Rock Creek Of Ottawa
Inspection history, citations, penalties and survey trends for this long-term care facility in Ottawa, Kansas.
- Location
- 1100 W 15th Street, Ottawa, Kansas 66067
- CMS Provider Number
- 175332
- Inspections on file
- 19
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Rock Creek Of Ottawa during CMS and state inspections, most recent first.
A resident with morbid obesity, COPD, osteoporosis, bilateral impairment, and cognitive impairment, who was dependent on staff and required a mechanical lift for transfers, was being moved by two CNAs from a wheelchair to a recliner using a Hoyer lift. As the resident was lowered, the top left sling strap came off the lift hook, and the resident slid to the floor, later being diagnosed with a left humerus fracture and returning with a shoulder immobilizer. An administrative nurse found the lift and sling functioning normally and determined during observation of the involved CNAs that they failed to maintain proper tension on the sling straps before raising the lift, allowing the sling to shift and the loops to detach, leading to the fall and injury.
The facility failed to ensure proper food storage and temperature management, leading to a deficiency in food safety standards. Observations revealed improperly sealed, labeled, or dated food items, and the walk-in freezer was not maintaining the required temperature. The previous dietary manager failed to log food temperatures and did not inform staff about the freezer's malfunction, resulting in resident complaints of nausea, vomiting, or diarrhea.
The facility failed to properly store and label medications, as two medication carts were found unlocked and unattended, with one containing opened and undated insulin pens. A CMA admitted to leaving the cart unlocked, and a LN confirmed that carts should not be left unlocked when out of view. The facility's policy required medications to be stored securely and labeled correctly, which was not followed, placing residents at risk.
A facility failed to ensure the privacy and dignity of a resident with chronic respiratory failure and dementia. The resident was observed in bed with the room door open, exposing his right leg and brief. Staff interviews confirmed that privacy measures should have been in place, but the facility did not provide a policy on dignity when requested.
The facility failed to use foot pedals during wheelchair transports for two severely cognitively impaired residents, resulting in one resident falling and sustaining minor injuries. Additionally, call lights were not within reach for three cognitively impaired residents, placing them at risk for preventable accidents and injuries.
A facility failed to provide written notification of transfer to a resident and their representative for several facility-initiated transfers to an acute hospital. The resident, with chronic respiratory failure, dementia, and CHF, required substantial assistance and supplemental oxygen. Despite these needs, the facility did not provide necessary written notifications for transfers, placing the resident at risk for uninformed care choices. Staff were unaware of the requirement for written notifications, and the facility's policy lacked guidance on this federal requirement.
A facility failed to set a resident's low air-loss mattress to the correct weight and did not ensure a pressure-reducing cushion was in another resident's wheelchair. Both residents were at risk for pressure ulcers, with one having a history of such injuries. Observations and staff interviews confirmed these deficiencies, which were contrary to the facility's Skin Management System policy.
A facility failed to provide necessary services to prevent worsening contractures in a resident's left hand. The resident had a history of contracture, hemiparesis, hemiplegia, and cerebral infarction, with severely impaired cognition and limited ROM. Despite a care plan for supportive devices, there was no documentation of their use, and observations showed the resident without these devices. Staff interviews revealed unclear documentation procedures, and the facility's ROM policy was not followed, risking further decline and discomfort for the resident.
The facility failed to secure an electrical furnace closet, making it accessible to 30 cognitively impaired residents, and did not ensure a resident's fall interventions were in place. The closet doors were easily opened, exposing high voltage electrical boxes, and a resident at high fall risk was observed without the necessary Dycem in her wheelchair, contrary to the care plan.
A resident with an indwelling catheter was found with their catheter drainage bag resting on the floor, contrary to the facility's policy. The resident had diagnoses of benign prostatic hyperplasia, cognitive-communication deficit, and hypertension, and was dependent on staff for toileting. Staff interviews confirmed the catheter bag should not be on the floor, but challenges were noted in attaching the bag to recliners.
A resident with chronic respiratory failure and other conditions did not receive continuous oxygen therapy as ordered by the physician. Observations showed the nasal cannula was not in use, and the oxygen concentrator was off, contrary to the care plan and physician's orders. Staff interviews confirmed the oversight, highlighting a failure to adhere to the facility's oxygen administration policy.
A resident with severe cognitive impairment did not receive prescribed eyedrops for over a week due to nursing staff's failure to verify and enter the medication order into the EMR system. Despite receiving the medication and instructions, the facility did not follow up with the resident's medical provider promptly, delaying the administration of the medication and placing the resident at risk for impaired quality of care.
