Pittsburg Care And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburg, Kansas.
- Location
- 1005 E Centennial Drive, Pittsburg, Kansas 66762
- CMS Provider Number
- 175208
- Inspections on file
- 20
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Pittsburg Care And Rehab during CMS and state inspections, most recent first.
The facility failed to fully implement its Legionella water management program as required by its infection prevention and control policy. Maintenance staff reported that only a single Legionella test of kitchen water had been conducted, which was negative, but there was no documentation of a facility water system map, no flow diagram of water distribution, and no identification of dead-end water areas where water could stagnate. This was inconsistent with the facility’s written policy that required waterborne microorganism control measures to follow CDC, HICPAC, FDA, and state and local health department recommendations.
A resident with dementia, severe cognitive impairment, and multiple psychiatric diagnoses had care-plan and physician orders requiring that staff sit and assist with every meal and snack due to weight loss. During observation, a CNA stood beside the resident’s Broda chair while attempting to assist with breakfast instead of sitting at eye level as specified. Staff interviews with a CMA and an LN confirmed that staff are expected to sit next to residents and engage them during meals, showing that the resident was not provided mealtime assistance in a manner consistent with her care plan or with dignified care practices.
Surveyors found that the facility did not include the required estimated daily rate for continued services on CMS-10055 SNF Advance Beneficiary Notices of Non-coverage for two residents whose Medicare Part A skilled stays ended and who remained for custodial care. The nurse responsible for issuing ABNs and administrative staff reported they had been instructed not to list the daily rate due to fluctuating prices, resulting in ABNs that lacked cost information despite facility policy outlining the need to inform Medicare beneficiaries about potential non-coverage and associated financial liability.
Surveyors found that PHI was not kept confidential when two unattended medication carts in separate hallways were left with unlocked laptop screens displaying a resident’s medications, DOB, allergy information, and code status, visible to anyone passing by and without nursing staff in view. Nursing staff and an administrative nurse acknowledged that carts should be locked and laptop screens closed or cleared when unattended, and facility policy required safeguarding all resident records to protect confidentiality.
Surveyors identified that two residents with dementia, depression, and anxiety were receiving daily antipsychotic medications without documented physician rationale or risk–benefit analysis for their continued use with non-approved indications. Each resident’s MDS showed severely impaired cognition and ongoing psychotropic use, while their care plans only directed staff to administer medications as ordered. Physician orders specified olanzapine for behaviors or a psychotic disorder, but the EMRs lacked documentation of multiple unsuccessful nonpharmacological interventions and risk–benefit considerations, and the available psychoactive medication consent forms did not contain the required physician justification, contrary to facility policy on psychotropic drug use.
A resident with dementia, major depressive disorder, anxiety, and bipolar disorder was admitted to hospice, but the facility failed to complete a required Significant Change MDS at the time of hospice admission. The resident had severely impaired cognition per prior MDS and CAA documentation and was receiving daily antipsychotic medication. The care plan only reflected hospice-provided extra bathing and did not include other hospice services, despite physician orders for hospice to evaluate and treat. Administrative nurses acknowledged that while a significant change MDS had been completed earlier for a different health status change, no new significant change MDS was done when hospice services began, contrary to the facility’s MDS transmission policy.
A resident with cardiomyopathy, COPD, depressive disorder, muscle weakness, and chronic joint and low back pain experienced frequent severe pain rated at 10/10 despite being on scheduled hydrocodone and topical diclofenac. The MDS and pain assessment documented frequent severe pain and scheduled opioid use, but there was no active PRN order for breakthrough pain, and the care plan lacked specific nonpharmacological pain interventions or an assessment of the resident’s acceptable pain level. Staff reported the resident continued to have significant pain in multiple joints, sometimes nonverbal but evident through facial expressions and decreased appetite, and an RN confirmed that orders and the care plan did not include PRN pain medication or nonpharmacological strategies, despite ongoing reports of severe pain.
Surveyors found that the facility did not fully integrate hospice services into the care plans for two residents receiving hospice care. Both residents had severe cognitive impairment and multiple psychiatric diagnoses, with documentation confirming hospice admission and physician orders for hospice evaluation and treatment. One resident’s care plan referenced hospice involvement and comfort measures but did not specify hospice services, while the other resident’s care plan only noted extra bathing by hospice. Staff reported that details of hospice services were kept in a separate hospice book and acknowledged that not all hospice services were reflected in the care plans, despite facility policy addressing hospice service provision and coordination.
