Nortonville Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Nortonville, Kansas.
- Location
- 412 E Walnut St, Nortonville, Kansas 66060
- CMS Provider Number
- 175323
- Inspections on file
- 30
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 50 (4 serious)
Citation history
Health deficiencies cited at Nortonville Health Care Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities developed a worsening left heel pressure ulcer after staff failed to implement a physician's order for suspension boots and did not document or apply the intervention. The order was not entered into the EMR, and the care plan did not address the required preventative measures. The wound deteriorated, and there was no evidence of timely physician notification or communication with the resident's representative, despite facility policies requiring these actions.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in unsafe conditions for residents.
The facility did not ensure RN coverage for eight consecutive hours daily, as required, with schedule reviews revealing multiple days without an RN on duty. Staff could only verify RN coverage through a staffing program, and the facility was unable to provide an RN coverage policy when asked.
The facility did not complete annual performance reviews for five staff members, including LNs, CMAs, and CNAs, who had been employed for over a year. Personnel records lacked documentation of these evaluations, and the administrative nurse could not verify their completion. The facility also failed to provide a policy for employee annual performance reviews when requested.
The facility did not maintain a system to accurately account for controlled medications in its emergency kit, with the kit being stored in an office that was found unlocked and unattended on several occasions. The emergency kit was received with one drawer unlocked and lacking an inventory list, containing Schedule 2 narcotics such as fentanyl, morphine, and tramadol. The facility also lacked a policy for narcotic storage and did not require receipts for kit deliveries, resulting in an inability to reconcile and safeguard controlled substances.
The facility did not ensure a licensed pharmacist performed required monthly drug regimen reviews for all residents, with missing documentation and reports for several months. A resident with multiple complex conditions and at risk for medication side effects did not have their medication regimen reviewed as required by policy.
Surveyors identified multiple sanitation and food safety issues in the kitchen, including unverified use of pasteurized eggs, dirty equipment and surfaces, expired chemical testing strips, dead insects above food prep areas, and structural problems such as missing baseboards and a back door gap. Dietary staff confirmed the need for cleaning and repair, and the facility's policies for cleaning and sanitizing were not followed.
The facility did not prioritize quality improvement, failed to develop and implement action plans, and did not conduct or document any Performance Improvement Projects (PIPs) for two consecutive years. Administrative staff confirmed the absence of PIPs and noted frequent changes in facility leadership. The facility also did not provide evidence of QAPI committee activities or regular data review as required by policy.
The facility did not maintain a QAA committee with the required members or meet at least quarterly, as sign-in sheets lacked key personnel and there was no documentation for meetings in the previous year. No Performance Improvement Projects were started or documented, contrary to the facility's QAPI policy.
The facility did not implement a water management program for Legionella prevention, despite staff training and an existing policy requiring routine cleaning and disinfection of potable water systems. Both maintenance and administrative staff confirmed that a surveillance system for Legionella was not in place.
The facility did not have a certified Infection Preventionist (IP) responsible for the infection prevention and control program, and could not provide documentation of a current certified IP. An administrative nurse confirmed the absence of a certified IP and was unsure if an infection tracking system had been in place previously, despite facility policy requiring the IP to oversee infection control activities and reporting.
A review of CNA records showed that several aides employed for over a year did not complete the required 12-hour in-service training, and facility leadership could not provide documentation to verify compliance.
Surveyors found that expired medications, including multivitamins, zinc tablets, Milk of Magnesia, and nicotine patches, were not removed from the medication room. An LN confirmed the medications were expired and should have been removed, and the facility could not provide a policy for medication storage or expired medications.
A facility serving 30 residents did not employ a full-time Certified Dietary Manager to oversee its food and nutrition services. The staff member acting as manager was not certified and had not begun certification training. The facility also could not provide a policy for employing a Certified Dietary Manager, relying instead on monthly visits and phone consultations from a Registered Dietitian.
