy for the completion of annual evaluations, resulting in a failure to ensure certified nursing staff received evaluations to assess competency and identify training needs.
Sanitation Deficiency in Food Storage and Preparation
Penalty
Summary
The facility failed to maintain sanitary conditions in the preparation, storage, and serving of food to its residents. During a facility tour, it was observed that the wood shelving unit used for stacking dishes and glasses in the ice room had loose chunks of dirt, with plates and glasses stored upside down in direct contact with the dirty shelves. Administrative Staff A confirmed the need for housekeeping and maintenance in the ice room but was unaware of who was responsible for cleaning it. Dietary staff BB and Housekeeping staff W had conflicting understandings of who was responsible for cleaning the ice room, with dietary staff using the plates and glasses stored there for holiday dinners. Further inspection revealed that dietary supplies, including foam cups, insulated bowls, and cup lids, were stored directly on the floor of the southeast storage room, which is against sanitary storage practices. Maintenance Staff U and Dietary staff BB acknowledged that supplies should be stored off the floor on appropriate racks. The facility's dietary services policy did not address the proper storage of dietary supplies and dishware to ensure sanitary food service, contributing to the deficiency in maintaining sanitary conditions.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) as required. Specifically, the facility did not accurately report 24-hour Licensed Nurse (LN) coverage on four dates between July 1, 2023, and September 30, 2023, and on six dates between October 1, 2023, and December 31, 2023. This deficiency was identified through a review of the Payroll Base Journal (PBJ) Staffing Data Report for the relevant fiscal quarters, which revealed gaps in 24-hour LN coverage on specified dates. During an interview, Administrative Nurse D indicated that she believed the PBJ was submitted correctly and was unaware of the discrepancies noted in the report. The facility's policy for Benefits Improvement Protection Act (BIPA) Nurse Staff Posting, revised in December 2019, instructed staff to post actual hours worked for licensed and unlicensed nursing staff. However, the facility lacked a specific policy for the submission of the PBJ to CMS, contributing to the inaccurate reporting of staffing information.
Inadequate Infection Tracking and Trending
Penalty
Summary
The facility failed to effectively track and trend infections among its residents, as evidenced by missing data in the Infection Control logbook for August and September 2024. The logbook for June 2024 documented two wound infections, three urinary tract infections, and two oral infections, but lacked culture reports to identify causative organisms. Administrative Nurse E admitted to documenting infections on a map of resident rooms to identify trends but was unaware of how to use the facility's electronic monitoring program. A COVID outbreak occurred in July 2024, affecting four residents and subsequently staff, although no current cases were reported. Administrative Nurse D expected staff to utilize the electronic data collection tool for tracking infections. The facility's policy on Antibiotic Use Protocol and Antibiotic Stewardship required staff to monitor infections and instruct on managing residents with infections, but the facility did not monitor infections to determine trends and prevent their spread.
Failure in Antibiotic Stewardship and Monitoring
Penalty
Summary
The facility failed to ensure adherence to antibiotic stewardship principles, which are crucial for preventing antibiotic resistance and the spread of multidrug-resistant organisms. A physician's order dated 07/26/24 instructed staff to administer Cefdinir, an antibiotic, to a resident twice a day for five days for health maintenance. However, interviews with administrative nurses revealed a lack of training and completion of the facility's computerized infection monitoring system. Specifically, Administrative Nurse E admitted to lacking training in the system, while Administrative Nurse D confirmed the absence of antibiotic stewardship and the incomplete monitoring system. The resident in question had previously been hospitalized for pneumonia and returned to the facility with an antibiotic order, yet the facility's policy on antibiotic use and stewardship was not followed, leading to the deficiency.
