Pioneer Ridge Retirement Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Lawrence, Kansas.
- Location
- 4851 Harvard Road, Lawrence, Kansas 66049
- CMS Provider Number
- 175445
- Inspections on file
- 22
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Pioneer Ridge Retirement Community during CMS and state inspections, most recent first.
A CNA did not have a required annual performance evaluation completed, as confirmed by facility administration and record review. The facility's policy mandates yearly evaluations to assess staff performance and training needs, but this process was not followed for the CNA in question.
Staff did not consistently document dishwashing, refrigerator, and freezer temperatures, and failed to wear required hairnets and beard guards in food prep areas. An open gallon of milk was found stored at an unsafe temperature without ice, and a staff member handled juice glasses by touching the drinking surface, contrary to facility policy.
The facility did not consistently identify or implement Enhanced Barrier Precautions for residents with PEG tubes and urinary catheters, failed to provide proper signage or PPE, and did not ensure sanitary storage of oxygen cannulas. Staff also did not always follow hand hygiene protocols or use barriers during blood glucose monitoring, resulting in multiple infection control deficiencies.
The facility did not maintain consistent infection control logs or track antibiotic use as required, with the responsible nurse confirming that monthly antibiotic tracking had not been completed for several months. Infection surveillance and documentation were incomplete, and there was no evidence of systematic education on antibiotic use and resistance, contrary to facility policy.
The facility did not have a qualified and certified Infection Preventionist on site, relying instead on a corporate nurse who was not present and an administrative nurse without specialized infection prevention training. The facility also could not provide a policy for the Infection Preventionist role when requested.
Surveyors found multiple medication and treatment carts left unlocked and unsupervised, containing prescription drugs, insulin, and treatment supplies. In one case, a cart laptop was left open, displaying a resident's protected health information. Staff interviews revealed uncertainty about locking requirements, despite facility policy mandating that all medications be secured and PHI protected.
The facility did not offer or document informed declinations or physician-documented contraindications for PCV20 and pneumococcal vaccinations for three residents. Records lacked evidence that the vaccine was offered or declined, and the responsible nurse confirmed that PCV20 had not been offered, despite facility policy requiring vaccinations per CDC guidelines.
Two residents with indwelling urinary catheters were observed in the dining room with visible, uncovered urinary collection bags during meal service. Staff interviews confirmed that privacy covers were expected to be used, and facility policy required dignity to be maintained, but these measures were not followed, resulting in a lack of privacy for the residents.
A treatment cart was left unsecured and unsupervised in a hallway, with its laptop open and displaying a resident's PHI in direct view. An LPN was unsure about the requirement to lock medication carts and acknowledged that PHI should not be left open on unattended computers, contrary to facility policy.
Several residents had their pain medications misappropriated when a nurse failed to properly document and secure narcotics, resulting in discrepancies between electronic and paper medication records. The affected individuals included those with fractures, cognitive impairment, and on hospice, and the errors occurred when narcotics were not promptly removed from the cart after discontinuation or discharge.
A resident with hypotension, Parkinson's disease, and a history of falls was transferred to the hospital after being found on the floor. The facility did not provide the required written notice of transfer/discharge or bed hold information to the resident or their legal representative, as confirmed by administrative staff and record review.
A resident with severe cognitive impairment, Parkinson's disease, and incontinence did not have a care plan that addressed all identified needs, including ADL assistance, incontinence care, and use of a Hoyer lift. Staff primarily relied on report sheets and verbal instructions, leading to inconsistent care delivery and lack of communication between management and direct care staff.
Two residents' care plans were not updated after significant changes in their care, including the removal of a specialized mattress following hospice discharge and the initiation of oxygen therapy. Staff confirmed that care plans did not reflect these changes, and interventions were not revised as required by facility policy.
A resident with CHF, hypotension, and atrial fibrillation did not have daily weights obtained and documented as ordered by the physician, despite being on a diuretic for edema. Over a 27-day period, staff missed recording weights on seven days, with no documentation of refusals or physician notification. Nursing staff and administration confirmed the expectation to follow physician orders and document any issues, but these steps were not followed.
A resident with multiple pressure injuries and significant risk factors did not receive consistent application of heel protectors or proper offloading, and the low air loss mattress was not set according to the resident's weight. The care plan lacked specific interventions for pressure injuries and did not direct staff to monitor the mattress settings, resulting in a failure to follow physician orders and facility policy.
A resident with severe cognitive impairment and a history of falls did not consistently receive fall prevention interventions as outlined in the care plan, including proper placement of fall mats and bed positioning. Staff interviews revealed lack of access to or awareness of the care plan, leading to inconsistent implementation of required safety measures.
A resident with dementia, anxiety, and depression received oxygen therapy without a documented physician indication or diagnosis for its use. The care plan lacked direction for oxygen administration, and the physician's order did not specify a diagnosis, contrary to facility policy and staff expectations.
A resident with end-stage renal disease and congestive heart failure required regular dialysis, but the facility failed to include necessary physician orders, care plan directions, and documentation for dialysis care, shunt access, and transportation. Staff interviews confirmed that essential information was missing from the resident's records, and the facility's policy requirements were not met.
The facility did not ensure that care plans for two residents receiving hospice care included required information about hospice providers, services, and supplies. Staff interviews confirmed that this information was missing from the care plans, and a hospice communication binder was unavailable for one resident. The facility's policy required coordination and documentation, but these steps were not followed.
The facility did not provide residents and visitors with access to the most recent state inspection results, as the survey binder in the lobby was missing the Statement of Deficiencies from a recent complaint survey. Administrative staff confirmed the omission, which was not in accordance with the facility's Resident Rights policy.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with a documented peanut allergy was served a peanut butter cookie due to staff failing to verify dietary restrictions on the meal ticket, resulting in an anaphylactic reaction and hospitalization. Staff did not follow established protocols for checking allergies during meal preparation and delivery, and the facility was unable to provide immediate epinephrine treatment.
