Minneola District Hospital Ltcu
Inspection history, citations, penalties and survey trends for this long-term care facility in Minneola, Kansas.
- Location
- 207 Chestnut, Minneola, Kansas 67865
- CMS Provider Number
- 17E470
- Inspections on file
- 12
- Latest survey
- March 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Minneola District Hospital Ltcu during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was served hot pureed foods without temperature checks, leading to discomfort and immediate jeopardy. The dietary staff did not verify food temperatures before sending them to nursing staff, and the facility's policy to assess food safety before feeding was not followed.
A resident with dementia and severely impaired cognition was hospitalized for dehydration due to the facility's failure to provide sufficient fluid intake. Despite care plan instructions and family requests, the resident's water was often out of reach, and staff did not consistently offer or encourage hydration. The facility's records showed multiple instances of inadequate fluid intake, leading to the resident's hospitalization for dehydration and a UTI.
A medication cart was found unlocked and unattended in a hallway, containing various medications, posing a risk to nine cognitively impaired, independently mobile residents. Staff interviews confirmed that the cart should have been locked when not in sight, but the facility lacked a specific policy for cart control when staff are absent.
The facility failed to maintain sanitary conditions in food storage, preparation, and service, risking foodborne illness for all residents. A trash can in the food prep area had a flip-top lid, and a dietary aide was observed pushing trash with a gloved hand and continuing food prep without changing gloves, violating the facility's hygiene policy.
The facility failed to maintain proper infection control during linen delivery. Clean laundry was transported with a cart cover improperly draped, exposing linens to potential contamination. Staff interviews and facility policy confirmed that all sides of the cart should be covered during transport.
The facility's laundry service area was found to be deficient in maintaining a safe and sanitary environment. Observations included uncovered soiled linen bins, broken and missing floor tiles in both soiled and clean areas, and an abraded doorway exposing bare wood. The facility also lacked a policy for maintenance and housekeeping in the laundry.
A resident was transferred to the shower room with her buttocks exposed, compromising her dignity. Additionally, a container in the dining room was labeled 'bibs only, no trash,' visible to all, affecting residents' dignity. Staff interviews revealed a lack of awareness and adherence to dignity protocols.
The facility failed to ensure accurate documentation and easy identification of residents' code statuses, leading to deficiencies in managing advanced directives. Several residents' records lacked physical DNR forms and necessary signatures, causing inconsistencies in their documented wishes. Staff interviews revealed confusion and difficulty in locating code status information during emergencies, highlighting gaps in training and policy implementation.
A discrepancy in the count of Lyrica pills for a resident was discovered during a narcotics count, revealing a failure in the facility's system for accurate accounting of controlled medications. The previous shift's CMA did not record the administration of Lyrica, and the oncoming CMA failed to perform an actual count, leading to an incorrect record. The facility's policy contained contradictory information regarding count signature requirements.
The facility failed to ensure timely responses to pharmacist recommendations for medication regimen reviews and gradual dose reductions for several residents, leading to potential unnecessary medication administration. Delays in physician responses ranged from 17 to 109 days, and the facility's policy lacked guidance on timely follow-up. Observations noted residents with severe cognitive impairments and potential overmedication, while staff were unclear on expected timelines for physician responses.
The facility did not ensure that daily nurse staffing sheets included accurate information, such as the facility name and total hours worked by staff. Observations showed missing details on the staffing sheet near the nurse's station, and a review of past sheets revealed similar issues. Administrative Staff C confirmed the inaccuracies and was unaware of the regulatory requirements.
Failure to Ensure Safe Food Temperatures for Resident
Penalty
Summary
The facility failed to ensure that a dependent resident, identified as R2, remained free from accident hazards and harm when staff fed him pureed foods without checking the temperature to ensure they were safe to eat. R2, who had severe cognitive impairment and was dependent on staff for assistance with eating, was served hot pureed soup and a pureed grilled cheese sandwich. The soup had been heated to 196 degrees Fahrenheit, and the sandwich to 150 degrees Fahrenheit, without the temperature being checked before serving. This resulted in R2 grimacing and pulling his head back, indicating discomfort from the hot food. The dietary staff heated the pureed foods in the microwave and placed them in insulated containers on a steam table, but did not check the temperatures before sending them to the nursing staff. The facility's food temperature logs showed that all meals lacked documentation of temperatures obtained prior to serving, with hot food items consistently above 165 degrees Fahrenheit. Dietary staff were unaware of any limitations on hot food temperatures to prevent burns, and nursing staff were expected to check food temperatures by holding their hand over the food before serving. The facility's policy required that all food be assessed for safety before assisting a resident with feeding, but this was not followed. The failure to check the temperature of the pureed foods before serving placed R2 in immediate jeopardy, as confirmed by the administrative staff who acknowledged the non-verbal signs of pain exhibited by R2 when served the hot food.
