Osage Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Osage City, Kansas.
- Location
- 1017 Main Street, Osage City, Kansas 66523
- CMS Provider Number
- 175256
- Inspections on file
- 16
- Latest survey
- October 23, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Osage Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to submit accurate staffing data to CMS, missing 24/7 Licensed Nurse coverage on multiple dates. Despite having 24/7 coverage, the facility's new reporting program led to errors in the Payroll Base Journal, violating CMS requirements.
The facility's laundry area was found to have several environmental deficiencies, including uncovered soiled linen barrels, unsanitizable bare concrete floors, and grime build-up. The table for folding clean laundry was also unsanitizable due to missing laminate. Administrative staff confirmed these issues, noting that the maintenance and administration teams were new and working on addressing such concerns. The facility lacked a policy for maintenance and housekeeping in the laundry.
The facility failed to maintain sanitary conditions in its kitchen, with issues such as dried-on food in the microwave, sticky build-up on equipment, and food debris in storage areas. The facility lacked a policy for kitchen cleanliness, and dietary staff were responsible for maintaining cleanliness.
The facility failed to properly dispose of garbage and refuse by not ensuring the dumpster lid outside the kitchen was kept closed. Observations on two occasions revealed the lid was left open, and dietary staff confirmed the expectation for lids to be closed. The facility lacked a policy to ensure compliance, resulting in this deficiency.
The facility failed to provide appropriate catheter care for four residents, leading to potential infection risks. Residents with indwelling catheters were observed with tubing dragging on the floor, and staff did not consistently use catheter anchors. Despite care plans and staff knowledge indicating the need to keep catheter tubing off the floor and secure, these practices were not followed, compromising resident safety and hygiene.
The facility failed to maintain a safe and sanitary environment in the beauty shop, lacking an operational ventilation fan and containing unsanitary grooming tools. Administrative Staff A confirmed these issues, and there was no policy to address them.
A resident with major depressive disorder and intact cognition was not assisted by staff in changing her soiled clothing, despite expressing the importance of being neat and clean. Observations showed the resident wearing a dirty T-shirt with dried-on food, and staff interviews confirmed the expectation to change soiled clothing was not met. This failure violated the facility's dignity policy.
A facility failed to complete a comprehensive care plan for a resident with severe cognitive impairment and wandering behaviors, who was at risk for elopement. Despite previous evaluations indicating high risk and an elopement attempt, the care plan lacked specific instructions for staff. Interviews revealed staff were unaware of the resident's risk status, and the facility's policy for monitoring and managing elopement risks was not effectively implemented.
A resident with multiple health conditions, including cerebral palsy, was not provided with necessary services for personal hygiene, specifically bathing and shaving, despite being cognitively intact and expressing preferences for these activities. The resident had not been offered a bath or shave for several days, resulting in an unkempt appearance. Staff confirmed the need for assistance with ADLs, but the facility failed to adhere to its policy of maintaining grooming and personal hygiene for residents unable to perform these activities independently.
A resident with multiple health conditions, including severe cognitive impairment, was not provided with sanitary pressure ulcer care. The resident lacked dressings on pressure ulcers, and CNAs did not use PPE as required. Additionally, a licensed nurse failed to follow proper hand hygiene protocols during wound care, which could lead to infection and hinder healing.
A resident with dementia and severe cognitive impairment exhibited wandering behaviors, yet the facility failed to implement interventions to ensure a safe environment. Despite previous high-risk elopement evaluations, the care plan lacked specific instructions, and staff were unaware of the resident's risk status. The facility's policy for managing wandering residents was not effectively followed.
A facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) for a resident with chronic wounds, leading to a deficiency. The resident, with severe cognitive impairment and multiple diagnoses, required specific wound care and repositioning due to incontinence. During an observation, two CNAs transferred the resident without PPE, unaware of the EBP requirement. Later, LNs provided wound care with PPE, confirming the resident's EBP status. An Administrative Nurse stated staff had been informed about PPE procedures, but the CNAs did not comply.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) as required. Specifically, the facility did not accurately report 24-hour per day Licensed Nurse (LN) coverage on multiple dates between April 1, 2023, and September 30, 2023. The Payroll Base Journal (PBJ) Staffing Data Report for the third quarter of fiscal year 2023 revealed a lack of 24/7 LN coverage on eleven specific dates, and the fourth quarter report showed similar deficiencies on four additional dates. During an interview, Consultant Staff HH acknowledged the possibility of inaccurate submission of licensed nurse hours, despite the facility maintaining 24/7 LN coverage. The facility had initiated a new reporting program to address erroneous calculations of PBJ Licensed Nurse hours. However, the facility's policy, effective since 2022, required the electronic submission of complete and accurate staffing information, including agency and contract staff, based on verifiable and auditable data in a uniform format as specified by CMS. The failure to comply with these requirements resulted in the identified deficiencies.
Laundry Area Environmental Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment in the laundry area, as observed during a tour with Housekeeping/Laundry staff. Several environmental concerns were identified, including two uncovered soiled linen barrels, a concrete floor with missing paint/sealant exposing unsanitizable bare concrete, and a wall beside the washing machine with peeling sheetrock and a build-up of grime and dust. Additionally, the egress from the soiled linen/washroom to the clean linen room had grime build-up and rolled-up tape with grime and dust stuck to it. The table used for folding clean laundry was unsanitizable due to a missing laminate strip, exposing unsealed bare wood. Administrative staff confirmed these findings and noted that the maintenance and administration teams were new and working on addressing environmental concerns throughout the facility. However, the facility lacked a policy related to maintenance and housekeeping in the laundry.
Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility, with a census of 39 residents, was found to have failed in maintaining sanitary conditions in its kitchen, which could potentially lead to foodborne bacteria. During an initial tour of the resident kitchenette, several areas of concern were noted. These included a dried-on food substance inside the microwave, a sticky build-up on the stationary can opener, and a large amount of dried, sticky substance on the hand soap dispenser plate. Additionally, food debris was found on the bottom shelf of a prep table, and dust and small food particles were present inside drawers containing serving utensils. Further observations revealed a black, sticky substance in the tracks of sliding doors holding clean dishes, food debris in the reach-in refrigerator, and ground-in food on a wire cart holding clean plates and bowls. A wire rack for clean pots and pans had a sticky substance and dust, while a plastic cart for coffee filters and tea bags had a sticky substance inside. The storeroom's wire shelves were dusty, and the dish room's freezers had food debris, including in the rubber door seal. Additionally, a wire rack for disposable items and plastic rolling carts for dishes were found with sticky substances and food build-up. The facility lacked a policy for kitchen cleanliness, and administrative staff indicated that dietary staff were responsible for maintaining kitchen cleanliness.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility, with a census of 39 residents, failed to properly dispose of garbage and refuse by not ensuring that the lid of the dumpster outside the kitchen was kept closed. During an initial tour of the kitchen, it was observed on two separate occasions that the dumpster lid was left open. Dietary staff confirmed that it was the expectation for the dumpster lids to be kept closed at all times. However, the facility did not have a policy in place to ensure the lids remained closed, leading to this deficiency.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate catheter care and treatment to prevent infection for four residents with indwelling catheters. Resident 27, who had chronic kidney disease, diabetes mellitus, hypertension, and cerebral palsy, was observed with his urinary catheter tubing laying directly on the floor beneath his wheelchair, with his foot resting on it. The resident reported that staff occasionally did not have catheter anchors available, and he had been treated for recurrent urinary tract infections. Staff interviews confirmed that the catheter bag and tubing should be positioned below the bladder and off the floor, and an anchor should be provided to prevent injury. Resident 14, diagnosed with chronic kidney disease, diabetes mellitus, and Parkinson's disease, was observed with catheter tubing dragging on the floor as he self-propelled his wheelchair. The care plan directed staff to change and care for his urinary catheter per physician orders and facility protocol. Staff interviews reiterated the importance of positioning the catheter bag and tubing below the bladder and off the floor to prevent infection. Resident 2, with neuromuscular dysfunction of the bladder and paraplegia, was observed with catheter tubing resting directly on the floor while in his wheelchair. The care plan instructed staff to ensure the tubing did not touch the floor. Similarly, Resident 16, with a neuromuscular disorder of the bladder, chronic kidney disease, and congestive heart failure, was observed with catheter tubing on the floor and without a catheter anchor in place. Staff interviews confirmed the expectation to secure catheter tubing with an anchoring device and maintain it off the floor to prevent trauma and risk of infection.