A resident with a documented peanut allergy experienced an anaphylactic reaction after being served a peanut butter cookie. The nurse on duty was unable to locate an Epi-pen and did not recognize that epinephrine was available in vial form in the emergency medication kit, resulting in delayed administration of the medication until EMS arrived. This incident demonstrated a lack of staff competency in identifying and administering emergency allergy treatment.
The facility failed to secure hazardous cleaning chemicals, leaving them accessible to cognitively impaired residents, and did not implement fall interventions for two residents as per their care plans. This included not securing call lights within reach and not placing fall mats correctly, increasing the risk of preventable accidents and injuries.
The facility failed to obtain consent or declinations for the PCV20 vaccine for several residents, including those who had previously received PCV13 and PPSV23. The Infection Preventionist had not started offering or obtaining consent for the PCV20, despite the facility's policy requiring documentation of vaccination history and provision of CDC information. This lack of documentation placed residents at increased risk for pneumonia complications.
A resident with multiple medical conditions and moderate cognitive impairment was found without a call light within reach on several occasions, contrary to facility policy. Staff interviews confirmed the oversight, and the resident's care plan did not address call light placement.
A resident with multiple health conditions and moderately impaired cognition was transferred to the hospital without receiving the required written notice. The facility's policy mandates written notice for transfers, but this was not provided, leading to potential miscommunication regarding the resident's care needs.
A resident with multiple health conditions and moderately impaired cognition was transferred to the hospital without receiving a bed hold notice, as required by the facility's policy. The facility's failure to provide this notice was confirmed by administrative staff, placing the resident at risk for impaired ability to return to the facility or their same room.
The facility failed to ensure proper application of pressure-relieving devices for two residents at risk for pressure ulcers. One resident, with a history of multiple health conditions, was observed with only one offloading boot despite orders for both heels. Another resident lacked a pressure-reducing cushion in their wheelchair, contrary to their care plan. Staff interviews revealed a lack of awareness and monitoring, leading to increased risk for pressure ulcers.
A resident with a history of hemiparesis and other medical conditions was not provided with a palm splint as required by her care plan, leading to a risk of decreased range of motion. Observations showed the resident without the splint on multiple occasions, and staff interviews revealed a lack of awareness and documentation regarding the splint's application. The facility's restorative policy was not followed, as the nursing staff failed to ensure the resident received the necessary device.
A facility failed to assess and implement interventions for a resident's incontinence, leading to increased risk of UTIs. The resident's care plan lacked direction for toileting, despite multiple antibiotic treatments for UTIs. Staff interviews revealed a lack of clear toileting schedules and documentation, contributing to the deficiency.
A resident's CPAP mask was not stored in a sanitary manner, increasing the risk of respiratory infection. The resident, with a history of sleep apnea and other health issues, had their CPAP mask left unsanitarily on the bed. Staff interviews revealed inconsistencies in storage procedures, and the facility lacked a policy for sanitary storage of respiratory equipment.
The facility failed to document safety assessments for the use of bed rails for two residents, both with severe cognitive impairments and using low air-loss mattresses. The absence of these assessments, including consent and advisement of risks and benefits, was confirmed through observations and staff interviews, placing the residents at risk for uninformed decisions and impaired safety.
A resident with diabetes and other medical conditions had multiple instances of elevated blood glucose levels, but the facility failed to notify the physician as required by the care plan. The resident's records showed several occurrences of blood glucose levels above 400 ml/dl without physician notification, despite staff acknowledging the responsibility to do so. This deficiency placed the resident at risk for complications related to hyperglycemia.
Two residents in the facility were found to have PRN lorazepam orders without a required 14-day stop date, placing them at risk for adverse effects. Despite the facility's policy mandating a stop date or physician-documented extension, these orders lacked such specifications. Nursing staff confirmed the expectation for a 14-day limit, indicating a failure to adhere to the policy.
A facility failed to include physician-ordered lab test results in a resident's clinical record, despite multiple urine analyses being ordered for possible UTIs. The resident's EMR documented several diagnoses, including hypertension and diabetes, and indicated a need for substantial assistance with toileting. An administrative nurse confirmed the results were not scanned into the EMR, and the facility lacked a policy on lab tests.
A facility failed to ensure a coordinated hospice care plan for a resident with multiple health issues, leading to a risk of inappropriate end-of-life care. The care plan lacked details on hospice services, and staff were unclear about the services provided. The facility's policy required an updated care plan to reflect coordination with hospice, which was not done.
The facility failed to implement proper infection control measures for two residents on Enhanced Barrier Precautions (EBP), lacking necessary signage and PPE. Additionally, respiratory equipment was not stored sanitarily, with oxygen tubing and nasal cannula left on a wheelchair seat without a sanitary bag. Staff interviews revealed a lack of understanding and implementation of EBP protocols, placing residents at risk for infectious diseases.
Annual Performance Evaluation Not Completed for CNA
Penalty
Summary
The facility failed to complete the required annual performance evaluation for one of five reviewed Certified Nurse Aides (CNA), specifically for a CNA hired on 09/30/23. During the review of performance evaluation and in-service records, no yearly performance evaluation was provided for this CNA upon request. The administrator confirmed that the evaluation was not available, and the administrative nurse stated that such evaluations are used to assess performance and identify areas for improvement among direct care staff. The facility's staffing policy requires annual performance reviews for all employees to identify strengths and training needs, but this was not followed for the identified CNA.
Failure to Maintain Food Safety and Sanitation Standards
Penalty
Summary
Staff failed to properly test dishwashing sanitization chemicals and did not consistently document freezer and refrigerator temperatures, as evidenced by missing entries on several days in the temperature logs. Additionally, an open, undated gallon of milk was found stored without ice at a temperature of 46 degrees, which was subsequently discarded. Staff members were observed not wearing required hairnets and beard guards while working in food preparation areas, and one staff member handled juice glasses by touching the drinking surface. Interviews with dietary staff confirmed that hairnets and facial hair nets should always be worn in the kitchen food prep area, and that glasses should be handled by the base to avoid contaminating the drinking surface. Staff also acknowledged that dishwashing machine, refrigerator, and freezer temperatures should be recorded daily, and that dairy products should be kept on ice to prevent spoilage. The facility's policy requires food to be stored at appropriate temperatures and for regular temperature checks to be conducted.
