Overland Park Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Overland Park, Kansas.
- Location
- 5211 W 103rd Street, Overland Park, Kansas 66207
- CMS Provider Number
- 175180
- Inspections on file
- 35
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Overland Park Post Acute during CMS and state inspections, most recent first.
A resident with DM and a left foot ulcer had detailed wound care and pneumatic compression pump orders from a wound care consultant, including daily dressing changes with Dakin’s solution and compression pump use two to three times daily. Facility staff documented that the resident returned from wound care with new orders but entered the dressing change frequency in the EMR as only three times weekly and implemented compression pumps once nightly, without a corresponding provider order for that reduced frequency. The resident and the consultant later reported that Dakin’s solution was not being used as ordered, daily dressing changes were not being performed, and the delivered lymphedema pumps were not used as prescribed. Staff interviews confirmed that the daily dressing order was not updated in the EMR, that nurses often had to reach out to obtain wound care orders, and that the facility discovered the pumps only after finding them at the front of the building, resulting in a failure to follow the consultant’s wound care and compression pump orders.
A resident with DM, mobility impairment, and moderate cognitive deficit had an order for diabetic shoes and heat-molded insoles, with the care plan identifying risk for ADL/mobility decline and need for assistance with ambulation and transfers. Nursing notes documented repeated early efforts to contact a diabetic shoe provider and fax required documents, but after a certain point there was no further EMR evidence of follow-up, even though the resident later reported still needing diabetic shoes and was observed with a rough, calloused right heel. Staff interviews revealed the process had been ongoing for an extended period, that the resident had previously missed an appointment with the shoe provider during a time of psychosis and involuntary placement, and that no subsequent referrals were documented by the provider, while the facility lacked a policy on durable medical equipment or accommodation of needs.
A resident with COPD and moderate cognitive impairment was admitted with a physician order for CPAP at bedtime and related humidifier care, but the care plan addressed only continuous oxygen and omitted CPAP. Over several months, the TAR documented many CPAP administrations and refusals even though no CPAP machine was ever present in the resident’s room, and eMAR notes recorded that the resident did not have a CPAP and stated the facility never obtained one. An LPN reported the resident never had a CPAP in the facility and that "refused" was used on the TAR both when the resident declined and when the device was unavailable, while administrative nursing staff were unaware if the resident had a CPAP and indicated the order should have been discontinued if no machine was available.
A resident with DM and moderate cognitive impairment had a standing order for weekly Mounjaro injections, but over several months only a small fraction of scheduled doses were administered, with most doses documented as unavailable or on order. Nursing documentation repeatedly noted that the drug was unavailable, awaiting delivery, or required clarification or prior authorization, yet there was no clear follow‑through to secure the medication or resolve the issues, and the physician progress note addressing very high fasting blood sugar did not mention the Mounjaro order. The administrative nurse reported not being informed of missed doses or any prior authorization need, while the resident stated they had not been receiving the injections but wanted to be on the medication, contrary to facility policy requiring a sufficient supply and timely administration of prescribed medications.
A resident with severe cognitive impairment and multiple medical conditions experienced two falls from bed, the second resulting in a femur fracture. After the first fall, staff only sent the resident to the hospital for evaluation and did not implement or document additional fall prevention interventions such as floor mats or bolstered mattresses. No thorough investigation or root cause analysis was conducted, and the care plan was not updated with new interventions until after the second fall.
The facility, with 87 residents, failed to employ a qualified CDM, as required for the director of food and nutrition services. Administrative Staff A confirmed the absence of a CDM and the ongoing search for one, while the Registered Dietician was present twice weekly. The facility could not provide a policy on the CDM, risking residents' dietary and nutritional needs.
A facility with 87 residents was found to have deficiencies in food storage and dishwashing practices. Observations revealed missing kitchen tiles, outdated freezer logs, and unlabeled food items, including pre-cooked meats and milk. The high-temperature dishwasher failed to reach the required sanitizing temperature. These issues, acknowledged by staff, placed residents at risk of foodborne illness and cross-contamination.
The facility did not conduct a thorough assessment to determine necessary resources for resident care, failing to specify staffing levels, skill sets, and contingency plans. This oversight placed 87 residents at risk for impaired care.
The facility failed to implement proper infection control measures, including the absence of signage for Enhanced Barrier Precautions (EBP) and unsanitary storage of respiratory equipment. Additionally, there was no Legionella management plan, and laundry water temperatures were insufficient for disinfection. Staff did not consistently perform hand hygiene, and soiled laundry was improperly handled, placing residents at risk for infections.
The facility did not ensure agency staff received required communication training, risking impaired care for 87 residents. Training records for CNAs were unavailable, and the facility relied on the agency to track training without verification. This violated the policy requiring all staff to participate in orientation and annual in-service training.
The facility failed to ensure agency staff received required resident rights training, as they did not maintain or verify training records for CNAs. This oversight placed residents at risk for impaired care and decreased quality of life.
The facility failed to ensure that agency staff, including CNAs, received the required infection control training as part of its infection prevention and control program. The facility did not maintain training records for agency staff, relying on the agency company to track their training. This deficiency was identified when the facility could not provide proof of training records for agency staff, as confirmed by an administrative nurse.