Deficiency in Beauty Shop Sanitation and Safety
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents using the beauty shop. During a tour, it was observed that the beauty shop lacked an operational negative pressure ventilation fan, which is essential for ensuring resident comfort when chemicals are used. Additionally, the filter on the free-standing dryer was covered in lint, and the workstation cabinet contained unsanitary items such as an unlabeled brush, comb, and a dual hair pick with hair in the bristles and teeth. Administrative Staff A confirmed these findings and acknowledged the unsanitary condition of the grooming tools. Furthermore, there was no policy in place to address these issues, contributing to the deficiency in maintaining a safe and sanitary environment for residents using the beauty shop.
Failure to Maintain Resident Dignity by Not Assisting with Clothing Change
Penalty
Summary
The facility failed to uphold the dignity and respect of Resident 22, who has a diagnosis of major depressive disorder with psychotic features and intact cognition, as evidenced by a BIMS score of 13 to 15. Despite being mostly independent with activities of daily living, the resident required staff assistance with dressing at times. On multiple occasions, staff did not assist the resident in changing her clothing when it became soiled with food, as observed on September 3rd and 4th, 2024. The resident expressed the importance of being neat and clean, yet was seen wearing a dirty T-shirt with dried-on food in the commons area and dining room. Interviews with staff, including CNAs and a licensed nurse, confirmed that the resident required assistance with dressing and that it was expected for staff to change residents' clothing when soiled. However, the resident's clothing was not changed until bedtime, despite visible food stains. The facility's policy on dignity, revised in August 2009, mandates that each resident be cared for in a manner that promotes quality of life, dignity, respect, and individuality. The facility's failure to assist the resident in changing her soiled clothing violated this policy.
Failure to Address Elopement Risk in Resident Care Plan
Penalty
Summary
The facility failed to complete a comprehensive care plan for Resident 12, who was at risk for elopement due to severe cognitive impairment and wandering behaviors. The resident's electronic medical record (EMR) indicated a diagnosis of dementia with a Brief Interview for Mental Status (BIMS) score of four, signifying severe cognitive impairment. Despite documented wandering behaviors and previous elopement evaluations indicating a high risk for elopement, the care plan revised on 06/06/24 lacked specific staff instructions regarding these behaviors. Additionally, an elopement attempt on 08/23/24 was documented without further follow-up or inclusion in the care plan. Interviews with facility staff revealed a lack of awareness and understanding regarding the resident's risk for elopement. Certified Nurse Aides (CNAs) and housekeeping staff were unsure of which residents were at risk and how to access this information. Licensed Nurse G and Administrative Nurse D indicated that elopement assessments were conducted upon admission and if an elopement attempt occurred, but the resident was not considered at risk according to their assessments. The facility's policy required systematic monitoring and management of residents at risk for elopement, including updating care plans with interventions to increase staff awareness, which was not adequately implemented for Resident 12.