Failure to Implement Infection Control Program and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to properly implement and maintain its infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for residents with certain medical devices. Several residents with percutaneous endoscopic gastrostomy (PEG) tubes and urinary catheters were not identified for EBP, and there was no signage or indicators in their rooms to alert staff and visitors of the required precautions. Additionally, personal protective equipment (PPE) was not readily available in these residents' rooms, and staff members were unaware of the need for EBP for residents with these devices. Observations revealed improper storage of oxygen nasal cannulas, with some found on the floor or wrapped around wheelchair handles, and not stored in a sanitary manner as per facility policy. Staff interviews confirmed a lack of awareness regarding proper storage procedures, and the facility's own policy required cannulas to be stored in plastic bags and replaced if contaminated. Furthermore, during blood glucose monitoring, a licensed nurse failed to place a barrier under the Accu-check monitor before setting it down in a resident's room and did not perform hand hygiene before donning gloves, contrary to facility policy and standard infection control practices. Staff interviews indicated gaps in knowledge and adherence to infection control protocols, including hand hygiene and the use of EBP for residents with urinary catheters and PEG tubes. Facility policies outlined the requirements for oxygen equipment management, EBP, and hand hygiene, but these were not consistently followed, leading to multiple deficiencies in infection prevention and control practices.
Failure to Implement Antibiotic Stewardship and Infection Control Tracking
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 efforts. Specifically, the facility was unable to provide infection control logs for several months, which should have included tracking and trending of infections, identification of possible outbreaks, and documentation of antibiotic administration. The infection control surveillance lacked consistent identification of infections and proper documentation. The administrative nurse responsible for antibiotic tracking admitted that monthly tracking of antibiotic use had not been completed since May 2025, and review of physician-ordered antibiotics for appropriate criteria was only done for self-education, not as part of a systematic program. The facility's policy required education on proper antibiotic use and resistance, but there was no evidence this was being consistently implemented.
Lack of Qualified Infection Preventionist for Infection Control Program
Penalty
Summary
The facility failed to designate a staff member with the required qualifications and certification as the Infection Preventionist responsible for the Infection Prevention and Control Program. Although a corporate nurse was listed as the Infection Preventionist, this individual was not present at the facility and only provided advice as needed. The administrative nurse on site stated he was responsible for the program but had not completed specialized education related to infection prevention. Additionally, the facility was unable to provide a policy regarding the Infection Preventionist when requested by surveyors.
Failure to Secure Medication Carts and Protect PHI
Penalty
Summary
Surveyors observed that three out of six medication carts in the facility were left unlocked and unsupervised, contrary to facility policy and accepted professional standards. On one occasion, an unlocked medication cart and an unsecured treatment cart containing prescription medications, stock medications, insulin, and treatment supplies were found unattended in the Blue Hall. A Certified Medication Aide later secured the carts and confirmed that staff were expected to lock them when not directly supervising. In another instance, an unsecured treatment cart containing stock medications, treatment supplies, and insulin was found outside a resident's room in the Red Hall. The cart's laptop was open, displaying a resident's picture and protected health information in direct view. A Licensed Nurse present was unsure about the locking requirements for medication carts but acknowledged that PHI should not be left open on computers when not in use. The facility's policy, revised in January 2021, requires that all drugs and biological agents be stored in locked compartments or areas and that staff supervise medications and biologicals during administration or use. Administrative staff confirmed that staff receive annual training on medication storage and resident safety expectations. Despite these policies and training, the observed lapses in securing medication carts and protecting PHI led to the identified deficiency.
Failure to Document and Offer Pneumococcal Vaccinations per Policy
Penalty
Summary
The facility failed to offer or obtain informed declinations or physician-documented contraindications for the Pneumococcal Conjugate Vaccine (PCV20) and pneumococcal vaccination for three residents. Specifically, clinical records for these residents lacked documentation that PCV20 was offered, that an informed declination was obtained, or that a physician-documented contraindication was present prior to the survey. One resident's record indicated they were not eligible for PCV20, but there was no documentation of the vaccine being offered, a declination, or a contraindication. The facility's immunization report showed previous administration of other pneumococcal vaccines, but not PCV20. The administrative nurse responsible for immunization tracking stated that the facility had not offered PCV20 and would need to consult CDC guidelines regarding eligibility. The facility's policy required offering pneumococcal vaccinations to all residents per CDC guidelines.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
During meal service, two residents with indwelling urinary catheters were observed in the main dining room without privacy covers on their urinary collection bags. One resident, who was cognitively impaired and physically dependent on staff, was seated in a Broda chair with his catheter bag visible and one-third full of urine, lacking any privacy cover. Another resident, who was cognitively intact but also physically dependent, had her catheter bag attached to her wheelchair, half full of urine, and similarly without a privacy barrier. Both residents' catheter bags were clearly visible to others in the dining area. Interviews with staff confirmed that all wheelchairs were equipped with bags intended to conceal urinary collection bags, and that staff were expected to use these dignity bags when transferring residents. Facility policies required staff to maintain privacy barriers for urinary catheters and to treat all residents in a dignified manner. Despite these policies and staff expectations, the observed failure to use privacy covers during meal service resulted in a lack of dignity for the affected residents.
Unsecured Treatment Cart and Exposed PHI
Penalty
Summary
A deficiency occurred when a treatment cart containing stock medications, treatment supplies, and insulin was left unsecured and unsupervised outside a resident's room. The cart's laptop was open and displayed the resident's picture and protected health information (PHI) in direct view. A licensed nurse was observed exiting the resident's room and stated uncertainty about whether medication carts should be locked, but indicated she would lock them during the survey inspection. The nurse also acknowledged that PHI should not be left open on computers when unattended. The facility's policy requires staff to ensure computers are locked or placed in hidden mode when not in use to protect resident privacy.
