Nottingham Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Olathe, Kansas.
- Location
- 14200 W 134th Place, Olathe, Kansas 66062
- CMS Provider Number
- 175540
- Inspections on file
- 15
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Nottingham Health And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found multiple medication and treatment carts unlocked and unattended in hallways, despite containing enteral meds, PRN creams, insulin pens, scheduled meds, and OTC meds. On different units, carts were observed left without staff present while holding resident-specific and general treatment supplies. In interviews, an LN and an administrative nurse acknowledged that carts are required to be locked when out of view or not in use, and facility policy specified that medications must be stored in accordance with state and federal requirements.
A resident with hemiplegia and intact cognition had no documented self-administration of medication assessment in the EMR and no care plan addressing self-medication, yet medications were left at the bedside in a pill cup by a CMA. The resident questioned what the pills were, and an LN, upon entering the room, could only tentatively identify one pill and had to remove the cup to verify with the CMA. The resident reported never being assessed to self-administer medications, while administrative staff later stated that appropriate self-administration should be care planned with a provider order and that medications should not be left at the bedside, contrary to the observed practice and the facility’s own medication administration policy.
A resident with hemiparesis after a stroke, severely impaired cognition (BIMS 0), neuromuscular bladder dysfunction, and unsteadiness on feet required extensive assistance with ADLs and was care planned for fall risk, including having frequently used items within reach and education on call light use. During observation, the resident was found in bed yelling for help to be repositioned while both the portable and cord call lights were out of reach—one on the bedside table and the other wrapped around and caught under the bed. Staff, including a CNA, an LN, and an administrative nurse, acknowledged that at least one call light should always be within easy reach of the resident, and the facility’s falls policy required maintaining an environment free from accident hazards with adequate supervision and assistive devices, which was not met in this situation.
The facility failed to secure hazardous areas, leaving laundry rooms with high-voltage panels and chemicals unlocked, accessible to cognitively impaired residents. Additionally, fall interventions for two residents were not implemented as per their care plans, with wheelchairs placed out of reach, increasing fall risk.
A facility with 74 residents was found to have deficiencies in food storage practices across its four kitchens. Observations revealed issues such as unlabeled and undated food items, an open ice machine with a plastic bowl on top, and opened food exposed to air. These practices were contrary to the facility's Dietary Food Storage policy, which requires labeling and dating of opened food to prevent spoilage and contamination, placing residents at risk for food-borne illness.
The facility failed to follow infection control standards, including enhanced barrier precautions, hand hygiene, and disinfection of shared mechanical lifts. A CNA did not sanitize a Hoyer lift after use and failed to perform hand hygiene before serving drinks. Soiled linens were also improperly handled. Staff interviews confirmed these actions were against the facility's infection control policy, putting residents at risk for infectious diseases.
A resident with heart failure and other conditions was provided personal care with open window blinds, exposing them to the street view. Staff interviews confirmed that blinds should be closed to maintain dignity, aligning with the facility's policy. This oversight risked negative psychosocial outcomes for the resident.
A facility failed to update a resident's care plan to include toileting after meals, despite the resident's risk for falls and a history of hemiparesis, osteoarthritis, and recent femur fracture. The resident was found on the floor after attempting to use the restroom independently, highlighting the omission of this critical intervention. Staff interviews confirmed that care plans should be reviewed and updated to ensure safe care.
A facility failed to consistently perform pre-dialysis assessments for a resident requiring hemodialysis, as outlined in their care plan. Despite having a process in place for communication between shifts and with the dialysis center, records lacked evidence of these assessments on multiple occasions. The resident had a complex medical history, including diabetes, hypertension, and renal failure.
A resident with muscle weakness and mobility issues was provided with side rails without a documented risk assessment or informed consent. The resident injured his elbow on the side rail, and staff interviews revealed inconsistencies in the assessment process. The facility's policy on bed device safety was not followed, compromising the resident's safety.
The facility failed to obtain consents or informed declinations for the PCV20 and influenza vaccinations for a resident. The resident's clinical record lacked documentation of whether these vaccines were offered, given, or declined. Although a declination was provided, it was not clear if it was for the current period. The infection preventionist noted that the facility reviews vaccine consent during care plans but does not require yearly signatures for declinations.
