Shawnee Gardens Healthcare & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Shawnee, Kansas.
- Location
- 6416 Long Street, Shawnee, Kansas 66216
- CMS Provider Number
- 175267
- Inspections on file
- 32
- Latest survey
- August 27, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Shawnee Gardens Healthcare & Rehab Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of stroke was denied visits from her family after the facility issued a trespassing order against her family member due to confrontational behavior and alleged verbal threats toward staff and the resident. The resident, who relied on family visits for social support, became visibly upset and expressed distress over the loss of visitation, while staff and the resident's representative confirmed no physical harm had occurred. The facility did not consult the LTC Ombudsman before restricting visitation, contrary to its policy on resident rights.
A resident with multiple comorbidities and a history of falls experienced a significant change in condition after staff failed to obtain physician-ordered urinalysis and laboratory tests. There was no documentation of attempts to collect the samples, resident refusals, or physician notification regarding the delays. The resident was later hospitalized with septic syndrome and urosepsis, and the facility could not provide the required lab results.
A cognitively impaired resident was sexually abused by another resident with a history of inappropriate sexual behaviors. The facility failed to implement preventative measures and adequately monitor the resident, leading to the incident. The victim did not consent to the touching, resulting in immediate jeopardy and fear.
A facility failed to implement effective preventative interventions for a resident with a history of sexual behaviors, placing female residents at risk. The resident's care plan lacked specific interventions for his behaviors, and incidents of inappropriate touching were not consistently documented or monitored. Staff interviews revealed inconsistencies in monitoring and reporting procedures, despite the facility's policy emphasizing resident safety and dignity.
A facility failed to effectively monitor and intervene in the behavioral health care of a resident with a history of sexual behaviors. Despite having a care plan, it lacked specific strategies and supervision requirements, leading to repeated inappropriate incidents with female residents. Staff interviews revealed inconsistencies in care plan execution, highlighting a deficiency in providing necessary behavioral health services.
The facility did not conduct a thorough assessment to determine necessary resources for competent care during routine and emergency situations. The assessment lacked details on resident capacity, input from residents, specific staffing needs, and required nursing competencies, putting all 115 residents at risk.
A facility with 115 residents failed to ensure agency staff received necessary communication training, risking impaired care and decreased quality of life. The facility could not provide training records for agency staff, including LNs and CNAs, as required by their policy. This oversight was identified during a review, highlighting a lapse in maintaining adequate training documentation.
A facility with 115 residents failed to ensure agency staff received required resident rights training, risking impaired care and decreased quality of life. The facility could not provide proof of training records for agency staff, including LNs and CNAs, during a review. Despite the facility's policy requiring sufficient staffing with appropriate training, the necessary records were unavailable, compromising resident safety and care quality.
The facility failed to ensure that agency staff received the required infection control training, as part of its infection prevention and control program. The facility could not provide proof of training records for agency staff, including an LN and a CNA. Administrative Nurse D stated that training records were typically reviewed online or communicated over the phone, but the facility was unable to provide the required records. This failure placed residents at risk for impaired care and decreased quality of life.
The facility failed to maintain resident dignity during meal assistance and personal care. Staff stood over two residents while feeding them, delayed addressing an incontinent accident in the dining room, and left a resident exposed during personal care. In the Memory Unit, a staff member made a derogatory comment about a resident's eating habits, leading to the resident refusing to eat. Additionally, staff referred to a resident as a "feeder" in a loud manner, violating the facility's dignity policy.
The facility failed to accommodate dietary preferences in the Memory Care Unit, with residents expressing dissatisfaction over limited breakfast options. Requests for specific items like pancakes, toast, and different cereals were denied, and coffee availability was delayed. Staff interviews revealed inconsistencies in food and beverage availability, contradicting the facility's policy to assess and accommodate residents' dietary needs and preferences.
The facility failed to implement effective infection control measures, including the absence of signage for Enhanced Barrier Precautions (EBP) and inadequate sanitation of shared equipment. Residents with medical conditions such as gastrostomy tubes and open wounds lacked protective equipment and signage. Additionally, staff did not perform proper hand hygiene, and trash was improperly stored, contributing to an unsanitary environment.