Misappropriation of Resident Pain Medications Due to Medication Management Failures
Penalty
Summary
Multiple residents experienced misappropriation of their pain medications when errors were identified in the administration and documentation of narcotics. The discrepancies occurred during shifts when a specific licensed nurse had possession of the narcotic keys. The affected residents included individuals with varying levels of cognitive and physical impairment, such as those recovering from fractures, with a history of falls, or on hospice care. The errors were discovered when inconsistencies were found between the electronic medical record and the paper medication administration records, specifically regarding the logging and administration of oxycodone. Further investigation revealed that narcotics were not consistently removed from the medication cart immediately after being discontinued or when a resident left the facility, contrary to established procedures. The facility's policy required that discontinued narcotics be secured by the DON and destroyed with the pharmacist's consultation, but this process was not always followed. The breakdown in medication management led to the wrongful use of residents' medications, constituting misappropriation as defined by the facility's abuse, neglect, and exploitation policy.
Failure to Provide Written Transfer/Discharge and Bed Hold Notices
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge and did not issue a bed hold notice with the required information for a resident who was hospitalized. The resident had diagnoses of hypotension and Parkinson's disease, with a documented history of falls and moderately impaired cognition. The care plan indicated the resident planned to return home, and the resident was transferred to the hospital by ambulance after being found on the floor by her bed. Administrative staff confirmed that neither the resident nor her legal representative received written notification or bed hold information at the time of the facility-initiated transfer. The facility's policy required that bed hold information be provided at the time of transfer, with social services responsible for delivering the written notification and follow-up. The deficiency was identified through observation, record review, and staff interviews, which confirmed the lack of required documentation and notification.
Failure to Implement Comprehensive Care Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with multiple complex medical conditions, including Parkinson's disease, benign prostatic hyperplasia, dysphagia, and dementia with severe cognitive impairment. The resident required extensive assistance with activities of daily living (ADLs), including being dependent on staff for toileting, dressing, oral hygiene, bathing, bed mobility, and transfers, and was frequently incontinent of bladder and always incontinent of bowel. Despite these needs being documented in assessments and the Minimum Data Set (MDS), the resident's care plan did not address his incontinence needs, ADL preferences, required level of assistance, or the use of a Hoyer lift with two staff for transfers. Observations and interviews revealed ongoing issues with communication between management and direct care staff regarding the delivery of care, with the resident's representative reporting that care was not consistently provided as discussed in care plan meetings. Direct care staff relied primarily on report sheets rather than the care plans, and only nurses had access to the care plans, with CNAs receiving instructions verbally. The facility's policy required individualized interventions and regular updates to care plans, but the resident's care plan failed to reflect his current needs and required interventions, resulting in a deficiency.
Failure to Revise Care Plans After Changes in Resident Needs
Penalty
Summary
The facility failed to revise and update care plans for two residents following significant changes in their care needs. One resident, diagnosed with dementia, limited mobility, muscle weakness, and anxiety, was previously on hospice services and had a low air-loss mattress as part of her care plan. After being taken off hospice, her specialized mattress was removed and replaced with a standard pressure-reducing mattress. Despite this change, her care plan continued to reference the low air-loss mattress and did not reflect the updated intervention. Staff interviews confirmed that the care plan was not revised after the change in her bed and that care plans should be updated when resident needs change. Another resident, with diagnoses of dementia, anxiety, and depression, required staff assistance with mobility and had a physician's order for oxygen therapy as needed. However, the resident's care plan did not include any direction for nursing staff regarding oxygen therapy, despite the order being present in the medical record. Staff interviews revealed that direct care staff relied on report sheets and verbal instructions for oxygen administration, but acknowledged that such interventions should be included in the care plan for clarity and consistency. The facility's policy required that care plans be reviewed and updated to reflect changes in residents' goals and care needs. In both cases, the care plans were not revised in a timely manner to reflect significant changes in the residents' care, such as the discontinuation of hospice services and the initiation of oxygen therapy. This failure was confirmed through record review, staff interviews, and direct observation.
Failure to Follow Physician Order for Daily Weights in Resident with CHF
Penalty
Summary
The facility failed to follow a physician's order to obtain and document daily weights for a resident with diagnoses of congestive heart failure (CHF), hypotension, and atrial fibrillation. The resident was prescribed a diuretic (Lasix) to manage edema and required daily weights to monitor for signs of CHF, as ordered by the physician. Review of the resident's electronic medical record (EMR), including the Vitals tab, Medication Administration Record (MAR), Progress Notes, and Treatment Administration Record (TAR), revealed that staff did not measure or record the resident's weight on seven specific dates within a 27-day period. There was no documentation indicating that the resident refused to be weighed on those dates, nor was there evidence that the physician was notified about the missed weights. Interviews with nursing staff and administration confirmed that it was the nurse's responsibility to ensure daily weights were obtained and documented, and that refusals or issues should be reported to the physician and documented in the EMR. The facility's policy required physician orders to be followed as related to the care needs of individual residents. Despite these expectations and policies, the required daily weights were not consistently obtained or documented, and appropriate notifications were not made when weights were missed.
Failure to Ensure Proper Pressure Ulcer Prevention and Mattress Settings
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer prevention and care for a resident with significant risk factors and existing pressure injuries. The resident, who had diagnoses including diabetes mellitus, dementia, and was dependent on staff for bathing and toileting, was documented as having one Stage 3 and two unstageable pressure wounds. The care plan lacked specific interventions for pressure injuries on the heels and coccyx, and did not provide staff direction for monitoring the low air loss (LAL) mattress. Physician orders required heel protectors to be used every shift and specific wound care regimens, but these were not consistently implemented. Observations revealed that the resident did not have heel boots applied and her heels were not consistently offloaded, despite orders and care plan requirements. The LAL mattress was set at 180 pounds, which did not match the resident's documented weight of 121.2 pounds, and there was no documentation or direction for staff to monitor or adjust the mattress settings. Interviews with staff indicated confusion about responsibility for applying heel protectors and monitoring the LAL mattress, and delays in obtaining necessary equipment such as heel boots. The facility's policy required individualized care plans and collaboration among care team members, but these measures were not fully implemented for this resident.