The facility failed to provide adequate activities on weekends, offering only self-led activities without staff involvement. The Activity Calendar for August and September 2024 showed no structured or group activities on weekends. The Resident Council and staff confirmed the absence of activities staff on weekends, contrary to the facility's policy to provide activities reflecting residents' interests and social needs.
The facility failed to ensure monthly drug regimen reviews were conducted for several residents, leading to unaddressed medication irregularities. A resident's antipsychotic medication lacked a CMS-approved indication or GDR, while another resident's medication was administered outside physician-ordered parameters. Additionally, dosing instructions for a topical medication were missing for two residents.
A resident with severe cognitive and physical impairments did not receive the necessary dining accommodations, such as a divided plate and built-up utensils, as specified in her care plan. Despite her medical conditions requiring these tools for self-feeding, staff failed to consistently provide them, leading to unmet care needs. Interviews revealed confusion among staff about responsibilities, and the facility lacked a policy to ensure proper accommodations.
The facility failed to provide the correct SNF Advance Beneficiary Notice (ABN) form, CMS-10055, to three residents, omitting the estimated cost for continued skilled services. Instead, form CMS-R-131 was issued, lacking necessary cost information. Staff interviews revealed a misunderstanding about the correct form, with the updated CMS-10055 form only recently provided for future use. This deficiency risked uninformed decisions by the residents.
A facility failed to provide written notice of transfer for a resident with multiple health conditions during hospital transfers. Despite the resident's intact cognition and need for careful monitoring, the facility did not issue written notifications, relying instead on phone calls. Staff interviews revealed confusion about notification responsibilities, and the facility lacked a relevant policy, leading to the deficiency.
The facility failed to complete quarterly MDS assessments for two residents within the required 92-day timeframe. One resident's assessment was started but not completed after an admission MDS, and another's quarterly MDS was initiated but remained incomplete. Administrative Staff C, responsible for MDS assessments, was unaware of the overdue assessments due to reliance on system alerts, placing residents at risk for unmet care needs.
A resident with severe cognitive impairment and multiple health issues did not receive consistent bathing assistance from staff, as required. Despite being dependent on staff for all ADLs, the resident did not receive a bath or shower for a period of time, leading to poor hygiene. Staff interviews revealed a lack of clarity regarding documentation and follow-up procedures for bathing, contributing to the deficiency.
Two residents at a facility were at risk for pressure ulcers due to improperly set low air-loss mattresses. One resident's mattress was set at 350 lbs despite weighing 206 lbs, and another's was unplugged and set at 350 lbs despite weighing 107.2 lbs. The facility lacked documentation and policies for proper mattress settings, contributing to the deficiency.
The facility failed to provide necessary restorative care and range of motion (ROM) services for three residents, leading to a risk of worsening contractures. One resident with Huntington's disease did not receive documented ROM exercises, another with left-sided hemiplegia from a stroke was only given self-led exercises without staff assistance, and a third with multiple sclerosis did not have a prescribed palm guard splint applied consistently. The facility lacked a restorative program and proper documentation, placing these residents at risk for further decline.
A facility failed to ensure proper communication and monitoring for a resident receiving dialysis. The resident, with end-stage renal failure, was not weighed before dialysis on multiple occasions, and communication sheets were often incomplete. Staff interviews confirmed the responsibility for these tasks, but the facility's policy was not consistently followed, risking the resident's health.
A facility failed to conduct a proper safety assessment for a resident's use of bed rails, obtain consent, and inform the resident or responsible party of associated risks and benefits. The resident had severe cognitive impairment and required assistance with daily activities. The facility's policy required an assessment of the resident's environment and safety risks before implementing bed rails, which was not followed.
The facility failed to administer antihypertensive medication per physician orders for a resident, and did not provide dosing instructions for Voltaren gel for two residents. These actions placed residents at risk for unnecessary medication use and side effects, as confirmed by staff interviews and record reviews.
The facility failed to ensure that three residents had a CMS-approved indication or required physician documentation for antipsychotic medication use without attempts at gradual dose reduction (GDR). Despite receiving antipsychotic medications, there was no documentation of GDR attempts or physician documentation contraindicating GDR for these residents, placing them at risk for unnecessary medication administration and possible adverse side effects.
A facility failed to implement a communication process with a hospice provider for a resident receiving end-of-life care. The resident's care plan lacked documentation of hospice services, creating a risk of missed or delayed care. Staff were unsure about the location and responsibility for updating care plans, and the facility lacked a hospice policy.
The facility did not provide mail delivery services to residents on Saturdays, resulting in mail being stored over the weekend and distributed on Monday. The absence of weekend activity staff, who previously handled mail distribution, led to this deficiency. Interviews with staff confirmed a lack of awareness or responsibility for weekend mail delivery, contrary to the facility's policy requiring mail to be delivered within 24 hours.
A resident with Parkinson's disease and intact cognition was subjected to abuse when a CNA attempted to pull a call light from their hands, causing the resident to fall from the bed and sustain a back injury. Despite the facility's policy to protect residents from abuse, the incident occurred, and the resident reported the abuse to staff and police, consistently describing the event.