Two residents were not assessed for eligibility to receive the pneumococcal PCV20 vaccine, and there was no documentation of the vaccine being offered, declined, or contraindicated. Medical records lacked evidence of consent or informed declination, and staff confirmed there was no system in place to check vaccine eligibility.
A resident with significant cognitive and physical impairments was discharged and transferred to another facility without prior notification to their court-appointed guardian. Although the guardian was involved in discussions about referrals and equipment, staff did not inform the guardian of the resident's acceptance and transfer to a new facility until after the discharge had occurred, contrary to facility policy.
A resident with a history of repeated falls and multiple risk factors experienced multiple falls due to the facility's failure to update and implement appropriate fall prevention interventions in the care plan. Despite documented incidents and staff awareness of the resident's needs, new interventions were not consistently added to the care plan, and required safety measures such as non-skid strips were not in place. The facility also could not provide a fall management program policy when requested.
A resident with dementia, anxiety, and major depressive disorder exhibited ongoing aggressive and inappropriate behaviors, including verbal outbursts, threats, and refusal of care. Despite a care plan outlining interventions such as redirection, paired care, and activity engagement, staff were unable to consistently manage the resident's behaviors, and the facility could not provide a dementia behavior management policy when requested.
A resident with multiple medical conditions did not receive seven physician-ordered medications, including an anticoagulant, antibiotic, antipsychotic, and others, for three consecutive days after admission. The resident, who was cognitively intact and independent, reported the missed doses, and a nurse confirmed the omission. Facility policy required timely administration of medications by licensed staff, but this was not followed.
The facility failed to provide timely delivery of physician-ordered medications for two residents, leading to missed doses of critical medications such as Eliquis, montelukast, ropinirole, tamsulosin, and tramadol. Despite attempts to contact the pharmacy, the medications were not delivered on time, and there was no evidence that providers were notified of the supply issues. Staff interviews indicated frequent delays in pharmacy deliveries and a lack of a local pharmacy for emergencies.
A resident with a history of heart failure and hemiplegia experienced a fall and subsequent critical health changes, including low blood pressure and a critical creatinine level. The facility failed to notify the physician or act on the resident's representative's request for hospital transfer, leading to the resident's admission to the ICU with acute kidney injury and dehydration.
A resident with a PICC line for IV antibiotics did not have their dressing changed for 38 days, leading to possible sepsis. The facility failed to monitor the dressing status and lacked orders for dressing changes, placing the resident in immediate jeopardy. Staff interviews revealed a lack of education and competency checks related to PICC line care.
A resident with a stage four pressure ulcer experienced wound deterioration due to the facility's failure to consistently assess wound characteristics and notify the physician of changes. Despite having a care plan that included a wound vac, the facility did not document changes or involve the physician in treatment decisions, leading to the resident's condition worsening and eventual transfer to the emergency room.
A resident with a history of amputation, heart failure, and hemiplegia fell during a Hoyer lift transfer when staff failed to widen the lift legs and did not use the backup loop on the sling. The resident sustained abrasions and skin tears and expressed fear of future lift use.
The facility did not provide quarterly statements for resident trust fund accounts, as required by policy. A resident's representative reported never receiving a statement, and Administrative Staff confirmed no statements had been sent due to lack of training. This oversight risked uninformed decisions and potential misappropriation of funds.
The facility failed to convey personal funds within 30 days for several residents after discharge or death, as required by policy. This deficiency involved significant balances in resident trust accounts and was compounded by staff's lack of understanding of procedures for handling these funds. Interviews revealed that families were not informed about the status of these accounts, highlighting a communication gap.
A resident with severely impaired cognition had unauthorized transactions from their trust fund, including a $300 debit card purchase. The facility failed to obtain necessary authorization from the resident's DPOA, violating their policy and risking misappropriation of funds.
