Phillips County Retirement Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Phillipsburg, Kansas.
- Location
- 1300 State Street, Phillipsburg, Kansas 67661
- CMS Provider Number
- 17E658
- Inspections on file
- 16
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Phillips County Retirement Center during CMS and state inspections, most recent first.
A resident with dementia, behavioral symptoms, impaired cognition, and osteoporosis experienced multiple falls, including falls with major injury and a hip fracture requiring surgery. The facility repeatedly failed to complete root cause analyses after these falls, did not finish required dementia and falls CAAs, and delayed implementing individualized interventions such as assisted transfers, toileting schedules, frequent checks, and environmental modifications. Many fall investigations were missing or incomplete, and staff on the floor lacked access to the care plan and did not independently develop fall-prevention measures, relying instead on a CNA and an RN to determine and communicate interventions, sometimes weeks after the events.
Surveyors found that the facility did not provide RN coverage for at least eight continuous hours daily and did not employ a full-time RN as DON. Review of posted staffing sheets and PBJ data showed numerous days with no RN hours recorded, despite a facility policy stating an RN would be employed for at least eight consecutive hours, seven days a week. Administrative staff confirmed there had been no RN in the DON role for an extended period, that the current DON is an LPN enrolled in an RN program, and that the DON job description did not require an active RN license.
The facility failed to implement core elements of an antibiotic stewardship program within its infection prevention and control system for a census of 29 residents, including a sample of 12. The Infection Control Log for a one-year period lacked documentation of organism identification, duration of prescribed antibiotics, and the infections treated, and this information could not be produced when requested. The Infection Preventionist, an administrative nurse, stated she only tracked which residents were on antibiotics in the EMR and was unable to provide tracking and trending data, noting that floor nurses were not completing the infection tracking documents. These practices did not conform to the facility’s Infection Preventionist policy, which required effective management of the infection prevention program using evidence-based practices and compliance with CMS and state regulations.
The facility failed to designate a staff member with the required qualifications and certification to serve as the Infection Preventionist for its infection prevention and control program, despite having 29 residents. An administrative nurse was identified by administration as the IP and had completed continuing education on Enhanced Barrier Precautions and antibiotic stewardship surveillance, but she confirmed she did not hold an Infection Preventionist certificate. Although the facility maintained an antibiotic administration and stewardship policy, there was no evidence that a properly certified IP was responsible for overseeing the infection prevention and control program.
Surveyors found that the facility failed to complete required Care Area Assessments (CAAs) for four residents whose annual MDS assessments triggered multiple areas, including ADL functional/rehab potential, cognitive loss/dementia, communication, urinary incontinence and indwelling catheter, behavioral symptoms, mood, falls, nutritional status, dehydration/fluid maintenance, dental care, pressure ulcer/injury, physical restraints, psychotropic drug use, and pain. An administrative nurse acknowledged that these CAAs were missed and stated she was still learning how to complete MDS assessments, despite a facility policy committing to accurate, timely, and complete MDS assessments.
The facility failed to accurately complete MDS assessments for several residents by coding bedrails as physical restraints used daily, even though the bedrails did not restrict residents’ mobility and were not actually used as restraints. An administrative nurse reported that she routinely marked bedrails as restraints on the MDS whenever a bed had rails installed, regardless of actual use or effect on mobility. This practice conflicted with the facility’s own policy committing to accurate, timely, and complete MDS assessments.
Surveyors observed an RN using a hallway medication cart to prepare medications, then walking away into resident rooms while leaving the cart unlocked and unattended, with the lock not engaged and the cart out of staff visual range. The RN acknowledged that both the cart and computer monitor should be locked whenever unattended, and an administrative nurse confirmed this expectation. This practice did not comply with the facility’s Medication Labeling and Storage policy, which requires all medications to be stored in a secure, locked location accessible only to designated staff.
Surveyors found that respiratory devices, including a CPAP mask and several nebulizer masks, were left on bedside surfaces or in personal items without sanitary containers, contrary to facility expectations for cleaning, drying, and bagging labeled respiratory equipment. Staff were also observed mishandling soiled laundry by carrying unbagged items against their uniforms instead of using appropriate transport methods. In addition, a CNA provided care to a resident with a urinary catheter while handling a urine-filled graduated cylinder wearing only gloves, despite EBP signage and training indicating that gown and gloves were required. Although the facility had policies for respiratory care and laundry, it could not provide a policy for Enhanced Barrier Precautions.
A dependent resident with severe cognitive impairment and multiple diagnoses, including Alzheimer’s disease and dementia, was observed seated in a Broda chair in a TV area wearing only a hospital gown and a sheet, which she lifted, exposing her incontinence brief to two male peers. Staff, including a CNA, an LPN, and an administrative nurse, acknowledged that residents should be fully dressed or completely covered before leaving their rooms and that incontinence briefs should never be exposed in common areas. The facility’s Resident Rights Policy states that residents are entitled to a dignified existence and that all staff must protect these rights, but this was not upheld in this incident.
