Sandpiper Healthcare & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wichita, Kansas.
- Location
- 5808 W 8th Street North, Wichita, Kansas 67212
- CMS Provider Number
- 175344
- Inspections on file
- 21
- Latest survey
- December 3, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sandpiper Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to meet professional standards for food service safety, as observed in their kitchen and walk-in freezer. Uncovered, unlabeled, and undated food items, including ice cream and shredded carrots, were found, along with dirty flour and sugar containers and light fixtures with bugs and debris. The Dietary Manager confirmed these issues, which violated the facility's Food Storage Policy and placed 73 residents at risk for foodborne illness.
A facility failed to date insulin pens for four residents and did not remove expired stock medications, including Senna Plus and Thiamin/vitamin B. An LPN confirmed the oversight, which violated the facility's Medication Storage policy requiring proper dating and disposal of medications.
The facility failed to maintain a sanitary environment in the main dining room, where numerous reddish-brown dried liquid stains were observed on the wall near the kitchen entrance. This condition was confirmed by an administrative nurse, who noted that both housekeeping and dietary staff were responsible for cleaning the area. The stains were in the location where a serving table had been moved, and despite documented daily cleaning tasks, the wall remained uncleaned, posing a risk to residents' health and well-being.
The facility failed to provide timely written notification of transfers for two residents, R25 and R6, to the hospital, as required by policy. R25, with a complex medical history, and R6, with multiple diagnoses, were transferred without written notice or notification to the LTCO. Staff confirmed the oversight, unaware of the requirement for hospital transfers.
The facility failed to provide two residents with written information about the bed hold policy when they were transferred to the hospital. This oversight placed the residents at risk of not being able to return to their original rooms. Staff confirmed the lack of documentation and awareness of the policy.
A resident at risk for pressure ulcers developed two facility-acquired pressure injuries due to the facility's failure to implement timely preventive measures. Despite being identified as at risk upon admission, the care plan lacked specific interventions until after the first ulcer was discovered. The resident developed additional pressure injuries, highlighting inadequate preventive care.
A resident with multiple health conditions and a history of falls was not transferred using a Hoyer lift as required, leading to a fall incident. The care plan did not initially include the need for a Hoyer lift, and staff were unsure of the correct transfer method, resulting in a deficiency in providing a safe environment.
A resident with multiple health conditions, including neuromuscular dysfunction of the bladder, received inadequate catheter care, placing them at risk for urinary tract infections. Observations showed improper management of the catheter collection bag, which was touching the floor and lacked a securement device. Staff failed to follow infection control protocols, such as wearing gowns and gloves, and there was no EBP signage in the resident's room, as confirmed by administrative nurses.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with indwelling medical devices, leading to increased infection risk. Staff did not consistently wear the required personal protective equipment (PPE), such as gowns and gloves, during high-contact care activities, despite facility policy and posted instructions. Observations and interviews confirmed these deficiencies.
The facility failed to store, prepare, and serve food under sanitary conditions, with issues including improper hair restraints, lack of dish machine temperature documentation, undated and uncovered food items, and staff not following recipes or hygiene protocols.
A resident with dementia and moderate cognitive impairment did not receive the physician-ordered gluten-free diet. The dietary staff initially served non-gluten-free chicken parmesan and later replaced it with roast beef without gluten-free gravy, deviating from the prescribed menu. The facility's policies on standardized recipes and therapeutic diets were not followed.
Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen and walk-in freezer. During an inspection, it was found that there were fourteen uncovered, unlabeled, and undated styrofoam bowls of chocolate ice cream on a tray, a three-gallon container of chocolate ice cream with the lid partially open, and an uncovered, unlabeled, opened, and unsealed plastic bag of shredded carrots. Additionally, an unlabeled, undated opened, and unsealed plastic bag of breaded fish was also found. These findings were verified by the Dietary Manager (DM), who acknowledged that the ice cream bowls were old and that staff should have labeled, dated, and sealed the items before placing them in the freezer. Further observations in the kitchen revealed that the flour and sugar containers had numerous different-sized blackish-gray areas around the outside, and the lids had a greasy gray substance with white particles. Additionally, fourteen fluorescent light fixtures contained bugs and debris inside the covers. The DM confirmed these findings and was unsure if maintenance had cleaned the ceiling lights. The facility's Food Storage Policy, which was undated, required all food items to be labeled with the name of the food and the date by which it should be consumed or discarded. The policy also stated that leftover contents of cans and prepared food should be stored in covered, labeled, and dated containers in refrigerators and freezers. The facility's failure to comply with these standards placed 73 residents at risk for foodborne illness.
Failure to Date Insulin Pens and Remove Expired Medications
Penalty
Summary
The facility failed to adequately store and label biologicals, specifically insulin pens, and expired stock medications. During an observation of the 300-hall medication cart, it was found that insulin pens for four residents were not dated when opened, nor did they have a discard date. This oversight involved long-acting insulin pens for residents who required them to manage high blood glucose levels. Additionally, four bottles of stock medications, including Senna Plus, Thiamin/vitamin B, Bisacodyl, and Allergy relief, were found to be expired and had not been removed or disposed of as required. A Licensed Nurse verified the expiration dates and the lack of dating on the insulin pens, acknowledging that staff were supposed to date the pens upon opening. The facility's Medication Storage policy indicated that all medications should be stored according to the manufacturer's recommendations and that the consultant pharmacist should routinely inspect medication rooms for discontinued and outdated drugs. The failure to date insulin pens and remove expired medications placed residents at risk of receiving expired or ineffective treatments.
Unsanitary Conditions in Main Dining Room
Penalty
Summary
The facility, with a census of 74 residents and a sample of 18 residents, failed to maintain a sanitary environment in one of its three dining rooms, specifically the main dining room. On November 5, 2024, an observation revealed numerous reddish-brown dried liquid stains on the wall to the right of the kitchen entrance door, spanning approximately eight feet long and three feet high. This unsanitary condition was confirmed by Administrative Nurse D on November 6, 2024, who acknowledged that both housekeeping and dietary staff were responsible for cleaning the area. The stains were located in the area where a serving table had recently been moved to the kitchen. The facility's Environmental Services Checklist documented daily cleaning tasks, yet the wall remained uncleaned, placing residents who dined in the main dining room at risk for impaired health and well-being.
Failure to Notify Residents and LTCO of Transfers
Penalty
Summary
The facility failed to provide timely written notification of facility-initiated transfers for two residents, R25 and R6, as required by their policy. R25, who had a complex medical history including congestive heart failure, MRSA, and osteomyelitis, was transferred to the hospital after calling 911 due to pain. The facility did not provide R25 with a written notice of the transfer, nor did they notify the State Long Term Care Ombudsman (LTCO) as required. This oversight was confirmed by Administrative Staff B, who stated that only residents discharged home were included in the monthly report to the LTCO. Similarly, R6, who had diagnoses including diabetes mellitus, schizoaffective disorder, and legal blindness, was transferred to the hospital for pain management. The facility again failed to provide a written notice of transfer to R6 and did not notify the LTCO. Administrative Staff E and Administrative Nurse D confirmed the lack of written notice and were unaware of the requirement to notify the LTCO for hospital transfers. The facility's Transfer and Discharge policy mandates that residents and their representatives receive a notice of transfer, and the LTCO be notified of such transfers. However, the facility did not adhere to this policy for emergency transfers to the hospital, resulting in a deficiency that placed both residents at risk of uninformed care choices and impaired rights.