Regent Park Rehabilitation And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Wichita, Kansas.
- Location
- 10604 East 13th Street N, Wichita, Kansas 67206
- CMS Provider Number
- 175527
- Inspections on file
- 17
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Regent Park Rehabilitation And Healthcare during CMS and state inspections, most recent first.
The facility failed to obtain complete and properly executed informed consents for psychotropic medications for multiple residents. Several residents were receiving antidepressants, antianxiety agents, and antipsychotics, yet their psychotropic consent forms were either missing signatures or did not list the specific medications, dosages, routes, or administration frequencies. Staff reported that informed consent was required before starting or changing psychotropic drugs and that consents were to be provided to residents or their representatives, and facility policy required signed consents at initiation and with dosage increases, but the documentation for these residents did not include the necessary medication details.
A resident’s Medicare Part A coverage ended, and the resident remained for LTC on a private pay basis, but the facility could not produce evidence that the required SNF Advance Beneficiary Notice of Non-coverage (ABN) Form CMS-10055 was provided. Social service notes stated that the ABN was given and that a private pay quote was discussed, and an email to the resident’s representative referenced appeal rights and possible continued therapy, but the documentation did not specifically reference the SNF ABN or include estimated costs for continued therapy. The social worker later acknowledged she could not show that the ABN form had been provided, and no copy of the completed form was in the record, despite facility policy requiring appropriate Medicare discharge notification and appeal information when coverage ends.
A resident with hemiplegia and a documented left-hand contracture risk had physician orders and a care plan directing staff to place a rolled washcloth or splint in the hand on every day and night shift, with the MAR consistently indicating the device was in place and no refusals. However, surveyors repeatedly observed the resident with the left hand hanging in a loose fist, swollen, and without any device, while the prescribed hand splint was found across the room. Therapy staff confirmed the resident’s flaccid left arm and provision of a resting hand splint or rolled towel, and nursing and administrative staff acknowledged the device was supposed to be in the hand at all times and documented on the MAR, demonstrating a failure to follow ordered interventions to prevent contracture.
A resident with pneumonia and post-stroke hemiparesis, care planned and ordered for continuous 2L oxygen due to ineffective gas exchange, was observed in the dining area with a portable oxygen tank attached to the wheelchair but not receiving oxygen; the nasal cannula was hanging unused and the tank was empty. Staff, including an LPN and a CMA, acknowledged the resident was supposed to be on oxygen at all times, and facility policy required use of portable oxygen when off the main concentrator, but this was not followed.
A deficiency was cited when an area of the facility was not kept free from accident hazards and did not provide adequate supervision to prevent accidents, as required by safety standards.
The facility failed to follow sanitary dietary standards related to food labeling, storage, and preparation, placing all residents at risk for food-borne illness. Observations included unlabeled and undated food items, improper handling of food containers, and unsanitary use of a food thermometer.
The facility failed to secure pressurized oxygen cylinders in a locked location, leaving them accessible to six cognitively impaired residents. Additionally, a resident with severe cognitive impairment was found with her bed in a high position while unsupervised, contrary to the facility's Fall policy. These deficiencies placed residents at risk for preventable accidents and injuries.
The facility failed to properly label and store medications, including leaving a medication cart unlocked and unattended, having opened and undated insulin pens and tuberculin vaccine serum vials, and lacking daily temperature documentation for the medication refrigerator. This placed residents at risk for adverse outcomes or ineffective medication regimens.
The facility failed to provide wheelchair foot pedals for a resident with multiple medical conditions, including hemiplegia and dementia. Staff were observed propelling the resident's wheelchair without foot pedals, requiring the resident to hold her feet up. This practice was confirmed by staff interviews and violated the facility's Accommodation of Needs policy, placing the resident at risk of impaired care and decreased quality of life.
A resident with severe cognitive impairment and multiple medical diagnoses had a low air-loss mattress pump set to incorrect weight settings, despite weighing only 111.4 lbs. The care plan and physician's orders lacked specific instructions for the mattress settings, and staff were unsure about the correct settings, leading to a risk of skin breakdown and pressure ulcers.
A facility failed to store a resident's CPAP mask and oxygen tubing in a sanitary manner, placing the resident at increased risk of respiratory infections. The CPAP mask was found on the bedside table, and the oxygen tubing was on the floor, contrary to facility policy requiring these items to be stored in plastic bags when not in use.