Failure to Implement Fall Prevention Interventions as Directed by Care Plan
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plan for a resident with significant cognitive impairment and multiple risk factors for falls. The resident had diagnoses including diabetes mellitus, senile degeneration of the brain, and dementia, with a Brief Interview for Mental Status (BIMS) score of zero, indicating severely impaired cognition. The resident was dependent on staff for bathing and toileting and had a documented history of multiple falls with injury. The care plan included specific interventions such as placing nonskid strips in front of the recliner, ensuring the call light was within reach, placing a fall mat next to the bed, keeping the bed in the lowest position, checking the resident every two hours, and providing non-slip socks. Observations and staff interviews revealed that these interventions were not consistently implemented. A CNA reported not having access to the care plan and relied on daily reports to determine which residents required fall mats or low bed positions. A licensed nurse was unsure if all staff had access to the care plan and was unclear about the requirements for bed positioning. The administrative nurse confirmed that fall mats should be placed on the side of the bed, not underneath, and that the last staff member leaving the room should ensure interventions were in place. During the survey, the fall mat was found under the resident's bed and had to be repositioned by the administrative nurse. The facility's policy required individualized interventions based on assessment, but these were not consistently followed for the resident in question.
Failure to Ensure Physician Indication for Oxygen Administration
Penalty
Summary
The facility failed to ensure that a physician's indication for oxygen administration was present for a resident who was receiving respiratory care. The resident's electronic medical record documented diagnoses of dementia, anxiety, and depression, with a recent assessment indicating intact cognition. The care plan included interventions for assistance with repositioning and noted functional limitations, but did not provide direction for nursing staff regarding oxygen therapy. The physician's order for oxygen administration specified the use of oxygen per nasal cannula as needed and monitoring of oxygen saturation, but did not include a diagnosis or indication for the use of oxygen. During interviews, both a licensed nurse and an administrative nurse confirmed that oxygen, as a medication, requires a diagnosis for administration, and that the current order lacked this necessary information. Observations showed the resident present in common areas, but there was no documentation or care plan guidance related to the use of oxygen therapy. The facility's own policy required physician orders for oxygen to include the rate, route, mask, and frequency, but the order in question did not meet these requirements.
Failure to Provide Standards of Care for Dialysis Services
Penalty
Summary
The facility failed to provide appropriate standards of care for a resident with end-stage renal disease (ESRD) who required dialysis. The resident's electronic medical record (EMR) documented diagnoses of congestive heart failure and ESRD, with a care area assessment indicating the need for dialysis three times a week and additional assistance with activities of daily living. Despite these needs, the resident's care plan and EMR lacked specific directions for staff regarding dialysis care, including the absence of physician orders for dialysis, instructions for accessing the resident's dialysis shunt, and details about the dialysis location, transportation provider, and schedule. Interviews with facility staff revealed that nurses relied on the treatment administration record, nursing report, and care plan for dialysis orders, but these documents did not contain the necessary information. Staff also indicated that dialysis care was managed externally and that there was no clear process for nursing staff to monitor or manage the resident's dialysis needs within the facility. The facility's own dialysis policy required a physician's order and arrangements for dialysis services and transportation, but these were not documented in the resident's records.
Failure to Document and Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure proper collaboration and documentation between the nursing home and hospice services for two residents who were receiving hospice care. For one resident with diagnoses including heart failure, depression, overactive bladder, and morbid obesity, the care plan did not include any entries related to hospice services, despite the resident being admitted to hospice. The care plan only addressed activities of daily living and risk for skin breakdown, omitting identification of the hospice provider, services, supplies, medications, or equipment provided by hospice. Interviews with staff confirmed that this information should have been included in the care plan. For another resident with a history of hemiparesis, hemiplegia following a stroke, cerebral palsy, and dysphagia, the care plan also lacked any indication of hospice care or hospice provider services, even though the resident had been admitted to hospice. The hospice communication binder, which should have been available, was missing. Staff interviews revealed uncertainty about whether hospice information needed to be included in the care plan, and staff relied on nursing report sheets or direct communication to identify hospice status and services. The facility's own hospice policy required coordination and clear identification of responsibilities among the facility, resident, and hospice provider, as well as ongoing communication. However, the lack of documentation in the care plans and the absence of the hospice binder for one resident demonstrated a failure to follow this policy and ensure effective collaboration and communication regarding hospice services.
Failure to Post State Inspection Results for Resident Access
Penalty
Summary
The facility failed to make previous state inspection information, specifically the Statement of Deficiencies from a recent complaint survey, accessible to residents and visitors. During a review, it was observed that the state agency results book available in the lobby did not include the required documentation of citations from the complaint survey. Administrative staff confirmed that the survey binder intended for residents, families, and visitors did not contain the previous state inspection results. The facility's own Resident Rights policy states that residents have the right to self-determination.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Prevent Allergen Exposure Results in Anaphylaxis and Hospitalization
Penalty
Summary
A resident with a documented peanut allergy was admitted for therapy services following a right femur fracture. The resident's electronic medical record (EMR) and care plan clearly indicated a peanut allergy, and the facility's meal ticket system also identified this dietary restriction. Despite these documented precautions, the resident was served a peanut butter cookie with dinner. Dietary staff failed to verify the resident's allergy on the meal ticket before plating and delivering the meal. The resident consumed the peanut butter cookie and subsequently experienced an anaphylactic reaction, including facial swelling and vomiting. The staff was unable to provide epinephrine in the form of an injection pen, as only vials were available in the facility's emergency medication kit. Emergency medical services were called, and the resident was transported to an acute care facility, where epinephrine was administered and the resident was admitted for anaphylaxis. Interviews with dietary and nursing staff confirmed that the facility's policy required verification of meal tickets for allergies and dietary needs during meal preparation and delivery. However, staff involved in the incident did not follow this protocol, resulting in the resident receiving a meal containing peanuts. The facility's failure to adhere to established procedures for identifying and accommodating food allergies led to the resident's severe allergic reaction and hospitalization.