A resident with hypertension, DM, severely impaired cognition (BIMS 0), and dependence in most ADLs was receiving multiple psychotropic medications, including an antianxiety agent. The EMR contained an order for lorazepam cream 0.5 mg to be applied every eight hours and PRN for dementia, but the order did not include the required 14-day stop date or any specified duration, and there was no physician rationale documented for extended PRN use. Staff interviews indicated that nurses were expected to notify physicians that PRN lorazepam required a stop date and that the DON was a second check for orders, yet this did not occur, and the facility was unable to provide its unnecessary psychotropic drug policy when requested.
The facility failed to complete a thorough facility-wide assessment to determine necessary resources for competent resident care during routine operations and emergencies. The self-assessment did not specify required staffing levels by unit, shift, or discipline (RN, LPN/LVN, CMA, CNA), nor did it incorporate resident acuity or census. It lacked complete resident condition reports, omitted documentation of staff competencies and skill sets needed for the resident population, and did not fully list contractual agreements for lab, radiology, therapy, hospital, transportation, lawn care, or snow removal services. An administrator acknowledged missing staffing breakdowns, uncompleted required sections, and unchecked competencies such as Safety and Missing Resident for all staff, despite a facility policy stating the assessment should guide staffing, competencies, and resource needs, including third-party contracts, for both day-to-day operations and emergencies.
A resident with paraplegia was left unsupervised outside by a CNA, resulting in the resident being found unresponsive with a high body temperature. The facility failed to follow the resident's care plan, which required supervision and assistance, and did not conduct a thorough investigation into the incident.
The facility did not employ a full-time RN as the Director of Nursing (DON) and failed to provide RN coverage for eight consecutive hours daily, as required by their policies. This deficiency was identified through a review of the 2023 nursing schedule, which showed more than 50 instances of inadequate RN coverage. Administrative Staff A confirmed the lack of a full-time DON and consistent RN coverage, citing challenges in securing RNs, which placed 31 residents at risk for inadequate care.
The facility failed to implement a water management program to address Legionella and other waterborne pathogens, placing residents at risk. Maintenance staff confirmed the absence of routine checks, and administrative staff lacked records of water monitoring. The facility's policy required risk assessments and control measures, but these were not followed, exposing residents to potential infection.
The facility failed to ensure a safe environment by leaving a chemical bottle in an unlocked cabinet in a kitchenette, risking the safety of 12 cognitively impaired, independently mobile residents. A LN confirmed the cabinet should be locked and moved the bottle to a secure location. An Administrative Nurse expected chemicals to be stored in locked cabinets, but the facility lacked a chemical storage policy.
A resident with paraplegia was found unresponsive outside in a wheelchair, showing signs of distress. Staff intervened, but the facility failed to report the incident to the State Agency or conduct an investigation. The resident was later observed outside again, unable to re-enter the facility independently, highlighting ongoing neglect issues.
A resident with paraplegia was found unresponsive outside in a wheelchair, with no means to contact the facility for help. The incident occurred when a CNA left the resident outside and went off shift without informing incoming staff. The facility failed to conduct a thorough investigation, as required by their policy, placing the resident at risk for ongoing neglect.
A resident with stasis ulcers on her shins did not have an updated care plan addressing her skin integrity needs. Despite having conditions like weakness, neuropathy, and localized edema, the care plan lacked instructions for wound care. Observations showed that staff were unaware of the treatment for the ulcers, and the administrative nurse admitted the care plan was not updated as required by facility policy. This oversight risked the resident's quality of care due to uncommunicated needs.
A facility failed to ensure a physician responded to a pharmacist's recommendation for a stop date on a resident's PRN lorazepam, risking unnecessary psychotropic side effects. The resident, with anxiety and hypertension, continued receiving the medication without a specified stop date, contrary to facility policy requiring a 14-day limit for PRN psychotropic drugs.
A facility failed to ensure a 14-day stop date or specified duration for a resident's PRN antianxiety medication, lorazepam. The resident, with anxiety and hypertension, received lorazepam for sleep and behavior issues, but the physician's order lacked a stop date. Observations confirmed the medication was administered without a stop date, contrary to the facility's policy requiring a 14-day stop date for PRN psychotropic medications.
A facility failed to label a resident's insulin flex pen with the date opened and discard date, as observed on a treatment cart. This was confirmed by an administrative nurse, who stated that nurses are required to date flex pens upon opening and discard expired medications. The facility's policy requires medications to be stored securely and labeled for single-resident use to prevent cross-contamination. This oversight placed the resident at risk for ineffective medication.