Failure to Transcribe and Implement Wound Care and Compression Pump Orders
Penalty
Summary
The deficiency involves the facility’s failure to correctly transcribe and follow wound care provider orders for a resident with a diabetic foot ulcer. The resident had type 2 DM with a foot ulcer, difficulty walking, and generalized muscle weakness, and was cognitively intact with a BIMS score of 15. Her care plan identified a diabetic foot ulcer on the left foot and interventions including administering treatments and supplements as ordered, obtaining labs as ordered, monitoring and documenting wound size and depth, and observing and reporting signs of infection. The Pressure Ulcer/Injury CAA documented that she was at risk for pressure ulcers due to decreased mobility and incontinence. Consultant wound care orders dated 12/10 and 01/07 directed the use of pneumatic compression pumps two to three times daily for one-hour increments as tolerated. On 01/28, the wound care provider issued detailed left foot wound care orders specifying cleansing with Dakin’s solution for three to five minutes, applying A&D ointment around the wound, weaving InterDry between toes, applying Hydrofera Blue to the wound, covering with Drawtex and an ABD pad, and wrapping with a CoFlex calamine multi-layer compression wrap, with dressing changes to occur daily except on days the resident went to the wound care center, and continued orders for pneumatic compression pumps two to three times daily. The nurse’s note on 01/28 documented that the resident returned from the wound care provider with new lab and wound care orders but did not specify the content of those orders. Instead of entering the daily dressing change frequency, an order starting 01/30 was entered for dressing changes only on Monday, Wednesday, and Friday, and a later order starting 02/05 directed lymphatic pumps to be applied once daily at night for 60 minutes, without documentation of a corresponding provider order for that reduced frequency. The wound care provider’s 02/04 progress note documented that the resident reported the facility was not using Dakin’s solution for wound cleansing as ordered, that the DME company confirmed delivery of the lymphedema pumps but staff had not used them, and that although daily dressing changes were ordered, the facility continued to perform dressing changes only two to three times per week. The provider also documented leaving several messages with the facility without response. On observation, the resident reported that her left foot dressing was not changed daily as ordered and that staff told her the compression dressing could stay on for a couple of days. Multiple administrative and licensed nursing staff interviews confirmed that the EMR still reflected a Monday/Wednesday/Friday schedule despite the 01/28 orders for daily dressing changes, that staff relied on wound care notes and sometimes had to call to obtain orders, and that the dressing change frequency had not been updated after the 01/28 visit. Staff also acknowledged that the facility learned of the compression pumps’ delivery only after finding them at the front of the building and that they should have followed up with the wound care provider regarding initiation of the pumps. Facility policies on wound care and medication/treatment orders required physician orders for procedures and administration of treatments only upon written orders, but did not address order transcription after appointments, and the failure to correctly transcribe and implement the wound care provider’s orders led to the identified deficiency.
Failure to Ensure Timely Diabetic Footwear and Foot Care Follow-Up
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary foot care and services for a resident with diabetes and mobility issues, specifically related to obtaining diabetic shoes. The resident had diagnoses including right knee pain, cognitive communication deficit, difficulty walking, and diabetes mellitus, with MDS assessments showing moderate cognitive impairment. The care plan identified actual risk for ADL/mobility decline and documented the need for staff assistance with ambulation and transfers, as well as encouragement of activity and exercise. A podiatry order form documented an order for diabetic shoes and heat-molded insoles, and nursing notes showed that staff attempted to contact the diabetic shoe provider multiple times over several days, faxing requested documents and leaving voicemails. After the last documented contact with the shoe provider, the EMR contained no further evidence of follow-up by the facility, despite the resident later stating she still needed diabetic shoes. Observation showed the resident seated or lying in her room, with a rough, calloused appearance on the right heel. A licensed nurse reported the facility had been working on obtaining the shoes for a year and a half and that the provider had not responded. An administrative nurse stated she expected weekly follow-up by nursing staff and acknowledged that the resident should at least have had an appointment date by that time. She later learned the resident had missed a prior appointment with the shoe provider and had not wanted to reschedule during a period of psychosis and involuntary placement, and that the provider had no record of further referrals beyond that missed appointment. The facility did not provide a policy on durable medical equipment or accommodation of needs.
Failure to Obtain and Provide Ordered CPAP Equipment
Penalty
Summary
The deficiency involves the facility’s failure to obtain and provide a physician‑ordered CPAP machine for a resident with COPD who was admitted with an active CPAP order. The resident’s EMR showed diagnoses including COPD and moderate cognitive impairment, with repeated BIMS scores of eight. The care plan dated 01/15/26 addressed continuous oxygen at 2 L and related interventions such as changing humidification and tubing, educating the resident on oxygen use, and observing oxygen precautions, but did not address the existing CPAP order. The EMR contained orders starting 08/08/25 for CPAP use at bedtime per home settings and for replacing distilled water in the humidifier prior to CPAP/BiPAP use. Review of the TAR from 08/08/25 to 01/31/26 showed numerous scheduled CPAP administrations documented as given, refused, on hold, or with other notations, despite the resident not having a CPAP machine in the facility. Multiple eMAR notes documented that the resident did not have CPAP equipment, did not use a CPAP, and stated the facility never obtained one. On observation, no CPAP machine was present in the resident’s room, and the resident confirmed she never received one and only used oxygen at night. A nurse acknowledged the resident never had a CPAP in the facility but had an order for it and stated she documented “refused” on the TAR both when the resident declined and when the machine was not available. Administrative nursing staff reported they did not know if the resident had a CPAP, indicated that residents usually brought their own machines, and stated the CPAP order should have been discontinued if no machine was available. The facility’s CPAP/BiPAP policy addressed reviewing physician orders for settings but did not address providing a CPAP machine.