Failure to Maintain Personal Hygiene for a Resident
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for Resident 27, specifically related to bathing and shaving. Resident 27, who has diagnoses including chronic kidney disease, diabetes mellitus, hypertension, retention of urine, and cerebral palsy, was cognitively intact and expressed the importance of making choices regarding personal hygiene. Despite having no functional limitations in range of motion, the resident required staff assistance for activities of daily living (ADLs) due to a decline in functional abilities. The care plan directed staff to assist with shaving during showers, but the electronic medical record indicated that the resident had not been offered a bath or shave since 08/31/24, resulting in an unkempt appearance with scraggly facial hair. Observations and interviews revealed that the resident preferred to bathe after lunch and before supper on specific days and required an electric razor and mirror to shave himself. However, the staff did not accommodate these preferences, and the resident had not been shaved for seven days. Staff members, including a CNA and a licensed nurse, confirmed that the resident needed assistance with ADLs, including bathing and shaving, and should be shaved on scheduled shower days and as needed. The facility's policy stated that residents unable to perform ADLs should receive necessary services to maintain grooming and personal hygiene, which was not adhered to in this case.
Failure to Provide Sanitary Pressure Ulcer Care
Penalty
Summary
The facility failed to provide sanitary pressure ulcer care for a resident with multiple health conditions, including multiple sclerosis, diabetes, urinary incontinence, and schizophrenia. The resident, who was severely cognitively impaired and receiving hospice services, had a stage three pressure ulcer and a surgical wound upon admission. The care plan required repositioning and brief changes every two hours due to incontinence and a history of skin breakdown. However, during an observation, it was noted that the resident lacked dressings on the sacrum and ischium, and the CNAs did not use PPE as required for Enhanced Barrier Precautions. Further observation revealed that the licensed nurse did not follow proper hand hygiene protocols during wound care. The nurse changed gloves without sanitizing hands between cleansing and dressing the wounds, which is against the facility's policy for clean dressing changes. The administrative nurse confirmed that the expectation was for staff to maintain dressings and adhere to proper hand hygiene and PPE protocols. This failure to ensure sanitary wound care could potentially lead to infection and hinder wound healing.
Failure to Address Wandering Behaviors in Resident with Dementia
Penalty
Summary
The facility failed to initiate interventions to ensure a safe and secure environment for a resident with a history of wandering behaviors. The resident, diagnosed with dementia and severe cognitive impairment, exhibited wandering behavior one to three days during assessment periods. Despite being identified as high risk for elopement in previous evaluations, the care plan lacked specific instructions regarding wandering behaviors. An incident on 08/23/24 documented the resident's attempt to elope, but no further documentation or interventions were noted. Staff interviews revealed a lack of awareness and understanding of which residents were at risk for elopement. Certified Nurse Aides and housekeeping staff were unsure of how to identify residents at risk, and the care plan did not reflect the resident's wandering behavior. The facility's policy required a systematic approach to managing residents at risk for elopement, including adding interventions to care plans and communicating them to staff, which was not effectively implemented in this case.
Failure to Follow Enhanced Barrier Precautions for Resident with Chronic Wounds
Penalty
Summary
The facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) for a resident with chronic wounds, which is necessary to prevent the spread of infection. The resident, who had multiple diagnoses including multiple sclerosis, diabetes, urinary incontinence, and schizophrenia, was assessed with severe cognitive impairment and had a stage three pressure ulcer and a surgical wound. The care plan required repositioning and brief changes every two hours due to incontinence and a history of skin damage. Physician orders specified wound care procedures for the resident's sacrum and ischium wounds. During an observation, two Certified Nurse Aides (CNAs) transferred the resident without donning Personal Protective Equipment (PPE), despite the resident being on EBP due to wounds. The CNAs were unaware of the EBP requirement, and the resident was found without dressings on her wounds. Later, two Licensed Nurses (LNs) provided wound care with appropriate PPE, confirming the resident's EBP status. An interview with an Administrative Nurse revealed that staff had been informed about the PPE procedures for this resident, yet the CNAs did not comply, leading to the deficiency.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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