Failure to Implement Physician-Ordered Wound Interventions and Notify Provider
Penalty
Summary
The facility failed to follow physician orders and implement preventative wound interventions for a resident with a left heel ulcer. After a consultant assessed the resident and ordered suspension boots and daily wound cleaning, the facility did not enter the order for suspension boots into the electronic medical record (EMR), nor did they apply the boots as directed. The resident's care plan and EMR lacked documentation of the suspension boots order, and there was no evidence that the intervention was implemented. Additionally, the facility did not notify the physician when the resident's left heel wound opened, as required by the order. The resident had multiple diagnoses, including congestive heart failure, diabetes mellitus, and dementia with agitation, and was at risk for skin issues due to impaired mobility and incontinence. Over time, the resident's wound worsened, progressing from a deep tissue injury to an unstageable pressure ulcer, and eventually required advanced wound care interventions such as a wound vac. The EMR showed gaps in documentation of wound assessments, notifications to the physician and the resident's representative, and implementation of ordered interventions. The care plan also failed to address the physician's order for heel protectors and did not include all necessary interventions related to the resident's left heel wound. Interviews with staff revealed confusion and lack of clarity regarding the implementation and documentation of physician orders for wound care and preventative devices. Staff were unsure if the suspension boots were ever ordered or applied, and the EMR did not reflect the order or its implementation. The facility's policies required prompt transcription and implementation of physician orders, as well as systematic pressure injury prevention and management, but these were not followed in this case, resulting in a decline in the resident's wound status and the development of additional complications.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility, with a census of 30 residents, failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week. Review of nursing schedules for June 2024 and March 2025 showed that no RN was on duty on three specific dates. Consulting staff confirmed RN coverage could only be verified through a staffing program, which had recently changed companies. Additionally, when requested, the facility was unable to provide a policy regarding RN coverage.
Failure to Complete Annual Staff Performance Reviews
Penalty
Summary
The facility failed to complete the required annual performance reviews for five staff members, including licensed nurses, certified medication aides, and certified nurse aides, all of whom had been employed for over a year. A review of personnel records showed that these employees did not have documented annual evaluations. When asked, the administrative nurse was unable to locate or verify the existence of these performance reviews. Additionally, the facility could not provide an Employee Annual Performance Review policy upon request.
Failure to Account for and Secure Controlled Medications in Emergency Kit
Penalty
Summary
The facility failed to maintain a system for accounting for controlled medications, specifically regarding the receipt and disposition of narcotics in the emergency kit. On multiple occasions, the door to the Administrative Nurse's office, where the emergency kit was stored, was found unlocked and unattended. The emergency kit itself was received with one of its drawers unlocked, containing Schedule 2 controlled substances such as fentanyl patches, morphine, and tramadol, among others. The kit did not include an inventory list of the narcotic medications, and staff were unable to access two of the three drawers. The facility did not have a policy related to the storage of narcotic medications and did not require a receipt upon delivery of the emergency kit. The pharmacy was notified of the issue with the emergency kit, but did not promptly resolve the problem. When a replacement kit was brought, it also lacked an inventory and contact information for unlocking, leading the facility to refuse it and return the damaged kit. The consultant pharmacist confirmed that the emergency kit should not have been accepted if it was damaged or unlocked, and that proper documentation and inventory should have been provided. The lack of a detailed system for tracking controlled substances and the absence of a storage policy contributed to the facility's inability to accurately reconcile and safeguard narcotic medications.
Failure to Provide Monthly Consultant Pharmacist Drug Regimen Review
Penalty
Summary
The facility failed to provide the services of a Consultant Pharmacist to review and identify irregularities in the drug regimens of all 30 residents during December 2024. Record review showed that monthly medication regimen reviews (MRRs) were documented for August, September, October, and November 2024, but there was no documentation of an MRR for December 2024. Additionally, when requested, the facility was unable to provide the Consultant Pharmacist reports for August through December 2024. Administrative staff reported a change in pharmacy providers in November 2024 and were unable to locate the pharmacist's recommendations for the relevant months. One resident in the sample, who had multiple diagnoses including major depressive disorder, anxiety, pain, diabetes, muscle spasms, repeated falls, and intervertebral disc degeneration, was identified as being at risk for adverse side effects from medications with black box warnings. The resident's care plan required regular pharmacy review and recommendations, but the lack of a December 2024 MRR and missing reports indicated that this oversight did not occur as required by facility policy. Facility policies stated that the consultant pharmacist would review each resident's medication regimen at least monthly to identify any irregularities.