Failure to Provide Ordered Mounjaro for Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide a physician‑ordered diabetes medication, Mounjaro, to a resident over an extended period. The resident had diagnoses including diabetes mellitus, pain in the right knee, cognitive communication deficit, difficulty in walking, and dementia with moderate cognitive impairment documented by BIMS scores of eight on both admission and quarterly MDS assessments. The resident’s care plan identified diabetes and included an intervention that staff would administer medications as ordered. An order in the EMR directed that Mounjaro 2.5 mg/0.5 mL be injected every Monday morning for diabetes starting in August. Review of the Treatment Administration Record showed that, between early September and the end of January, staff administered only two of 22 scheduled Mounjaro doses, with two doses left blank and 18 doses marked as “Other/See Nurses Notes.” Multiple eMAR notes documented that Mounjaro was unavailable, on order, or awaiting delivery or clarification, and later entries repeatedly stated that the medication was unavailable. One note indicated the facility was awaiting clarification on Mounjaro without specifying what clarification was needed, and another documented that the NP was notified without stating what was communicated. During this same period, a physician progress note recorded a fasting blood sugar over 500 mg/dL and ordered an increase in Lantus and an endocrinology appointment, but did not address the ongoing Mounjaro order. Nursing staff interviews revealed that the nurse responsible for the resident’s medications understood that Mounjaro required prior authorization and that the pharmacy had indicated it would be covered once but would need prior authorization for subsequent fills. The nurse stated her usual practice was to place residents needing prior authorization into the provider’s folder and document this in the EMR, and to call the provider if a resident had not received a medication. However, the administrative nurse reported she had not received any reports that the resident was not receiving Mounjaro and had not seen any prior authorization request for it, despite expecting staff to notify her and the physician after one missed dose. The resident reported not receiving Mounjaro injections and expressed a desire to be on the medication. The facility’s Pharmacy Services Overview policy required that residents have a sufficient supply of prescribed medications and receive them in a timely manner, which was not met in this case.
Failure to Implement and Document Fall Prevention Interventions After Resident Falls
Penalty
Summary
The facility failed to investigate, determine causative factors, and implement relevant interventions to prevent further falls for a resident with severe cognitive impairment and multiple medical conditions, including Lewy body dementia, brain neoplasms, reduced mobility, and a history of stroke. The resident was dependent on staff for bed mobility, transfers, and toileting, and used a wheelchair. Despite being identified as at risk for falls due to deconditioning, gait, and balance problems, the care plan did not include additional fall interventions after the resident was found lying face down on the floor at the bedside following a fall. After the initial fall, staff assessed the resident, found no visible injuries, and sent her to the hospital for evaluation. The only intervention documented in response to this fall was the hospital evaluation; no further fall prevention measures, such as floor mats or bolstered mattresses, were implemented at that time. The facility did not conduct a thorough investigation or root cause analysis beyond noting that the resident did not know what happened and had rolled out of bed. There was no evidence of additional interventions being added to the care plan following this incident. Subsequently, the resident experienced another unwitnessed fall from bed, resulting in a left femur fracture. Staff again assessed the resident, provided pain management, and sent her to the hospital after continued complaints of pain. Only after this second fall were interventions such as a bolstered mattress and fall mat put in place. Interviews with facility staff confirmed that no additional fall interventions were added after the first fall, and there was no documented investigation or comprehensive review of the incident. The facility's policy required staff to identify and implement interventions based on specific risks and causes, but this was not followed after the initial fall.
Lack of Qualified Dietary Manager in Facility
Penalty
Summary
The facility, with a census of 87 residents, failed to ensure that the director of food and nutrition services possessed the required qualifications of a certified dietary manager (CDM). This deficiency was identified through observation, record review, and interviews. Administrative Staff A acknowledged that the facility was in the process of hiring a new CDM and additional dietary staff. It was noted that the Registered Dietician was present at the facility at least twice a week, but there was no CDM currently employed. The facility was unable to provide a policy regarding the CDM when requested, indicating a lack of compliance with staffing requirements for the food and nutrition services department. This situation placed residents at risk for unmet dietary and nutritional needs.
Deficiencies in Food Storage and Dishwashing Practices
Penalty
Summary
The facility, with a census of 87 residents, was found to have deficiencies in food storage and dishwashing practices during a survey. Observations revealed that the kitchen had an area with missing ceramic tiles, exposing cement flooring, and the freezer temperature logs had not been updated since two days prior to the survey. Additionally, clean plates were stored without covers, and several food items in the refrigerator and freezer were not labeled or dated, including pre-cooked hot dogs, sausage links, roast beef slices, and opened milk jugs. These practices did not comply with the facility's updated Food Receiving and Storage policy, which requires all food to be covered, labeled, and dated. Furthermore, the facility's high-temperature dishwasher was not functioning properly, as it failed to reach the required temperature of at least 180 degrees during the rinse cycle, necessary for sanitizing kitchenware and dishes. This issue was reported to maintenance for repair. The dietary consultant acknowledged the lack of labeling and dating of food items and mentioned ongoing renovations, including fixing the kitchen flooring. The administrative staff confirmed that a specialist was contracted to repair the dishwasher. These deficiencies in food storage and dishwashing placed residents at risk of foodborne illness and cross-contamination.
