Rossville Healthcare & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rossville, Kansas.
- Location
- 600 Perry, Rossville, Kansas 66533
- CMS Provider Number
- 175397
- Inspections on file
- 25
- Latest survey
- June 25, 2025
- Citations (last 12 mo.)
- 13 (1 serious)
Citation history
Health deficiencies cited at Rossville Healthcare & Rehab Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls experienced multiple incidents due to the facility's failure to consistently implement and monitor fall prevention interventions, including missing safety signs and visual cues. Additionally, surveyors found unsecured hazardous chemicals and accessible appliances in common areas and the memory care unit, with staff lacking training on safety procedures. These deficiencies resulted in unsafe conditions for cognitively impaired and independently mobile residents.
The facility did not complete required annual performance evaluations for five CNAs who had been employed for over a year. Review of records and staff interviews confirmed that no documentation of yearly evaluations was available for these staff members, despite facility policy mandating annual reviews.
Surveyors found that food items such as ice cream and pie were stored in the kitchen freezer and refrigerator without labels or dates, and clean plates and bowls were stored facing upwards, contrary to facility policy. The kitchenette area was also found to be unsanitary, with old food debris and open, unlabeled food items. Dietary staff confirmed that these practices did not meet the facility's standards for safe food handling and storage.
The facility did not complete a thorough assessment to determine necessary resources for competent resident care during daily operations and emergencies. The assessment lacked details on shift-specific staffing for weekends and the Memory Care Unit, and PBJ data showed consistently low weekend staffing. This deficiency impacted all residents.
The facility did not submit complete and accurate direct care staffing information to CMS through PBJ, as required. Despite PBJ reports indicating low weekend staffing, administrative staff stated that weekend staffing was not low and that data was based on payroll hours. The submitted information did not accurately reflect actual staffing levels, especially on weekends.
Surveyors identified that the facility did not maintain an effective QAA program, resulting in multiple deficiencies such as undignified meal care, inaccessible call lights, unsafe wheelchair transport, unsecured hazardous materials, unsanitary storage of respiratory equipment, lack of required staff training and evaluations, incomplete staffing records, and improper medication management. These failures affected resident safety, dignity, and quality of care across several areas.
Five CNAs employed for over a year did not complete the required 12 hours of annual in-service education, including training in dementia care and abuse prevention. Facility records lacked documentation of completed training, and administrative staff confirmed the deficiency. No policy regarding yearly in-service education was provided.
Staff did not consistently ensure that call lights were within reach for several residents, leaving them unable to communicate their needs. Additionally, some residents, including those with severe cognitive impairment, were transported in wheelchairs without foot pedals, resulting in their feet dragging on the ground. Staff interviews confirmed that these practices did not align with facility policy requiring the use of assistive devices and safe transport procedures.
Surveyors found that trash, gloves, and linens were left on handrails, floors, and radiators, and that respiratory equipment for several residents, including nasal cannulas and a CPAP mask, was not stored in a sanitary manner. Additionally, a Hoyer lift was not sanitized between resident uses. Staff interviews confirmed that these practices did not align with facility policy for infection prevention and control.
A resident with severe cognitive impairment and total dependence on staff for daily care was repeatedly assisted with meals by staff standing over her, contrary to her care plan and facility policy. Staff interviews confirmed that proper procedure required sitting next to residents during meal assistance to maintain dignity, but this was not followed.
Staff left a resident's electronic medical record open and visible on a wall kiosk monitor, failing to secure the resident's private health information. Interviews with CNA, LN, and administrative nursing staff confirmed that this action was not in line with facility policy, which requires staff to maintain resident privacy and confidentiality.
A resident with complex medical needs was assisted with eating while reclined in a Broda chair, despite physician orders requiring upright positioning during meals. The care plan was not updated to reflect new dietary and positioning interventions after the resident's status changed from NPO with tube feeding to a mechanical soft diet with max assistance. Staff were unclear about the current care plan directives, and observations confirmed the resident was not positioned as ordered during meal assistance.
Staff did not provide necessary assistance with eating and positioning for two residents with severe cognitive and physical impairments. One resident was left to eat independently despite being dependent on staff for meals, while another was transported without proper footwear or footrest support, contrary to care plan requirements. Staff interviews confirmed awareness of care plans, but the needed support was not provided.