Removal Plan
- Education and policies reviewed by the Care Plan Team
- Held a QAPI meeting to discuss issues identified and plan of correction with Medical Director, CEO, COO, LTC Director, DON, ADON, Floor Charge Nurse, CSSD and Dietary Manager
- Education provided to ensure nursing staff and dietary staff know the correct procedure for monitoring food temperatures prior to serving pureed food to a resident
- All staff will be notified of changes in procedure and given verbal education and instruction on serving pureed food to a resident prior to returning to work. Signatures will be collected to signify understanding
- Dietary will track pureed food for temperature prior to leaving the kitchen and will not leave the kitchen window unless between the range of 145-165 degrees Fahrenheit. A log will be created to allow staff to log temperature prior to serving and include section for comments if the food did not leave the kitchen for a specific reason. The Dietary Manager will check documentation for compliance
- Audit will be performed during mealtimes, and randomly
- Results of Audits findings will be reviewed at QAPI meetings
Failure to Maintain Resident Hydration
Penalty
Summary
The facility failed to provide sufficient fluid intake to maintain proper hydration and health for Resident 6, who was diagnosed with dementia and amnesia, and had severely impaired cognition. The resident was dependent on staff for all activities of daily living, including eating, and required supervision and assistance. Despite the family's requests and care plan instructions to encourage fluid intake and keep water accessible, the facility did not consistently ensure that the resident had access to fluids. Observations revealed that the resident's water was often out of reach, and staff did not offer or encourage hydration during certain periods. The facility's records showed that Resident 6 had multiple instances of fluid intake below 1500 cc per day, which is below the facility's hydration policy requirements. The resident was hospitalized for dehydration and a urinary tract infection, which was attributed to insufficient fluid intake. Interviews with administrative nurses confirmed that the task to offer fluids was not consistently documented or completed, contributing to the resident's hospitalization. The facility's failure to adhere to its hydration policy resulted in actual harm to the resident.
Unsecured Medication Cart Poses Risk to Residents
Penalty
Summary
The facility failed to ensure the secure storage of medications, as observed on a specific date when a medication cart was found unlocked and unattended in a hallway between the dining and commons areas. This cart contained oral, topical, and inhaled medications. The incident was confirmed by a Certified Medication Aide (CMA) who acknowledged that the cart should be locked when not attended or within her line of sight. Further interviews with a Licensed Nurse (LN) and an Administrative Nurse confirmed that the facility's practice requires medication carts to be locked when out of the responsible person's line of sight, including when their back is turned. The deficiency placed nine cognitively impaired, independently mobile residents at risk, as identified by the Administrative Nurse. Despite the facility having a Controlled Medications Policy and Procedure, it failed to provide a specific policy outlining the process for medication cart control when staff are not present. This oversight in policy and practice led to the unsecured medication cart being accessible in a common area, posing a potential risk to residents.
Sanitation Lapses in Food Preparation
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage, preparation, and service, which placed all residents at risk for foodborne illness. During an observation, a trash can located at the hand washing sink in the food preparation area was found to have a flip-top lid instead of a foot-operated lid, which could lead to contamination. Additionally, a dietary aide was observed pushing down trash into the trash can with a gloved hand and then resuming food preparation without changing gloves. This action violated the facility's Food Preparation and Service Policy, which mandates that gloves must be changed between tasks to prevent contamination. The policy also prohibits bare hand contact with food and requires gloves to be worn when handling food directly. These lapses in hygiene and sanitary practices contributed to the deficiency.
Infection Control Deficiency in Linen Delivery
Penalty
Summary
The facility failed to maintain a comprehensive infection control program related to the delivery of clean linens. During an observation, it was noted that laundry personnel transported clean resident laundry in a cart with one of the side covers draped over the top, exposing the clean laundry to potential contamination. Interviews with Laundry Staff Z, Laundry Supervisor W, and Administrative Staff H confirmed that the linen cart should have all sides covered during transport and when unattended in the hallway. The facility's policy, dated 01/15/25, also stated that the sides of the linen cart should be closed while in motion and at each destination to prevent contamination. This oversight had the potential to lead to contamination of clean linens during delivery.
Deficiencies in Laundry Service Area
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment in the laundry service area, as observed during a tour with Administrative Staff H and Laundry/Housekeeping Staff W. The deficiencies included two uncovered soiled linen bins with a sock hanging off the side, indicating improper containment of soiled items. Additionally, the walkway tiled floor from the soiled linen area to the clean area was not sanitizable due to two broken and missing floor tiles. Similarly, the floor in the clean linen processing area had two missing tiles beside the washing machine, compromising its sanitizability. Furthermore, the egress from the clean linen room to the hallway entrance/exit doorway had multiple abrasions exposing bare wood, which was also not sanitizable. The facility lacked a policy related to maintenance and housekeeping in the laundry, contributing to these environmental concerns.