A resident with multiple medical conditions and impaired cognition was found to have their call light out of reach on two occasions, leaving them vulnerable to unmet care needs. Facility staff confirmed that call lights should be within reach, but this was not ensured, resulting in a deficiency.
A resident's care plan was not updated to reflect the discontinuation of a Foley catheter, leaving outdated instructions regarding toileting needs. Despite the resident's ability to manage toileting independently, the care plan continued to reference the catheter. Staff interviews confirmed the oversight, highlighting the need for regular updates to care plans to ensure accurate care instructions.
A resident with severe cognitive impairment and language barriers did not receive adequate communication support, leading to multiple incidents of confusion and distress. Despite care plan instructions to use translation services, staff failed to implement these strategies, resulting in the resident's inability to communicate effectively and causing disturbances in the Memory Care Unit.
The facility failed to provide adequate ADL assistance for several residents, including toileting and eating. A resident with quadriplegia was left with urine leaking onto the floor, another with severe cognitive impairment was not checked for incontinence for over four hours, and a third resident was unable to eat due to lack of staff assistance. These deficiencies highlight a failure to adhere to care plans and provide necessary support.
A resident with multiple sclerosis and a history of pressure ulcers had their low air-loss mattress set incorrectly at 220 lbs instead of their actual weight of 137 lbs. The facility's staff failed to ensure the mattress was set according to the resident's weight, as required by the care plan and facility policy, placing the resident at risk for skin breakdown.
A facility failed to implement fall prevention measures for two residents. One resident's wheelchair lacked an anti-rollback device, despite being at risk for falls due to severe cognitive impairment and limited mobility. Another resident's bed was left in a high position, posing a fall risk, despite her dependence on staff for mobility. Staff were unsure about the implementation of these safety measures, indicating a lapse in following care plans.
A facility failed to consistently communicate a resident's medical condition with the dialysis center, leading to a deficiency in dialysis care. The resident, with multiple medical conditions, required hemodialysis three times a week. The facility's records lacked evidence of necessary pre- and post-dialysis assessments on several dates, despite expectations for nursing staff to complete and return communication sheets. This failure placed the resident at risk of potential adverse outcomes related to dialysis.
A facility failed to provide appropriate dementia-related care for a resident with severe cognitive impairment, leading to inadequate communication and supervision. The resident, who required an interpreter, was not effectively redirected during incidents of confusion and wandering. Staff did not use translation services, resulting in unmanaged interactions with other residents. This deficiency risked the resident's quality of life and dignity.
The facility failed to ensure controlled substances were reconciled between shifts, with missing signatures on Narcotic Hand Off Count Sheets for multiple dates. Staff interviews confirmed that narcotics should be counted and documented at each shift change, as per facility policy. This failure placed residents at risk for medication misappropriation and diversion.
The facility failed to ensure a CP identified and reported missing dosage and application location for a resident's medication, placing them at risk for side effects. Additionally, the facility did not ensure CP recommendations for another resident were reviewed by the physician, risking unnecessary medication use. Staff interviews revealed a lack of clarity and action regarding pharmacy recommendations.
A resident with quadriplegia and dementia was at risk due to a deficiency in medication administration. The facility failed to ensure the resident's diclofenac order included a specific dosage and application area, leading to potential unnecessary medication use. The resident required significant assistance and had severely impaired cognition, and the facility could not provide a policy on physician's orders.
The facility failed to ensure proper collaboration and communication with hospice services for two residents receiving end-of-life care. For one resident, the care plan lacked documentation of medications, personal care items, and hospice visit frequency. Another resident's care plan did not specify hospice services such as medication and equipment. Both residents had complex medical histories, and the lack of coordination created a risk of missed or delayed services.
The facility failed to obtain informed declinations for the PCV20 vaccine for two residents, whose records showed refusals without documented informed declinations. This oversight was identified during a review of the facility's immunization practices, which require a signed consent form to be placed in the resident's permanent medical record.
The facility did not comply with the requirement to post daily staffing information, including the census, and maintain these records for 18 months. Inspections revealed missing census information on posted staffing sheets and multiple missing records over several months. An administrative nurse confirmed the requirement, but the facility lacked a related policy.