A resident with Alzheimer's disease and severe cognitive impairment experienced multiple non-injury falls due to inadequate dementia-related behavioral services. The facility's care plan and interventions, such as the use of a soft-touch call light and fidget devices, were insufficient and poorly documented. The resident's impulsiveness and lack of safety awareness, combined with missing safety equipment, contributed to the falls, highlighting a failure to adhere to the facility's dementia care policy.
A facility failed to follow physician parameters for a hypertensive medication prescribed to a resident with congestive heart failure and hypertension. The resident's MAR showed blood pressure readings below the set parameters, but these were not documented in the clinical record. Staff interviews revealed that the CMA was aware of the need to hold the medication if blood pressure was outside parameters but failed to document it. This resulted in the potential for unnecessary medication administration.
A facility failed to ensure a resident had a CMS-approved indication for the antipsychotic medication Seroquel, used for managing moods related to Alzheimer's dementia with agitation. The resident's care plan included documentation of agitation and non-pharmacological interventions, but there was no pharmacy review for the medication. Staff interviews revealed uncertainty about the appropriate diagnosis for Seroquel use, and the facility did not provide a policy on psychotropic medications when requested.
The facility failed to follow infection control practices for oxygen equipment and Foley catheter care, risking resident safety. A resident's catheter bag was on the floor, and another's oxygen cannula was not stored properly. Staff interviews confirmed these practices violated the facility's infection prevention policy.
Improper Hoyer Lift Technique Leads to Resident Fall and Fractured Humerus
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide safe mechanical lift transfers for a resident who required staff assistance and a Hoyer lift for all transfers. The resident had morbid obesity, COPD, osteoporosis, bilateral impairment, and moderate to severe cognitive impairment, and was dependent on staff for transfers, toileting, and bathing per MDS and CAA assessments. These assessments documented that the resident required a mechanical lift for transfers and was dependent on staff for mobility-related ADLs. On the date of the incident, two CNAs were transferring the resident using a Hoyer lift from a wheelchair to a recliner. According to the facility’s incident report and notarized witness statements from both CNAs, one CNA operated the Hoyer lift from the front while the other CNA guided and positioned the resident from behind the recliner. As the resident was being lowered into the recliner, the top left sling strap/loop came off the Hoyer hook, causing the resident to slide out of the sling and fall to the floor. The resident immediately complained of left shoulder pain and right shin pain, and staff observed a bruise on the right wrist. The resident was sent to the ER, where imaging confirmed a left humerus fracture measuring 3.1 cm, and the resident returned with a shoulder abduction immobilizer. An administrative nurse later inspected the lift and sling and found both to be functioning within normal limits. During subsequent transfer training with the involved CNAs, the administrative nurse observed that when the CNAs placed the sling strap loops onto the lift, they did not ensure there was tension on the straps before raising the lift, which allowed the lift sheet to shift to one side and the loops to come off the lift. This improper technique directly contributed to the sling strap detaching from the lift and the resident’s fall and injury.
Deficiency in Food Storage and Temperature Management
Penalty
Summary
The facility failed to ensure proper food storage and temperature management, leading to a deficiency in food safety standards. Observations revealed that several food items, including cottage cheese, milk, bread, macaroni, pasta shells, potato patties, chicken strips, and breadsticks, were not properly sealed, labeled, or dated. Additionally, the facility's walk-in freezer was not maintaining the required temperature, and there were alterations in the temperature logs for the freezer. The facility was unable to provide daily prepared food temperature logs, and there were missing food temperature readings for specific dates in December 2024. The deficiency was further compounded by the lack of communication and documentation from the previous dietary manager, who failed to log food temperatures and did not inform administrative staff about the freezer's malfunction in a timely manner. This resulted in numerous resident complaints of nausea, vomiting, or diarrhea during the first few days of December 2024. Interviews with dietary staff and administrative personnel confirmed the lack of proper food temperature logging and the abrupt departure of the previous dietary manager, which contributed to the oversight in maintaining food safety standards.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to properly store and label medications, as observed during a survey. On the initial tour, two medication carts on the same hallway were found unlocked and unattended. One of these carts contained two opened and undated insulin pens. A Certified Medication Aide (CMA) admitted to mistakenly leaving the cart unlocked, acknowledging that it should never be left unattended and unlocked. A Licensed Nurse (LN) confirmed that medication carts should not be left unlocked when out of view and that insulin pens should be labeled with both an open date and a discard date. Further interviews revealed that the facility's policy required medications to be stored safely, securely, and properly, following the manufacturer's recommendations and federal and state laws. The Administrative Nurse stated that insulin pens should be stored in the refrigerator until use, and once removed, they should be labeled with an open date and a discard date and stored in a locked medication cart. The facility's failure to adhere to these protocols placed residents at risk for adverse outcomes or ineffective medication regimens.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure the privacy and dignity of a resident, identified as R28, while he was in bed. R28 had a medical history of chronic respiratory failure, dementia, and congestive heart failure, and required substantial assistance for activities of daily living. Observations revealed that R28 was lying in bed with his room door open, and his right leg and brief were visible from the doorway, indicating a lack of privacy. The privacy curtain in the room was not drawn, which exposed R28 to anyone passing by. Interviews with facility staff, including a Certified Nurse Aide and a Licensed Nurse, confirmed that residents should not be exposed and that privacy measures such as closing the door or drawing the curtain should be in place. Despite these acknowledgments, the facility did not provide a policy regarding dignity when requested. This oversight in maintaining R28's privacy and dignity placed him at risk of decreased self-esteem and self-worth.