Two residents with significant cognitive and physical impairments, both at risk for pressure ulcers, were observed without required pressure-reducing boots or floating of heels as ordered in their care plans and physician orders. Despite clear documentation and staff awareness tools, these interventions were not consistently implemented, contrary to facility policy and best practices for pressure injury prevention.
Two residents with contractures and severe cognitive impairment did not receive prescribed splints and positioning devices as ordered in their care plans and by occupational therapy. Observations showed both residents without the required devices over multiple days, and staff interviews revealed confusion about responsibility for applying splints and the timing of restorative interventions. Documentation of restorative care was inconsistent, and the facility's restorative program was in the process of being revamped, resulting in a lack of consistent implementation of required interventions.
A resident with severe cognitive and physical impairments, who recently transitioned to a mechanical soft diet while continuing tube feedings, was observed being assisted with eating while reclined in a Broda chair rather than upright as required by physician orders and care plan. Staff interviews and facility policy confirmed the need for upright positioning during meals to prevent swallowing complications, but this was not consistently followed, placing the resident at risk.
A resident with multiple diagnoses requiring CPAP therapy was found to have their CPAP mask and tubing stored on the floor instead of in a sanitary, dated bag as required by facility policy and physician orders. Staff interviews confirmed knowledge of proper storage procedures, but the equipment was not stored appropriately, resulting in a deficiency related to respiratory care equipment sanitation.
A resident with dementia and multiple comorbidities did not receive individualized, person-centered activities or interventions as required by facility policy. The care plan lacked specific dementia care strategies, and staff interviews confirmed the absence of tailored interventions, despite expectations for such care on the memory unit.
A consultant pharmacist did not identify or report the use of antipsychotic medications prescribed without CMS-approved indications for three residents with dementia and related conditions. Despite monthly medication regimen reviews, inappropriate orders for Olanzapine and Quetiapine were not flagged or reported, and there was no physician-documented rationale for their use. Nursing and administrative staff confirmed that these indications were not appropriate, and facility policy requiring timely reporting of such irregularities was not followed.
Two residents with severe cognitive impairment were prescribed antipsychotic medications without CMS-approved indications, with orders citing mood disorder, dementia, or depression as the rationale. Despite care plan reviews and pharmacy recommendations, there was no physician-documented justification or risk versus benefit analysis for the continued use of these medications, contrary to facility policy and regulatory requirements.
The facility did not retain daily nurse staffing documentation for 31 days as required, despite having a policy to keep such records accessible for at least 18 months. An administrative nurse confirmed that the staff scheduler was responsible for posting and retaining these records.
A facility failed to ensure a CNA received effective communication training, leading to an incident where the CNA and a resident engaged in inappropriate verbal exchanges. The CNA was accused of throwing a cup of ice, and both parties used inappropriate language. The facility could not provide documentation of the required training, and administrative staff were unable to confirm its completion.
A resident with schizoaffective disorder and borderline personality disorder was verbally abused by a CNA, leading to a confrontation where derogatory language was exchanged. Despite the facility's policy and care plan directives, the staff member failed to disengage or seek assistance, resulting in a deficiency in protecting the resident from verbal abuse.
A resident with dementia was discharged from a facility following aggressive behavior and arrest, but the discharge notice sent to the resident's representative was incomplete, lacking appeal rights and contact information for advocacy agencies. The notice was not verified before sending, leading to a deficiency in resident rights.