The facility failed to administer an as-needed diuretic for a resident with severe cognitive impairment and multiple health conditions and did not consistently monitor blood pressure before administering a beta-blocker to another resident with a history of stroke and hypertension.
The facility failed to maintain ongoing communication with hospice services for a resident with severe cognitive impairment and multiple medical conditions. The care plan lacked essential information, and staff were unaware of the specifics of hospice services, placing the resident at risk for delayed services and uncommunicated care needs.
The facility failed to ensure a functional call light system for each resident, affecting their ability to summon assistance. Two residents reported non-functional call lights, which was confirmed upon inspection. Maintenance staff were unaware of the immediate protocol for fixing call lights, and staff were instructed to increase checks on residents every 15 minutes if a call light was not working. The facility's policy required an operational call system, but two of the four hallways had non-functional call lights.
The facility failed to ensure the posted nursing hours included the required information and were posted in a prominent, readily accessible location. The daily census was missing from the posted staff sheet, and the information was placed under a folder outside the assistant director of nursing's office, making it difficult for residents and visitors to access. Additionally, the facility lacked a policy related to the posted nursing information.
Failure to Obtain Complete Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents and/or their representatives were fully informed about specific psychotropic medications, including their names, dosages, routes, and frequencies, as required for informed consent. For one resident with orders for mirtazapine for depression, fluoxetine for depression, and alprazolam for anxiety, the psychotropic medication consent form was dated several months after the medication orders and did not list any of the prescribed psychotropic medications or their details. Another resident with orders for mirtazapine for insomnia and fluoxetine for a mood disorder had a signed psychotropic consent form that also lacked the names of the medications, their dosages, routes, or administration frequencies. A third resident had multiple psychotropic orders, including sertraline for depression, quetiapine in two different strengths for major depressive disorder and behavioral disturbances, mirtazapine for depression, and lorazepam for anxiety. The scanned psychotropic consent for this resident was unsigned and similarly did not specify any of the psychotropic medications, their dosages, routes, or frequencies. Staff interviews confirmed that informed consent was expected before starting or changing psychotropic medications and that consents were to be provided to residents and/or their legal representatives. The facility’s own policy required a signed informed consent on initiation and with any dosage increase of psychoactive medications to ensure potential adverse effects were reviewed, but the documentation reviewed for these residents did not meet those requirements.
Failure to Provide Required SNF ABN and Cost Information When Medicare Coverage Ended
Penalty
Summary
The deficiency involves the facility’s failure to provide the required Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage (ABN) Form CMS-10055 to a Medicare Part A beneficiary when his covered stay ended and he remained in the facility. The resident census was 61, with 15 residents sampled and three reviewed for beneficiary notifications. For one resident, documentation showed that his Medicare Part A last covered day was 01/28/26, after which he remained in the facility for long-term care on a private pay basis. Facility records, including the medical record and business office documentation, did not contain evidence that the SNF ABN Form CMS-10055 was provided. A social service note dated 01/30/26 stated that the social worker provided the SNF ABN and that the resident would remain private pay for approximately 30–60 days until an apartment was available, and that a private pay quote was given to the resident’s representative. Another social service note, created on 02/09/26 with an effective date of 01/30/26, documented that the resident requested staff review the SNF ABN with his representative, who was not present and whose arrival time was unknown. Email communication from the facility to the resident’s representative on 01/27/26 indicated there was a form the resident would need to sign that reviewed his appeal rights and his right to appeal if he believed Medicare should cover the long-term care stay, and that the appeal could take up to four months while therapy continued, with room, board, and therapy to be billed if the appeal was unfavorable. However, this email chain did not mention the SNF ABN or provide an estimated cost to continue therapy services. During an interview on 02/10/26, the social worker stated the ABN should be provided prior to discharge and reported that she had provided the form, but that the resident did not sign or return it because he wanted to review it with his representative. She confirmed she was unable to show that the resident was provided with the ABN Form CMS-10055 because she did not have a copy. The facility’s policy dated 12/01/17 required appropriate notification of discharge from Medicare services, including appeal rights, when Medicare coverage ends, but the appropriate notification of discharge from Medicare services was not provided in this case.