Inadequate Facility-Wide Assessment for Resident Care
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment did not specify the staffing levels required for each unit, including the number of RNs, LPNs/LVNs, CMAs, and CNAs needed based on patient acuity and census. Additionally, the assessment lacked details on staffing-specific skill sets for each resident unit, a contingency plan for non-emergency events that could impact resident care, and a strategy for recruiting and retaining direct care staff. Furthermore, the assessment did not incorporate input from residents and their representatives. During an interview, Administrative Nurse D mentioned that the facility was in the process of updating the assessment. However, the facility was unable to provide a policy related to the facility assessment when requested. This oversight placed all 87 residents at risk for impaired care due to the lack of a thorough and updated assessment.
Inadequate Infection Control and Water Management
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, as evidenced by the lack of signage or indicators for Enhanced Barrier Precautions (EBP) in rooms of residents requiring such precautions. During inspections, it was observed that several residents with medical devices such as PEG tubes, tracheostomies, and catheters did not have readily available personal protective equipment (PPE) or appropriate signage to alert staff and visitors of the necessary precautions. Additionally, respiratory equipment was found stored in an unsanitary manner, with nebulizer masks and cannulas left uncontained. The facility also failed to maintain adequate water management practices, particularly concerning Legionella prevention. There was no documented plan for managing and preventing Legionella contamination, and the water temperature in the laundry facilities was insufficient for effective cleaning and disinfection. The washer temperature was recorded at only 134 degrees Fahrenheit, below the required 165 degrees Fahrenheit, due to issues with the hot water system. Furthermore, staff did not consistently perform adequate hand hygiene, as observed when CNAs donned gloves without washing their hands and handled soiled laundry without proper containment. These practices, along with the lack of sanitary storage for respiratory equipment and improper transport of linens, placed residents at risk for infectious diseases. The facility's policies on maintenance, hand hygiene, and EBP were not effectively implemented, contributing to these deficiencies.
Failure to Ensure Agency Staff Training
Penalty
Summary
The facility failed to ensure that agency staff received the required communication training, which placed residents at risk for impaired care and decreased quality of life. The facility had a census of 87 residents and was unable to provide proof of training records for agency staff, specifically for Certified Nurse's Aides (CNA) N, O, and P. During an interview, Administrative Nurse D stated that the facility did not keep records for agency staff onsite and relied on the agency company to track their training. The facility's policy required all staff, including agency or contractual staff, to participate in orientation and annual in-service training, but the facility did not verify or maintain records of such training for agency staff.
Failure to Ensure Agency Staff Training on Resident Rights
Penalty
Summary
The facility, with a census of 87 residents, failed to ensure that agency staff received the required resident rights training, which is essential for providing proper care and maintaining the quality of life for residents. During a review on 09/11/24, the facility was unable to provide proof of training records for agency staff, specifically for Certified Nurse's Aides (CNA) N, O, and P. Administrative Nurse D confirmed that the facility did not keep records for agency staff onsite, relying instead on the agency company to track their training. The facility's policy required all staff, including agency or contractual staff, to participate in orientation and annual in-service training, but the facility did not verify or maintain records of such training for agency staff. This oversight placed residents at risk for impaired care and decreased quality of life.
Failure to Ensure Infection Control Training for Agency Staff
Penalty
Summary
The facility, with a census of 87 residents, failed to ensure that agency staff received the required infection control training, which is a part of its infection prevention and control program. During a review on 09/11/24, the facility was unable to provide proof of training records for agency staff, specifically for Certified Nurse's Aides (CNA) N, O, and P. Administrative Nurse D confirmed that the facility did not maintain records for agency staff training onsite, relying instead on the agency company to track their training. The facility's policy required all staff, including agency or contractual staff, to participate in orientation and annual in-service training. However, the facility did not verify or keep records of the agency staff's training, leading to a deficiency in ensuring the completion of the required infection control training for staff providing care in the facility.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility, with a census of 87 residents, failed to provide adequate activities on weekends that met the residents' interests, social needs, and preferences. A review of the facility's Activity Calendar for July, August, and September 2024 revealed that only self-led activities were offered on Saturdays and Sundays in August and September, with no structured or group activities available. The Resident Council reported a lack of activities on weekends due to the absence of available staff to direct or assist with activities. Activities Staff Z confirmed that she worked Monday through Friday and had an assistant who previously provided activities on weekends, but he no longer worked those days. Certified Nurse's Aide M also noted that activities staff were not present on weekends, leaving residents with only self-led activities. The facility's Activities policy, revised in May 2013, stated that residents should be provided with activities reflecting their choices and interests, but this was not adhered to on weekends, placing residents at risk for boredom, isolation, and decreased quality of life.