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide two residents, R25 and R6, with written information regarding the facility's bed hold policy when they were transferred to the hospital. This deficiency was identified during a survey that included a sample of 18 residents out of a census of 74. The lack of documentation and communication regarding the bed hold policy placed these residents at risk of not being permitted to return to the facility and resume residence in their original rooms. Resident R25, who had a history of congestive heart failure, MRSA, osteomyelitis, and other serious conditions, was transferred to the hospital due to worsening discitis and an abscess. Despite the facility's policy requiring a bed hold notice to be provided at the time of transfer, R25's clinical record lacked evidence of such documentation. Administrative staff confirmed that the notice was not provided, which was a violation of the facility's own policy. Similarly, Resident R6, who had diagnoses including diabetes mellitus, schizoaffective disorder, and legal blindness, was admitted to the hospital for pain. The facility again failed to provide a bed hold notice, as confirmed by both the resident and staff members. The absence of documentation and awareness among staff about the bed hold policy further highlighted the facility's failure to adhere to its procedures, thereby placing R6 at risk of not being able to return to the facility and resume residence in the same room.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to initiate timely interventions to prevent the development of pressure ulcers for Resident 128, who developed two facility-acquired pressure injuries. Upon admission, Resident 128 was identified as being at risk for pressure ulcers due to factors such as impaired cognition, functional mobility impairment, and incontinence. Despite these risk factors, the care plan lacked specific interventions to prevent pressure ulcers until after the first ulcer was identified on August 9, 2024. Prior to this, the resident's skin was noted to be intact, and no skin concerns were documented on August 8, 2024. On August 9, 2024, a wound was discovered on Resident 128's left heel, and the wound nurse was notified. The initial wound care note documented a pressure ulcer on the left heel with specific measurements and characteristics, including eschar and serous drainage. Interventions such as offloading the heels and nutritional supplements were ordered. However, the interdisciplinary team noted that the resident was not wearing heel protectors while in bed, which contributed to the development of the wound. The care plan was subsequently updated to include heel protectors and other pressure relief measures. Despite these interventions, Resident 128 developed additional pressure injuries, including a new pressure ulcer on the right heel and a deep tissue injury on the left plantar foot. Observations revealed that the resident's feet were hitting the footboard, which was later removed. The facility's failure to implement timely and adequate preventive measures for pressure ulcer risk factors resulted in the development of multiple pressure injuries for Resident 128, placing him at risk for further complications.
Failure to Use Hoyer Lift for Resident Transfer
Penalty
Summary
The facility failed to provide an environment free from accident hazards when staff did not use the Hoyer lift for a safe transfer of Resident 130, who required it according to her admission note. Resident 130 was admitted with multiple diagnoses, including diabetes mellitus, chronic obstructive pulmonary disease, atrial fibrillation, anemia, osteoarthritis, COVID-19 with acute and chronic respiratory failure, sepsis, and neuromuscular dysfunction of the bladder. Her baseline activities of daily living care plan indicated she needed assistance due to weakness from a recent hospitalization and had safety concerns related to a history of falls or risk for falls. Despite this, the care plan did not initially include the requirement for a Hoyer lift, which was only documented after a fall incident. On a specific date, a progress note documented a witnessed fall when staff attempted to transfer Resident 130 from her wheelchair to her recliner without using the Hoyer lift. The resident's legs buckled, and she had to be lowered to the floor, indicating she was unable to stand or participate fully in transfers. Observations and interviews revealed that staff were unsure of the correct transfer method for Resident 130, and the care plan was still being developed. The facility's Fall Prevention Program required that each resident be assessed for fall risks and receive appropriate care, but this was not adequately implemented for Resident 130, leading to the deficiency.