The facility failed to maintain sanitary conditions in the therapy room, with unlabeled and expired food items found in the refrigerator and freezer, and a rusted, dirty microwave. Interviews confirmed the use of kitchen equipment for resident rehabilitation, but policies for food storage and equipment cleaning were not followed, risking foodborne illness.
A resident with chronic back pain and osteoarthritis requested positioning rails to aid in movement and alleviate pain. Despite communicating this need to multiple staff members, the request was not addressed promptly. The facility's policy required an assessment for such devices, which was delayed, impacting the resident's pain management and independence.
A facility failed to accurately document the administration of opioid medication for a resident with chronic pain in their MDS assessments. Despite receiving Fentanyl every 72 hours as per physician's orders, the MDS inaccurately indicated no opioid use. This discrepancy was confirmed by an administrative nurse, highlighting a failure in accurate assessment and documentation.
A resident with Huntington's disease and severe cognitive impairment experienced multiple falls due to the facility's failure to maintain nonskid strips in the bathroom. Observations showed worn and non-adhered strips, and staff interviews revealed frequent ambulation without assistance. The facility lacked a policy for inspecting nonskid strips, contributing to the deficiency.
A resident with a diagnosis of constipation did not receive necessary PRN medications for constipation over several periods, despite having physician's orders and a facility protocol in place. The staff failed to administer the medications or document any refusal by the resident, leading to the resident going without a bowel movement for several days on multiple occasions.
Failure to Implement Comprehensive Legionella Water Management Program
Penalty
Summary
The facility failed to implement a comprehensive water management program for Legionella disease as part of its infection prevention and control program for a census of 60 residents. During an observation and interview, the maintenance staff reported that the facility relied on a single Legionella testing kit performed on kitchen water in late December, which showed no Legionella detected. However, the maintenance staff verified there was no documentation of a map showing the facility’s incoming water source, no flow diagram of the facility’s water distribution system, and no identification of dead-end water areas where water could stagnate. The facility’s written Water Management, Legionella Testing policy, dated October 2022, stated that approaches to controlling waterborne microorganisms, including water systems decontamination, would be consistent with CDC, HICPAC, FDA, and state and local health department requirements, but the lack of these key documents demonstrated the policy was not fully implemented. No specific residents, their medical histories, or clinical conditions at the time of the deficiency were described in the report.
Failure to Provide Dignified, Care-Plan-Compliant Mealtime Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect, dignity, and appropriate care during mealtimes. The resident had diagnoses including dementia, major depressive disorder, anxiety, and bipolar disorder, with documentation of severely impaired cognition on the MDS and CAA, and daily antipsychotic use. The resident’s care plan and physician orders specified that staff were to provide set-up assistance to supervision with one staff, that someone must sit and assist her with every meal and snacks three times a day due to weight loss, and that she was to be assisted with meal intake at every meal. Despite these documented needs and interventions, observation showed that during breakfast the resident was seated in a Broda chair at the dining room table while a CNA stood next to her attempting to assist with the meal, rather than sitting next to her as required. Subsequent interviews with a CMA and a licensed nurse confirmed that nursing staff should be seated next to residents when assisting with meals, at eye level, and engaging them in conversation. These observations and staff statements demonstrate that the resident was not assisted in the manner specified in her care plan and orders, and that staff did not follow the expected practice for dignified, respectful mealtime assistance.
Failure to Include Estimated Daily Rate on SNF ABN Notices
Penalty
Summary
The facility failed to properly complete CMS-10055 Skilled Nursing Facility (SNF) Advance Beneficiary Notices of Non-coverage (ABNs) by omitting the estimated daily rate for continued services when Medicare Part A coverage ended. Record review showed that one resident’s Medicare Part A episode ran from 01/08/26 to 02/09/26, after which the resident remained in the facility for custodial care. The ABN issued on 02/09/26 did not include a daily rate for services. Another resident’s Medicare Part A episode ran from 08/25/25 to 11/07/25, and this resident also remained in the facility for custodial care. The ABN issued on 11/05/25 likewise lacked a daily rate for services. During interviews, the administrative nurse responsible for issuing ABNs at the time of discharge from skilled therapy stated that she had been instructed by the regional manager not to include the daily rate for services on the ABN due to fluctuations in the rate. Administrative staff also confirmed that the facility did not include the rate for services on ABN notices because the rate changed. The facility’s Beneficiary Notices policy, last approved in 07/2025, documented that Medicare beneficiaries have the right to have Medicare determine coverage for skilled services and described both expedited and standard appeals processes, including the need to inform beneficiaries of possible non-coverage and potential cost shifting from the SNF to the beneficiary, but the ABNs reviewed did not contain the required cost information.