Failure to Conduct Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review (MRR) for several residents, including those identified as R31, R79, R28, R39, and R50. The MRRs from October 2023 to December 2023 were not provided, and the facility could not locate the consultant pharmacist's (CP) recommendations for this period. This lack of documentation and review placed residents at risk for unnecessary medication effects and related complications. For Resident 31, the facility did not ensure that the CP identified and recommended a CMS-approved indication or a gradual dose reduction (GDR) for the antipsychotic medication Seroquel. The resident's records lacked a physician's documented clinical rationale for the continued use of Seroquel without a GDR or approved indication. Similarly, Resident 79's records showed a lack of CP recommendations for a CMS-approved indication for Seroquel or a GDR, and the facility failed to identify and report the lack of dosing instructions for Voltaren gel. Resident 28's records also lacked evidence of CP recommendations for a GDR or CMS-approved indication for the antipsychotic medication quetiapine. Additionally, the facility failed to identify and report the lack of dosing instructions for Voltaren gel. For Resident 39, the facility did not ensure that the CP identified and reported that antihypertensive and diuretic medications were administered outside the physician-ordered parameters. These deficiencies placed the residents at risk for unnecessary medication use, side effects, and physical complications.
Failure to Provide Necessary Dining Accommodations
Penalty
Summary
The facility failed to provide necessary accommodations for a resident, identified as R44, who required specific utensils and a divided plate to feed herself due to her medical conditions. R44's medical history included schizophrenia, obesity, hypertension, edema, anemia, anxiety, weakness, hypoxia, and dysphagia, with a severely impaired cognitive status and physical impairments on both sides of her body. Her care plan specified the use of a divided plate and built-up utensils, yet observations revealed that these accommodations were not consistently provided. On multiple occasions, R44 was given regular plates and utensils without foam grips, requiring her to request the appropriate items from staff. Interviews with staff members, including a Certified Nurse's Aide, a Licensed Nurse, and an Administrative Nurse, indicated a lack of clarity and responsibility regarding the provision of the correct dining tools. The dietary department was supposed to supply the necessary items, while nursing staff were expected to ensure their use. However, this coordination failed, as evidenced by R44's repeated need to ask for the correct utensils and plates. The facility did not have an accommodation of needs policy available, contributing to the oversight and leaving R44 vulnerable to unmet care needs.
Failure to Provide Correct ABN Form to Residents
Penalty
Summary
The facility failed to provide the correct Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage (ABN) form, CMS-10055, to three residents, which should have included the estimated cost for continued skilled services. Instead, the facility issued form CMS-R-131, which did not contain the necessary cost information. This oversight affected residents who had completed their Medicare Part A episodes but remained in the facility for custodial care. Specifically, the records for three residents showed that they were not given the appropriate notice, potentially impacting their ability to make informed decisions about their care. Interviews with facility staff revealed a misunderstanding regarding the correct ABN form to use. Social Services staff indicated that they were instructed to use a different form, and the Director of Nursing had only recently provided the updated CMS-10055 form to be used starting in October 2024. The facility's policy, last revised in September 2022, stated that residents should be informed in advance of any changes to their billing, but this was not adhered to in these cases. This deficiency placed the residents at risk of making uninformed decisions regarding their continued care.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide written notice of transfer or discharge for a resident, identified as R39, during facility-initiated transfers to the hospital. R39, who had diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, hypertension, and sleep apnea, was transferred to the hospital on multiple occasions without receiving the required written notification. The resident's electronic medical record and care plan indicated intact cognition and an increased risk of adverse side effects from medications, necessitating careful monitoring and communication. Despite these needs, the facility did not provide evidence of written notification to R39 or their legal representative for the transfers. Interviews with facility staff revealed a lack of clarity regarding responsibility for sending such notifications, with Social Services and nursing staff assuming phone notifications sufficed. The facility also lacked a policy related to written notification for facility-initiated transfers, contributing to the deficiency and placing R39 at risk of uninformed choices and miscommunication regarding care needs.
Failure to Complete Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments for two residents, R84 and R17, within the required 92-day timeframe. For R84, an Admission MDS was completed on 04/30/24, with the next quarterly assessment reference date (ARD) set for 07/31/24. However, the quarterly MDS was started on 07/26/24 but never completed, leaving no completed and accepted MDS assessments since 04/30/24. Similarly, for R17, a quarterly MDS was completed on 04/19/24, with the next quarterly ARD set for 07/19/24. The quarterly MDS was started on 07/19/24 but remained incomplete, with no completed and accepted MDS assessments since 04/19/24. Administrative Staff C, who took over completing the MDS assessments after an ownership change, stated that she completed the assessments remotely and relied on reports from nurses, social workers, and therapists for any changes and pertinent information. She acknowledged the requirement to update MDS assessments quarterly, annually, and with significant changes. Despite reviewing the system and flagging due assessments, she was unaware that R17 and R84's assessments were past due, as the system typically flagged and alerted her. This oversight placed the residents at risk for unidentified and unmet care needs.