Failure to Prevent Accidents and Secure Environmental Hazards
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents. One resident with severe cognitive impairment, a history of repeated falls, and multiple risk factors had several documented falls. Despite being identified as a high fall risk and having numerous care plan interventions in place, the facility did not consistently implement or monitor these interventions. Observations revealed that required safety signs were missing from the resident's room, and visual cues such as bright tape on wheelchair brakes were not present. Additionally, the facility was unable to provide root cause analyses or investigations for several of the resident's falls, nor could they provide evidence that medication reviews, as required by the care plan, were completed following these incidents. Environmental hazards were also identified throughout the facility. During inspections, surveyors found that the power shut-off for the kitchenette oven and stovetop was not activated, leaving the appliances operational and accessible to residents. A working toaster was also left plugged in and accessible. In another area, an unlocked maintenance closet contained multiple bottles of hazardous disinfectant cleaners. On the secured memory care unit, a cognitively impaired and independently mobile resident was observed rummaging through an unlocked cabinet containing bleach and disinfectant spray, with no staff supervision provided at the time. Staff interviews confirmed that hazardous materials and equipment were not consistently secured, and direct care staff were not trained on how to deactivate the oven/stovetop power. The facility's own policies required that hazardous materials be kept out of residents' reach and that accident hazards be minimized through preventative interventions and supervision. However, these policies were not followed, as evidenced by the unsecured chemicals, accessible appliances, and lack of staff training. The failure to secure hazardous materials and equipment, combined with the lack of effective fall prevention interventions and monitoring, placed multiple cognitively impaired and independently mobile residents at risk for accidents and injuries.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete yearly performance evaluations for five Certified Nurse Aides (CNAs) who had been employed for more than 12 months. Record review showed that none of the five CNAs reviewed had a documented annual performance evaluation available upon request. Interviews with administrative staff confirmed that department directors were responsible for conducting these evaluations, and the facility's policy required annual formal written evaluations for all employees. This deficiency was identified through a review of personnel records and staff interviews, with no evidence provided that the required evaluations had been completed for the CNAs in question.
Failure to Maintain Sanitary Food Storage and Handling Practices
Penalty
Summary
Surveyors observed multiple failures to follow sanitary dietary standards in the facility's kitchen and dining areas. During a walkthrough, 13 uncovered cups of chocolate ice cream were found open to the air in the reach-in freezer, and these cups were both unlabeled and undated. Additionally, an opened chocolate pie was found in the refrigerator without a label or date. In the plate and utensil storage area, stacked bowls were stored in a plastic bin facing upward, and clean plates on food carts were also stored facing upwards. The open kitchenette in the main entry area had stains and old food debris inside the refrigerator and microwave, and the kitchenette freezer contained open, unlabeled, and undated food items. Dietary staff confirmed that facility policy required all food items to be labeled and dated before storage and that utensils and plates should be stored facing downward to prevent cross-contamination. The facility's Food Preparation and Service policy, revised in December 2024, specified that food service employees must handle food and equipment in compliance with safe handling practices, including proper labeling, dating, and sanitary storage. These observed practices were not in accordance with the facility's policy and professional standards, resulting in a deficiency related to food and equipment storage.
Failure to Conduct Comprehensive Facility-Wide Resource Assessment
Penalty
Summary
The facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. The assessment provided by administrative staff was updated to reflect recent CMS staffing requirements and identified required staffing needs per day, but did not specify staffing needs by shift for weekends or for the specialized Memory Care Unit. Review of the facility's Payroll Based Journal (PBJ) data over a one-year period revealed excessively low weekend staffing for all four quarters. The facility's own policy required assessment of resources for evenings, nights, and weekends, but the documentation did not meet these requirements. This deficiency affected all 74 residents in the facility.
Failure to Submit Accurate Staffing Data via PBJ
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare & Medicaid Services (CMS) through Payroll Based Journaling (PBJ), as required by federal regulations. Review of the PBJ report for all four quarters of Fiscal Year 2024 indicated the facility triggered for low weekend staffing. However, interviews with administrative staff revealed that they believed weekend staffing was not low, despite occasional call-ins, and that the information submitted was based on payroll hours. The facility's policy required submission of accurate staffing data, including agency and contract staff, using verifiable and auditable data, but the submitted information did not reflect actual staffing levels, particularly on weekends.
