Ness County Hospital Ltcu Dba Cedar Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Ness City, Kansas.
- Location
- 312 Custer Street, Ness City, Kansas 67560
- CMS Provider Number
- 17E625
- Inspections on file
- 14
- Latest survey
- October 20, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Ness County Hospital Ltcu Dba Cedar Village during CMS and state inspections, most recent first.
A resident with dementia and a history of falls was pushed in a wheelchair without foot pedals by an LPN, leading the resident to place her feet on the ground and fall headfirst, resulting in a significant laceration and emergency treatment. The care plan did not address the use of foot pedals, and observations showed other wheelchairs in the facility also lacked foot pedals.
A resident with severe cognitive impairment and multiple medical conditions was left in urine-soiled pajamas and taken into common areas and activities without being properly dressed or having pressure-relieving boots on. Staff did not follow care plan directives for toileting and hygiene, and the resident expressed discomfort and awareness of not being dressed, resulting in a failure to maintain dignity.
A resident with multiple chronic conditions, cognitive impairment, and a history of falls experienced repeated falls resulting in serious injuries due to the facility's failure to implement and revise effective care plan interventions. Despite recommendations and documented risks, interventions were inconsistently applied, and the resident continued to fall, highlighting deficiencies in care planning and intervention implementation.
A resident with cognitive impairment and multiple medical conditions did not receive consistent meal assistance as required by their care plan, resulting in difficulty accessing food and significant weight loss. Staff failed to monitor intake, provide supplements, and notify the RD as directed, and assistance during meals was delayed or insufficient.
A resident with multiple health conditions, including dementia and edema, developed a Stage 3 pressure ulcer due to the facility's failure to consistently implement and document pressure ulcer prevention interventions. Staff did not ensure the resident wore pressure-relieving boots at all times, left her heels unprotected during transfers and while in common areas, and did not follow care plan directives for repositioning and toileting. These lapses led to the development and worsening of the pressure ulcer.
A resident with multiple medical conditions and moderately impaired cognition experienced repeated falls resulting in fractures, despite being identified as high risk and having interventions such as a reacher and floor grip strips in place. The resident continued to fall while attempting activities independently, and staff noted noncompliance with safety instructions. The facility's interventions did not effectively address the resident's needs or provide adequate supervision, leading to continued accidents and injuries.
A resident with multiple medical conditions and moderately impaired cognition experienced repeated falls resulting in fractures, despite being identified as high risk and having several interventions in place. The interventions, such as providing a reacher and floor grip strips, were ineffective, and the resident continued to fall and sustain injuries. Staff relied on a release of responsibility form signed by the resident, who had impaired cognition, and discontinued a chair alarm, while new interventions were not adequately individualized or effective.
Two residents received psychotropic medications without proper oversight: one was prescribed an antipsychotic for an unapproved indication, and another received a PRN antianxiety medication without a required stop date. The consultant pharmacist's monthly reviews did not address these issues, and facility policy requirements for medication review and documentation were not followed.
Failure to Ensure Wheelchair Foot Pedals Resulted in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure that foot pedals were attached to a resident's wheelchair while the resident was being pushed by a licensed nurse. The resident, who had a history of Lewy body dementia, congestive heart failure, chronic pain syndrome, and repeated falls, was known to have severely impaired cognition, poor safety awareness, and a high risk for falls. The care plan identified the resident as a high fall risk and included several interventions for supervision and fall prevention, but did not specify the use of foot pedals on the wheelchair. On the day of the incident, the resident was being assisted by a licensed nurse who propelled the resident in a wheelchair without foot pedals. The resident placed her feet on the ground while being pushed, which caused her to fall headfirst to the floor. As a result, the resident sustained a 7.5 cm laceration on her forehead, a small hematoma, and required emergency transfer for evaluation and suturing of the wound. Observations and interviews confirmed that the wheelchair did not have foot pedals at the time of the fall, and that this was not an isolated issue, as other wheelchairs in the facility were also observed without foot pedals. The facility's fall risk assessment policy required identification and mitigation of environmental hazards and the addition of interventions to care plans to minimize fall risks. However, the lack of foot pedals on the wheelchair during transport directly contributed to the resident's fall and injury. Staff interviews revealed that there was no prior education or specific intervention in the care plan regarding the use of foot pedals, and audits after the incident found that other residents' wheelchairs also lacked foot pedals.