Dignity Issues During Resident Transfer and Dining
Penalty
Summary
The facility failed to protect the dignity of a resident, identified as R10, during a transfer from her room to the shower room. An observation revealed that R10 was transported in a shower chair covered with a white sheet from her neck to her knees, leaving her buttocks exposed. This exposure was visible to anyone in the area, which compromised the resident's dignity. Interviews with staff, including a Certified Medication Aide (CMA) and a Licensed Nurse (LN), indicated that residents should be fully covered during such transfers, but there was a lack of awareness that R10's buttocks were exposed. Additionally, the facility did not honor the dignity of residents in the dining room by labeling a container for soiled clothing protectors as 'bibs only, no trash.' This label was visible to all residents, staff, and visitors, potentially affecting the residents' dignity and psychosocial well-being. An administrative staff member acknowledged that the term 'clothing protector' should be used instead of 'bib' and confirmed that the labeling would be corrected. The facility's Resident Rights policy emphasizes treating each resident with dignity, which was not upheld in these instances.
Deficiencies in Advanced Directives Documentation
Penalty
Summary
The facility failed to ensure that each resident's code status was accurately documented and easily identifiable, leading to deficiencies in the management of advanced directives for several residents. Specifically, the facility's admission packet lacked prompts or forms for residents or their representatives to fill out regarding advanced directives. For Resident 17, the electronic health record (EHR) indicated a Do Not Resuscitate (DNR) status, but there was no physical DNR form or physician order to confirm this status. The care plan inconsistently documented the resident's code status, and the physical chart lacked a signed DNR form. Similarly, Resident 3's EHR and physical chart were missing a physical DNR form and lacked necessary signatures on advanced directives. The physician's orders included a DNR, but the documentation was incomplete, with missing signatures from the resident, a witness, and a physician. Resident 14's records also showed inconsistencies, with the EHR indicating a DNR status but lacking a physical DNR form and necessary signatures on advanced directives. Resident 171's records documented a full code status with special instructions for Do Not Intubate (DNI), but there was no DNI form available. Interviews with staff revealed confusion and difficulty in locating and verifying residents' code statuses during emergencies. Certified Nurse Aides and Certified Medication Aides indicated that they would rely on the EHR or ask other staff members if unsure about a resident's code status. Administrative Nurse C confirmed the difficulty in identifying orders and acknowledged that new and agency staff lacked training on locating code status information. The facility's policies on CPR and advanced directives were not effectively implemented, resulting in missing or incomplete documentation for several residents.
Controlled Medication Count Discrepancy
Penalty
Summary
The facility failed to ensure an effective system for the accurate accounting and reconciliation of controlled medications, specifically Lyrica pills for a resident. During a medication cart narcotics count, a discrepancy was found where the count sheet displayed 39 pills, but the hard count was 38 pills. This discrepancy was not caught during the count by the Certified Medication Aide (CMA) K, who documented that the night nurse had not taken anything from the cart. CMA K took the cart at 6:20 AM to start the morning medication pass but did not count the pills in the bottle, leading to the incorrect recording of the Lyrica count. The facility's investigation revealed that the previous shift's CMA S had given the resident their evening Lyrica and failed to record it on the count sheet. Subsequently, CMA K did not perform an actual count of the Lyrica and recorded the wrong number during her morning counts. The facility's policy for controlled medications, which was revised recently, contained contradicting information regarding count signature requirements, contributing to the failure in maintaining an accurate accounting system for controlled substances.
Delayed Response to Pharmacist Recommendations in LTC Facility
Penalty
Summary
The facility failed to ensure a timely response to the pharmacist's identified and reported irregularities and recommendations for several residents, leading to potential administration of unnecessary medications. For Resident 8, the pharmacist recommended gradual dose reductions (GDR) for medications such as Duloxetine and Risperidone, but the physician's responses were delayed by 20 days and 21 days, respectively. Additionally, the facility took 10 days to transcribe the physician's response for Risperidone, further delaying the process. The facility's policy on Drug Regimen Review lacked guidance on timely follow-up, contributing to these delays. Resident 15 also experienced delays in the response to pharmacist recommendations for GDR of medications like Fluoxetine and Abilify. The physician's responses were delayed by 17 days for both medications. Observations noted the resident was sedate and had a flat affect, indicating potential overmedication. The facility's process for handling pharmacist recommendations was not clearly defined, and staff were unsure of the expected timeline for physician responses. For Resident 17, the facility failed to ensure timely physician response to GDR requests for medications such as Klonopin and Cymbalta, with delays of 109 days and 44 days, respectively. Similarly, Resident 6's medication regimen review was not adequately addressed, with no response to a GDR recommendation for Trazodone and missing documentation for a monthly review. The facility's policy did not address timely follow-up, and no performance improvement plan was in place to address these deficiencies.
Inaccurate Nurse Staffing Information Posted
Penalty
Summary
The facility failed to ensure that the posted daily nurse staffing sheets included accurate and identifiable information, such as the facility name and the total number of actual hours worked per shift by licensed and unlicensed staff. During an observation, it was noted that the daily staffing sheet near the nurse's station lacked this critical information. A review of the staffing sheets from a previous date revealed that most sheets were missing the total number and actual hours worked per shift. During an interview, Administrative Staff C confirmed the inaccuracies and admitted to being unaware of the regulatory requirements for the staffing sheets. The facility's policy on Sufficient Staffing mandates that leadership provide adequate personnel on a 24-hour basis and that staffing and census information be posted prominently for accessibility to residents and visitors.
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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