Failure to Provide Consistent Bathing for a Resident
Penalty
Summary
The facility failed to ensure consistent bathing for a resident, identified as R44, who required assistance from staff to complete activities of daily living (ADLs). R44's medical history included schizophrenia, obesity, hypertension, edema, anemia, anxiety, weakness, hypoxia, and dysphagia. The resident was documented as having severely impaired cognition and was dependent on staff for all ADLs. Despite this, the facility's records showed that R44 did not receive a bath or shower from August 31, 2024, through September 10, 2024. Observations noted that R44's hair appeared greasy, and she had long fingernails, indicating a lack of personal hygiene care. Interviews with staff revealed that Certified Nurse Aides (CNAs) were responsible for filling out bath sheets to ensure residents received baths, and nursing staff were expected to check these sheets. However, there was uncertainty among staff about whether baths were documented in the Electronic Medical Record (EMR). The facility's bathing policy required staff to notify supervisors if a resident refused a bath and to report any issues according to facility policy. The failure to provide consistent bathing for R44 placed her at risk for complications related to poor hygiene and impaired dignity.
Inadequate Pressure Ulcer Prevention Due to Improper Mattress Settings
Penalty
Summary
The facility failed to ensure that the low air-loss mattress pumps for two residents, R37 and R26, were set and functioning correctly for adequate pressure relief, placing them at risk for complications related to skin breakdown and pressure ulcers. R37, who had severe cognitive impairment and was dependent on staff for activities of daily living, had a low air-loss mattress set at 350 lbs, which was not adjusted according to his weight of 206 lbs. The care plan for R37 lacked guidance on the appropriate settings for the mattress, and there was no documentation in the electronic medical records regarding the mattress settings. R26, who was at high risk for pressure ulcers due to severe cognitive impairment and other medical conditions, also had a low air-loss mattress set at 350 lbs, despite weighing only 107.2 lbs. Additionally, the mattress was found to be unplugged and deflated during an inspection. The care plan for R26 did not provide direction on the use of the low air-loss mattress or the appropriate weight settings. Interviews with staff revealed that the mattresses were installed and set by central supply based on the residents' weights, but there was a lack of clarity and documentation regarding the specific settings required for each resident. The facility did not provide a policy related to pressure ulcer prevention or the use of low air-loss mattress systems, contributing to the deficiency in care for these residents.
Failure to Provide Restorative Care and ROM Services
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve the range of motion (ROM) for three residents, R26, R50, and R9, leading to a risk of worsening contractures. R26, diagnosed with Huntington's disease and other conditions, was dependent on staff for all activities of daily living (ADLs) and was not receiving restorative treatment. Observations noted that R26's hands were curled and closed, indicating a lack of ROM exercises. Interviews with staff revealed that the facility did not have a restorative program in place, and there was no documentation of ROM exercises being performed for R26. R50, who had suffered a stroke resulting in left-sided hemiplegia, was also not receiving the necessary restorative services to maintain her ROM and ADL abilities. Despite being dependent on staff for various ADLs, R50 was only provided with a list of self-led exercises, which she struggled to perform due to her condition. The facility lacked documentation of any passive or active ROM activities for R50, and staff did not monitor or assist her with the exercises, leaving her at risk for further decline while waiting for therapy services to begin. R9, diagnosed with multiple sclerosis and a contracture of the right hand, was supposed to have a palm guard splint applied daily to reduce digit contracture. However, the splint was not applied on several occasions due to its unavailability, and R9 was not on any restorative program. Interviews with staff indicated a lack of awareness and documentation regarding the splint's application, further contributing to the risk of decreased mobility and impaired quality of life for R9.
Failure in Dialysis Communication and Monitoring
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding a resident's health status with each procedure. The resident, who had diagnoses of major depressive disorder, end-stage renal failure, and muscle weakness, required dialysis services three times a week. The facility's records indicated that the resident was not weighed before dialysis appointments on eight occasions, as required by the physician's orders. Additionally, the dialysis communication binder lacked completed communication sheets for several dates, indicating a failure to document and relay necessary health information between the facility and the dialysis center. Interviews with facility staff revealed that it was their responsibility to ensure weights were recorded and communication sheets were filled out. However, the inspection of the dialysis communication binder showed that this was not consistently done. The facility's Hemodialysis policy emphasized the importance of coordinating with the dialysis center to monitor changes in the resident's condition, but this was not adhered to, placing the resident at risk for complications related to end-stage renal failure.
Failure to Conduct Proper Safety Assessment for Bed Rails
Penalty
Summary
The facility failed to ensure that a resident, identified as R37, had a proper safety assessment for the use of side rails, consent for their use, and that the resident and/or responsible party were informed of the risks and benefits associated with side rails. R37's medical records indicated diagnoses of anxiety, congestive heart failure, and Parkinsonism, with a severe cognitive impairment score. The resident required assistance with activities of daily living and had a low air-loss mattress, but there was no documentation of the use of bilateral bed cane-style side rails in the care plan or physician orders. Observations and interviews revealed that the facility did not conduct a safety assessment that considered the risks associated with the low air-loss mattress. Although a Nursing Entrapment Risk Assessment was completed, it failed to identify these risks. Staff inspections of the bed were conducted each shift, but documentation of quarterly inspections was unclear. The facility's policy required an assessment of the resident's environment, medical conditions, functional abilities, and safety risks before implementing bed rails, which was not adhered to in this case.