Widespread Kitchen Sanitation and Food Safety Deficiencies
Penalty
Summary
Surveyors observed multiple sanitation and food safety deficiencies in the facility's kitchen during meal preparation and service for all residents. Dietary staff reported cooking eggs to order, including over-easy and sunny-side-up, but could not verify that the eggs used were pasteurized as required. The kitchen's back door had a gap allowing outside light to enter, and the window above the microwave, where bread was stored, had a layer of brown dust. The handwashing sink and eyewash station were dirty, and two wheeled carts had greasy, linty material on the wheels and shelves. Additional observations included brown stains on ceiling tiles, food debris on oven surfaces, dried food remnants in stove drip pans, and lint on shelving used for cutting boards. Dead insects were found in a fluorescent light above food prep areas, and a container holding thermometers and chemical testing strips was covered in brown dust, with the strips found to be expired. Further issues included an ice machine floor drain lacking the required two-inch air gap and baseboards throughout the kitchen that were missing or coming unattached from the walls. Dietary staff confirmed the need for cleaning and repair in these areas and acknowledged that undercooked eggs should be pasteurized. The facility's own Nutritional Service policy requires adherence to federal and state food codes for cleaning and sanitizing equipment, but these standards were not met as evidenced by the observations.
Failure to Implement and Document QAPI Activities
Penalty
Summary
The facility failed to prioritize quality improvement, develop and implement action plans, conduct at least one Performance Improvement Project (PIP) annually, and regularly review, analyze, and act on collected data. During the survey, the facility was unable to provide documentation of any PIPs for the years 2024 and 2025. Administrative staff confirmed that no PIPs had been started or documented in the previous year, and noted that the facility had experienced turnover with seven administrators in the past two years. The facility's QAPI policy required the development and maintenance of a comprehensive, data-driven QAPI program, including systematic identification, reporting, investigation, analysis, and prevention of adverse events. The policy also specified the composition of the QAPI committee and the frequency of meetings. Despite these requirements, the facility did not provide evidence of QAPI committee activities or action plans addressing quality deficiencies, placing all 30 residents at risk for a lack of quality improvement activities.
Failure to Maintain Required QAA Committee Membership and Meetings
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) committee with the required membership and meeting frequency. Specifically, the QAA committee did not have documented attendance from the medical director or their representative, the administrator or governance leadership, or the consultant pharmacist. Sign-in sheets were only available for two meetings in 2025, with no documentation for meetings in 2024. Administrative staff confirmed the absence of these records and were unable to locate them within the facility. Additionally, the facility did not initiate any Performance Improvement Projects (PIPs) during the current year and had no documentation of PIPs from the previous year. The facility's QAPI policy required a comprehensive, data-driven program with systematic identification and prevention of adverse events, and specified the required committee members and quarterly meetings. The lack of proper QAA committee function and documentation placed all 30 residents at risk for impaired care and services.
Failure to Implement Legionella Water Management Program
Penalty
Summary
The facility failed to implement a water management program for Legionella disease prevention, as required by its own policy. Maintenance staff reported attending training on Legionella prevention but had not yet developed a surveillance system. Administrative staff confirmed the absence of a surveillance system for Legionella prevention. The facility's policy stated that potable water systems should be routinely cleaned and disinfected, but this was not being carried out. This deficiency was identified during a review of records and staff interviews, with a facility census of 30 residents at the time.
Lack of Certified Infection Preventionist for Infection Control Program
Penalty
Summary
The facility failed to ensure that the staff member designated as the Infection Preventionist (IP), who was responsible for the Infection Prevention and Control Program, had completed the required specialized training in infection prevention and control. Upon request, the facility was unable to provide documentation of a current certified IP employed at the facility. An administrative nurse confirmed that there was no current certified IP and stated she had only been employed for four weeks, expressing uncertainty about the existence of an infection tracking system prior to her employment. The facility's policy indicated that the IP was responsible for oversight of the infection prevention and control program, including surveillance activities, documentation, and reporting to the Quality Assessment and Assurance committee.