Failure to Ensure Proper Use of Assistive Devices and Call Light Accessibility
Penalty
Summary
The facility failed to ensure the appropriate use of foot pedals during wheelchair transports for two residents, both of whom were severely cognitively impaired. One resident fell out of his wheelchair while being pushed in the hallway without foot pedals, resulting in a minor injury with skin tears on his left elbow, wrist, hand, and below his left eye. Another resident was observed being pushed in a wheelchair without foot pedals, requiring staff to remind him to pick up his feet. Additionally, the facility did not ensure that call lights were within reach for three residents, all of whom were cognitively impaired. One resident was unable to reach her call light, which was placed across the room, while another resident's call light was pinned to the wall at the foot of her bed, out of reach. A third resident's call light was stuck between the mattress and bed cane, making it inaccessible. These deficiencies placed the residents at risk for preventable accidents and injuries.
Failure to Provide Written Notification of Transfer
Penalty
Summary
The facility failed to provide written notification of transfer to a resident, identified as R28, and his representative for several facility-initiated transfers to an acute hospital. This deficiency was identified during a survey that included a sample of 19 residents, with four reviewed for hospitalization. The lack of written notification included the absence of details such as the reason for the transfer, the effective date, the specific location, the right to appeal, and contact information for the state entity and ombudsman. This oversight placed R28 at risk for uninformed care choices. R28's medical history included chronic respiratory failure, dementia, and congestive heart failure. The resident had moderately impaired cognition, required a wheelchair for mobility, and needed substantial assistance with activities of daily living. R28 was frequently incontinent and required supplemental oxygen and a BiPAP machine. Despite these needs, the facility did not provide the necessary written notifications for transfers on multiple occasions, including specific dates in March, May, July, August, and December. Interviews with facility staff, including social services and nursing personnel, revealed a lack of awareness regarding the requirement for written notifications. Staff members indicated that they typically called the resident's representative to inform them of a transfer but did not provide written documentation. The facility's discharge or transfer policy, last revised in January 2023, did not include guidance on the federal requirement for notice before transfer, as outlined in the CMS state operations manual.
Failure to Ensure Proper Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident's low air-loss mattress was set to the appropriate weight settings according to her current weight. The resident, who had a history of muscle weakness, cognitive impairment, and pressure ulcers, was admitted with two stage-two pressure injuries and was at risk for further pressure injury development. Despite the resident's weight being recorded as 135.4 lbs, the mattress was locked at a setting for 200 lbs, which was not adjusted to match her current weight. This oversight was noted during observations, and staff interviews revealed a lack of clarity on how to adjust the mattress settings to accommodate weight changes. Additionally, the facility failed to ensure that another resident's wheelchair had a pressure-reducing cushion in place as per her care-planned interventions. This resident, who had a history of pressure ulcers and was at risk for skin breakdown, was observed multiple times without the necessary pressure-reducing cushion in her wheelchair. Staff interviews confirmed that the cushion was expected to be in place to prevent further skin breakdown, yet it was consistently missing during observations. The facility's Skin Management System policy required the implementation of preventative interventions to minimize the risk of skin breakdown and pressure injuries. However, the failure to properly set the low air-loss mattress and ensure the presence of a pressure-reducing cushion in the wheelchair placed both residents at risk for complications related to skin breakdown and pressure ulcers.