Unlocked and Unattended Medication and Treatment Carts
Penalty
Summary
Surveyors identified a deficiency related to improper storage of medications and biologicals when multiple medication and treatment carts were found unlocked and unattended in facility hallways. During the initial tour on 04/06/26 at 07:50 AM, a treatment cart on Holiday House was observed unlocked and unattended; it contained one resident’s enteral medications, resident supplies, and PRN creams. At 08:10 AM the same day, a treatment cart on another unit was found unlocked and unattended, containing residents’ treatment supplies, PRN creams, and two insulin pens. At 08:20 AM on 04/06/26, a medication cart on that same unit was observed unlocked and unattended in the hallway with three insulins and creams for treatments inside. On 04/07/26 at 07:36 AM, another medication cart on the same unit was again observed unlocked and unattended in the hallway, containing scheduled medications and over-the-counter medications. During interviews, a licensed nurse stated that treatment and medication carts should be locked when out of the nurse’s view, and an administrative nurse confirmed that medication and treatment carts should be locked when not being used. The facility’s Medication Labeling and Storage policy dated 01/30/26 documented that medications would be labeled and stored in accordance with facility requirements and Kansas and Federal laws, including appropriate and safe labeling of medications dispensed to all residents.
Failure to Assess Resident Before Leaving Medications at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to assess a resident for the ability to safely self-administer medications before leaving medications at the bedside unsupervised. The resident had a diagnosis of hemiplegia affecting the left nondominant side and an Annual MDS showing a BIMS score of 15, indicating intact cognition. However, the resident’s EMR contained no Self-Administration of Medications assessment, and the Baseline Care Plan did not address self-medication. Despite this lack of assessment and care plan direction, staff practice resulted in medications being left in the resident’s room. During observation, the resident was noted to have a pill cup with two pills on the bedside table and stated she had a question about what the pills were. When a licensed nurse entered, the resident asked what the pills were; the nurse stated one looked like Tylenol but would need to check on the other pill and then said she needed to ask the CMA who had placed and left the medications in the room. The nurse removed the pills to consult the CMA. The resident reported she had never been assessed to self-administer medications to her recollection. When interviewed, administrative staff stated that residents appropriate for self-administration would be identified in the care plan after provider notification and an order, and also stated that medications should not be left at the bedside, which contrasted with the observed practice and the facility’s own Medication Administration Policy referencing a Self-Administration Policy and Procedure.
Failure to Keep Call Lights Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call lights were within reach, as required to keep the environment free from accident hazards and provide adequate supervision to prevent accidents. The resident had multiple significant diagnoses, including hemiparesis/hemiplegia following a stroke, neuromuscular bladder dysfunction, unsteadiness on feet, and major depressive disorder. A recent MDS documented a BIMS score of zero, indicating severely impaired cognition, and showed the resident required setup or cleanup for eating, substantial/maximal assistance with bathing and oral care, and was dependent on staff for toileting. The MDS also documented impairment of one side of the upper and lower extremities and that the resident had not had any falls since admission. A Falls Care Area assessment documented that the falls CAA triggered due to a fall and medications that could increase fall risk, and that the resident would receive medications as ordered, assistance with ADLs, nonskid footwear, and therapy. The care plan included directions for staff to place frequently used items within reach at night, re-educate the resident on call light use, place nonskid strips around the bed, address fall risk due to unawareness of limitations, and use bolsters on the bed. On the survey date, the resident was observed lying in bed with her upper body and right arm leaning to the right and her legs on the left side of the bed, while she yelled out for help to be repositioned. At that time, her portable box call light was on the bedside table and her cord call light was wrapped around the overhead table and caught under the bed, so neither call light was within her reach. Staff interviews confirmed that the resident’s portable call light should be on the overhead table where she could reach it, and that either the portable or cord call light should always be within reach of the resident. An administrative nurse also stated that residents’ call lights should be placed within their reach. The facility’s Falls policy stated that each resident would receive services and care to ensure the environment remained as free from accident hazards as possible and that each resident would receive adequate supervision and assistive devices to prevent accidents, which was not followed in this instance when the resident’s call lights were not accessible.