Failure to Provide Required In-Service Training for CNAs
Penalty
Summary
The facility failed to maintain an appropriate and effective in-service training program for nurse aides, as required by regulations. Specifically, a review of the records for three randomly selected Certified Nurse Aides (CNAs) who had been employed for more than a year revealed that they did not complete the required 12-hour in-service training. When asked, the Administrative Nurse was unable to verify that these CNAs had received the mandated training, and the facility could not provide documentation of the required in-service hours. This deficiency was identified through observation, record review, and staff interview, and affected a facility with a census of 30 residents.
Expired Medications Not Removed from Medication Room
Penalty
Summary
Surveyors observed that the facility failed to remove expired medications from the medication room, as evidenced by the presence of multiple expired stock medications including multivitamins with iron, zinc tablets, Milk of Magnesia, and nicotine patches. These medications were found to have expiration dates ranging from 04/2024 to 03/2025. A licensed nurse confirmed that these medications were expired and should have been removed from possible use. Additionally, when requested, the facility was unable to provide a policy regarding medication storage or the handling of expired medications. The facility had a census of 30 residents, with a sample of 12 residents included in the review. The failure to remove expired medications was identified through observation, interview, and record review during the survey.
Lack of Certified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility, with a census of 30 residents, failed to employ a full-time Certified Dietary Manager to oversee the food and nutrition service. During an observation, kitchen staff were seen completing the morning meal and preparing for the midday meal. The staff member identified as the manager confirmed she was not a Certified Dietary Manager and had not enrolled in a certification course. She also stated that a Registered Dietitian visited monthly and was available by phone for consultation. When requested, the facility was unable to provide a policy regarding the employment of a Certified Dietary Manager.
Failure to Assess and Document Pneumococcal Vaccination Eligibility and Consent
Penalty
Summary
The facility failed to assess two residents for eligibility to receive the pneumococcal PCV20 vaccination and did not offer, obtain informed declination, or secure a physician-documented contraindication for the vaccine as required by CDC guidelines. Review of the clinical medical records for these residents showed no evidence that the facility, the residents, or their representatives received or signed a consent to receive or an informed declination for the pneumococcal vaccine. The records also indicated that no pneumococcal vaccination had been given historically, offered, or declined. An administrative nurse confirmed that there was no system in place to check residents' eligibility status for pneumococcal vaccines at the time of the survey.
Failure to Notify Guardian Prior to Resident Discharge and Transfer
Penalty
Summary
The facility failed to notify a resident's guardian prior to the resident's discharge and transfer to another facility. The resident in question had a history of anxiety, traumatic brain injury, aphagia, dysphagia, and convulsions, and was documented as having moderately impaired cognition, requiring supervision for eating and total assistance for all other activities of daily living. The resident had an active court-appointed guardian, and the facility's records showed ongoing communication with the guardian regarding therapy services, equipment needs, and the search for alternative placement due to the facility's VA contract expiring. However, although the guardian was involved in discussions about referrals and equipment, documentation revealed that the guardian was not notified of the resident's actual discharge and transfer until after it had occurred. Staff interviews confirmed that the social services staff did not notify the guardian of the resident's acceptance and transfer to a new facility until the day of discharge, despite having received acceptance from the new facility several days prior. The facility's own discharge planning policy required that residents and their representatives be assisted in choosing appropriate care providers and be provided with accessible information about care options. Administrative staff verified that notification of a resident's representative or guardian prior to transfers or discharges was required, but this did not occur in this instance.
