Rolling Hills Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Wichita, Kansas.
- Location
- 1319 Seville Street, Wichita, Kansas 67209
- CMS Provider Number
- 175253
- Inspections on file
- 19
- Latest survey
- April 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Rolling Hills Health And Rehab during CMS and state inspections, most recent first.
A resident with a complex medical history was rehospitalized after receiving medications that should have been discontinued upon their return to the facility. The medications, hydrochlorothiazide and lisinopril, were administered due to their presence on the MAR, despite discharge instructions to discontinue them. This error resulted in the resident experiencing low blood pressure and heart rate, necessitating ICU care.
The facility failed to ensure a safe environment for residents, leading to multiple deficiencies. A resident was not provided with the correct slide board for transfers, risking falls. Another resident faced entrapment risks due to unsafe bedrails, while hazardous materials were found in a cognitively impaired resident's room. Additionally, a resident smoked without a required apron, violating their care plan. These issues placed residents at risk for preventable accidents and injuries.
A facility failed to update a resident's care plan after the discontinuation of hydrochlorothiazide (HCTZ), a diuretic medication. Despite hospital discharge instructions to stop HCTZ and lisinopril, the resident continued to receive these medications. The care plan still included directives for administering HCTZ, placing the resident at risk for inappropriate care due to uncommunicated care needs. The interdisciplinary team did not revise the care plan, contrary to facility policy.
A facility failed to maintain ongoing communication with a dialysis provider for a resident with stage four CKD, risking health complications. The resident required dialysis thrice weekly, but the facility's records lacked completed information from the dialysis center for over two months. Despite policy requirements for detailed communication, the facility did not receive necessary updates, relying instead on calls from the dialysis center for any changes.
A facility failed to obtain written informed consent for the use of side rails for a resident with dementia and other health conditions, placing her at risk for injury. The resident's family demanded the use of side rails despite the risks, and the facility documented verbal consent but did not secure a signed Risk versus Benefits form. Observations confirmed the presence of side rails, and the facility's policy required written consent for such restraints, which was not obtained.
A facility failed to ensure CNA staff had adequate competency in using a slide board for a resident with a history of cerebrovascular accident and hemiparesis. The resident, dependent on staff for transfers, was lowered to the ground during a transfer due to weakness. Observations showed CNAs struggled with finding a suitable gait belt and using the slide board correctly. The facility's competency policy required regular training, but the provided competencies lacked training for slide board transfers, placing the resident at risk for injury.
A facility failed to ensure proper oversight by the Consultant Pharmacist, leading to deficiencies in medication management for two residents. One resident received an antipsychotic medication without appropriate documentation or indication, while another resident's irregular blood pressure and pulse readings were not reported to the physician as required. These oversights placed the residents at risk for unnecessary medication and side effects.
A facility failed to notify a physician when a resident's blood pressure and pulse were outside the ordered parameters, despite instructions to do so. The resident, with atherosclerosis and impaired cognition, was on amiodarone, and the care plan required notifying the physician if the heart rate was below 60 BPM or DBP below 90. The clinical record showed these conditions occurred without physician notification, confirmed by an administrative nurse, placing the resident at risk for ineffective medication regimens.
A facility failed to ensure a resident did not receive antipsychotic medication without appropriate indication or required physician documentation. The resident, diagnosed with dementia and major depressive disorder, was given Seroquel for unspecified dementia with behavioral disturbances. The facility's policy required proper documentation and non-pharmacological interventions, which were not met, placing the resident at risk for unintended effects.
The facility failed to properly prepare pureed diets for two residents, compromising the meals' nutritive value and palatability. Observations revealed that dietary staff did not use a recipe for pureeing meatloaf and initially omitted pureed bread rolls from the menu, contrary to facility policy. This placed the residents at risk for impaired nutrition.
Medication Error Leads to Resident Rehospitalization
Penalty
Summary
The facility failed to prevent a significant medication error for a resident, identified as R40, who received medications that should have been discontinued. R40 had a complex medical history, including bradycardia, cerebrovascular accident, chronic kidney disease, hypertension, depression, hypotension, acute kidney failure, and diabetes mellitus. Upon discharge from the hospital, the physician ordered the discontinuation of hydrochlorothiazide (HCTZ) and lisinopril, but these medications were not removed from the resident's Medication Administration Record (MAR). On the morning following R40's return to the facility, a Certified Medication Aide (CMA) administered the HCTZ and lisinopril as they were still active on the MAR. This administration occurred despite the discharge instructions to discontinue these medications. Later that day, R40 exhibited symptoms of low blood pressure and a low heart rate, leading to rehospitalization in the intensive care unit (ICU) to rule out a cerebrovascular accident and address the low heart rate and blood pressure. The facility's policy on managing medication errors was not followed, as the medications were not discontinued from the MAR, and the error was not immediately identified. The administrative staff and nurses involved did not verify the discontinuation of the medications upon the resident's readmission, leading to the administration of the incorrect medications and subsequent adverse effects on R40's health.