Failure to Protect PHI on Unattended Medication Carts
Penalty
Summary
Surveyors identified a failure to maintain confidentiality of residents' protected health information (PHI) related to unsecured medication carts with visible electronic records. With a facility census of 60 residents and a sample of 15, observations showed a medication cart parked in the east hallway with a laptop on top, the screen unlocked and displaying a resident’s PHI, including medications, date of birth, allergy information, and code status. This screen was visible to anyone passing by, and no nursing staff were in view of the cart at the time of the observation. A similar observation was made in the west hallway, where another medication cart was parked with an unlocked laptop displaying a resident’s medications, date of birth, allergy information, and code status, again with no nursing staff present. Licensed nurses interviewed stated that the medication cart should be locked and the laptop screen cleared or closed when staff walk away, and an administrative nurse confirmed the expectation that laptop screens be closed or resident information cleared when staff are not working at the cart. The facility’s Confidentiality and Privacy of Information policy, last approved in 10/2025, documented that all resident information would be treated confidentially and that resident records of all types would be safeguarded to protect confidentiality.
Lack of Physician Rationale for Antipsychotic Use in Residents With Dementia
Penalty
Summary
Surveyors found that the facility failed to ensure appropriate indications and physician documentation for the continued use of antipsychotic medications in two residents with dementia. One resident had diagnoses of dementia, depression, and anxiety, with a Quarterly MDS showing severely impaired cognition and documentation of daily antipsychotic, antidepressant, anticonvulsant, and opioid use. The resident’s CAA noted daily antipsychotic use for dementia, and the care plan intervention was limited to administering medications as ordered. A physician order directed Zyprexa 5 mg twice daily via PEG tube or by mouth for combative behavior, hitting, and scratching. However, the clinical record lacked physician documentation of the risk versus benefit for this antipsychotic use with a non-approved indication in a resident with dementia, and the facility could not provide such documentation upon request. The only available consent form for psychoactive medication therapy did not include the required physician rationale or documentation of multiple unsuccessful nonpharmacological interventions. A second resident, also with diagnoses of dementia, depression, and anxiety and severely impaired cognition on the Quarterly MDS, was receiving hospice services and had received antipsychotic, antidepressant, antianxiety, and opioid medications. The CAA documented daily antipsychotic use for dementia, and the care plan intervention again only directed staff to administer medications as ordered. A physician order prescribed olanzapine 5 mg by mouth at bedtime for a psychotic disorder. Similar to the first resident, the clinical record for this resident lacked physician documentation of risk versus benefit for antipsychotic use with a non-approved indication in a resident with dementia, and the facility was unable to provide this documentation when requested. The consent form for psychoactive medication therapy for this resident also lacked the physician documentation supporting continued use with a non-approved indication, despite the facility’s policy stating that psychotropic drugs would only be used when necessary to treat specific indicated and effective conditions and not for staff discipline or convenience.
Failure to Complete Significant Change MDS Upon Hospice Admission
Penalty
Summary
The facility failed to identify a significant change in condition and complete a comprehensive Significant Change MDS when a resident was admitted to hospice services. The resident had documented diagnoses of dementia, major depressive disorder, anxiety, and bipolar disorder. A Significant MDS dated 12/28/25 showed a BIMS score of 99 with a staff interview indicating severely impaired cognition, and a Cognitive Loss/Dementia CAA dated 01/02/26 documented dementia and daily antipsychotic use. The care plan included an intervention for hospice to provide extra bathing on Mondays and Thursdays but lacked documentation of other hospice services. Physician orders dated 01/21/26 directed hospice of the family's choice to evaluate and treat, and the resident was observed seated in a Broda chair at the dining room table while a CNA attempted to assist with breakfast. Administrative staff interviews revealed that the required Significant Change MDS was not completed at the time of the resident's admission to hospice. One administrative nurse stated she had completed a significant change MDS prior to the resident's hospice admission and acknowledged she should have completed another significant MDS after hospice admission. Another administrative nurse confirmed that the significant change MDS was not completed when the resident was admitted to hospice, clarifying that the earlier significant change MDS had been done for a prior significant change in health status. The facility's policy on Electronic Transmission of the MDS, effective 10/2025, stated that MDS assessments, including significant change assessments, would be transmitted per state and federal guidelines, but this was not followed for the hospice admission event.