A facility failed to coordinate hospice care for a resident with Alzheimer's, aphasia, and dementia, leading to a lack of a comprehensive care plan. The resident's care plan did not include hospice services, and there was no communication book or external document related to hospice care. An administrative nurse confirmed the absence of hospice information in the facility's records, despite the facility's policy requiring a coordinated plan of care.
The facility did not obtain signed consent for flu vaccinations for three residents, as their medical records lacked evidence of being offered the vaccine. Despite sending out consent forms annually, the facility did not follow up on unreturned forms, leading to some residents not receiving vaccinations. Administrative Nurse D acknowledged the difficulty in contacting some residents' representatives. The facility's policy required offering vaccinations on admission and annually, with documentation of immunization status.
Failure to Perform Resident-Centered Post-Fall Analysis and Timely Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to conduct resident-centered post-fall analyses and to implement timely, appropriate fall-prevention interventions for a cognitively impaired resident with multiple falls and serious injuries. The resident had dementia, anxiety, and osteoporosis, with documented memory problems, moderately impaired cognition, behavioral symptoms, rejection of care, and wandering. MDS assessments showed the resident required assistance with transfers and walking, self-propelled in a wheelchair, and had multiple falls, including falls with major injury. Despite these risk factors, the Cognitive Loss/Dementia and Falls Care Area Assessments triggered on 10/07/25 were not completed, and the care plan, while listing numerous generic fall-risk interventions, did not consistently reflect individualized analysis of why specific falls occurred. Across numerous documented falls, the facility’s fall investigations were incomplete or missing, and root cause analyses were not performed. For a fall on 08/05/24, the post-fall evaluation noted a non-injury fall, but the investigation lacked an RCA, and only a general intervention to place grip strips in front of recliners was documented. The facility could not provide any fall investigations or interventions for falls on 10/04/24, 11/01/24, and 12/23/24. For other falls on 10/03/24, 11/02/24, 12/22/24, and 12/28/24, investigations were provided but did not identify causal factors, and interventions such as assistance with gait belt and walker, toileting after evening meal, 15-minute checks, use of a recliner in the commons area, and placement in a low bed were initiated 18–22 days after the falls. A fall report dated 01/03/25 documented a fall with minor injury, but the progress notes contained no corresponding entry, and the fall report again lacked an RCA. The resident experienced a series of significant events related to falls and injuries that were not linked to timely, resident-specific analysis. After a non-injury fall on 12/23/24, the resident later reported increased pelvic, hip, and lower back pain, leading to x-rays that revealed a right greater trochanteric fracture. The resident was initially returned from the ED with non-surgical management orders, but the next day had another unwitnessed fall with right leg shortening and rotation, and was sent back to the ED where the fracture was found to be worse, further fractured, and dislocated, ultimately requiring surgery. A later fall on 02/12/25 resulted in left leg pain and outward rotation and was classified as a fall with major injury, yet the associated investigation again lacked an RCA. Additional falls on 07/10/25, 09/23/25, 10/25/25, 12/05/25, 12/14/25, and 01/08/26 were documented in post-fall evaluations, but the report does not describe completed, detailed causal analyses for these events. Facility processes and staff practices contributed to the deficiency. Floor nurses and CNAs reported they did not have access to the electronic care plan and relied on Administrative Staff C and Administrative Nurse D to determine and communicate fall interventions, often via shift report or an intervention book. Staff stated they did not create or implement their own fall-prevention interventions, and that the care plan book was often kept in an office, limiting access. Administrative Nurse D acknowledged that fall investigations were incomplete or missing, lacked root cause analysis, and that the facility did not have a fall packet to guide staff documentation. She also stated that IDT meetings to review falls and develop interventions were not consistently held within 24–48 hours and were now held only when possible due to scheduling conflicts. Administrative Staff C, a CNA, reported she was in charge of care plan interventions for falls, could revise care plans without DON approval, and that residents could go two to four weeks between a fall and the development of a new intervention, further demonstrating the lack of timely, resident-centered analysis and intervention after falls. The facility’s own Fall Prevention Protocol stated that each resident would receive services and care to ensure the environment remained as free from accident hazards as possible and that each resident would receive adequate supervision and assistive devices to prevent accidents. However, the pattern of missing or incomplete fall investigations, absence of root cause analyses, delayed implementation of interventions, and limited staff access to and involvement in care planning for falls shows that this protocol was not followed for this resident. The repeated falls, including those resulting in major injuries and surgery, occurred in the context of these systemic failures in post-fall assessment and individualized intervention planning.