Multiple Safety Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for several residents, leading to multiple deficiencies. One resident, who had a history of falls and required assistance for mobility, was not provided with the correct type of slide board during transfers. Despite a previous staff-assisted fall, the facility did not address the risk adequately, and staff continued to use an inappropriate slide board, which posed a risk for further falls and injuries. Observations revealed that staff struggled to find a suitable gait belt and used a flat, wooden slide board that was not appropriate for the resident's needs. Another resident was at risk for entrapment due to large openings in the side rails of their bed. Despite the facility's awareness of the risk, the family insisted on using the quarter-rails, and the facility did not implement alternative safety measures. The facility's policy on the use of physical restraints, including bedrails, was not adequately followed, as there was no signed consent from the resident or responsible party, and the facility failed to explore less restrictive alternatives. Additionally, a resident with moderate cognitive impairment had hazardous materials, including hydrogen peroxide and medicated shampoos, stored openly in their room, contrary to safety protocols. The facility did not have a policy regarding accidents, and the items were only removed after being observed by staff. Furthermore, another resident who required a smoking apron as per their care plan was observed smoking without one, indicating a failure to adhere to the care plan and smoking policy. These deficiencies placed the residents at risk for preventable accidents and injuries.
Failure to Update Care Plan After Medication Discontinuation
Penalty
Summary
The facility failed to revise the care plan for Resident 40 after the discontinuation of hydrochlorothiazide (HCTZ), a diuretic medication. This oversight was identified during a review of the resident's electronic medical record, which documented multiple diagnoses including bradycardia, cerebrovascular accident, chronic kidney disease, hypertension, depression, hypotension, acute kidney failure, and diabetes mellitus. Despite the hospital discharge summary directing the discontinuation of HCTZ and lisinopril, the medication administration record showed that Resident 40 continued to receive these medications. The care plan, which should have been updated to reflect the discontinuation, still included directives for administering HCTZ and monitoring for adverse effects. The interdisciplinary team, responsible for care plan updates, did not remove the diuretic therapy care plan for HCTZ when the medication was discontinued. This failure to update the care plan placed Resident 40 at risk for inappropriate care due to uncommunicated care needs. The facility's policy on using care plans emphasizes the importance of updating care plans to reflect changes in a resident's condition, which was not adhered to in this case. The administrative nurse confirmed that the care plan should have been revised following the discontinuation of the medication.
Failure in Communication with Dialysis Provider
Penalty
Summary
The facility failed to ensure ongoing communication with the dialysis provider regarding a resident's dialysis treatments, which placed the resident at risk for complications and health decline. The resident, identified as having stage four chronic kidney disease, required dialysis three times a week. Despite this critical need, the facility's records revealed a lack of completed information from the dialysis center regarding the resident's treatment, monitoring, or orders over a period of more than two months. The facility's policy required detailed communication between the facility and the dialysis provider, including information on medication administration, new orders, lab results, vital signs, weights, and other critical health indicators. However, the facility did not receive the necessary communication sheets back from the dialysis center, and the administrative nurse confirmed that the facility relied on the dialysis center to call them if there were any changes or important information. This lack of communication and documentation was a direct violation of the facility's dialysis policy and placed the resident at risk for health complications.
Failure to Obtain Written Informed Consent for Side Rail Use
Penalty
Summary
The facility failed to obtain written informed consent for the use of side rails for a resident, identified as R10, which placed her at risk for accident or injury due to uninformed choices regarding side rail use. R10 had a history of dementia, anxiety, hypertension, and chronic obstructive pulmonary disease, and was dependent on staff for toileting, mobility, and transfers. The facility's records indicated that R10 used side rails for mobility, but no alternatives to bed rails were attempted, and the family demanded their use despite the risks. The facility's documentation, including the Electronic Medical Record and the Care Plan, noted that side rail precautions were discussed with R10's family, and consent was obtained verbally. However, the Risk versus Benefits form, which outlined the potential risks associated with side rail use, lacked a signature from the resident or responsible party. The form was signed by two administrative nurses, but it only documented that the facility spoke to the responsible party and the physician via phone. Observations confirmed that R10's bed had quarter-rails on both sides, and the facility's policy required written consent for the use of restraints, including bed rails. The policy also mandated that restraints should only be used after other alternatives had been tried unsuccessfully and upon the written order of a physician. Despite these requirements, the facility did not obtain the necessary written informed consent, leading to the deficiency.