Failure to Maintain Effective QAA Program and Address Multiple Quality Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assessment and Assurance (QAA) program, as evidenced by multiple deficiencies identified during the survey. Surveyors observed that the QAA committee did not adequately address or correct quality deficiencies prior to the survey, resulting in ongoing issues affecting resident care and safety. The facility's QAPI policy outlined a comprehensive, data-driven approach to quality improvement, but in practice, the facility did not implement or follow through with these processes, as shown by the repeated and varied deficiencies across multiple care areas. Specific deficiencies included failures in providing dignified care during meals, ensuring reasonable accommodation for residents' needs such as accessible call lights and safe wheelchair transport, and protecting the privacy and confidentiality of medical records. Additional issues were noted in the areas of nutrition and hydration, with improper positioning of residents during meals, and in the use of pressure-reducing devices for residents at risk of pressure ulcers. The facility also failed to apply necessary splints for residents with contractures and dysphagia, and did not secure hazardous materials or equipment, exposing cognitively impaired residents to immediate jeopardy. Environmental hazards, lack of effective fall interventions, and unsanitary storage of respiratory equipment were also documented. Further deficiencies were found in staff management and training, including the absence of required yearly performance evaluations and in-service education for Certified Nurse Aides, incomplete and inaccurate staffing data submission, and failure to maintain required nurse staffing records. The facility did not conduct a thorough facility-wide assessment to determine necessary resources for competent care, and failed to ensure person-centered activities for residents with dementia. Medication management was also deficient, with the consultant pharmacist and physicians not providing appropriate indications or risk-benefit analyses for antipsychotic medications. Dietary services were found lacking in sanitary standards, and infection control practices were not consistently followed, as evidenced by improper storage of oxygen tubing, CPAP masks, and unsanitary handling of equipment and supplies.
Failure to Ensure Required In-Service Education for CNAs
Penalty
Summary
The facility failed to ensure that five Certified Nurse Aides (CNAs), each employed for more than 12 months, completed the required 12 hours of in-service education within the past year. Record review showed that none of the sampled CNAs had documentation of completing the mandated in-service training, which includes education in dementia care and abuse prevention. During an interview, an administrative nurse confirmed that it was a team responsibility to ensure direct care staff received the required education, and acknowledged the facility had recently hired a clinical nursing educator to assist with in-services. Additionally, the facility was unable to provide a policy related to the required yearly in-service education.
Failure to Ensure Call Light Accessibility and Safe Wheelchair Transport
Penalty
Summary
Staff failed to ensure that several residents had access to their call lights, leaving them unable to communicate their needs. During observations, multiple residents were found in their beds with call lights either on the floor, behind the bed, or otherwise out of reach. These residents attempted to locate their call lights but were unsuccessful. Interviews with staff confirmed that call lights are expected to be within reach of all residents at all times, but this was not consistently maintained. Additionally, staff were observed transporting residents in wheelchairs without foot pedals attached. Several residents, including those with severe cognitive impairment, were pushed in their wheelchairs while their feet dragged or slid on the ground. Staff interviews confirmed that foot pedals are required to be used during transport to prevent residents' feet from touching the ground. The facility's policy requires reasonable accommodation of residents' needs, including the use of assistive devices and ensuring safety during transport, but these practices were not followed.
Infection Control Deficiencies in Equipment and Environmental Sanitation
Penalty
Summary
Surveyors observed multiple infection control deficiencies throughout the facility, including trash, gloves, and trash bags left on handrails and floors in various halls, as well as linens, dishes, and other items placed on radiators and registers. Additionally, two residents' nasal cannula oxygen tubing was found wrapped around stationary canisters in their rooms and not stored in a sanitary manner. Another resident's CPAP mask and tubing were observed lying on the floor between the bed and the wall, rather than being stored in a clean bag as required by facility policy. These observations were corroborated by staff interviews, which confirmed that respiratory equipment should be stored in dated bags and that trash should not be left on surfaces or the floor. Further, shared equipment such as the Hoyer lift was not sanitized between resident uses, as evidenced by a Certified Medication Aide moving the lift from one resident's room to another without cleaning it. Staff interviews indicated awareness of the proper procedures for storing respiratory equipment and sanitizing shared devices, as well as the availability of cleaning supplies. The facility's infection prevention and control policy requires maintaining a safe and sanitary environment to prevent the transmission of communicable diseases, but these practices were not consistently followed, resulting in the cited deficiencies.