Failure to Prevent Worsening of Contractures in Resident
Penalty
Summary
The facility failed to provide necessary services and treatment to prevent the worsening of contractures in a resident's left hand. The resident, identified as R24, had a medical history that included contracture of the left hand, hemiparesis, hemiplegia, and cerebral infarction. The resident's Minimum Data Set (MDS) indicated severely impaired cognition and limited range of motion (ROM) in the upper and lower extremities on one side, requiring staff assistance for activities of daily living. Despite a care plan that included the use of supportive devices such as a washcloth, a weighted stuffed animal, and a hand splint to prevent further contracture formation, there was no documentation of these devices being applied or refused from December 1, 2024, to January 29, 2025. Observations on multiple occasions revealed that the resident was not using any contracture prevention devices, and the call light was out of reach, indicating a lack of adherence to the care plan. Interviews with staff, including a Certified Medication Aide and a Licensed Nurse, revealed a lack of clarity on documentation procedures for the application of supportive devices. The facility's policy on range of motion, revised in January 2023, emphasized the importance of preventing loss of ROM and providing appropriate treatment to increase or maintain ROM. However, the facility did not ensure that the resident received the necessary services and treatment, leaving the resident at risk for further decline and discomfort.
Failure to Secure Hazardous Areas and Implement Fall Interventions
Penalty
Summary
The facility failed to secure an electrical furnace closet, which was easily accessible due to damage to the door's frame, placing 30 cognitively impaired and independently mobile residents at risk for preventable injuries and accidents. During an initial walkthrough, it was observed that the closet doors, although locked, could be easily pulled open, exposing numerous electrical boxes with high voltage warnings. Administrative staff confirmed the issue and acknowledged that the room should be lockable, as per the facility's accident policy, which mandates an environment free from hazards. Additionally, the facility did not ensure that a resident's care-planned fall interventions were in place. The resident, who had a history of falls and was identified as a high fall risk, was observed without the necessary Dycem in her wheelchair, which was intended to prevent her from sliding out. Despite the care plan specifying the use of Dycem, staff members were either unaware or did not ensure its presence, contrary to the facility's fall prevention policy. This oversight placed the resident at further risk for injuries related to falls.
Inadequate Catheter Care for Resident
Penalty
Summary
The facility failed to provide appropriate treatment for a resident, identified as R67, who had an indwelling catheter. The deficiency was observed when R67's catheter drainage bag was found resting directly on the floor under his recliner. This observation was made despite the facility's policy and care plan, which required that the catheter bag and tubing be positioned below the level of the bladder and away from the entrance of the room door. The facility's policy also mandated daily catheter care to promote hygiene and reduce infection risk. R67's medical records indicated diagnoses of benign prostatic hyperplasia, cognitive-communication deficit, and hypertension. The resident was noted to have severely impaired cognition and was dependent on staff assistance for toileting. Interviews with facility staff, including a CNA and a licensed nurse, confirmed that the catheter bag should not be placed on the floor. An administrative nurse acknowledged the difficulty in finding a suitable place to attach the catheter bag on recliners. The failure to adhere to the facility's catheter care policy placed R67 at risk for catheter-related complications.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident, identified as R28, received physician-ordered supplemental oxygen continuously as required. Observations revealed that R28's nasal cannula was not in use and was not stored in the provided storage bag, with the oxygen concentrator turned off. This oversight was noted despite R28's medical history, which included chronic respiratory failure, dementia, and congestive heart failure, conditions that necessitate continuous oxygen support. The resident's care plan and physician's orders clearly indicated the need for continuous oxygen via nasal cannula, yet this was not adhered to. Interviews with facility staff, including a Certified Nurse Aide and a Licensed Nurse, confirmed that R28 was supposed to be on continuous oxygen and that the nasal cannula should be stored properly when not in use. The staff acknowledged their responsibility to ensure the resident's oxygen was on to prevent further respiratory issues. The facility's policy on oxygen administration also supported the need for adherence to physician orders. The failure to provide continuous oxygen and properly store the nasal cannula placed R28 at risk of respiratory complications and possible infection.
Failure to Administer Prescribed Eyedrops
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate skills and knowledge to manage a resident's physician-ordered medication. A resident with severe cognitive impairment and multiple medical conditions, including dementia and a history of stroke, was prescribed Refresh Plus Ophthalmic Solution for dry eyes. Despite receiving the medication and instructions from the resident's representative, the nursing staff did not add the eyedrops to the resident's orders or administer them as prescribed. The facility did not follow up with the resident's outside medical provider in a timely manner, resulting in a delay of over a week before the medication was reordered and administered. Interviews with facility staff revealed that the nurse on duty was responsible for verifying and entering outside orders into the Electronic Medical Records (EMR) system. However, this process was not completed, leading to a lapse in the resident's medication routine. The facility's Nursing Staff Competency policy, which mandates that staff have the necessary competencies and skills to ensure resident safety, was not adhered to in this instance. This oversight placed the resident at risk for impaired quality of care due to the failure to administer the prescribed medication.