Failure to Maintain Required RN Coverage and Full-Time RN DON
Penalty
Summary
The deficiency involves the facility’s failure to provide required RN coverage for at least eight continuous hours daily and to employ a full-time RN as the DON. Surveyors observed the posted daily staffing sheets on three separate days and found no RN hours documented. Review of the facility’s Payroll Based Journal (PBJ) staffing data for FY Q4 2025 showed multiple dates across July, August, and September with no recorded RN hours. The facility’s own undated Registered Nurse policy stated that an RN would be employed for at least eight consecutive hours, seven days per week, but the documented staffing patterns did not reflect this requirement. Administrative staff confirmed that the facility had not had an RN serving in the DON role since 2023 and that the individual currently functioning as DON was an LPN enrolled in an RN program, with an anticipated completion date in the future. Administrative staff also confirmed the accuracy of the PBJ report for dates with no RN coverage and declined to review those dates with the survey team. They reported that the facility did not provide skilled services, stating those were provided by a neighboring hospital, and that the facility was actively but unsuccessfully recruiting RNs. The job description for the DON provided to surveyors did not specify that the DON must hold an active, unencumbered RN license, further evidencing the lack of a full-time RN in the DON role as required.
Failure to Implement Core Elements of Antibiotic Stewardship
Penalty
Summary
The facility failed to develop and implement the core elements of an antibiotic stewardship program as part of its infection prevention and control program for its 29 residents, 12 of whom were included in the sample. Review of the Infection Control Log for tracking and trending infections from March 2025 through February 2026 showed no documentation of organism identification, duration of prescribed antibiotics, or the specific infections being treated, and the facility was unable to provide this information when requested. The Infection Preventionist, who was also an administrative nurse, reported that she only tracked which residents were taking antibiotics in the EMR and confirmed she could not provide tracking and trending data for antibiotic use. She stated that floor nurses were expected to open the infection document for tracking but were not completing the form, leaving her with only records of antibiotics that residents had taken for infections, without the additional required details. This practice did not align with the facility’s Infection Preventionist policy, which assigned responsibility for effective direction, management, and operation of the infection prevention program, including use of evidence-based practices and compliance with CMS and state regulatory requirements. No additional resident-specific medical histories or conditions at the time of the deficiency were provided in the report.
Lack of Qualified Infection Preventionist for Infection Control Program
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) with the required training and certification to be responsible for the Infection Prevention and Control Program for a census of 29 residents. During the entrance conference, an administrative staff member identified an administrative nurse as the facility’s IP, stating she was a licensed nurse who had been completing continuing education in infection prevention. Documentation provided by the facility showed that this nurse had completed education on Enhanced Barrier Precautions and implementation of an antibiotic stewardship surveillance plan. In a subsequent interview, the administrative nurse confirmed she had been performing IP duties and participating in continuing education but acknowledged she did not hold an Infection Preventionist certificate, and that the facility’s plan was for her to take the course and obtain the certificate. The facility also had an undated antibiotic administration policy describing appropriate use and stewardship of antibiotics, but there was no evidence that a properly qualified and certified IP had been designated to oversee the infection prevention and control program.
Failure to Complete Required CAAs for Multiple Residents’ Annual MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to complete required Care Area Assessments (CAAs) for multiple residents whose comprehensive Minimum Data Set (MDS) assessments triggered these areas. The facility had a census of 29 residents with 12 residents sampled, and record review showed that four residents’ annual MDS assessments had triggered multiple CAAs that were not completed. One resident’s annual MDS dated 09/28/25 triggered CAAs for ADL Functional/Rehabilitation Potential, urinary incontinence and indwelling catheter, falls, nutritional status, dehydration/fluid maintenance, dental care, pressure ulcer/injury, and psychotropic drug use, but none of these CAAs were completed. Another resident’s annual MDS dated 10/07/25 triggered CAAs for cognitive loss/dementia, communication, urinary incontinence and indwelling catheter, behavioral symptoms, falls, pressure ulcer/injury, psychotropic drug use, and pain, which were also not completed. A third resident’s annual MDS dated 08/25/25 triggered CAAs for ADL Functional/Rehabilitation Potential, urinary incontinence and indwelling catheter, nutritional status, pressure ulcer/injury, physical restraints, and pain, but these CAAs were not completed. A fourth resident’s annual MDS dated 04/16/25 triggered CAAs for cognitive loss/dementia, communication, urinary incontinence and indwelling catheter, mood state, falls, nutritional status, dental care, pressure ulcer/injury, psychotropic drug use, and pain, and these CAAs were likewise not completed. During an interview on 03/10/26 at 4:06 PM, an administrative nurse acknowledged that the CAAs for these residents were missed, stated that the CAAs should be filled out to more accurately trigger care plan interventions, and noted she was still learning how to complete MDS assessments. The facility’s undated MDS Accuracy Audits policy documented a commitment to ensuring the accuracy, timeliness, and completeness of all MDS assessments.