Inadequate Catheter Care for a Resident
Penalty
Summary
The facility failed to provide adequate catheter care for Resident 130, who was at risk for urinary tract infection and other catheter-related complications. Resident 130 had multiple diagnoses, including diabetes mellitus, chronic obstructive pulmonary disease, atrial fibrillation, anemia, osteoarthritis, COVID-19 with acute and chronic respiratory failure, sepsis, and neuromuscular dysfunction of the bladder. Observations revealed that the urinary catheter collection bag was improperly managed, with the bag touching the floor and lacking a securement device. Staff did not follow proper infection control protocols, such as wearing gowns and gloves when handling the catheter. Certified Medication Aide R and Certified Nurse Aide O were observed not adhering to the facility's catheter care policy. CMA R did not wear a gown while emptying the catheter bag, and CNA O handled the catheter bag and tubing without gloves or a gown. Additionally, there was no evidence-based practice (EBP) signage in the resident's room, which was confirmed by Administrative Nurses F and D. The facility's catheter care policy required catheter care every shift, covered drainage bags, and proper documentation, which were not followed, leading to the deficiency.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control protocols for Enhanced Barrier Precautions (EBP) for two residents, one with a peripherally inserted central catheter (PICC) and another with a urinary catheter. Observations revealed that a licensed nurse entered the room of the resident with the PICC line and donned only gloves, despite signage indicating the need for both gown and gloves. Similarly, a certified medication aide did not wear a gown while handling the urinary catheter of the second resident, and the catheter bag was observed on the floor, which was verified as inappropriate by a certified nurse aide. Interviews with administrative nurses confirmed that EBP should have been initiated for the resident with the catheter upon admission, and that staff should have worn the appropriate PPE when providing care. The facility's policy on EBP, dated August 2024, required the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices. The lack of adherence to these precautions placed the residents at increased risk for infection.
Failure to Maintain Sanitary Conditions in Food Storage, Preparation, and Serving
Penalty
Summary
The facility failed to store, prepare, and serve food under sanitary conditions for the residents. Observations revealed multiple issues in the kitchen area, including dietary staff not wearing proper hair restraints, such as beard covers and hats that fully cover hair. Additionally, the dish machine log lacked documentation of wash and rinse temperatures since 04/02/24, and various food items in the walk-in refrigerator were either undated, uncovered, or past their expiration dates. For example, a bag of deli meat lacked a date, and several pitchers of juice were past their seven-day usage timeframe. Uncovered trays of muffins and brownies were also noted, and dietary staff were observed handling food without following proper hygiene protocols, such as changing gloves after touching surfaces and before handling food again. Further observations indicated that dietary staff were not following recipes when preparing meals, leading to inconsistencies in food preparation. For instance, pureed chicken parmesan, buttered peas, and buttered noodles were prepared without using recipes or proper measurements. The food temperature log also lacked documentation of measured food temperatures from the lunch meal, and staff were observed not recording temperatures at the time they were measured. Additionally, food items on the steam table were not consistently maintained at safe temperatures, with mechanical soft chicken being removed to be reheated after being found at 123 degrees Fahrenheit. Interviews with dietary staff revealed a lack of adherence to facility policies regarding food safety and sanitation. Staff admitted to not checking dish machine temperatures as required and not following recipes for meal preparation. The facility's policies on food preparation, handling, and storage were not being followed, leading to multiple instances of unsanitary conditions and potential food safety hazards. The facility's failure to maintain proper food storage, preparation, and serving practices compromised the sanitary conditions necessary for resident safety.
Failure to Follow Gluten-Free Diet for Resident
Penalty
Summary
The facility failed to follow the physician-ordered gluten-free diet for a resident diagnosed with dementia and moderate cognitive impairment. Despite the resident's electronic medical record indicating an allergy to gluten and a physician's order for a gluten-free diet, the dietary staff did not adhere to the prescribed menu. On the observed date, the resident was initially served chicken parmesan prepared with flour, which is not gluten-free. Upon realizing the mistake, the dietary staff replaced the chicken with roast beef but almost added non-gluten-free gravy, which was prevented by the surveyor's intervention. The resident was ultimately served roast beef, buttered peas, and potato chips, deviating from the gluten-free menu items. The resident, who had a history of avoiding gluten due to its impact on his energy levels, was not aware of his gluten allergy at the time of the incident. The facility's policies on standardized recipes and therapeutic diets were not followed, as evidenced by the dietary staff's failure to use the correct gluten-free recipe for chicken parmesan. The incident highlights a lapse in the facility's adherence to dietary orders and protocols, resulting in the resident not receiving the appropriate therapeutic diet as prescribed by the physician.
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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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