Failure to Update Fall Prevention Interventions and Care Plan
Penalty
Summary
The facility failed to identify and implement appropriate interventions to prevent falls for a resident with a history of repeated falls and multiple risk factors, including impaired mobility, moderately impaired cognition, and use of medications such as antianxiety agents, antidepressants, diuretics, and opioids. The resident's care plan documented the risk for falls and included interventions such as reminding the resident to notify staff when not feeling well, applying non-skid strips at the bedside, answering the call light promptly, and ensuring the resident wore nonskid socks and footwear during transfers and walking. However, after documented falls, the care plan and electronic medical record were not updated with new interventions to address the ongoing risk. The resident experienced multiple falls, including one incident where the resident slid off the bed while reaching for a television remote and another where the resident slid down in the bathroom while wearing shoes with no tread. Observations revealed the absence of non-skid strips at the bedside, and staff interviews indicated that interventions following falls were not consistently documented or updated in the care plan. Additionally, the facility was unable to provide a fall management program policy upon request.
Failure to Provide Appropriate Dementia Care and Behavioral Management
Penalty
Summary
The facility failed to provide appropriate supervision, treatment, and services to a resident diagnosed with dementia, anxiety, and major depressive disorder, who also exhibited aggressive behaviors. The resident's medical record documented moderately impaired cognition, inattention, disorganized thinking, and fluctuating levels of consciousness, as well as frequent pain and total incontinence. The care plan identified risks for outbursts, yelling, spitting, and refusal of care, and directed staff to use redirection, paired care, and activity engagement as interventions. Despite these documented interventions, multiple progress notes and staff interviews revealed ongoing incidents of verbal aggression, refusal of care, and inappropriate interactions with other residents, including the use of profanity, threats, and physical actions such as throwing objects. Staff reported that the resident was not easily redirected and required separation from another resident due to behavioral issues. The care plan also included consulting mental health services and medication management, but the facility was unable to provide a dementia behavior management policy when requested. Observations and interviews confirmed that the resident continued to display aggressive and inappropriate behaviors toward staff and other residents, indicating that the facility did not consistently implement or document effective behavioral management strategies as outlined in the care plan.
Failure to Administer Physician-Ordered Medications for Three Days
Penalty
Summary
Staff failed to administer seven physician-ordered medications to a resident for three consecutive days following admission. The medications included an anticoagulant, antibiotic, anti-inflammatory, anticonvulsant, diuretic, antipsychotic, and a vitamin for anemia. The resident's electronic medical record documented multiple diagnoses, including cellulitis, anemia, bipolar disorder, hypertension, acute embolism, thrombosis, osteomyelitis, and an open wound. The resident was cognitively intact, used a walker, and was independent with activities of daily living. The medication administration record confirmed that none of the prescribed medications were given on the specified three days. The resident reported to surveyors that several of his medications, including psychoactive drugs, were not administered for a few days after admission. A licensed nurse verified that the medications were not given as ordered. Facility policy required medications to be administered by licensed staff as ordered by the physician and in accordance with professional standards, but this was not followed in this instance.
Failure to Ensure Timely Medication Delivery
Penalty
Summary
The facility failed to ensure the availability of physician-ordered medications for two residents, R1 and R2, which posed a risk for physical complications and less than desired therapeutic effects. R1, who was admitted with diagnoses including acute kidney injury, atrial fibrillation, and hyperlipidemia, did not receive her prescribed medications, including Eliquis, montelukast, and ropinirole, on multiple occasions due to delays in delivery from the pharmacy. The facility's records showed repeated instances where R1's medications were marked as 'Hold/See Progress Notes' or 'Other/See Progress Notes,' indicating they were not administered as ordered. Despite the facility's attempts to contact the pharmacy, there was no evidence that R1's provider was notified about the medication supply issues. Similarly, R2, who had diagnoses of chronic obstructive pulmonary disease and major depressive disorder, experienced delays in receiving his prescribed medications, including tamsulosin and tramadol. The facility's records documented several instances where R2's medications were not available, and the facility was waiting for delivery from the pharmacy. Although the facility made R2's provider and pharmacy aware of the situation, the medications were still not delivered in a timely manner, leading to gaps in R2's medication regimen. Interviews with facility staff, including a Certified Medication Aide and a Licensed Nurse, revealed that the pharmacy frequently failed to deliver medications on time, and the facility did not have a local pharmacy for emergencies. The facility's policy on administering oral medications did not address the process for ordering medications or ensuring timely pharmacy services. This lack of a clear protocol contributed to the failure to provide necessary medications to R1 and R2, highlighting a significant deficiency in the facility's pharmaceutical services.