Removal Plan
- R1 was immediately assessed and provided emergency medical treatment.
- The facility identified all at-risk residents with potential food allergies.
- The facility provided in-service education for all staff related to reviewing meal cards, dietary requirements, and allergies.
- The facility provided one-to-one education for the Dietary Staff CC and DD.
- The facility completed interviews with three identified residents with potential food allergies.
- The facility will provide ongoing routine in-services related to food services to all staff.
Failure to Ensure Staff Competency in Emergency Allergy Response
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary skills and knowledge to identify and administer available epinephrine during a resident's anaphylactic episode. A resident with a history of peanut allergy, Parkinson's Disease, vision and hearing impairments, and a recent femur fracture was served a peanut butter cookie, resulting in facial swelling and vomiting. The resident's care plan documented the peanut allergy, but when the allergic reaction occurred, the nurse on duty was unable to locate an epinephrine auto-injector (Epi-pen) in the emergency medication kit and did not recognize that epinephrine was available in vial form within the kit. As a result, emergency medical services were called, and the resident was transported to an acute care facility where epinephrine was administered. Record review and staff interviews confirmed that the emergency medication kits contained epinephrine vials, and each kit included a list of medications. However, the nurse did not consult the list during the emergency and was unaware of the presence of epinephrine in vial form. The facility was unable to provide a policy related to staff competencies when requested. This lack of staff competency in identifying and administering emergency medication during an anaphylactic event constituted a deficiency in care for the resident and potentially for all residents with allergies.
Failure to Secure Hazardous Chemicals and Implement Fall Interventions
Penalty
Summary
The facility failed to secure potentially hazardous cleaning chemicals in a safe, locked area, which were accessible to seven cognitively impaired independently mobile residents. During an inspection, it was observed that a shower room door was propped open, and an unlocked closet contained a spray bottle of multi-purpose cleaner and a bottle of isopropyl alcohol, both labeled as hazardous. Staff interviews confirmed that these items should have been secured, and the facility's policy required hazardous materials to be stored in a locked area. This oversight placed the residents at risk for preventable accidents and injuries. The facility also failed to implement fall interventions as per the care plans for two residents, R29 and R34. R29, who had a history of falls and was at risk due to conditions such as hemiparesis and hemiplegia, was found on multiple occasions without necessary fall prevention measures in place. His call light was out of reach, and his recliner lacked the Dycem material specified in his care plan. Despite being identified as a fall risk, these interventions were not consistently applied, increasing his risk of injury from falls. Similarly, R34, who had severe cognitive impairment and was at risk for falls, did not have her fall mat in place next to her bed, and her call light was also out of reach. Observations showed that the fall mat was improperly placed on an empty bed, contrary to her care plan. Staff interviews confirmed that these interventions should have been in place to prevent falls. The facility's failure to adhere to its own policies and care plans for these residents placed them at risk for falls and related injuries.
Failure to Document Pneumococcal Vaccination Consents
Penalty
Summary
The facility failed to obtain consent or declinations for the Pneumococcal Conjugate Vaccine (PCV20) for several residents, specifically R32, R10, R46, and R34. This oversight was identified through record reviews and interviews, revealing that the facility did not document whether these residents were offered or declined the PCV20 vaccination. For instance, R32's clinical record showed that the PCV13 was administered, but there was no documentation regarding the PCV20. Similarly, R10's record indicated a previous PCV13 administration, but lacked any documentation for the PCV20. R46's record was missing any documentation of PCV20 being offered or declined, and R34's record, despite showing previous vaccinations with PCV13 and PPSV23, also lacked documentation for PCV20 or any physician-documented contraindication. The facility's Infection Preventionist, Administrative Nurse D, acknowledged that she had not started offering or obtaining consent for the PCV20, as she was still in discussions with the physician about which residents should receive it. The facility's policy stated that at the time of admission, a history of previous pneumococcal vaccinations should be obtained, and residents should be provided with the CDC vaccination information summary. However, the facility did not adhere to this policy, as evidenced by the lack of documentation for the PCV20 vaccine, placing the residents at increased risk for complications related to pneumonia.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R45, had a call light within her reach, which is a necessary accommodation for her care needs. R45 has a medical history that includes aphasia, hemiparesis affecting her left side, dysphagia, diabetes mellitus, major depressive disorder, anemia, hypertension, and anxiety. Her cognitive function is moderately impaired, and she is dependent on staff for most activities of daily living, except for eating. Observations on multiple occasions revealed that R45's call light was not within her reach, leaving her unable to call for assistance when needed. The facility's policy requires that the environment and staff behaviors support the resident's safe and independent functioning, including the placement of call lights within reach. Despite this policy, staff interviews confirmed that the call light was not consistently placed within R45's reach, as it was either clipped to a blanket out of reach or left on the bed. This oversight in accommodating R45's needs was not addressed in her care plan, contributing to the deficiency identified by the surveyors.