Failure to Implement Ordered Hand Splint/Positioning Device to Prevent Contracture
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered care and services to prevent reduction in range of motion and contracture development for a resident with left-sided weakness and a left-hand contracture risk. The resident had a history of hemiplegia and hemiparesis following a stroke affecting the left nondominant side, and the admission MDS documented a contracture of the left hand with intact cognition. The care plan and physician’s orders directed staff to place a clean, dry, rolled washcloth between the resident’s fingers and palm and ensure good hygiene on every day and night shift. The MAR from late September through early February documented that the rolled washcloth was in place every day and night with no refusals, and progress notes did not document any refusals or missed treatments. Despite this documentation, surveyor observations on multiple occasions showed the resident without any device in the left hand to address contracture risk. The resident was observed in a wheelchair with the left hand hanging down in a loose fist and swollen, and later in bed with the left hand dangling, swollen, and without a rolled cloth or device. The resident reported that therapy had given her a hand device described as a pool noodle with a strap to prevent her hand from contracting and stated she should have been wearing it at the time, but it was observed across the room on her dresser. A therapy consultant reported that an evaluation had been completed for a left-hand contracture, that the resident’s left arm was completely flaccid, and that a simple resting hand splint or rolled towel had been provided for use. Nursing staff and an administrative nurse confirmed that a towel or splint was supposed to be in the resident’s hand at all times and that nurses were responsible for placement and documentation on the MAR. The facility’s restorative nursing policy stated that goals for elders receiving restorative services include preventing contractures.
Failure to Provide Ordered Continuous Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered continuous oxygen therapy to a resident with significant medical needs. The resident had diagnoses including pneumonia, anxiety, and hemiplegia/hemiparesis following a stroke, and her admission MDS documented intact cognition with receipt of oxygen. Her Care Area Assessment noted impaired physical functioning related to a past stroke with left-sided weakness and a need for staff assistance with all care. The resident’s care plan documented she was to be on oxygen related to ineffective gas exchange, with an order for two liters of oxygen continuously. Physician’s orders directed staff to monitor oxygen saturation and provide oxygen at two liters every day and night shift. During observation, the resident was seated in the dining room in a wheelchair with a portable oxygen tank attached to the back of the wheelchair and a bag containing nasal cannula tubing. The nasal cannula prongs were hanging freely and were not in use, and the resident was not receiving oxygen despite the continuous oxygen order. When a licensed nurse placed the nasal cannula on the resident and attempted to turn on the oxygen, the portable tank was found to be empty, and the nurse then returned the resident to her room to place her on oxygen via a concentrator. Subsequent interviews with a CMA and another licensed nurse confirmed their understanding that the resident required oxygen all the time, and an administrative nurse stated she expected nurses to follow the oxygen orders. The facility’s oxygen therapy policy stated that residents would use oxygen from a portable source when off the main concentrator, but this was not implemented for the resident at the time of observation.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents occurring. There is no mention of specific residents, staff, or detailed events, but the deficiency centers on the lack of appropriate hazard prevention and supervision in the area in question.
Failure to Follow Sanitary Dietary Standards
Penalty
Summary
The facility failed to follow sanitary dietary standards related to food labeling, storage, and preparation, placing all residents at risk for food-borne illness. During an initial tour, surveyors observed mixed fruit and a steam table pan containing fruit in the refrigerator without labels or dates, and a large canister of flour also without a label or date. The freezer contained opened and unsealed bags of fish, sausage, potatoes, and chicken, all without labels or dates. Additionally, a storage container of mashed potatoes in the small freezer had no lid, label, or date. During lunch service, dietary staff were seen carrying multiple residents' fruit cups while touching the tops of the opened containers. Furthermore, a dietary staff member touched the probe of a food thermometer with bare hands without cleaning it before checking food temperatures. The facility did not provide a policy related to food storage and preparation when requested.
Failure to Secure Oxygen Cylinders and Maintain Safe Bed Height
Penalty
Summary
The facility failed to secure pressurized oxygen cylinders in a safe, locked location, leaving them accessible to six cognitively impaired, independently mobile residents. During a walkthrough, it was observed that the door to the Clean Room containing 37 pressurized oxygen cylinders was propped open. Staff acknowledged that the door should have been closed and locked, as per the facility's Oxygen Storage policy, which mandates that oxygen cylinders be stored in a secured room with proper ventilation. This oversight placed the residents at risk for preventable accidents and injuries. Additionally, the facility failed to maintain Resident 11's bed at a safe height while she was unsupervised in her room. Resident 11, who had severe cognitive impairment and was dependent on staff for bed mobility, was found with her bed in a high position. Staff confirmed that beds for residents with severe cognitive impairment should never be left in a high position when unsupervised. The facility's Fall policy requires that residents be assessed for fall risks and that interventions be identified to prevent accidents. The failure to lower Resident 11's bed height placed her at risk for preventable falls and injuries.