Failure to Maintain Resident Dignity and Hygiene
Penalty
Summary
The facility failed to maintain the dignity of a resident with severe cognitive impairment and multiple medical conditions, including pressure ulcers, dementia, acute kidney failure, anxiety, vitamin deficiency, and pain. The resident was observed in bed with a heavily urine-soiled disposable bed pad and pajama pants soiled with urine from the waist to the back of the knees. Staff reported the resident had last been toileted approximately three hours prior. The resident was then transferred out of bed without socks or pressure-relieving boots, placed in a sit-to-stand lift, and taken into the common area and activity room in pajamas, with her heels unprotected and dragging on the floor. The resident expressed feeling cold and later stated she was not dressed, indicating awareness of her undignified state. Staff failed to provide timely hygiene care, as the resident was not bathed or properly dressed before being taken into public areas. The care plan directed staff to assist with all activities of daily living, including toileting every two hours and maintaining personal hygiene, but these directives were not followed. Staff also failed to communicate respectfully, with one CNA blaming a coworker for not providing a bath. The facility's policy required care to be provided in a manner that maintains and enhances each resident's dignity and respect, but this was not upheld in the care of this resident.
Failure to Implement Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to implement effective care plan interventions to prevent a resident from experiencing repeated falls and sustaining major injuries. The resident had a history of chronic medical conditions, including COPD, hypertension, chronic atrial fibrillation, and multiple fractures, and was assessed as having moderately impaired cognition and significant functional limitations. Despite being identified as high risk for falls and having a care plan in place, the resident experienced multiple falls resulting in serious injuries such as pelvic and hand fractures, as well as skin tears and bleeding. Documentation revealed that after each fall, recommendations were made, such as providing a reacher, reminding the resident to call for assistance, and taking the resident to the bathroom after meals. However, the interventions were not consistently effective or adequately tailored to the resident's needs, particularly given the resident's cognitive impairment and noncompliance with staff assistance. The care plan was not sufficiently revised or implemented to address the ongoing risk, and some interventions, such as the use of a chair alarm, were discontinued despite continued falls. Staff interviews confirmed that the resident often acted independently, had poor safety awareness, and did not always follow directions. The facility allowed the resident to sign a release of responsibility form regarding falls, even though the resident had moderately impaired cognition. The care plan policy required ongoing assessment and revision, but the facility did not ensure that effective interventions were in place and followed, resulting in continued risk for falls and injuries.
Failure to Provide Adequate Meal Assistance and Nutritional Support
Penalty
Summary
A deficiency occurred when staff failed to provide necessary meal assistance to a resident with moderately impaired cognition and multiple medical diagnoses, including hypertensive heart disease, atrial fibrillation, urinary retention, and major depressive disorder. The resident's care plan indicated that assistance with eating should be provided depending on his condition each day, and staff were directed to monitor intake, offer alternatives or supplements if intake was less than 50%, and closely monitor weight. Despite these directives, the electronic medical record lacked documentation of consistent weight monitoring and did not specify the frequency of weighing the resident. Observations revealed that the resident struggled to access and consume meals independently. During one meal, the resident was unable to reach his food and water without help from a tablemate, and staff assistance was delayed and insufficient, with staff leaving before the resident finished eating. On another occasion, the resident was left unable to reach his breakfast until staff were prompted to assist, and even then, assistance was inconsistent and distracted. Interviews with staff confirmed awareness of the resident's recent decline and increased need for assistance, but there was a lack of coordination and follow-through in providing the required support. Additionally, the resident experienced significant weight loss over a short period, with documentation showing a 12% loss in 30 days. Although dietary staff had standing orders for interventions in the event of weight loss, such as supplements and meal fortification, there was no evidence that these interventions were consistently implemented or that the registered dietician was notified of the ongoing weight loss. Staff interviews revealed confusion about responsibilities for monitoring intake and providing supplements, further contributing to the failure to meet the resident's nutritional needs.
Failure to Prevent and Manage Pressure Ulcer Development
Penalty
Summary
A resident with a history of dementia, acute kidney failure, edema, and pressure ulcers developed a Stage 3 pressure ulcer on her right heel while under the care of the facility. The resident was dependent on staff for transfers, toileting, and mobility, and was identified as being at risk for pressure ulcers. Despite this, there were inconsistencies in the assessment of her risk, as the Braden Scale initially indicated she was not at risk, but later assessments documented her as at risk. The care plan directed staff to float the resident's heels, use pressure-relieving devices, and ensure heel protectors were worn at all times, but these interventions were not consistently implemented. Documentation revealed that the resident's pressure ulcer worsened over time, with measurements and wound characteristics changing, and orders for various wound care treatments being issued. There were lapses in following physician and wound care orders, such as delays in providing pressure-relieving boots and lack of documentation that certain interventions, like the use of a gel cushion, were put into place. Staff interviews indicated uncertainty about how the wound developed and why it took an extended period to implement necessary interventions. Observations showed that the resident was left without pressure-relieving boots for extended periods, including while being transferred and while in common areas, and her heels were unprotected and in contact with the floor. Additionally, the resident experienced prolonged periods without toileting, was left in soiled clothing and bedding, and was not consistently dressed or provided with appropriate foot protection. Staff were observed not following the care plan directives, and there was confusion among staff regarding responsibilities for the resident's care. The facility's own wound management policy emphasized the importance of comprehensive wound care and prevention, but the documented actions and observations demonstrated a failure to prevent the development and worsening of a Stage 3 pressure ulcer for this resident.