Inaccurate MDS Coding of Bedrails as Physical Restraints
Penalty
Summary
Surveyors found that the facility failed to ensure accurate completion of MDS assessments for five residents regarding the use of bedrails as restraints. For these residents, multiple Quarterly MDS assessments documented that bedrails were used as physical restraints on a daily basis during the look-back periods. Specifically, the MDS assessments dated 01/20/25, 11/25/25, 01/16/26, 02/15/26, and 12/20/25 each indicated daily use of bedrails as physical restraints. However, during an interview on 03/10/26 at 4:06 PM, Administrative Nurse D stated she had coded bedrails as restraints on the MDS for all residents whose beds had bedrails installed, regardless of whether the residents actually used the bedrails or whether the bedrails restricted their mobility. Administrative Nurse D further confirmed that, for the identified residents, the bedrails did not restrict mobility and therefore did not meet the definition of a restraint, despite being coded as such on the MDS. She also stated that her expectation was that MDS assessments accurately reflect each resident’s status. The facility’s undated “Minimum Data Set (MDS) Accuracy Audits” policy documented that the facility was committed to ensuring the accuracy, timeliness, and completeness of all MDS assessments, which contrasted with the inaccurate coding practice described.
Unlocked and Unattended Medication Cart Left Accessible in Hallway
Penalty
Summary
The deficiency involves failure to ensure medications were stored securely in locked compartments accessible only to designated staff. The facility had a census of 29 residents, with one medication room, three medication carts, and one treatment cart. During an observation, a licensed nurse approached a medication cart parked directly outside the nurse's station, prepared medications in a small cup, locked only the computer screen, and then walked away from the cart, which remained unlocked. The cart’s lock was positioned outward, indicating it was not engaged and that the contents were accessible to anyone who attempted to open it. The nurse then entered a resident’s room down the hall, leaving the unlocked cart unattended and out of staff visual range. Upon returning, she logged back into the computer, prepared medications for another resident, again locked the monitor screen, closed the medication drawer, and walked down the hall into another resident’s room, once more leaving the cart unlocked and unsupervised. During interview, the nurse acknowledged that the medication cart and computer monitor should be locked every time they are left unattended. The administrative nurse also stated she expected staff to lock the medication cart before walking away. The facility’s Medication Labeling and Storage policy required all medications to be stored in a secure, locked location accessible only to designated staff.
Infection Control Failures in Respiratory Equipment Storage, PPE Use, and Laundry Handling
Penalty
Summary
Surveyors identified multiple infection prevention and control deficiencies involving respiratory equipment, personal protective equipment (PPE) use, and laundry handling. During an initial walk-through, one resident’s CPAP mask was found lying directly on the bedside table without being stored in a sanitary container. Three other residents’ nebulizer masks were also observed either on bedside tables or hanging over a side table and lying in a magazine rack, all without sanitary containers. Facility nursing leadership later stated that respiratory equipment should be rinsed, laid to dry covered, and then placed in a marked bag labeled with the resident’s name and date when not in use, which was not done in these cases. Surveyors also observed improper handling of dirty laundry and failure to follow Enhanced Barrier Precautions (EBP) PPE requirements. A CNA was seen carrying unbagged dirty laundry close to their uniform down a hallway to a dirty laundry barrel, contrary to the administrative nurse’s expectation that staff move the laundry tub to the resident’s door and avoid carrying dirty laundry next to their clothing. Another CNA was observed holding a graduated cylinder containing dark amber urine while wearing only gloves and no additional PPE, despite the resident having a urinary catheter and signage on the door indicating required PPE for EBP. Staff interviews confirmed that all CNAs had been trained on EBP and that a gown and gloves were expected for personal care of residents with urinary catheters. The facility was unable to provide a policy for EBP when requested, despite having written policies for respiratory care and laundry protocols.
Failure to Maintain Resident Dignity in Common Area
Penalty
Summary
Surveyors identified a deficiency related to resident dignity when a dependent resident with severe cognitive impairment was observed in a common TV area wearing only a green hospital gown with a white sheet over her lap. The resident’s EMR documented diagnoses including Alzheimer’s disease, dementia, aphasia, anxiety, pain, and major depressive disorder, and her most recent MDS showed a BIMS score of 0, indicating severely impaired cognition, and dependence on staff for all ADLs. While seated in a Broda chair in the TV room, the resident moved her hands up and down, raising her sheet and gown so that her white incontinence brief became visible to two male residents seated in the same area. Staff interviews confirmed that this situation was inconsistent with facility expectations and policy. A CNA stated the resident should have been dressed or completely covered and that residents should not be exposed to other residents. A licensed nurse stated residents should not be in the TV room wearing only a gown and sheet and should remain in their rooms until the bath aide was ready for them. An administrative nurse stated facility protocol required residents to be dressed and groomed before leaving their rooms, that residents should be fully dressed when in the TV area, and that incontinence briefs should never be exposed. The facility’s Resident Rights Policy documented that all residents have the right to a dignified existence and that all staff are responsible for protecting those rights, underscoring that the observed exposure of the resident’s incontinence brief in a public area constituted a failure to ensure dignity.