Failure to Provide Adequate Dementia Care Leads to Multiple Falls
Penalty
Summary
The facility failed to provide adequate dementia-related behavioral services for Resident 65, who was diagnosed with Alzheimer's disease and exhibited severe cognitive impairment. The resident's medical records indicated a history of falls, dysphagia, muscle weakness, and cognitive-communication disorder. Despite these conditions, the facility did not effectively implement interventions to prevent falls and promote the resident's well-being. The care plan noted the need for substantial assistance with daily activities and the use of a soft-touch call light, but these measures were insufficient to prevent multiple non-injury falls. Observations and interviews revealed that the resident experienced several falls due to impulsiveness and lack of safety awareness. The facility's records showed that the resident fell out of his wheelchair and bed on multiple occasions, often due to missing or improperly used safety equipment such as foot pedals and fall mats. The facility attempted to engage the resident with fidget devices and conversations about farming, but these efforts were inconsistent and poorly documented. Staff interviews confirmed that the resident often refused sensory devices, and there was a lack of documentation regarding these refusals. The facility's policy on dementia care emphasized individualized care interventions and the use of the least restrictive approaches. However, the facility did not adhere to this policy, as evidenced by the resident's repeated falls and lack of engagement in meaningful activities. The failure to provide appropriate dementia-related behavioral services placed the resident at risk for decreased quality of life, isolation, and impaired dignity, as noted in the report.
Failure to Follow Physician Parameters for Hypertensive Medication
Penalty
Summary
The facility failed to ensure that physician parameters were followed for a hypertensive medication prescribed to a resident with a history of congestive heart failure and hypertension. The resident's electronic medical record indicated that Carvedilol, an antihypertensive medication, was to be held if the systolic blood pressure was less than 110 mmHg or the diastolic blood pressure was less than 60 mmHg. However, the Medication Administration Record (MAR) showed that the resident's blood pressure was below the set parameters on several occasions, yet there was a lack of documentation of the blood pressure readings in the clinical record. Interviews with facility staff revealed that the Certified Medication Aide (CMA) was aware of the need to hold the medication if the blood pressure was outside the parameters but failed to document the blood pressure readings on the MAR. The Licensed Nurse confirmed that blood pressure readings should be recorded and reported if they fall outside the physician-ordered parameters. The facility's policy required that drugs be administered only upon the written order of a licensed prescriber, and the failure to adhere to this policy resulted in the potential for unnecessary medication administration, which could lead to harmful side effects.
Inadequate CMS-Approved Indication for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as R8, had an adequate CMS-approved indication for the use of the antipsychotic medication Seroquel. R8, who had diagnoses of Alzheimer's disease, dementia, and hypertension, was taking Seroquel daily to manage moods related to Alzheimer's dementia with agitation. However, the facility did not have a CMS-approved diagnosis for the use of this antipsychotic medication. The resident's care plan included documentation of episodes of agitation and the use of non-pharmacological interventions, but there was no evidence of a pharmacy review for the medication. Interviews with facility staff revealed a lack of clarity regarding the appropriate diagnosis for the use of Seroquel. A licensed nurse stated that the pharmacy typically assists with medication reviews, but there was no indication that a review had been conducted for R8. The administrative nurse acknowledged that Alzheimer's disease and dementia are not approved diagnoses for antipsychotic use and mentioned the need to obtain appropriate documentation from the resident's physician. The facility also failed to provide a policy regarding psychotropic medications or physician orders when requested, highlighting a deficiency in ensuring proper medication administration and documentation for R8.
Infection Control Deficiencies in Oxygen and Catheter Equipment Handling
Penalty
Summary
The facility failed to adhere to sanitary infection control practices concerning the storage of oxygen equipment and the care of Foley catheters, which placed residents at risk for infectious diseases. During an observation, a resident's urinary catheter collection bag was found resting directly on the floor, with amber-colored urine visible inside. This practice contradicts the facility's policy, which requires that the collection bag be maintained below the level of the bladder and not touch the floor to prevent contamination and potential infection. Additionally, another resident's supplemental oxygen nasal cannula was observed resting on top of the bed without a plastic storage bag, contrary to the facility's infection prevention policy. Staff interviews revealed that oxygen tubing and equipment should be stored in clean plastic bags when not in use, and any contaminated equipment should be replaced. The facility's policy, revised in October 2022, mandates that all medical equipment be handled and stored to minimize contamination risk, yet these practices were not followed, leading to the identified deficiencies.
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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