Failure to Properly Label and Store Medications
Penalty
Summary
The facility failed to properly label and store medications, which placed residents at risk for adverse outcomes or ineffective medication regimens. Specifically, a licensed nurse left a medication cart unlocked and unattended in the 100-hallway. Additionally, the treatment cart contained three opened and undated insulin pens, and the medication room contained two opened and undated vials of tuberculin vaccine serum. The medication refrigerator temperature log also lacked evidence of daily temperature measurements and documentation for multiple dates in March and April 2024. Interviews with staff confirmed that insulin pens and tuberculin vaccine serum vials should be labeled and dated when opened, and the medication refrigerator temperature should be monitored and documented daily. The facility's Storage of Medications policy requires all drugs and biologicals to be stored in a safe, secure, and orderly manner, with compartments locked when not in use. The facility's failure to adhere to these policies could potentially cause adverse consequences or ineffective treatment for the residents.
Failure to Provide Wheelchair Foot Pedals
Penalty
Summary
The facility failed to provide wheelchair foot pedals for Resident 40, who has multiple medical conditions including hemiplegia, cerebral infarction, hypertension, dementia, overactive bladder, and glaucoma. The resident's care plan indicated she required extensive assistance with activities of daily living (ADLs) and used a wheelchair for mobility. Despite this, staff were observed propelling the resident's wheelchair without foot pedals on multiple occasions, requiring the resident to hold her feet up while being moved. This practice was confirmed by staff interviews, where both a Licensed Nurse and a Certified Nurse's Aide stated that wheelchairs should have foot pedals when propelled by staff. The facility's Accommodation of Needs policy mandates that each resident has the right to receive services with reasonable accommodation of individual needs, including the use of equipment and assistive devices necessary for daily living activities. The failure to provide wheelchair foot pedals for Resident 40 was a direct violation of this policy, placing the resident at risk of impaired care and decreased quality of life. The deficiency was documented through observations, interviews, and record reviews, highlighting a significant lapse in adhering to the facility's own standards and policies.
Incorrect Low Air-Loss Mattress Settings
Penalty
Summary
The facility failed to ensure that a resident's pressure-reducing interventions were implemented correctly. The resident, who had severe cognitive impairment and multiple medical diagnoses including COPD, dementia, dysphagia, repeated falls, and a pressure ulcer, was dependent on staff for bed mobility, transfers, toileting, bathing, and dressing. The resident's care plan included the use of a low air-loss mattress to prevent further skin breakdown and pressure ulcers. However, the care plan lacked specific instructions related to the monitoring and settings for the mattress pump, and the physician's orders also did not include these details. Observations revealed that the resident's low air-loss mattress pump was consistently set to an incorrect weight setting, ranging from 180 lbs to 210 lbs, despite the resident weighing only 111.4 lbs. Interviews with staff indicated that they were unsure if the care plan covered instructions for the mattress settings and that they were expected to check the bed and equipment each shift. The facility's policy on low air-loss mattresses stated that the mattress should be adjusted no less than 50 pounds above the patient's weight or to the patient's preference or comfort level, but this was not followed in practice. The failure to set the low air-loss mattress pump to the appropriate weight setting placed the resident at risk for complications related to skin breakdown and pressure ulcers. The facility's lack of specific instructions in the care plan and physician's orders, combined with staff's uncertainty about the correct settings, contributed to this deficiency.
Improper Storage of CPAP Mask and Oxygen Tubing
Penalty
Summary
The facility failed to ensure the proper storage of a resident's CPAP mask and oxygen tubing, which were found in unsanitary conditions. The CPAP mask was observed lying directly on the bedside table, and the oxygen tubing was found undated and unbagged on the floor. This was contrary to the facility's policy, which required these items to be stored in plastic bags when not in use to prevent contamination. Interviews with staff confirmed that the CPAP mask and oxygen tubing should always be stored in a sanitary manner, and the oxygen tubing should be replaced if it touches the floor. The resident involved had a history of obstructive sleep apnea, respiratory failure with hypoxemia, and hypertension, and was documented to have severely impaired cognition. The care plan for the resident lacked specific instructions for cleaning and storing the CPAP mask. The facility's failure to adhere to its own policies placed the resident at increased risk of developing respiratory infections and complications. The deficiency was identified during an observation and was corroborated by staff interviews and a review of the resident's medical records.