Inadequate Pain Management and Care Planning for Resident With Chronic Severe Pain
Penalty
Summary
The facility failed to provide adequate pain management for a resident with chronic pain in the knees, lower back, and shoulders. The resident had diagnoses including cardiomyopathy, COPD, depressive disorder, need for assistance with personal care, and muscle weakness, and had intact cognition per a recent MDS. The MDS documented that the resident frequently experienced pain at a level of 10 on a 0–10 scale, which occasionally affected sleep, and that the resident was on a scheduled pain medication regimen and received nonpharmacological interventions, with no PRN pain medications. The Pain CAA indicated the resident took an opioid every six hours for low back pain and was to be monitored every shift and as needed for any pain. The care plan documented use of an opioid for chronic joint and lower back pain and directed staff to assess pain type, location, and characteristics before and after administration of PRN medication, and stated that long-acting opioid use was appropriate based on the resident’s history, but it lacked specific directions for nonpharmacological pain interventions. Physician orders included hydrocodone-acetaminophen 10-325 mg every six hours for low back pain, diclofenac gel to the right knee three times daily, and an order to monitor pain every shift related to PRN hydrocodone use, but there was no active PRN order for breakthrough pain. A physician progress note documented the resident reporting pain at level 10 in the right leg and knee, described as achy with pins and needles and worsened by movement, while taking hydrocodone 10 mg every six hours. During surveyor observation, the resident reported significant ongoing pain in joints, knees, shoulders, and lower back despite routine pain medication. A CNA reported the resident did not always verbalize pain but showed signs such as facial expressions and decreased appetite, which she reported to the nurse. A licensed nurse confirmed that physician orders lacked PRN pain medication despite reports of pain at level 10 and that the care plan and orders lacked direction for nonpharmacological pain interventions. An administrative nurse acknowledged the resident was on routine hydrocodone without breakthrough pain medication, had no nonpharmacological interventions in the care plan, and that there had been no assessment of the resident’s acceptable pain level or consultation for ongoing pain, in the context of a facility policy addressing unnecessary medications and appropriate duration based on assessment and therapeutic goals.
Failure to Integrate Hospice Services Into Resident Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate collaboration with hospice providers and to incorporate hospice services into the residents’ care plans. One resident with dementia, depression, anxiety, and severely impaired cognition had documentation in the EMR and MDS indicating she was receiving hospice services, with a nursing note confirming hospice admission. Her care plan referenced consulting with the physician and social services to have hospice care in the facility and included comfort-focused interventions such as oxygen for comfort and pain management. However, the care plan did not clearly outline the specific hospice services being provided, despite her documented hospice status. Another resident with dementia, major depressive disorder, anxiety, bipolar disorder, and severely impaired cognition had an order for hospice of the family’s choice to evaluate and treat and was confirmed by nursing staff to have been admitted to hospice. The care plan for this resident only documented that hospice would provide extra bathing on two specified days and lacked other hospice services. Staff interviews revealed that information about hospice services was kept in a separate hospice-provided book and that not all hospice services were included in residents’ care plans. An administrative nurse acknowledged that the facility only included some, but not all, hospice services on the care plans, contrary to the facility’s hospice program policy that addressed services to be provided and coordination of care.
Unsanitary Food Storage and Equipment Maintenance in Therapy Room
Penalty
Summary
The facility failed to ensure sanitary food storage and maintenance of kitchen equipment in the therapy room, as observed during a survey. Unlabeled and undated hamburger patties were found in the therapy room refrigerator freezer, along with medical devices and cold packs. The refrigerator contained expired almond milk and yogurt, as well as a sack with various foods in undated, unmarked Styrofoam containers. Additionally, an opened container of chicken broth was found without an open date. The microwave in the therapy room was observed to have rusted surfaces and splatters of unidentified substances. Interviews with Maintenance Staff U and Therapy Consultant GG confirmed the unsanitary conditions and the use of kitchen equipment for resident rehabilitation purposes. The facility's policy on foods brought in by family or visitors required perishable foods to be stored in resealable containers with labels, but this was not adhered to. Furthermore, there was no policy for cleaning the microwave, contributing to the unsanitary conditions. The facility's failure to maintain the therapy room refrigerator, freezer, and microwave in a sanitary manner and to ensure food items did not exceed their use-by date posed a risk of foodborne illness among residents.