Failure to Provide Dignified Meal Assistance
Penalty
Summary
Staff failed to provide a dignified care environment for a resident with severe cognitive impairment and multiple medical diagnoses, including aphasia, dementia, and hypertension. The resident was totally dependent on staff for all activities of daily living and required set-up assistance during meals, as documented in her care plan and assessments. Despite care plan instructions to provide supervision, cueing, and a quiet environment during mealtimes, staff were observed standing over the resident while attempting to feed her during both breakfast and lunch on separate occasions. The resident consumed only a small portion of her meal during one of these observed instances. Interviews with facility staff, including a CNA and an administrative nurse, confirmed that the expectation was for staff to sit next to residents when providing meal assistance and not to stand over them. The facility's own dementia care policy emphasized the importance of ensuring a dignified care environment. The observed actions were inconsistent with both facility policy and staff expectations, resulting in a failure to honor the resident's right to dignity during mealtimes.
Failure to Secure Resident Medical Record Information
Penalty
Summary
Facility staff failed to secure and protect the privacy and confidentiality of a resident's medical record. On one occasion, staff left the resident's point of care (POC) information open and visible on the electronic medical record (EMR) wall kiosk monitor. Interviews with a certified nurse aide, a licensed nurse, and an administrative nurse confirmed that staff are expected to lock screens and not leave resident information visible after charting. Facility policy requires staff to maintain resident privacy and dignity by protecting personal and medical information.
Failure to Update Care Plan and Ensure Proper Positioning During Meals
Penalty
Summary
The facility failed to ensure that a resident with multiple complex medical conditions, including dementia, Parkinson's disease, hemiplegia, and respiratory failure, was positioned appropriately in his Broda chair while being assisted with eating. The resident had recently transitioned from being NPO and dependent on tube feeding to receiving a mechanical soft diet with max assistance, in addition to continued enteral feedings. Despite physician orders specifying that the resident should be upright in the wheelchair during meals and remain upright for 30 minutes post intake, observations showed the resident was reclined back in his Broda chair during meal assistance on multiple occasions. The resident's care plan was not updated in a timely manner to reflect the new dietary orders and positioning requirements. The care plan continued to direct staff to provide tube feedings and water flushes, but lacked revised interventions for the current nutrition/eating order, including the need for upright positioning during oral intake. Staff interviews revealed uncertainty about whether the care plan had been updated to include the new diet and positioning interventions, and the MDS coordinator or nurses were identified as responsible for ensuring care plan updates following status changes. Facility policy required that the comprehensive care plan be reviewed and revised upon a change in resident status, with the interdisciplinary team collaborating on new interventions. However, the lack of timely care plan revision and failure to direct staff on the resident's current dietary and positioning needs resulted in the resident being assisted with eating while not properly positioned, contrary to physician orders and best practices for safe swallowing.
Failure to Provide Required ADL Assistance and Positioning
Penalty
Summary
Staff failed to provide necessary assistance with activities of daily living (ADLs) for two residents with severe cognitive and physical impairments. One resident, diagnosed with epilepsy, dysphagia, and dementia, was documented as being dependent on staff for eating and other ADLs. Despite this, multiple observations showed the resident left unattended during meals, struggling to eat a pureed diet without staff assistance or encouragement, even though the care plan and assessments clearly indicated a need for substantial to maximum assistance. Another resident, with diagnoses including Alzheimer's disease, congestive heart failure, and dysphagia, was also dependent on staff for ADLs and required specific positioning and footwear for safety and comfort. Observations revealed this resident was transported in a wheelchair without socks or appropriate footwear, and the footrest was not positioned correctly, leaving her feet dangling and uncovered. The care plan specified the need for bilateral lower extremity support and appropriate footwear, but these interventions were not provided as required. Interviews with staff confirmed that care plans and the Kardex were available to guide the level of assistance needed, and that it was the staff's responsibility to ensure residents received the necessary support. Facility policy required that residents unable to perform ADLs independently must receive services to maintain nutrition, hygiene, and comfort, but these requirements were not met for the two residents observed.