Failure to Secure Hazardous Areas and Implement Fall Interventions
Penalty
Summary
The facility failed to secure hazardous areas, such as laundry rooms containing high-voltage circuit panels and cleaning chemicals, which were left unlocked and accessible to nine cognitively impaired, independently mobile residents. This oversight was observed during a walkthrough, where it was noted that the rooms contained unlocked electrical panels and hazardous chemicals, posing a risk of preventable accidents. Despite the facility's policy requiring these areas to be locked and inaccessible to residents, staff did not adhere to these safety protocols, thereby exposing residents to potential harm. Additionally, the facility did not implement appropriate fall interventions for two residents, R43 and R2, who were at risk of falls due to their medical conditions. R43, who had a history of falls and required assistance for transfers, was found with his wheelchair placed out of reach, contrary to his care plan. Staff interviews revealed that the care plan was not followed, as the wheelchair should have been placed next to his bed within reach. This failure to adhere to the care plan increased the risk of falls for R43. Similarly, R2, who had a history of falls and required assistance with activities of daily living, was not provided with the necessary fall interventions as outlined in her care plan. Observations showed that her wheelchair was not placed beside her as required, and staff were not fully aware of the interventions needed to prevent falls. The facility's failure to ensure that R2's fall interventions were followed placed her at risk for falls and related injuries.
Deficiencies in Food Storage Practices
Penalty
Summary
The facility, with a census of 74 residents, was found to have deficiencies in food storage practices during a survey. Observations during the initial tour revealed several issues with food storage across the facility's four kitchens. In the Uptown Bistro storage area, an ice machine was found with its lid open and a plastic bowl sitting on top of the ice, which could lead to contamination. Additionally, a small steam table pan in the freezer contained ground meat in a plastic bag that was neither labeled nor dated. Other items, such as a bag of mixed vegetables and a bag of frozen cookie dough, were found opened to air and undated in the freezer. Further observations in the [NAME]/[NAME] house pantry showed a bag of flour on the shelf that was opened and not dated, along with bags of lime gelatin, packets of au gratin cheese mix, bags of pasta, and boxes of cream of wheat, all without dates. In the [NAME]/[NAME] hallway refrigerator, bags of sliced turkey and ham were undated. In [NAME]'s kitchen, a box of egg whites was open to air with no label or date, and small bags of tomatoes, cabbage, and onions were in the vegetable container without labels and dates. Dietary staff confirmed that foods should be labeled and dated as soon as they are opened, as per the facility's Dietary Food Storage policy. The failure to adhere to these standards placed residents at risk for food-borne illness due to potential contamination and spoilage.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to sanitary infection control standards, particularly concerning enhanced barrier precautions, hand hygiene, and the disinfection of shared mechanical lifts. Observations revealed that a Certified Nurse Aide (CNA) pushed a Hoyer lift out of a resident's room without sanitizing it. Additionally, soiled linens were found on the floor of another resident's room. Another CNA was observed exiting a resident's room with a Hoyer lift while wearing an enhanced barrier precaution gown, which was discarded without sanitizing the lift. This CNA also failed to perform hand hygiene after handling the lift and before serving drinks to residents. Interviews with staff, including a Licensed Nurse and an Administrative Nurse, confirmed that the facility's infection control policy required hand hygiene between resident care and when visibly soiled, as well as the cleaning and sanitization of shared equipment like the Hoyer lift. The policy also mandated the proper handling of soiled linens. Despite these guidelines, the facility's practices did not align with the infection control standards, placing residents at risk for infectious diseases.
Failure to Ensure Resident Dignity During Personal Care
Penalty
Summary
The facility failed to ensure a resident's right to dignity and respect during personal care. The incident involved a resident with a history of heart failure, hypertension, and peripheral vascular disease, who required assistance with dressing. Despite the resident's cognitive status being documented as moderately impaired to intact, staff provided personal care with the window blinds open, exposing the resident to the view of the side street. This action was observed when a Certified Nurse Aide and a Certified Medication Aide transferred the resident using a mechanical lift and assisted with dressing while the blinds remained open. Interviews with facility staff, including a Certified Medication Aide, a Licensed Nurse, and an Administrative Nurse, confirmed that the window blinds should be closed during personal care to maintain resident dignity. The facility's Right to Dignity policy, reviewed earlier in the year, emphasized the importance of providing care that promotes respect and dignity. The failure to close the blinds during personal care placed the resident at risk for negative psychosocial outcomes and decreased dignity.