Failure to Follow Physician Orders and Provide Complete Medication Instructions
Penalty
Summary
The facility failed to ensure that antihypertensive medication was administered according to physician-ordered parameters for a resident with multiple diagnoses, including hypertension and atrial fibrillation. The resident's medication administration record revealed that Torsemide and Carvedilol were given outside the specified parameters on several occasions, despite orders to hold the medication if certain blood pressure or heart rate thresholds were not met. Interviews with administrative nurses confirmed that medications should be administered as ordered, and the facility's policy required specific instructions for medication orders. Additionally, the facility did not provide dosing instructions for Voltaren gel for two residents, one with anxiety and depressive disorder and another with arthritis and Lewy body dementia. The orders for Voltaren gel lacked specific dosage amounts, which was against the facility's medication orders policy. Administrative nurses acknowledged that all medication orders should include dosing instructions and that the consultant pharmacist should have identified the missing information during monthly medication reviews. These deficiencies placed the residents at risk for unnecessary medication use, side effects, and physical complications. The facility's failure to adhere to physician orders and ensure complete medication instructions contributed to these risks, as confirmed by the observations, record reviews, and staff interviews conducted during the survey.
Failure to Ensure CMS-Approved Indication for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that three residents, identified as R28, R31, and R79, had a CMS-approved indication or the required physician documentation for the use of antipsychotic medications without attempts at gradual dose reduction (GDR). For Resident 28, the electronic medical record documented diagnoses of anxiety, depressive disorder, and psychosis, with a BIMS score indicating intact cognition. Despite receiving antipsychotic medication, there was no documentation of a GDR attempt or physician documentation contraindicating a GDR. The facility was unable to provide evidence of the required physician documentation for the continued use of Seroquel. Resident 31's records showed diagnoses of hypertension, delusional disorders, and vascular dementia, with severely impaired cognitive skills. The resident routinely received antipsychotic medication, but no GDR was attempted or documented as clinically contraindicated. The facility lacked a physician's documented clinical rationale for the continued use of Seroquel without a GDR or approved indication for use. Observations noted that the resident displayed no behaviors that would necessitate the continued use of the medication. Resident 79's records indicated diagnoses of hallucinations, anxiety disorder, Lewy body dementia, and Parkinson's disease, with severely impaired cognitive skills. The resident received antipsychotic medications routinely, but no GDR was attempted. The facility failed to provide a physician's documented clinical rationale for the continued use of Seroquel without a GDR or approved indication for use. Observations noted that the resident was pacing with a staff member, and the facility was unable to provide the necessary documentation upon request.
Deficient Communication with Hospice Provider
Penalty
Summary
The facility failed to ensure a proper communication process was implemented between the facility and the hospice provider for a resident receiving hospice services. The resident, identified as R24, had multiple diagnoses including fibromyalgia, arthritis, brain damage, hypertension, epilepsy, anxiety, depressive disorder, and dysphagia. The resident's care plan indicated they were at the end of life and receiving hospice services, but it lacked documentation of communication with nursing staff regarding the specific services, medication, and equipment provided by hospice. This lack of documentation and communication created a risk of missed or delayed services and inadequate end-of-life care for the resident. Observations and interviews revealed that staff were unsure about the location of hospice care plans and whose responsibility it was to update facility care plans with hospice-provided services. A Certified Nursing Aide thought the care plans were in binders at the nurse's desk, while a Licensed Nurse was unsure about the duty of updating care plans. An Administrative Nurse stated that the facility collaborates with hospice through the plan of care, which should include schedules for hospice staff visits and details of equipment and medication provided. However, the facility did not provide a hospice policy, indicating a lack of structured collaboration with the hospice provider.
Failure to Provide Mail Delivery on Saturdays
Penalty
Summary
The facility failed to provide mail delivery services to residents on Saturdays, as identified during a survey with a census of 87 residents and a sample of 20 residents. Observations and interviews revealed that the mail was stored over the weekend at the east nurse's station and distributed the following Monday. The Resident Council reported the absence of mail services on Saturdays, attributing it to the weekend activity staff no longer being available. Activities Staff Z confirmed that she worked only Monday through Friday and that her assistant, who previously handled weekend mail distribution, no longer worked weekends. Certified Nurse's Aid M and Administrative Nurse D both indicated a lack of awareness or responsibility for mail distribution on weekends. The facility's undated mail policy stated that mail should be delivered unopened and within 24 hours of receipt, which was not adhered to on Saturdays.
Resident Abuse Incident Involving CNA
Penalty
Summary
The facility failed to protect a resident from abuse when a Certified Nurse Aide (CNA) attempted to pull a call light from the resident's hands, resulting in the resident being pulled from the bed onto the floor. This incident placed the resident at risk of pain, injury, and ongoing abuse. The resident, who had a history of Parkinson's disease, anxiety, and depression, reported the abuse, stating that the CNA's actions caused him to fall and hurt his back. The resident's medical records indicated intact cognition and required assistance with certain activities of daily living. The care plan included interventions for monitoring pain, anxiety, and depression, as well as ensuring a safe environment with a reachable call light. Despite these measures, the incident occurred, and the resident reported the abuse to multiple staff members, who documented the resident's account of being pulled from the bed and sustaining a back injury. The facility's policy on abuse, neglect, and exploitation lacked a date but stated that protections would be provided for residents' health, welfare, and rights. However, the facility did not ensure the resident remained free from abuse, as evidenced by the CNA's actions. The incident was reported to the police, and the resident consistently described the event to various staff members, corroborating the account of being pulled from the bed and injured.
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Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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