PRN Lorazepam Order Lacked Required Stop Date and Rationale
Penalty
Summary
The deficiency involves the facility’s failure to ensure an as-needed psychotropic medication order for a resident included a required 14-day stop date or a specified duration with physician rationale for extended use. The resident had diagnoses of hypertension and diabetes mellitus and a BIMS score of zero, indicating severely impaired cognition, and required substantial to maximal assistance with all ADLs except eating. The MDS documented that the resident received an antidepressant, hypnotic, and antianxiety medication during the observation period. The Psychotropic Use CAA noted no adverse reactions to antidepressant treatment, and the care plan included goals for the resident to be free from medication side effects and symptoms related to black box warnings, with pharmacist consultation and education for the DPOA and the resident. Despite these care plan elements, the EMR orders showed lorazepam cream 0.5 mg to be applied every eight hours and as needed for dementia without a 14-day stop date or any specified duration. The EMR also lacked a physician’s rationale for the extended as-needed use of lorazepam. Nursing staff interviews confirmed that nurses taking orders were expected to inform physicians that as-needed lorazepam required a stop date and that the DON served as a second check for all orders. Administrative staff stated the facility’s policy was to follow regulations for as-needed psychotropic medications, but the facility did not provide an unnecessary psychotropic drug policy when requested by surveyors.
Incomplete Facility-Wide Assessment of Staffing, Competencies, and Resources
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough, facility-wide assessment to determine the resources necessary to care for residents competently during routine operations and emergencies. With a census of 29 residents and a sample of 12 residents, surveyors reviewed an undated Long-Term Care Self-Assessment provided by administrative staff. The assessment did not identify specific staffing levels needed for each unit, nor did it specify the number of RNs, LPNs/LVNs, CMAs, and CNAs required based on unit, resident acuity, and census. It also lacked staffing levels for each shift, including evenings and weekends. The assessment did not fully document resident condition reports or any extenuating circumstances that would make those condition reports unusual. The assessment further failed to document staff competencies and skill sets necessary to provide the level and types of care needed for the facility’s resident population. It did not fully document contractual agreements with outside providers for services such as laboratory, radiology, therapy, hospital, or transportation, and it omitted contracts for lawn care and snow removal. Administrative staff reported that the assessment was reviewed annually, most recently on a specific date, and acknowledged that the facility did not have a vision or mission statement. The administrative staff member stated he was unaware that certain sections of the assessment (orange boxes) were required to be completed, confirmed that the staffing breakdown per unit was missing, and verified that unchecked competencies (including Safety and Missing Resident for all staff) indicated those staff were not responsible for those competencies. The facility’s own Facility Assessment Policy stated that the assessment was to be the foundation for determining staffing levels, competencies, and resources, and was to address resident care needs, staff competencies, and third-party contracts during normal operations and emergencies, but the completed assessment did not meet these requirements.
Neglect of Resident Leading to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure a resident, identified as R14, remained free from neglect, which placed him in immediate jeopardy. R14, who had diagnoses of paraplegia, spinal stenosis, and muscle weakness, required extensive assistance with activities of daily living and used a wheelchair for mobility. On a particular day, a Certified Nurse Aide (CNA) assisted R14 into the courtyard and left him there without any means to contact the facility or return inside. R14 was found unresponsive outside several hours later, with a dangerously high body temperature and elevated pulse, indicating severe neglect in supervision and care. R14's care plan required staff to assist him with all activities of daily living and to provide supervision, especially when he was outside. However, the facility failed to adhere to this plan. The CNA who assisted R14 outside did not inform the oncoming staff that R14 was outside, leading to a lack of supervision for over three hours. During this time, R14 was exposed to conditions that led to his unresponsiveness and required emergency medical intervention. The facility's failure to conduct a thorough investigation into the incident further compounded the deficiency. There was no evidence of a facility investigation, witness statements, or analysis of causative factors related to the event. This lack of documentation and follow-up indicates a significant oversight in the facility's procedures for handling such incidents, as outlined in their Abuse, Neglect, and Exploitation policy.
Removal Plan
- The facility will no longer employ the nurse on duty.
- The facility will train all current staff and will train all future employees including the agency staff on outdoor safety and neglect.
- The facility provided re-training on the Abuse, Neglect, and Exploitation Policy.
- The facility created a procedure specific to the incident that all staff were trained on.
- The administration will monitor outdoor safety on an ongoing basis.
- Staff will ensure residents outside receive adequate visual checks and adequate hydration.
Failure to Provide Full-Time DON and RN Coverage
Penalty
Summary
The facility failed to comply with regulatory requirements by not employing a full-time Registered Nurse (RN) as the Director of Nursing (DON) and not providing RN coverage for eight consecutive hours a day, seven days a week. The facility had a census of 31 residents, and the deficiency was identified through observation, record review, and interviews. A review of the nursing schedule from January to December 2023 revealed that there was no RN coverage for eight consecutive hours on more than 50 occasions. Administrative Staff A confirmed the absence of a full-time RN as DON and the lack of consistent RN coverage, citing difficulties in securing an RN except occasionally from an agency. The facility's policies required a full-time DON and RN coverage for eight consecutive hours daily, which were not met, placing the residents at risk for inadequate care.