Failure to Respond to Critical Health Changes
Penalty
Summary
The facility failed to respond promptly to a critical change in a resident's health status, which included a critical lab result and abnormally low blood pressure. The resident, who had a history of heart failure, hemiplegia, and an above-knee amputation, experienced a fall from a Hoyer lift, resulting in back pain and shakiness. Despite these symptoms and a critical creatinine level indicating potential kidney issues, the facility did not notify the physician or take immediate action to address the resident's declining condition. On the day following the fall, the resident's blood pressure readings were significantly below the physician-ordered parameters, yet the facility staff failed to notify the physician. The resident's representative requested that the resident be sent to the hospital, but the staff hesitated, citing potential difficulties in returning the resident if not admitted. It was only after the Program of All-Inclusive Care for the Elderly (PACE) intervened that the resident was sent to the hospital, where they were diagnosed with acute kidney injury and dehydration, and admitted to the ICU. The facility's inaction and failure to communicate the resident's critical condition to the physician placed the resident in immediate jeopardy. The resident's medical records and staff interviews revealed a lack of timely response to the resident's low blood pressure and critical lab results, as well as a failure to honor the resident's representative's request for hospital transfer. This deficiency resulted in the resident's admission to the ICU with severe health complications.
Failure to Provide Appropriate PICC Line Care
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident's peripherally inserted central catheter (PICC) line, including monitoring for complications and performing sterile dressing changes as per the standards of care. The resident, who was admitted with a PICC line for intravenous antibiotics, did not have their PICC dressing changed for 38 days, which was discovered when the resident was sent to an acute care hospital for possible sepsis. The hospital staff identified the outdated dressing, which had not been changed since the resident's admission, potentially contributing to the resident's sepsis. The resident's electronic medical record lacked evidence of any PICC dressing changes during their stay at the facility. Despite having orders to flush the PICC line, there were no orders or documentation regarding dressing changes. The facility's staff failed to monitor the dressing status and did not identify the absence of dressing change orders. This oversight placed the resident in immediate jeopardy, as the lack of proper PICC line care increased the risk of infection. Interviews with facility staff revealed a lack of education and competency checks related to PICC line care. A licensed nurse admitted to not receiving any training on PICC line care at the facility, despite having prior experience. The facility's administrative nurse confirmed that staff had not received PICC line care education before a recent skills fair and that there were no skills checks to ensure staff competency. The facility did not provide a policy related to PICC line care, further highlighting the deficiency in staff training and protocol adherence.
Failure in Wound Care Management
Penalty
Summary
The facility failed to provide appropriate wound care for a resident with a stage four pressure ulcer on the sacrum, leading to the deterioration of the wound and worsening of the infection. The resident, who had a history of cerebral infarction, pressure-induced deep tissue damage, and other medical conditions, was admitted with a sacral wound and was on IV antibiotics. The care plan included the use of a wound vac, with specific instructions for wound assessment and physician notification in case of changes. However, the facility did not consistently assess the wound characteristics or notify the physician of changes, such as bleeding and skin breakdown around the wound. Throughout the resident's stay, there were multiple instances where the wound assessments were incomplete or lacked documentation of changes in the wound's condition. Despite the presence of a wound vac, the facility did not have a contingency plan for when the wound vac could not be placed due to skin breakdown. The resident's wound showed signs of deterioration, including increased redness, skin breakdown, and necrotic tissue, but these changes were not communicated to the physician in a timely manner. The facility's records also lacked evidence of physician involvement in the decision-making process for wound care adjustments. The situation escalated when the resident's condition worsened, leading to a decline in alertness and vital signs, and the wound developed a strong foul odor. The resident was eventually sent to the emergency room, where the wound was found to be necrotic with significant tunneling. Interviews with facility staff revealed a lack of communication and documentation regarding the wound's condition and the absence of a clear protocol for handling wound care complications. The facility's failure to adhere to wound care standards and ensure physician involvement contributed to the resident's deteriorating condition.