Facility Fails to Maintain Sanitary Ice Room
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the ice room, as observed during a facility tour. The floor was covered with black grime, and the wood shelving unit used for stacking dishes and glasses had loose chunks of dirt. Used crumpled paper towels were found on the floor, and the walls had missing paint. Additionally, the floor was unsanitizable due to missing paint or sealant in front of the ice machine. These conditions were confirmed by Administrative Staff A, who was unaware of who was responsible for cleaning and repairing the ice room due to recent staff changes. Dietary staff BB believed that housekeeping was responsible for cleaning the ice room, while Housekeeping staff W stated that the dietary staff was responsible, indicating a lack of clarity regarding cleaning responsibilities. The facility did not have a policy addressing the maintenance and cleaning of the ice machine/storage room, contributing to the unsanitary conditions observed. This lack of policy and clear responsibility led to the failure in ensuring a safe and sanitary environment for residents and staff.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility, with a census of 29 residents, failed to maintain a clean, comfortable, and homelike environment on four of five resident halls. During an environmental tour, several areas of concern were identified. A resident room on the northeast hall had a strong urine odor, indicating inadequate cleaning or maintenance. Additionally, a shower room on the same hall had rust around the drain and a large amount of loose hair, with a clean linen cart stored uncovered, and loose handrails on each side of the toilet. Further observations included a beauty shop on the central hall with a large glob of cut hair in the sink drain, and a laundry room handwashing sink containing dead bugs and small pieces of trash. On the southeast hall, a shower room had a toilet riser stored directly on the floor next to the toilet, with the cove base underneath the handwashing sink peeling from the floor, and the wall leading into the shower corner in poor repair with peeling and broken tile. These findings were confirmed by Maintenance/Housekeeping Staff U, highlighting the facility's failure to adhere to its housekeeping and maintenance policy.
Failure to Provide Grooming Services for Resident
Penalty
Summary
The facility failed to provide grooming services for a resident, identified as R5, who required assistance with personal hygiene. R5 had a medical history that included schizoaffective disorder, diabetes, depression, and pneumonia due to COVID. The resident's cognitive status was assessed with a BIMS score of 12, indicating moderate cognitive impairment, which later declined to a score of five, indicating severe cognitive impairment. Despite having no impairment in upper or lower extremities, R5 required substantial assistance with personal hygiene. Observations revealed that R5 had several days' worth of facial hair, overgrown sideburns and eyebrows, hair in his ears and nose, and long fingernails, indicating a lack of grooming. Interviews with staff revealed that grooming was typically done on bath days, which were Sundays and Thursdays, but R5 expressed difficulty with his electric razor and fingernail clippers. Social Service Staff X was in the process of finding a beautician for grooming services and was unaware of the last grooming service provided to R5. Administrative Nurse D expected staff to provide grooming services per the standard of practice, but the facility did not have a grooming policy in place. This lack of grooming services resulted in R5 not being maintained in a dignified manner.
Failure to Update Care Plan for Skin Tear Prevention
Penalty
Summary
The facility failed to review and revise the care plan for a resident, identified as R3, to address skin tear prevention. R3 had multiple medical conditions, including cerebral palsy, osteoarthritis, diabetes, hypertension, sleep apnea, gout, anxiety disorder, and pain, which contributed to his risk for skin tears. The resident was non-ambulatory, dependent on staff for activities of daily living, and had contractures in his extremities. Despite these risks, the care plan did not include updated interventions for a current skin tear on R3's left hand or strategies to prevent further injuries. Observations and interviews revealed that R3 sustained a skin tear on his left hand after hitting it on a dining room table. The care plan lacked an intervention for this injury, and there was no physician's order or treatment administration record for the skin tear. Staff confirmed that the care plan should have been updated to guide care and prevent further injuries. Despite the incident, the table with a metal edge, which contributed to the injury, remained in the dining room, posing a continued risk to R3 and other residents. The facility's policy on wound prevention and management required staff to develop interventions for optimal care and healing of skin alterations. However, the facility did not adhere to this policy, as evidenced by the lack of immediate intervention and care plan updates following R3's skin tear. The failure to address the identified causes of injury and implement preventive measures placed R3 at risk for repeated skin tears.