Failure to Apply Pressure-Reducing Devices for At-Risk Residents
Penalty
Summary
The facility failed to ensure that pressure-reducing devices were in place for two residents who were at risk for the development of pressure ulcers. One resident, with diagnoses including epilepsy, dysphagia, and dementia, was documented as having severely impaired cognition and was dependent on staff for mobility and activities of daily living. Physician orders and care plans specified the use of pressure-relieving boots on both lower extremities, but multiple observations over several days showed the resident without these boots while seated in a Broda chair and while in bed. Staff interviews revealed a lack of documentation and inconsistent communication regarding the application of these devices, despite the care plan and physician orders. Another resident, with a history of hypertension, anemia, Alzheimer's disease, diabetes, and other conditions, was also identified as being at risk for pressure ulcers due to incontinence and immobility. The care plan required the use of a foam mattress and floating of heels in bed, as well as the use of pressure-relieving boots. Observations found the resident in bed without heels floated and the boots not in use, despite being present in the room. Staff interviews indicated that information about the need for these interventions was available in the care plan and Kardex, but the interventions were not consistently implemented. The facility's own policy committed to the prevention of avoidable pressure injuries and the promotion of healing for existing injuries. However, the lack of adherence to physician orders and care plans for pressure ulcer prevention devices resulted in a failure to provide appropriate care for residents at risk, as evidenced by direct observations and staff statements.
Failure to Apply Prescribed Splints and Positioning Devices for Residents with Contractures
Penalty
Summary
The facility failed to ensure that two residents with contractures and impaired mobility received appropriate application of prescribed splints and positioning devices as recommended by occupational therapy and documented in their care plans and physician orders. For one resident with severe cognitive impairment, multiple diagnoses including Alzheimer's disease, contractures, and muscle weakness, the care plan and physician orders specified the use of bilateral upper extremity resting hand splints for 4-6 hours daily, with hand rolls as an alternative and regular skin checks. However, over several days of observation, the resident was repeatedly seen without the required splints or hand rolls, and staff interviews revealed confusion about who was responsible for applying these devices and when restorative therapy was provided. Another resident, also with severe cognitive impairment, contractures, and dysphagia, had a care plan and orders for the use of a cockup splint for the left wrist to address contractures. Observations showed the resident without the prescribed splint, with the affected hand and wrist curled to the chest. Staff interviews again indicated uncertainty regarding responsibility for applying splints and the timing of restorative interventions. The facility's restorative nursing program policy required maintenance and restorative services to maintain or improve residents' abilities, but documentation and staff responses indicated a lack of consistent implementation. The deficient practice was further evidenced by gaps in restorative nursing documentation, with progress notes not updated for several months and restorative tasks inconsistently marked as completed. Administrative staff acknowledged the restorative program was being revamped, but at the time of the survey, there was no clear process ensuring that residents with contractures received the prescribed supportive devices and interventions as outlined in their care plans and physician orders.
Failure to Properly Position Resident During Meal Assistance
Penalty
Summary
Staff failed to ensure a resident with multiple complex medical conditions, including dementia, Parkinson's disease, hemiplegia, and a history of respiratory failure, was properly positioned in his Broda chair while being assisted with eating. The resident had recently transitioned from being NPO and dependent on tube feeding to receiving a mechanical soft diet with continued enteral nutrition. Physician orders and the care plan specified that the resident should be upright during oral intake to minimize the risk of swallowing complications. On two separate occasions, the resident was observed reclined in his Broda chair at approximately a 45-degree angle while being assisted with meals. Staff members, including a CNA and an activities staff member, provided assistance without ensuring the resident was in the required upright position. After realizing the improper positioning, one staff member adjusted the chair, but the resident had already been assisted with eating while reclined. Interviews with staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that the expectation was for the resident to be upright during meals to reduce the risk of choking or aspiration. Facility policy also directed staff to ensure residents were appropriately positioned during meals. The failure to follow these directives resulted in the resident being at risk for swallowing complications and possible aspiration during meal assistance.
CPAP Equipment Not Stored in Sanitary Manner
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including respiratory failure, COPD, Parkinson's disease, and schizophrenia, was observed to have their CPAP mask and tubing stored on the floor between the bed and the wall, rather than in a sanitary manner. The resident's care plan and physician orders required the use of CPAP nightly, regular cleaning of the mask and tubing, and proper storage of respiratory equipment. The facility's policy also specified that CPAP equipment should be cleaned according to guidelines and stored in a bag with a date when not in use. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that the expectation was for all respiratory equipment to be stored in a dated bag and that bags should be changed weekly. Despite these policies and staff knowledge, the resident's CPAP equipment was not stored as required, leading to a failure to maintain sanitary conditions for respiratory care equipment.