Failure to Timely Provide Positioning Devices for Resident
Penalty
Summary
The facility failed to timely assess and accommodate a resident's request for positioning devices to aid in movement and alleviate back pain. The resident, who had diagnoses including chronic back pain and osteoarthritis, was assessed with normal cognitive function and required supervision with activities of daily living. Despite the resident's ability to communicate his needs, he reported requesting positioning rails multiple times without them being provided. Observations and interviews revealed that the resident expressed his preference for positioning rails to several staff members, but the request was not acted upon until much later. A licensed nurse was unaware of the request until an interview, after which a work order was placed. The facility's policy required staff to assess the appropriateness of such devices, but this was not done in a timely manner, resulting in a delay in addressing the resident's needs for pain management and independence in bed mobility.
Inaccurate MDS Documentation for Opioid Medication
Penalty
Summary
The facility failed to complete accurate Minimum Data Sets (MDS) for a resident, identified as Resident 25, regarding the administration of opioid medications. The resident, who had a diagnosis of chronic pain, was documented in the Annual MDS and Quarterly MDS as not receiving opioid medication, despite evidence to the contrary. The resident's Electronic Medical Record (EMR) and Medication Administration Record (MAR) indicated that she was receiving Fentanyl, an opioid medication, every 72 hours as per physician's orders. This discrepancy was confirmed by Administrative Nurse D, who acknowledged that the MDSs were inaccurately coded during the lookback period of the assessments. The resident's care plan for pain management, revised in April 2024, instructed staff to administer a Fentanyl pain patch for chronic pain, which was consistent with the physician's orders documented in the EMR. However, the MDS assessments failed to reflect the administration of this opioid medication, leading to inaccurate documentation. The facility utilized the Resident Assessment Instrument (RAI) for the completion of MDSs, yet the oversight in coding resulted in the failure to accurately assess the resident's medication regimen.
Failure to Maintain Fall Interventions for Resident with Huntington's Disease
Penalty
Summary
The facility failed to maintain fall interventions for a resident diagnosed with Huntington's disease, major depressive disorder, and anxiety, who was assessed with severe cognitive impairment. The resident had a history of repeated falls, weakness, lack of coordination, and unsteadiness, and was independent for most activities of daily living, using a walker for mobility. Despite these needs, the resident experienced multiple falls, including two non-injury falls and one non-major injury fall since the last assessment. The care plan required nonskid strips in the bathroom and by the recliner, as well as fall mats, to prevent falls. Observations revealed that the nonskid strips in the resident's bathroom were worn and not adhered to the floor, increasing the risk of falls. Interviews with staff indicated that the resident often ambulated without a walker or calling for assistance, and the nonskid strips were frequently compromised due to wetness from the resident's habits. Maintenance staff confirmed the issue with the nonskid strips, and there was no facility policy for their inspection. This lack of maintenance and policy led to the deficiency in ensuring the resident's safety as care planned.
Failure to Administer PRN Medications for Constipation
Penalty
Summary
The facility failed to ensure that a resident remained free from unnecessary medications by not administering as-needed (PRN) medications for constipation. The resident, who had a diagnosis of constipation and was dependent on staff for toileting needs, did not have a bowel movement for several days on multiple occasions. Despite having physician's orders for various laxatives and stool softeners, the staff did not administer these medications or document any refusal by the resident to take them. The facility's bowel management protocol required staff to administer specific medications if a resident did not have a bowel movement for three, four, or five days, but this protocol was not followed. The resident's electronic medical record showed that there were three separate periods where the resident went without a bowel movement for four to six days. During these times, the staff failed to administer PRN medications or document any refusal by the resident to accept bowel management interventions. Interviews with facility staff revealed that the resident would sometimes refuse the ordered PRN medications, but there was no documentation to support this. The facility's protocol also required staff to make a brief nurse's note if a resident refused the protocol, which was not done in this case.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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