Failure to Implement Water Management Program for Legionella
Penalty
Summary
The facility failed to implement a comprehensive water management program to address the risk of Legionella and other waterborne pathogens, which placed residents at risk for infectious diseases. During an observation, Maintenance Staff U confirmed the absence of routine water management checks and noted that the 300 hall was not in use, with no regular flushing of water in unoccupied rooms. Administrative Staff A acknowledged that while the city conducted monthly water checks, there were no records available, and the facility lacked a system to monitor standing water and mitigate the risk of Legionella. The facility's Legionella Surveillance policy outlined the need for Legionella risk assessments, identification of potential growth areas, and implementation of control measures. However, the facility did not adhere to these standards, as evidenced by the lack of regular inspections, microbiological monitoring, temperature checks, and flushing. The policy also required documentation of all monitoring activities and the appointment of a responsible person for the water system, which was not fulfilled. This failure to implement a water management program exposed residents to the risk of contracting Legionella pneumonia.
Chemical Storage Deficiency in Kitchenette
Penalty
Summary
The facility failed to ensure an environment free from accident hazards when staff left a gallon chemical bottle in an unlocked bottom cabinet in one of three kitchenettes. This incident placed 12 cognitively impaired, independently mobile residents at risk for preventable accidents or injuries. During an observation, a plastic gallon bottle of Attack Enzyme odor digester, drain opener, and maintainer was found in an unlocked cabinet underneath the sink in a kitchenette located off the family dining room. The label on the bottle warned to keep it out of reach of children, avoid contact with eyes, and noted it may cause skin irritation. A Licensed Nurse verified the finding and acknowledged that the cabinet should be locked, subsequently moving the bottle to a locked housekeeping closet. An Administrative Nurse later stated that staff were expected to store chemicals in a locked cabinet. The facility did not provide a chemical storage policy upon request, highlighting a lapse in ensuring a safe environment for residents.
Failure to Report Neglect Incident
Penalty
Summary
The facility failed to report an incident of neglect involving a resident, identified as R14, to the State Agency as required. R14, who had diagnoses including paraplegia, spinal stenosis, and muscle weakness, required extensive assistance with activities of daily living and used a wheelchair for mobility. On a particular day, R14 was found outside unresponsive in his wheelchair, with no shirt on, and showing signs of distress such as drooling and minimal responsiveness. Staff intervened by cooling him down and calling EMS, who later transported him for further care. However, the facility did not conduct an investigation into the incident, nor did they report it to the State Agency, as evidenced by the lack of documentation in R14's electronic health record. Further observations revealed that R14 was again outside on the front patio, unable to re-enter the facility on his own. Administrative Staff B had to assist him inside, and it was noted that R14 was unaware of how to use his walkie-talkie, which was meant for communication. Administrative Staff A later confirmed that a CNA had let R14 outside as she went off duty, and the oncoming staff did not check on him. The facility's policy required the Nursing Home Administrator to report such incidents, but this was not done, placing R14 at risk for ongoing neglect.
Failure to Investigate Neglect Incident
Penalty
Summary
The facility failed to thoroughly investigate an incident of neglect involving a resident with paraplegia, spinal stenosis, and muscle weakness, who required extensive assistance with activities of daily living and used a wheelchair for mobility. The resident was found outside unresponsive in his wheelchair, with no means to contact the facility for assistance. The incident occurred when a CNA took the resident outside and went off shift without informing the incoming staff, leaving the resident unattended. The resident's care plan required staff to assist with all activities of daily living and to monitor for signs of immobility, skin breakdown, and fall-related injuries. However, the facility did not conduct a written investigation or gather witness statements and causative factors related to the event. The facility's policy mandates that all allegations of neglect be thoroughly investigated, including a root cause analysis and review by the Quality Assurance Performance Improvement Committee. Despite the policy, the facility was unable to provide evidence of an investigation into the incident. Administrative staff acknowledged that the resident was left outside without any means to contact the facility and that the staff was not informed of the resident's whereabouts. This lack of investigation placed the resident at risk for unidentified and ongoing neglect.