Failure to Provide Adequate Skin Care and Monitoring
Penalty
Summary
The facility failed to ensure that a resident, identified as R3, received appropriate treatment and care for a skin condition in accordance with professional standards of practice and the resident's care plan. R3, who has cerebral palsy, osteoarthritis, diabetes, hypertension, sleep apnea, gout, anxiety disorder, and experiences constant pain, was at risk for skin breakdown. Despite being identified as at risk for pressure ulcers, the resident's care plan lacked specific interventions for a current skin tear on the left hand and did not include updated measures to prevent further skin injuries. Observations and interviews revealed that R3 sustained multiple skin tears, including one on the left hand caused by hitting it on a dining room table with a metal edge. The facility's care plan did not reflect immediate interventions to prevent further injuries, and there was no physician's order or treatment administration record for the existing skin tear. Staff members confirmed that the care plan should have been updated to guide care and prevent further injuries, but this was not done. The facility's policy on wound prevention and management required the development of interventions to promote healing and prevent skin integrity concerns. However, the facility did not adhere to this policy, as evidenced by the lack of a physician's order for the skin tear, failure to update the care plan, and continued use of a hazardous table in the dining room. These oversights contributed to the resident's repeated skin injuries and inadequate monitoring and treatment of the skin condition.
Failure to Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to adequately monitor a resident, identified as R11, who was receiving antipsychotic medication for schizophrenia. The resident's electronic medical record indicated a diagnosis of schizophrenia and documented the use of antipsychotic medication, specifically Risperidone, prescribed at 1 mg twice daily. Despite the resident having intact cognition, as evidenced by a BIMS score of 14-15, the facility did not perform the required DISCUS assessments to monitor for tardive dyskinesia, a potential side effect of antipsychotic medications. The last recorded DISCUS assessment was completed on 01/10/24, and subsequent recommendations by Consultant Staff GG to conduct these assessments every six months were not followed. The facility lacked a policy regarding the completion of DISCUS assessments, which contributed to the oversight. Administrative Nurse D acknowledged the lapse, confirming that the DISCUS assessments had not been conducted for over eight months, despite the consultant's recommendations. This failure to monitor the resident's use of antipsychotic medication represents a deficiency in the facility's care practices, as it did not adhere to the recommended monitoring schedule to ensure the resident's safety and well-being.
Inaccurate MDS Completion for Resident with Fall History
Penalty
Summary
The facility failed to complete an accurate Significant Change Minimum Data Set (MDS) for a resident with a history of falls. The resident, diagnosed with dementia and severe cognitive impairment, experienced multiple falls, including one injury fall, since the prior assessment. Despite these incidents, the Fall Care Area Assessment (CAA) lacked necessary information regarding the resident's falls, which is a critical component for assessing and planning care for residents at high risk of falls. The resident's care plan, revised earlier in the year, indicated that the resident could be impulsive and required specific interventions to prevent falls, such as ensuring the room was free from clutter and not leaving the resident alone in a wheelchair. However, the facility's documentation, including the Significant Change MDS and the Fall CAA, did not accurately reflect the resident's fall history and risk, as confirmed by an administrative nurse. This oversight indicates a failure in the facility's use of the Resident Assessment Instrument (RAI) for accurate MDS completion.
Failure to Complete Daily Staff Posting
Penalty
Summary
The facility failed to complete the Daily Staff Posting to include the total and actual hours worked by direct care staff as required. The deficiency was identified during a review of the Daily Staffing Sheet dated from September 12, 2024, through September 18, 2024, which revealed a lack of actual hours worked for licensed and certified nursing staff. An interview with Business Office Staff EE on September 19, 2024, disclosed that she was responsible for logging the actual hours worked from the time clock and posting it on a Daily Staff Posting, but this had not been done since June 11, 2024. Additionally, an interview with Administrative Nurse D on the same day revealed that she filled in the Daily Staffing sheet to ensure adequate staff, while the business office was supposed to fill in the actual hours worked based on the time clock. The facility's Benefits Improvement Protection Act (BIPA) Nurse Staff Posting policy, revised in December 2019, instructed the charge nurse for the shift to fill in the total hours worked at the end of the shift, and the business office personnel were to verify and record the actual hours worked using payroll data. The facility's failure to calculate the total and actual hours worked by direct care staff on the Daily Staffing Sheet and/or on the Daily Staff Posting led to the deficiency.
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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