Resident Falls During Hoyer Lift Transfer Due to Staff Error
Penalty
Summary
The facility failed to ensure a resident remained free from preventable accidents during a Hoyer lift transfer. The resident, who had a history of amputation, heart failure, and hemiplegia, required total assistance for transfers. During a transfer to a shower chair, the resident fell from the Hoyer lift when the sling loops became unattached, resulting in the resident hitting their back on the lift leg and sustaining abrasions and skin tears. The incident occurred when two staff members, a Certified Nurse Aide (CNA) and a Certified Medication Aide (CMA), were performing the transfer. They did not widen the Hoyer lift legs after clearing the bed, as per the manufacturer's instructions, which caused the lift to become unsteady. Additionally, the staff did not use the backup loop on the sling, contributing to the resident's fall. The resident expressed fear of using the Hoyer lift in the future and experienced pain following the incident. The facility's investigation revealed that the staff involved did not follow proper procedures for using the Hoyer lift, including ensuring the correct sling size and placement, and using the appropriate sling lift loops.
Failure to Distribute Quarterly Trust Fund Statements
Penalty
Summary
The facility failed to distribute quarterly statements to residents with trust fund accounts, as required by their policy. The facility had 30 active resident trust fund accounts with a total balance of $63,621.38. A sample review included nine residents, and it was found that a resident's representative had never received a quarterly statement regarding the resident's trust account, despite making inquiries after the resident's discharge. Administrative Staff C confirmed that no quarterly statements had been sent out for any trust accounts, citing a lack of training on the matter. The facility's policy mandates that quarterly statements be provided in writing to residents or their representatives within 30 days after the end of the quarter and upon request. This failure placed residents at risk for uninformed decisions regarding their trust funds and potential misappropriation.
Failure to Convey Resident Trust Funds Timely
Penalty
Summary
The facility failed to ensure the timely conveyance of personal funds for several residents following their discharge or death, as required by their policy. The report identifies that the facility had 30 active resident trust fund accounts, with a sample review of nine residents. Specifically, the facility did not convey the personal funds within 30 days for five residents, placing them at risk for impaired rights and misappropriation. The trial balance revealed significant balances in the trust accounts of these residents, including one resident who was discharged and four who had died in the facility. Interviews with facility staff revealed a lack of understanding and adherence to the policy regarding the handling of resident trust funds. Administrative Staff C admitted uncertainty about the procedures for managing trust funds upon a resident's death and indicated that she typically contacted the family to arrange for funeral expenses. She also acknowledged that she was scheduled for training on how to handle older accounts. Furthermore, there was a lack of communication with the families regarding the status of these accounts, as evidenced by a representative of one resident who had not received any account statements or responses to inquiries about the trust fund balance.
Failure to Obtain Authorization for Resident's Trust Fund Transactions
Penalty
Summary
The facility failed to properly manage a resident's trust fund by not obtaining the necessary authorization for transactions. The resident, identified as having severely impaired cognition, had two debits from their trust account: one for $124.61 and another for $300.00. The first transaction was for personal needs items, which was authorized by the resident's durable power of attorney (DPOA) due to the resident's inability to sign. However, the second transaction for a debit card purchase was not authorized by the DPOA, despite a receipt indicating the resident's signature and a note about buying a debit card for online orders. The DPOA was unaware of the $300.00 debit card purchase and expressed concern about the resident's vulnerability due to dementia. Administrative staff acknowledged that authorization from the DPOA should have been obtained for expenditures from the resident's trust fund, especially given the resident's cognitive impairment. The facility's policy requires written authorization for managing residents' funds, but this was not followed, leading to a risk of impaired rights and potential misappropriation of the resident's funds.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