Failure to Administer Medications as Ordered and Monitor Vital Signs
Penalty
Summary
The facility failed to administer an as-needed diuretic medication as ordered for a resident with severe cognitive impairment and multiple health conditions, including obstructive sleep apnea, respiratory failure, and hypertension. The resident's care plan required staff to administer medications as ordered and to monitor for weight gain, which would necessitate the administration of the diuretic. However, the facility's records showed that the diuretic was not administered on several occasions when the resident's weight indicated it was necessary. Observations also noted that the resident's CPAP mask and oxygen tubing were not properly stored, indicating a lack of adherence to care protocols. Another resident with a history of stroke, hemiplegia, hypertension, and dementia was prescribed metoprolol, a beta-blocker, with specific instructions to monitor blood pressure and pulse before administration. The facility's records lacked consistent evidence that these vital signs were monitored before giving the medication. Interviews with staff confirmed that the blood pressure should be documented before administering the medication, but this was not consistently done. The facility's policies required that all medications be administered as ordered and that residents be monitored for adverse drug reactions. Despite these policies, the facility failed to follow physician orders for both residents, leading to potential risks of unnecessary medication side effects or ineffective therapeutic regimens.
Failure to Maintain Communication with Hospice Services
Penalty
Summary
The facility failed to maintain ongoing communication with hospice services related to a resident's bi-weekly hospice visits. The resident, who had severe cognitive impairment and multiple medical conditions including COPD, dementia, dysphagia, repeated falls, and a pressure ulcer, was dependent on staff for various activities of daily living. Despite being on hospice care, the resident's care plan lacked essential information such as contact details for the hospice service, the services provided, and the frequency of hospice nursing staff visits. Additionally, the facility's electronic medical records did not contain scanned hospice communications showing the bi-weekly visits and the services provided during those visits. Interviews with facility staff revealed a lack of awareness and documentation regarding the hospice services provided to the resident. Licensed Nurse J and Administrative Nurse D were unsure about the location of hospice documentation and the specifics of the services, medications, and equipment provided by hospice. The facility had stopped using communication books, and the hospice documentation was not readily available in the care plan or the nursing office. This lack of communication and documentation placed the resident at risk for delayed services and uncommunicated care needs, as the facility did not collaborate effectively with hospice services to ensure comprehensive care.
Non-Functional Call Light System
Penalty
Summary
The facility failed to ensure a functional and fully operational call light system for each resident, placing them at risk for delayed care and decreased psychosocial well-being. Resident 212 reported that her call light had not worked since her admission, and she was instructed to yell for help if needed. An inspection confirmed the call light was non-functional. Similarly, Resident 6 reported her call light was not working, which was also confirmed upon inspection. Maintenance staff stated the system is checked weekly, but there was no clear protocol for immediate resolution if the call light could not be fixed right away. Licensed Nurse J and Certified Medication Aide M indicated that staff would notify maintenance and increase the frequency of checks on residents every 15 minutes if a call light was not functioning. Administrative Nurse D acknowledged issues with the new call light system and stated that staff were expected to notify the on-call supervisor and maintenance for any outages. The facility's Call Light policy required an operational electronic call system, and in case of malfunction, nursing staff were to initiate 15-minute resident checks. The facility failed to ensure operational call lights in two of the four hallways, affecting the residents' ability to summon assistance when needed.
Failure to Post Required Nursing Staffing Information
Penalty
Summary
The facility failed to ensure the posted nursing hours included the required information and were posted in a prominent, readily accessible location for residents or visitors. The facility identified a census of 66 residents. Upon review of 18 months of posted nurse staffing information, it was found that the daily census was not included on the posted staff sheet. Additionally, the posted nursing staff information was located on the wall outside the assistant director of nursing's office under a folder, which required visitors and residents to flip the folder up to see the information. Administrative Staff A confirmed this setup and acknowledged that the posted staffing was covered. The facility was also unable to provide a policy related to the posted nursing information.
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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