Failure to Provide Person-Centered Dementia Care Interventions
Penalty
Summary
The facility failed to provide necessary person-centered activities and interventions for a resident diagnosed with dementia, as required by their own policy and care standards. The resident had multiple diagnoses, including dementia, major depressive disorder, Parkinson's disease, and bipolar disorder, and was dependent on staff for activities of daily living, used a wheelchair, and required a feeding tube. The resident's care plan included general communication strategies and environmental modifications but lacked individualized, person-centered activities and services specific to dementia care needs. Observations showed the resident was left alone, vocalizing in his native language, with no staff present to provide engagement or support. Interviews with staff, including a CNA, a licensed nurse, and an administrative nurse, revealed that they expected a dementia care plan with specific interventions for residents with dementia, especially those residing on the memory care unit. However, they could not explain why such person-centered dementia interventions were not in place for this resident. The facility's own dementia care policy required individualized, non-pharmacological approaches and meaningful activities, but these were not reflected in the resident's care plan or observed care.
Failure to Identify and Report Inappropriate Antipsychotic Use by Consultant Pharmacist
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported the lack of appropriate Centers for Medicare and Medicaid Services (CMS) approved indications for the use of antipsychotic medications in three residents. Multiple monthly drug regimen reviews were conducted by the CP, but the reviews did not identify or report that antipsychotic medications, such as Olanzapine (Zyprexa) and Quetiapine (Seroquel), were being prescribed for diagnoses that are not CMS-approved indications, such as dementia, mood disorder, and depression. The facility's policy required the CP to complete a monthly review for each resident and report irregular findings within 72 hours, but this was not followed in these cases. One resident with severe cognitive impairment and multiple diagnoses, including dementia and mood disorder, received Olanzapine for extended periods under various orders, all lacking a CMS-approved indication. The CP's monthly reviews from January 2024 through March 2025 did not identify or report this inappropriate use. Another resident with dementia, major depressive disorder, Parkinson's disease, and bipolar disorder received Seroquel for agitation and bipolar disorder, but the orders also lacked CMS-approved indications for use in dementia. The CP again failed to identify or report these irregularities during the monthly reviews. A third resident with dementia, depression, and hypertension was prescribed Seroquel for agitation and later for depression, without a physician-documented rationale for these indications. Although the CP eventually recommended a change in the medication indication, there was still no documentation of an appropriate rationale, and the facility could not provide one when requested. Interviews with nursing staff and administrative nurses confirmed that the use of antipsychotic medications for mood, dementia, or depression alone was not appropriate and that the CP was expected to report such irregularities, which did not occur as required by facility policy.
Failure to Document CMS-Approved Indications for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that physicians provided appropriate Centers for Medicare and Medicaid Services (CMS) approved indications for the use of antipsychotic medications for two residents. In both cases, the medical records documented the use of antipsychotic medications for diagnoses such as mood disorder, dementia, and depression, none of which are CMS-approved indications for these medications in residents with dementia. The orders for antipsychotic medications, including Olanzapine and Quetiapine, repeatedly lacked a documented, appropriate rationale for use as required by CMS guidelines. For one resident with severe cognitive impairment, multiple orders for Olanzapine were issued over several months, each time citing mood disorder or dementia as the indication. The care plan and assessments noted the resident's significant cognitive and physical impairments, as well as the use of multiple psychotropic medications. Despite ongoing monitoring and care plan reviews, there was no documentation of a CMS-approved indication for the antipsychotic, nor was there evidence of a risk versus benefit analysis for its continued use. Another resident, also with severe cognitive impairment and a history of dementia and depression, was prescribed Quetiapine for agitation and later for depression. The consulting pharmacist identified that the indication for use was not approved, and although the order was changed to depression, there was still no physician-documented rationale for the use of the antipsychotic. Staff interviews confirmed that the diagnoses used were not appropriate indications for antipsychotic use, and the facility's own policy required that psychotropics only be used when necessary to treat a specific condition and after considering risks and benefits. The lack of appropriate documentation and rationale for these medications constituted the deficiency.