Failure to Provide Written Notice for Resident Transfer
Penalty
Summary
The facility failed to provide timely written notice for a facility-initiated transfer of a resident, identified as R31, to the hospital. R31's electronic medical record documented several diagnoses, including hypertension, diabetes mellitus, urinary incontinence, overweight, neoplasm of the right breast, and back pain. The resident had a Brief Interview of Mental Status score indicating moderately impaired cognition and required substantial to maximum assistance with transfers. A recent fall resulted in a laceration requiring sutures, and the care plan included reminders for the resident to use the call light for assistance. Despite these documented needs, the facility did not provide written notice of the transfer to the resident or their legal representative. The deficiency was identified through a review of R31's electronic medical record and interviews with facility staff. A social services note documented the resident's transfer to the hospital, but there was no evidence of a written notice being provided. Administrative staff confirmed the absence of such documentation. The facility's discharge criteria policy requires written notice of transfer or discharge, but this was not adhered to in R31's case, placing the resident at risk of uninformed choices and miscommunication regarding care needs.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a bed hold notice to Resident 31 or their legal representative when the resident was transferred to the hospital. The resident's electronic medical record (EMR) documented several diagnoses, including hypertension, diabetes mellitus, urinary incontinence, overweight, neoplasm of the right breast, and back pain. The resident had a Brief Interview of Mental Status (BIMS) score indicating moderately impaired cognition and required substantial to maximum assistance with transfers. A recent fall had resulted in a laceration requiring sutures. Despite these documented needs, the facility did not provide the required bed hold notice upon the resident's transfer to the hospital. The facility's bed-hold policy, dated November 28, 2017, mandates that a written notice specifying the duration of the bed-hold policy be provided at the time of a resident's transfer for hospitalization or therapeutic leave. However, the facility was unable to provide evidence that such a notice was given to Resident 31 or their representative. This oversight was confirmed by administrative staff, who verified the absence of documentation regarding the bed-hold notification. The lack of a bed hold notice placed the resident at risk for impaired ability to return to the facility or their same room.
Failure to Apply Pressure-Relieving Devices
Penalty
Summary
The facility failed to ensure proper application of offloading boots for a resident, identified as R45, who was at high risk for pressure ulcers. R45's medical history included conditions such as aphasia, hemiparesis, dysphagia, diabetes mellitus, major depressive disorder, anemia, hypertension, and anxiety. The resident was dependent on staff for most activities of daily living and required a mechanical lift and a Broda chair. Despite physician orders for offloading boots to be worn at all times, observations revealed that R45 only had one boot on her right heel, and the other boot was missing. Interviews with staff indicated a lack of awareness and responsibility for ensuring both boots were applied, with suggestions that the missing boot might have been sent to the laundry. Another resident, R29, was also at risk for pressure-related injuries due to conditions such as hemiparesis and hemiplegia following a cerebrovascular accident. R29's care plan included the use of a pressure-reducing cushion in his wheelchair to prevent skin breakdown. However, observations showed that R29's wheelchair lacked the necessary pressure-reducing cushion. Interviews with nursing staff revealed a lack of clarity and monitoring regarding the presence of pressure-relieving devices for residents at risk of pressure-related injuries. The facility's Wound Assessment, Prevention, and Treatment policy emphasized the prevention of pressure ulcers and the development of comprehensive, individualized care plans. Despite this policy, the facility did not ensure the availability and application of pressure-relieving devices for residents R45 and R29, placing them at increased risk for pressure ulcers. The failure to adhere to the care plans and physician orders for these residents highlighted deficiencies in the facility's implementation of pressure ulcer prevention strategies.
Failure to Apply Palm Splint for Resident
Penalty
Summary
The facility failed to ensure that a palm splint was applied to Resident 45's left hand, as documented in her care plan. Resident 45, who has a history of aphasia, hemiparesis affecting the left side, and other medical conditions, was observed on multiple occasions without the palm splint, which was intended to prevent contractures and maintain range of motion. The care plan specified that the splint should be removed twice daily for gentle range of motion exercises and hand hygiene, but there was no documentation of the splint being applied or any refusals by the resident to wear it. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's need for the palm splint. A licensed nurse and a certified nurse's aide both indicated that the resident's care plan should have informed them of the requirement for the splint, but it was not reflected in the Treatment Administration Record. The administrative nurse confirmed that the nursing staff was responsible for ensuring the application of special devices like splints, as outlined in the resident's care plan. The facility's restorative policy emphasized the importance of providing restorative nursing services to promote independence and safety, which was not adhered to in this case.
Failure to Address Incontinence and Implement Toileting Program
Penalty
Summary
The facility failed to assess, identify, and implement interventions for a resident's incontinence, which placed the resident at risk of impaired dignity and increased risk for urinary tract infections (UTIs). The resident's electronic medical record documented diagnoses including hypertension, diabetes mellitus, urinary incontinence, and other conditions. The resident's Minimum Data Set (MDS) indicated moderately impaired cognition and a need for substantial to maximum assistance with toileting hygiene. However, the MDS also noted that the resident did not have a trial of a toileting program, and the care plan lacked direction regarding toileting and incontinence care. Observations and interviews revealed that the nursing staff did not have a clear plan of care addressing the resident's toileting needs. The resident's clinical record lacked evidence of an assessment of bladder incontinence to evaluate causative factors and voiding patterns. Despite multiple physician orders for antibiotics related to UTIs, the facility did not provide a urinary incontinence policy. Interviews with staff indicated that toileting schedules should be in place, but there was no documentation or clear guidance in the resident's care plan. This deficiency in care planning and implementation placed the resident at risk of further complications and UTIs.
Improper Storage of CPAP Mask
Penalty
Summary
The facility failed to ensure the sanitary storage of a CPAP mask for a resident, identified as R21, who was at increased risk for respiratory infection and complications. R21's medical history included sleep apnea, diabetes mellitus, congestive heart failure, thrombocytopenia, and major depressive disorder. The resident's care plan lacked specific interventions or directions related to the use and storage of the CPAP equipment. Observations on two separate occasions revealed that R21's CPAP mask was left unsanitarily on the bed, once covered with a blanket, without being stored in a sanitary container. Interviews with facility staff, including a Licensed Nurse, a Certified Nurse's Aide, and an Administrative Nurse, revealed inconsistencies in the understanding and implementation of proper storage procedures for respiratory equipment. The facility did not provide a policy for the sanitary storage of such equipment, contributing to the deficiency. The lack of a clear protocol and staff awareness regarding the sanitary storage of CPAP masks led to the increased risk of respiratory infection for R21.