Failure to Prevent Repeated Falls and Injuries Due to Ineffective Interventions
Penalty
Summary
A deficiency was identified when a resident with multiple medical conditions, including COPD, hypertension, chronic atrial fibrillation, and a history of fractures, experienced repeated falls resulting in significant injuries such as pelvic and finger fractures. The resident had moderately impaired cognition, was dependent on staff for several activities of daily living, and had a documented history of falls with major injuries. Despite being assessed as high risk for falls and having a care plan in place, the interventions implemented were ineffective in preventing further incidents. The resident's falls occurred under various circumstances, including reaching for items on the floor, attempting to go to the bathroom independently, and getting up from a chair without assistance. Interventions such as providing a reacher, placing floor grip strips, and instructing staff to take the resident to the bathroom after meals were documented. However, the resident continued to fall, and staff noted the resident's noncompliance with safety instructions and poor safety awareness. The facility also had the resident sign a release of responsibility form, despite the resident's moderately impaired cognition. Facility policy required individualized, resident-centered approaches to safety, including adequate supervision and monitoring the effectiveness of interventions. However, the repeated falls and injuries, along with the reliance on interventions that did not address the resident's cognitive limitations or ensure adequate supervision, demonstrated a failure to maintain an environment free from accident hazards and to provide sufficient supervision to prevent accidents.
Failure to Prevent Repeated Falls and Injuries Due to Ineffective Interventions
Penalty
Summary
A resident with multiple complex medical conditions, including COPD, edema, hypertension, chronic atrial fibrillation, and a history of fractures, experienced repeated falls resulting in significant injuries such as pelvic and finger fractures. The resident had moderately impaired cognition, was dependent on staff for several activities of daily living, and had a documented history of falls with major injuries. Despite being identified as high risk for falls, the interventions implemented by the facility, such as providing a reacher, placing floor grip strips, and instructing staff to assist the resident to the bathroom after meals, were not effective in preventing further incidents. The resident's care plan and fall risk assessments documented ongoing falls and injuries, with repeated recommendations for interventions that did not adequately address the underlying issues. The resident was noted to be noncompliant with staff assistance, had poor safety awareness, and did not consistently follow directions, yet interventions remained largely unchanged or were not sufficiently individualized. The facility also had the resident sign a release of responsibility form for falls, despite the resident's moderately impaired cognition, and discontinued the use of a chair alarm. Staff interviews confirmed that the resident often acted independently, sometimes against staff advice, and that the responsibility for implementing new interventions after each fall was assigned to charge nurses. The facility's policy emphasized individualized, resident-centered safety interventions and adequate supervision, but the repeated falls and injuries indicated that the interventions in place were ineffective and did not prevent further harm to the resident.
Failure to Ensure Proper Psychotropic Medication Management and Review
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed an adequate monthly drug regimen review for two residents, resulting in deficiencies related to psychotropic medication management. For one resident with diagnoses including insomnia, vascular dementia, depression, and anxiety disorder, the medical record showed the use of Aripiprazole, an antipsychotic, prescribed for insomnia—an unapproved indication. The resident's care plan noted the need to monitor for adverse drug reactions and review pharmacy recommendations, but the consultant pharmacist's monthly reviews over several months did not document the unapproved indication or address the risk versus benefit of continuing the medication. The administrative nurse confirmed that the pharmacist had not notified the facility or physician about the inappropriate use of Aripiprazole. Another resident, diagnosed with dementia, altered mental status, Parkinson's disease, and other conditions, had a physician order for Alprazolam, an antianxiety medication, to be administered as needed for anxiety and agitation. This order lacked a required end or stop date. The care plan for this resident directed staff to monitor for adverse reactions and review pharmacy consultant recommendations, but both the electronic medical record and the consultant pharmacist's monthly reviews lacked documentation regarding the use and monitoring of the as-needed Alprazolam. The administrative nurse stated that it was the charge nurse's responsibility to obtain a stop date for PRN psychotropic medications and that the consultant pharmacist should have recommended one as well. The facility's own policy required that psychotropic medication orders include a qualifying diagnosis and specific target behaviors, and that the consultant pharmacist review the appropriateness of all medication orders. The policy also required monitoring the need for psychotropic medications and evaluating the effectiveness of PRN orders. The facility did not ensure compliance with these requirements, resulting in residents being at risk of receiving unnecessary psychotropic medications.
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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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