Failure to Update Care Plan for Resident with Stasis Ulcers
Penalty
Summary
The facility failed to review and revise the care plan for a resident with stasis ulcers on her shins, which are open wounds caused by circulation problems in the leg veins. The resident's electronic medical record documented diagnoses of weakness, neuropathy, and localized edema. The resident had a Brief Interview of Mental Status score indicating moderately impaired cognition and required partial to moderate staff assistance with most activities of daily living. Despite these conditions, the care plan, last revised on 05/01/24, did not include a section on skin integrity or instructions for caring for the resident's bilateral lower legs. Observations and interviews revealed that the licensed nurse was unaware of the appearance or treatment of the resident's ulcers, as the resident received wound care at the hospital. The administrative nurse confirmed the absence of a skin integrity section in the care plan and acknowledged responsibility for updating it. The facility's policy stated that changes in a resident's condition require updates to the care plan, but this was not done for the resident's venous ulcers. This oversight placed the resident at risk for decreased quality of care due to uncommunicated care needs.
Failure to Implement Pharmacist's Recommendation for PRN Medication Stop Date
Penalty
Summary
The facility failed to ensure that a physician acknowledged and responded to a Consultant Pharmacist's recommendation regarding a stop date for a resident's PRN antianxiety medication. The resident, identified as R19, had diagnoses of anxiety and hypertension and was receiving lorazepam, an antianxiety medication, without a specified stop date. The Consultant Pharmacist recommended a 14-day stop date for the medication, but the clinical record lacked evidence of a physician's response to this recommendation. This oversight placed the resident at risk for unintended effects related to psychotropic drug medications. Observations and interviews revealed that the resident continued to receive lorazepam PRN without a stop date, and the facility's policy required a 14-day stop date for PRN psychotropic medications. The Administrative Nurse confirmed that the pharmacist's recommendations were sent to the physician, but there was no response regarding the duration or rationale for the continued use of the medication. The facility's policy also required an assessment and documentation of the resident's response to the medication before extending its use, which was not adhered to in this case.
Failure to Ensure Stop Date for PRN Antianxiety Medication
Penalty
Summary
The facility failed to ensure a 14-day stop date or a specified duration with rationale for a resident's ongoing as-needed (PRN) antianxiety medication, lorazepam. The resident, identified as R19, had diagnoses of anxiety and hypertension and was noted to have moderately impaired cognition. The resident's care plan indicated the use of lorazepam for trouble sleeping and behavior problems, with a specific dosage at bedtime and an additional dose allowed during the night. However, the physician's order for lorazepam lacked a stop date, and there was no documented rationale for the extended use of the PRN medication. Observations and interviews confirmed that the resident received lorazepam PRN without a stop date, which was verified by the administrative nurse. The facility's policy on psychotropic drug use required a 14-day stop date for PRN psychotropic medications, with an assessment and documented rationale for continued use if necessary. The absence of a stop date or specified duration for R19's lorazepam placed the resident at risk for adverse psychotropic medication side effects.
Failure to Label Insulin Pen
Penalty
Summary
The facility failed to appropriately store medications by not labeling a resident's insulin flex pen with the date it was opened and the discard date. During an observation of the treatment cart, it was found that the Basaglar flex pen for a resident lacked these essential labels. This oversight was confirmed by Administrative Nurse D, who acknowledged that nurses are required to date the flex pens upon opening and discard expired insulin and medications. The facility's Medication Storage and Labeling policy mandates that medications and biologicals be stored in secured, clean, and sanitary conditions, with insulin pens clearly labeled for single-resident use to prevent cross-contamination. The failure to label and date the insulin pen placed the resident at risk for receiving ineffective medication.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to ensure a coordinated plan of care for a resident receiving hospice services, which placed the resident at risk for inappropriate end-of-life care. The resident, who had diagnoses of Alzheimer's disease, aphasia, and dementia, was admitted to the facility and received hospice treatment. However, the resident's nursing care plan lacked information regarding hospice services and evidence of coordination between the hospice and the facility. The facility did not maintain a communication book or external document related to the resident's hospice services, and the care plan did not reflect the resident's hospice status. Observations and interviews revealed that the facility had initial hospice admit notes with limited care plan information but lacked a complete plan of care. An administrative nurse confirmed the absence of hospice information in the facility's electronic health records and acknowledged difficulties in receiving information from the hospice. The facility's hospice program policy required a coordinated comprehensive plan of care involving communication between hospice, the resident, family, and external resources, which was not adhered to in this case.
Failure to Obtain Consent for Influenza Vaccinations
Penalty
Summary
The facility failed to obtain signed consent for influenza immunizations for three residents, identified as R4, R13, and R18, during the flu season. The clinical medical records for these residents lacked evidence that the facility or the residents' representatives received or were offered the current influenza vaccine. Administrative Nurse D confirmed that while the facility sent out consent forms annually, they did not receive all forms back and did not follow up, resulting in some residents not receiving the vaccinations. Additionally, it was noted that some residents' representatives were difficult to contact and did not return the forms. The facility's Immunization Policy, revised in March 2024, stated that all residents would be offered vaccinations on admission and annually, with documentation of each resident's immunization status in their clinical record. The failure to offer or obtain informed declinations for the flu vaccination placed the residents at risk of acquiring, spreading, and experiencing complications from influenza.
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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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