Providence Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Kansas.
- Location
- 8909 Parallel Pky, Kansas City, Kansas 66112
- CMS Provider Number
- 175159
- Inspections on file
- 15
- Latest survey
- September 3, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Providence Place during CMS and state inspections, most recent first.
Staff did not test dishwashing sanitization chemicals due to lack of test strips and failed to label and date opened food items, as evidenced by an open, undated gallon of milk found in the refrigerator. Dietary staff confirmed the absence of required testing and labeling practices.
Hazardous cleaning chemicals were left unsecured and accessible to cognitively impaired, mobile residents. A resident with severe cognitive impairment experienced a non-injury fall when staff failed to lock wheelchair brakes during a transfer. Another resident with a history of falls was observed with their call light and personal items out of reach, contrary to care plan interventions. Staff interviews confirmed that these actions did not follow facility policy or care plans.
A medication storage room containing stock medications and enteral feeding solutions was found unlocked during a walkthrough. An LN confirmed the door should always be locked, but reported issues with the doorknob sticking. Facility policy requires all medications to be secured in locked storage.
Surveyors identified multiple infection control deficiencies, including trash left on a PPE cart, a clean linen closet propped open, lack of accessible hand hygiene supplies in the laundry area, and missing gloves in the dirty laundry area. Staff interviews confirmed these practices were inconsistent with facility policy and that all staff are responsible for maintaining proper infection control.
A resident with significant physical and cognitive impairments was not provided with required adaptive utensils and a two-handled cup during meals, despite documented care plans and orders. Staff served meals with standard utensils, and the resident was observed struggling to eat while wearing wrist orthoses. Staff interviews confirmed expectations to follow care plans, but the adaptive equipment was not provided as required.
A resident with severe cognitive and physical impairments, dependent on staff for personal care, was repeatedly observed with dirty fingernails containing a dark substance. Despite facility policy and staff interviews confirming responsibility for nail care during bathing and showers, staff did not consistently ensure the resident's fingernails were clean.
A resident with end-stage renal disease and multiple comorbidities did not have consistent pre- and post-dialysis communication and assessment documentation as required by facility policy. Nursing and administrative staff confirmed that dialysis communication forms were often missing from the resident's record, and procedures to obtain or return these forms from the dialysis center were not reliably followed, resulting in incomplete documentation of dialysis care.
A resident with severe cognitive impairment, decreased mobility, and multiple diagnoses was provided with bilateral bed rails without documented evidence that alternatives had been tried and failed, as required by facility policy. The assessment also lacked information on drug classifications that could increase entrapment risk, resulting in a deficiency related to bed rail use.
A resident with severe cognitive impairment and multiple diagnoses was prescribed Dulcolax DR without 'do not crush' instructions, despite a consultant pharmacist's recommendation to add this directive. The facility did not act on the pharmacist's recommendation as required by policy, and the medication administration record lacked the necessary instruction.
The facility did not accurately document and submit weekend staffing coverage hours in its Payroll Based Journaling (PBJ) reports to CMS, despite using agency staff and having no gaps in internal schedules or time sheets. This discrepancy was identified when the facility's PBJ data triggered for excessively low weekend staffing, and an administrative nurse acknowledged that agency staff hours may not have been properly reported.
Failure to Test Dishwashing Sanitizer and Label Opened Food Items
Penalty
Summary
Staff failed to properly test dishwashing sanitization chemicals and did not ensure that opened food items were labeled and dated. During a kitchen and dining area tour, surveyors observed an open, undated gallon of milk in the refrigerator. Dietary staff confirmed that dishes were being washed by hand in a three-sink system using hot water and chemicals, but there were no test strips available to verify the effectiveness of the sanitization process, nor was there a log to review. Staff also acknowledged that all opened food items should be labeled and dated, but this was not done for the milk observed during the inspection.