Inadequate CNA Competency in Slide Board Transfer
Penalty
Summary
The facility failed to ensure that Certified Nurse Aide (CNA) staff possessed adequate competency and skill for the use of a slide board for a resident, who was lowered to the ground during a slide board transfer. The resident, identified as R6, had a medical history that included cerebrovascular accident, hemiparesis/hemiplegia affecting the left side, muscle weakness, diabetes mellitus, hypertension, and obesity. The resident was dependent on staff for various activities, including transfers, and had a high risk for falls as documented in multiple assessments. The care plan for the resident directed staff to use a Beasy transfer board, gait belt, and have the right leg leading for transfers. If the resident was too weak, a Hoyer lift with two staff was to be used. However, during an incident, CNA M reported that while performing a two-person transfer with a gait belt and slide board, the resident became weak, and the CNA lowered the resident to the floor. The investigation noted that the care plan was followed, but the CNA was later educated to use the Hoyer lift if the resident experienced weakness. Observations revealed that CNA M and another CNA struggled to find a suitable gait belt for the resident and had difficulty using the slide board correctly. The slide board used lacked a circular seat, and the transfer was not performed correctly, as noted by an administrative nurse. The facility's competency policy required regular in-service training, but the competencies provided did not include training or observation for a transfer with the slide board. The facility failed to ensure that CNA staff had the necessary skills and competencies for the use of a slide board, placing the resident at risk for injury.
Pharmacist Oversight Deficiencies in Medication Management
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported the lack of an appropriate indication or required physician documentation for a resident's use of an antipsychotic medication, Seroquel. The resident, who had diagnoses of dementia and major depressive disorder, was receiving Seroquel for an inappropriate diagnosis of anxiety, which was later changed to dementia with behavioral disturbances. However, the CP's monthly medication reviews did not consistently address the need for continued use of Seroquel, despite previous recommendations to evaluate its use due to potential metabolic side effects. Another resident's care was compromised due to the facility's failure to ensure the CP identified and reported irregularities in blood pressure and pulse monitoring. The resident, diagnosed with atherosclerosis, was receiving amiodarone, with specific instructions to notify the physician if the heart rate or blood pressure fell below certain parameters. The clinical records showed that these parameters were not met on several occasions, yet there was no documentation of physician notification, and the CP's regimen reviews did not address these irregularities. The facility's Pharmacist Services Overview policy required collaboration with the facility, Medical Director, and Attending Physician to provide timely and appropriate pharmacy services. However, the CP did not fulfill this role effectively, as evidenced by the failure to report the unapproved indication for the antipsychotic medication and the lack of monitoring for the resident's blood pressure and pulse. These deficiencies placed the residents at risk for unnecessary medication and related side effects.
Failure to Notify Physician of Out-of-Parameter Vital Signs
Penalty
Summary
The facility failed to notify the physician when a resident's blood pressure and pulse were outside the physician-ordered parameters, which is a deficiency in ensuring the resident's drug regimen was free from unnecessary drugs. The resident, who had a diagnosis of atherosclerosis of the coronary arteries and severely impaired cognition, was prescribed amiodarone to manage an irregular heartbeat. The care plan and physician's order instructed staff to hold the medication and notify the physician if the resident's heart rate was less than 60 beats per minute (BPM) or if the diastolic blood pressure (DBP) was less than 90. Despite these instructions, the resident's clinical record showed that the DBP was less than 90 daily from September 12 to November 13, and the pulse was less than 60 BPM on several specific dates, without documentation that the physician was notified. An administrative nurse confirmed the findings and acknowledged an error in entering the order, but emphasized that staff should have followed the physician's order. This oversight placed the resident at risk for ineffective medication regimens and unnecessary medication side effects.
Failure to Document Appropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as R37, did not receive antipsychotic medication without an appropriate indication or the required physician documentation for its use. R37, who had diagnoses of dementia and major depressive disorder, was receiving Seroquel, an antipsychotic medication, for unspecified dementia with behavioral disturbances. However, the resident's electronic medical record lacked a documented physician rationale that included unsuccessful attempts for non-pharmacological symptom management and an assessment of the risk versus benefits for the continued use of Seroquel. Observations and interviews revealed that the facility's administrative nurse verified the resident received Seroquel for dementia with behavioral disturbances, which she believed was an appropriate indication. However, the facility's policy required that psychotropic medications be used only when necessary and with proper documentation, including non-pharmacological interventions attempted and the resident's quality of life being negatively impacted by the non-use of the medications. The facility's failure to adhere to these requirements placed R37 at risk for unintended effects related to psychotropic medications.
Deficiency in Pureed Diet Preparation
Penalty
Summary
The facility failed to correctly prepare a pureed diet for two residents, which compromised the nutritive value and palatability of the meals. During observations, it was noted that the dietary staff prepared pureed vegetables and meatloaf without following a recipe for the meatloaf, which is against the facility's policy. The vegetables were blended with food thickener and leftover vegetable juice to achieve the correct consistency, while the meatloaf was blended with ketchup. However, the dietary staff did not prepare the bread roll in a pureed form initially, which was part of the menu for residents on a pureed diet. The facility's policy, dated October 2024, mandates that meals should conserve value, flavor, and appearance, and be served at a safe and appetizing temperature. However, the policy lacked specific guidelines for preparing pureed diets, leading to the deficiency. The dietary staff's failure to use a recipe for the meatloaf and to initially provide pureed bread rolls resulted in meals that did not meet the required standards, placing the affected residents at risk for impaired nutrition.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