Failure to Maintain Required Nurse Staffing Records
Penalty
Summary
The facility failed to maintain the required daily nurse staffing data for the mandated 18-month period. During a review of posted staffing sheets covering a specified timeframe, it was found that documentation for 31 specific days was missing and could not be provided by the facility. The facility had a census of 74 residents at the time of the review. According to an administrative nurse, the staff scheduler was responsible for ensuring that nursing hours were both posted and retained as required. The facility's policy stated that nurse staffing information should be readily available and maintained in the Human Resources Department for at least 18 months or as required by state law.
Deficiency in Effective Communication Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nurse Aide (CNA) received the required education on effective communication, which led to an incident involving inappropriate interactions between the CNA and a resident. The incident occurred when the CNA, identified as CNA M, was heard by a Licensed Nurse (LN) speaking with a resident, who responded negatively to the CNA's presence. Later, the resident requested a cup of ice, and upon the CNA's return, a verbal altercation ensued, with both the resident and the CNA using inappropriate language towards each other. The CNA was accused of throwing a cup of ice, which resulted in water and ice being observed on the floor, side table, and bed. The CNA claimed that the resident used racial slurs, and the situation escalated to the point where local law enforcement was notified. The facility was unable to provide documentation that the CNA had completed the required effective communication training, which was part of the onboarding process. Administrative staff could not confirm whether the training had been completed, and the facility did not have a policy on the required education, including effective communication training. This lack of documentation and training contributed to the incident, placing residents at risk for impaired care.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R1, from verbal abuse by a staff member, specifically a Certified Nursing Assistant (CNA) referred to as CNA M. R1, who has a history of schizoaffective disorder and borderline personality disorder, was involved in an incident where verbal abuse occurred. The resident's care plan noted that R1 frequently rejected care and had outbursts, and staff were instructed to handle her with calmness and redirection. However, during an interaction, CNA M and R1 engaged in a verbal altercation where inappropriate and derogatory language was exchanged. The incident began when CNA M brought a cup of ice to R1, which led to a confrontation. Witness statements from Licensed Nurses (LNs) G and H indicated that R1 accused CNA M of throwing the ice, and both parties used racial slurs and derogatory terms towards each other. The situation escalated, with R1 becoming noticeably upset and agitated. Despite the facility's policy to prevent abuse and the care plan's directives, the staff member did not disengage or seek assistance, resulting in a failure to protect R1 from verbal abuse. The facility's policy on Abuse, Neglect, and Exploitation requires the protection of residents from verbal abuse, defined as the use of disparaging and derogatory terms. The incident was reported to local law enforcement, and the facility took immediate action by suspending CNA M. However, the deficiency in ensuring R1's protection from verbal abuse was evident, as the staff did not follow the established procedures to de-escalate the situation and safeguard the resident's well-being.
Incomplete Discharge Notification for Resident with Dementia
Penalty
Summary
The facility failed to provide the required information on an involuntary notification of discharge to a resident and/or his representative, which placed the resident at risk for an inappropriate discharge and impaired resident rights. The resident, who had a diagnosis of dementia with severe cognitive impairment and behavioral disturbances, was admitted to the facility and later discharged following an incident where he exhibited aggressive behavior towards staff. On the day of the incident, the resident hit an employee, continued to be agitated, and was eventually arrested by the police after further aggressive actions. The facility's records indicated that an emergency discharge was ordered due to the resident's violence against staff and subsequent arrest. However, the Notice of Transfer or Discharge provided to the resident's representative was incomplete, lacking essential information such as the resident's appeal rights and contact details for relevant advocacy agencies. The notice was sent via email, but the second page was blank, and the necessary information was not verified before sending. Interviews with administrative staff revealed that the notice was the first one sent by the staff member responsible, and there was uncertainty about whether the correct form was used. The facility's policy required that in cases of emergency discharge, notice requirements and procedures for facility-initiated discharges be followed, but this was not adhered to in this instance, leading to the deficiency.
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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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