Failure to Document Safety Assessments for Bed Rails
Penalty
Summary
The facility failed to ensure that two residents, R12 and R46, had documented safety assessments for the use of side rails, which addressed the risk of entrapment, consent for the use, and documentation that the residents and/or their responsible parties were advised of the risks and/or benefits of the use of the side rails. This deficiency was identified through observations, record reviews, and interviews conducted by surveyors. The absence of these assessments placed the residents at risk for uninformed decisions and impaired safety related to the risks associated with the use of side rails. Resident R12 had a medical history that included hemiparesis/hemiplegia, aphasia, dysphagia, and dementia, with a BIMS score indicating severe cognitive impairment. Despite being dependent on staff for all activities of daily living and using a low air-loss mattress, R12's electronic medical records lacked evidence of a safety assessment for the use of side rails. The facility was unable to provide documentation of consent or advisement of risks and benefits, even though R12's bed had bilateral side rails in the up position during an observation. Similarly, Resident R46, who had severe cognitive impairment and required supervision or touch assistance for daily activities, also lacked a documented safety assessment for the use of side rails. Her care plan did not acknowledge the use of bilateral side rails, and her records did not include consent or advisement of risks and benefits. Observations confirmed the presence of side rails on her bed, which also had a low air-loss mattress. The facility's failure to document these assessments and consents was confirmed through staff interviews and a review of the facility's policies.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify a resident's physician according to the physician-ordered parameters for blood glucose monitoring, which is a deficiency in the care provided. The resident, identified as R21, had multiple medical conditions including diabetes mellitus, sleep apnea, congestive heart failure, thrombocytopenia, and major depressive disorder. The resident's care plan required that the physician be notified if blood glucose levels exceeded 300 ml/dl or fell below 70 ml/dl. However, the facility's records showed multiple instances where the resident's blood glucose levels were above 400 ml/dl, and there was no evidence that the physician was notified as required. The resident's electronic medical record documented several instances of elevated blood glucose levels, specifically on dates such as 09/09/24, 09/12/24, 09/13/24, and 09/22/24, without any indication of physician notification. Interviews with facility staff confirmed that it was the nurse's responsibility to notify the physician of any blood glucose readings outside the specified parameters. Despite this, the facility did not provide a policy for blood glucose monitoring, and the failure to notify the physician placed the resident at risk for complications related to hyperglycemia and unnecessary medication use.
Failure to Implement Stop Dates for PRN Lorazepam Orders
Penalty
Summary
The facility failed to ensure that two residents, R34 and R32, had a stop date for their as-needed (PRN) lorazepam orders, which is an anti-anxiety medication. This oversight was identified during a survey that included a review of unnecessary medications for six residents. The absence of a stop date for PRN lorazepam placed these residents at risk for adverse effects from psychotropic medications. Resident R34 had a history of multiple medical conditions, including hemiparesis following a stroke, anxiety, major depressive disorder, and epilepsy. The resident's care plan indicated a need for monitoring adverse effects from psychotropic medications. However, the electronic medical record (EMR) showed an order for lorazepam without a specified stop date, contrary to the facility's policy requiring a 14-day limit unless extended by a physician with documented rationale. Similarly, Resident R32, who had diagnoses of ALS, depressive disorder, and anxiety, also had an order for PRN lorazepam without a stop date or specified duration. The facility's policy mandates a 14-day limit for such medications unless a physician provides a documented reason for extension. Interviews with nursing staff confirmed the expectation for a 14-day stop date, highlighting a lapse in adherence to the facility's psychoactive medication policy.
Failure to Document Lab Results in Resident's Record
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory test results for a resident, identified as R31, were included in the resident's clinical record. This oversight was discovered during a review of R31's Electronic Medical Record (EMR), which documented several diagnoses including hypertension, diabetes mellitus, urinary incontinence, and a neoplasm of the right breast. The resident's Annual Minimum Data Set (MDS) indicated moderately impaired cognition and a need for substantial assistance with toileting hygiene. Despite urine analyses being ordered on multiple occasions for possible urinary tract infections, the clinical record lacked evidence of the culture and sensitivity results for these tests. Upon investigation, it was found that the culture results were sent to the physician for review but were not scanned into the resident's medical record as required. An administrative nurse confirmed that the results had not been properly documented in the EMR. Additionally, the facility did not provide a policy related to laboratory tests, which contributed to the deficiency. This failure to include critical laboratory test results in the resident's clinical record could lead to unnecessary tests and delayed treatment.
Lack of Coordinated Hospice Care Plan 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 multiple diagnoses including aphasia, hemiparesis, dysphagia, diabetes mellitus, major depressive disorder, anemia, hypertension, and anxiety, was documented as receiving hospice care. However, the care plan did not include specific details about the services hospice would provide, such as medication, supplies, or the frequency and availability of hospice worker visits. This lack of coordination was evident in the absence of listed medications in the hospice plan of care and the lack of clarity among staff about the hospice services provided. Interviews with facility staff revealed a lack of awareness and understanding of the hospice services being provided to the resident. A licensed nurse and a certified nursing aide both expressed uncertainty about what hospice provided for the resident, and the administrator nurse acknowledged that hospice providers developed detailed care plans but believed that all hospice services should be included in the facility's care plan. The facility's policy required that the plan of care be updated to reflect coordination with hospice services, but this was not done, leading to the deficiency.
Inadequate Implementation of Infection Control Measures
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for residents on Enhanced Barrier Precautions (EBP). During a walkthrough, it was observed that there was no EBP indicator signage or personal protective equipment (PPE) available in or around the rooms of two residents, one with wounds and another with a Foley catheter. This lack of signage and PPE availability was contrary to the facility's policy, which required such measures to alert staff and visitors of the necessary precautions to prevent the transmission of resistant organisms. Additionally, the facility did not store respiratory equipment in a sanitary manner, as evidenced by the observation of a resident's oxygen tank tubing and nasal cannula resting on the seat of her wheelchair without a sanitary storage bag. Interviews with staff revealed a lack of understanding and implementation of EBP protocols, with one CNA unsure of the precautions and a Licensed Nurse acknowledging the need for signage and PPE for residents with open wounds or catheters. The facility's failure to adhere to its own policies placed residents at risk for infectious diseases.
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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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