Failure to Secure Hazardous Chemicals and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to secure hazardous cleaning chemicals in a locked area, leaving disinfectant bleach wipes and a Clorox spray bottle accessible in an unsecured cabinet on the 300 Hall. These chemicals were labeled with warnings indicating they were hazardous to humans and should be kept out of reach of children. Eight cognitively impaired, independently mobile residents had access to this area. Staff interviews confirmed that facility policy required chemicals to be locked up, but this was not followed at the time of observation. A resident with severe cognitive impairment, chronic kidney disease, emphysema, muscle weakness, and a history of falls experienced a non-injury fall during a transfer. Staff failed to lock the brakes on the resident's wheelchair before attempting the transfer, causing the wheelchair to move and resulting in the resident being assisted to the ground. The care plan for this resident required staff to lock wheelchair brakes before transfers, and staff had been educated on this procedure, but it was not followed during the incident. Another resident with diabetes, renal failure, cognitive impairment, and a history of falls was observed sitting in a recliner with their call light and personal items out of reach, contrary to the care plan interventions. The care plan specified that the call light and needed items should be within reach and that staff should encourage the resident to call for assistance. Staff interviews confirmed that it was everyone's responsibility to ensure fall interventions were in place as care planned, but these interventions were not implemented at the time of observation.
Medication Storage Room Found Unsecured
Penalty
Summary
A deficiency was identified when one of two medication storage rooms, specifically the 100 Hall Team Office medication storage room, was found unsecured during an initial facility walkthrough. The room contained shelves of stock medication, enteral feeding solutions, and medical supplies. A licensed nurse confirmed that the door should be locked at all times due to the presence of medications, but noted that the doorknob sometimes stuck and did not close properly. Facility staff were expected to ensure the room remained locked when exiting, as per the facility's Medication Storage policy, which requires all medication to be secured in a locked manner.
Infection Control Lapses in Trash Disposal, Linen Storage, and Hand Hygiene
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices as evidenced by several observed deficiencies. During an initial walkthrough, a clear bag of trash was found left on top of a PPE cart in the 300 halls, and a clean linen closet was observed propped open in the same area. In the laundry room, there was no visible handwashing sink or PPE available. Staff reported that handwashing required retrieving soap from the dirty laundry area, using a laundry soaking sink, and then returning to the dirty area to dry hands, indicating a lack of accessible hand hygiene supplies. Additionally, gloves were not available in the dirty laundry area, and staff were not consistently aware of the location of the handwashing sink in the laundry room. Interviews with staff confirmed that trash should not be left on PPE carts, linen closets should not be propped open, and it is the responsibility of all staff to ensure proper disposal of trash and maintenance of infection control standards. The facility's infection control policy requires the provision of necessary supplies and oversight to ensure hand hygiene, but observations and staff statements indicated lapses in these practices. These deficiencies were identified among a census of 35 residents, including seven on Enhanced Barrier Precautions.
Failure to Provide Required Adaptive Utensils During Meals
Penalty
Summary
The facility failed to provide a resident with the required adaptive utensils during mealtimes, despite clear documentation in the care plan and physician orders indicating the need for built-up silverware and a two-handled cup to support self-feeding. The resident, who had diagnoses including left-sided hemiplegia, cerebral infarction, dysphagia, muscle weakness, cognitive communication disorder, reduced mobility, and muscle contractures, was observed eating multiple meals with standard utensils and a regular cup, while wearing wrist orthoses. Staff did not offer the adaptive equipment during these meals, and the resident was noted to have difficulty handling the utensils. Interviews with staff confirmed that they were expected to review care plans and dietary requirements before serving meals, and that information about special utensils was accessible to all staff. The facility's policy required screening and provision of adaptive equipment to improve resident independence and quality of care. Despite these expectations and policies, the resident did not receive the necessary adaptive utensils during observed meals, constituting a failure to implement the care plan and physician orders.
Failure to Maintain Resident Nail Hygiene During ADL Assistance
Penalty
Summary
Staff failed to provide adequate assistance with activities of daily living (ADL) for a resident who was dependent on staff for personal care due to multiple diagnoses, including dementia, hemiparesis following a stroke, Parkinson's disease, and muscle weakness. The resident's medical record and care plan documented severe cognitive impairment and a need for staff assistance with bathing, toileting, oral hygiene, and dressing. Despite these needs, observations on multiple occasions revealed that the resident's fingernails had a dark brown substance underneath, indicating they were not being kept clean. Interviews with facility staff confirmed that CNAs are responsible for cleaning residents' fingernails during showers or bed baths, and that all staff are expected to monitor nail cleanliness. The facility's policy emphasized promoting cleanliness during bathing and showering. However, the repeated observations of dirty fingernails demonstrated that staff did not consistently ensure the resident's fingernails were clean, resulting in a failure to meet the resident's ADL needs as outlined in their care plan.