Failure to Update Care Plan for Toileting Needs
Penalty
Summary
The facility failed to revise the care plan for Resident 44 to include toileting needs after meals, despite this intervention being discussed in an interdisciplinary team note. Resident 44, who has a medical history including hemiparesis, osteoarthritis, anxiety disorder, cerebral infarction, and a recent femur fracture, was identified as being at risk for falls. The resident's Minimum Data Set (MDS) indicated mild cognitive impairment and frequent incontinence, requiring substantial assistance with activities of daily living. Despite these needs, the care plan did not reflect the necessary toileting intervention after meals, which was identified as a preventive measure following a fall incident. The deficiency was highlighted when Resident 44 was found on the floor after attempting to use the restroom independently, indicating a lack of communication and implementation of the discussed care plan changes. The facility's policy required ongoing assessments to ensure care plans accurately reflect residents' needs, but this was not adhered to in Resident 44's case. Interviews with staff confirmed that care plans should be reviewed and updated to include all necessary interventions, yet the omission of the toileting after meals intervention placed the resident at risk for further accidents and falls.
Failure to Perform Pre-Dialysis Assessments
Penalty
Summary
The facility failed to consistently perform and communicate pre-dialysis assessments for a resident, identified as R7, who required hemodialysis due to end-stage renal failure. R7's medical history included diabetes mellitus, hypertension, renal failure, epilepsy, cognitive communication deficit, and protein calorie malnutrition. The care plan for R7 required nursing staff to communicate the resident's condition with the dialysis center using a written communication form for each visit. However, the clinical record review revealed a lack of evidence for pre-hemodialysis assessments on multiple specified dates. Interviews with facility staff, including a Licensed Nurse and an Administrative Nurse, indicated that the process involved the night shift nurse filling out a pre-assessment with vital signs and medications, which was then sent with the resident to the dialysis center. Upon the resident's return, the afternoon nurse was responsible for documenting any new orders and conducting a post-assessment. Despite this process, the facility's records did not consistently reflect the completion of pre-dialysis assessments, as required by the facility's Hemo-Dialysis policy, which emphasized accurate and consistent communication to maintain medical management and coordination of care.
Failure to Document Side Rail Assessment and Consent
Penalty
Summary
The facility failed to ensure that a resident, identified as R60, had a documented risk assessment for the use of side rails, consent for their use, and failed to inform the resident or their representative of the associated risks and benefits. R60's electronic medical record indicated diagnoses of generalized muscle weakness, need for assistance with personal care, difficulty with walking, and hypertension. Despite these conditions, there was no evidence of a safety assessment for side rails prior to their installation. The facility provided a side rail assessment with handwritten information, but it was not found in the resident's clinical record during the survey. Additionally, R60 experienced an injury when he hit his right elbow on the small side rail of his bed while trying to reach his phone, resulting in swelling and pain. Interviews with staff revealed inconsistencies in the process of assessing and installing side rails. A Licensed Nurse stated she had never completed a side rail assessment, and the decision for side rail installation was made by the Director of Nursing. The facility's policy indicated that bed devices should be assessed for need and safety, but this was not adhered to, placing R60 at risk for uninformed decisions and impaired safety.
Failure to Obtain Vaccination Consents for a Resident
Penalty
Summary
The facility failed to offer and obtain consents or informed declinations for the Pneumococcal Conjugate Vaccine (PCV20) and influenza vaccination for a resident identified as R17. R17 was admitted on an unspecified date, and a review of their clinical record showed a lack of documentation indicating whether the PCV20 vaccine or the influenza vaccine for the last flu season was offered, given, or declined. Although the facility provided a declination dated 10/06/22, it was not clear if this was for the current vaccination period. Administrative Nurse E, the infection preventionist, stated that the facility reviews vaccine consent during care plans but does not require residents or their representatives to sign yearly for declinations. The facility's Immunization Policy, dated 01/31/24, acknowledges the importance of vaccines in reducing healthcare costs and preventing illness, hospitalization, and death. However, the failure to obtain the necessary consents or declinations for R17 placed the resident at increased risk for acquiring, transmitting, or experiencing complications from pneumococcal disease or influenza.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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