Failure to Ensure Consistent Pre- and Post-Dialysis Communication and Assessment
Penalty
Summary
The facility failed to consistently communicate a resident's medical condition through pre- and post-dialysis communication prior to and after hemodialysis sessions. The resident in question had multiple complex medical diagnoses, including end-stage renal disease requiring hemodialysis, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, peripheral vascular disease, and a recent cervical spine fracture requiring a neck collar. The care plan required daily assessment of the arteriovenous (AV) fistula and completion of dialysis communication forms before and after each dialysis session. However, review of the electronic medical record revealed missing documentation of pre- and post-dialysis assessments and communication forms on several specified dates. Interviews with nursing staff and administration confirmed that the process for handling dialysis communication sheets was not consistently followed. Staff reported that completed forms were to be placed in a binder and scanned into the resident's chart, and if missing, the dialysis center was to be contacted for a report. Administrative staff acknowledged ongoing issues with obtaining completed communication sheets from the dialysis center and had attempted to address this by sending the forms in a binder. Despite these procedures, the required documentation was not consistently present, resulting in a failure to ensure proper communication and assessment related to the resident's dialysis care.
Failure to Document Alternatives Prior to Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident had a documented risk assessment that included alternatives that had been tried and failed prior to the use of bed rails. The resident in question had diagnoses of major depressive disorder, Alzheimer's disease, cerebrovascular accident, and was noted to have severely impaired cognition, decreased mobility, blindness, and dementia. The care plan indicated the use of bilateral upper quarter bedrails to assist with bed mobility, and the facility's assessment documented that the resident's representative had given verbal consent for the side rails. However, the assessment did not include documentation of alternatives to bed rails that had been attempted and found ineffective, nor did it address drug classifications that could increase the risk of entrapment. Observations confirmed that the resident was using bilateral upper bed rails, and staff interviews revealed that side rail assessments were conducted at admission, quarterly, annually, and with significant changes. Staff also stated that the interdisciplinary team reviewed factors such as medication, mobility, mental status, safety awareness, and history of falls when making decisions about side rail use. Despite these procedures, the facility's policy required that appropriate alternatives be attempted before installing bed rails, and this was not documented in the resident's assessment, resulting in a deficiency.
Failure to Implement Pharmacist's Medication Safety Recommendation
Penalty
Summary
The facility failed to act upon the Consultant Pharmacist's recommendation to add 'do not crush' instructions to a resident's Dulcolax delayed release (DR) medication order. The resident in question had diagnoses of major depressive disorder, Alzheimer's disease, and a history of cerebrovascular accident, with severely impaired cognition and significant assistance required for activities of daily living. The resident's care area assessment indicated a risk of adverse side effects from medications, and the care plan directed nursing staff to administer medications as ordered by the physician. However, the medication order for Dulcolax DR did not include 'do not crush' instructions, despite the pharmacist's recommendation documented in the monthly medication review. Review of the resident's medication administration record for the relevant month confirmed the absence of the 'do not crush' directive for Dulcolax. Interviews with administrative nursing staff revealed an expectation that pharmacy recommendations would be reviewed and acted upon within seven days, but this was not done in this case. The facility's policy required that drug regimen reviews be conducted monthly by a licensed pharmacist, with any identified irregularities reported to the attending physician, medical director, and director of nursing services for action. The failure to implement the pharmacist's recommendation resulted in a deficiency related to the management of the resident's medication regimen.
Failure to Accurately Report Weekend Staffing in PBJ Data
Penalty
Summary
The facility failed to submit accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) through Payroll Based Journaling (PBJ) by not properly documenting weekend staffing coverage hours. During the review period, the facility reported a census of 36 residents and a sample of 12 residents was included. Although the facility's working schedules, time sheets, and posted staffing hours showed no gaps or loss of hours, the submitted PBJ data triggered for excessively low weekend staffing for the first quarter of the fiscal year. An administrative nurse confirmed that agency staff were used during the period in question, but their hours may not have been appropriately documented in the PBJ reporting. The facility's policy required accurate electronic reporting of staffing and census information to CMS and mandated that this information be made available to residents, family members, and the public within 24 hours of a request.
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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