A cognitively impaired resident experienced multiple falls despite various interventions. The facility failed to provide adequate post-fall care, including neurological evaluations, after an unwitnessed fall that resulted in head trauma and fractures. Staff inconsistencies in following post-fall protocols were noted.
Failure to Honor Resident Visitation Rights
Penalty
Summary
A resident with a history of cerebral infarction and severe cognitive impairment, as indicated by a BIMS score of three, was denied the right to receive visitors of her choosing at the time of her choosing. The resident's care plan allowed her to make daily decisions and emphasized maintaining a consistent routine to reduce confusion. Despite this, the facility issued a trespassing order against the resident's family member following an incident where the family member was reported to have been confrontational with staff and allegedly threatened to slap the resident. The family member denied threatening the resident but admitted to using profanity and confronting staff. The facility's investigation documented that staff intervened when the family member became verbally abusive and refused to leave, resulting in police involvement and the issuance of a trespassing order that barred the family member from visiting for one year. The resident expressed distress over the inability to see her family, stating that her family was her only visitor and that she never felt unsafe around them. The resident became visibly upset and cried when discussing the situation, indicating a negative impact on her psychosocial well-being. Interviews with staff and the resident's representative revealed that while the family member had issues controlling anger and was verbally abusive to staff, there was no evidence of physical violence toward the resident. The facility did not consult the Long-Term Care Ombudsman regarding the visitation restriction. The facility's policy states that residents have the right to receive visitors of their choosing, but this right was not upheld in this case, resulting in social isolation and emotional distress for the resident.
Failure to Obtain and Document Physician-Ordered Labs and Notify Physician of Delays
Penalty
Summary
The facility failed to obtain a physician-ordered urinalysis (UA) and other laboratory tests for a resident, despite orders being placed. The resident had a history of chronic kidney disease, recurrent UTIs, atrial fibrillation, repeated falls, and cognitive communication deficits. Orders for a UA, CBC, CMP, and magnesium were placed, but the medical record lacked documentation of any attempts to collect the samples or any refusals by the resident prior to a significant change in condition. There was also no evidence that the physician was notified of the inability to obtain the samples or of any refusals. The resident experienced multiple falls and a change in condition over several days, including confusion, disorientation, and eventually unresponsiveness with respiratory distress. Despite these changes, staff did not document attempts to obtain the ordered tests, nor did they notify the physician about the delays or the resident's refusals. Interviews with staff confirmed that while some claimed the resident refused the UA and labs, there was no documentation of these refusals or of physician notification in the medical record. The facility's own policies required timely notification of changes in condition and provision of physician-ordered services, but these were not followed. Ultimately, the resident was sent to the hospital in an unresponsive state with a high fever and was admitted to the ICU for septic syndrome, urosepsis, and other acute conditions. The lack of timely diagnostic testing and failure to notify the physician of the delays or refusals contributed to a delay in care. The facility was unable to provide any results for the ordered tests, and staff interviews revealed inconsistent practices and a lack of adherence to documentation and notification protocols.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to prevent an episode of resident-to-resident sexual abuse involving two cognitively impaired residents. On the specified date, staff witnessed one resident groping another resident's nipples, breast, and buttocks while both were seated at the dinner table on a locked unit for cognitively impaired residents. The victim voiced that she did not consent to the touching, placing her in immediate jeopardy and at risk for ongoing abuse and fear. The resident who committed the abuse had a history of sexual behaviors related to psychiatric illness, as noted in his medical records. Despite this, his care plan did not adequately address his sexual behaviors, and he was moved to a new unit without implementing preventative interventions. The resident's care plan included instructions for staff to explain and reinforce why his behaviors were inappropriate, but it failed to prevent the incident. Additionally, the facility's staff did not ensure close monitoring of the resident, which contributed to the occurrence of the abuse. The facility's policy on abuse, neglect, and exploitation was not effectively enforced, as evidenced by the failure to protect the victim from abuse. The facility did not identify and implement necessary preventative measures related to the resident's sexual behaviors upon his relocation to a new unit, placing other female residents at risk for similar incidents. This deficiency resulted in feelings of fear and potential psychosocial harm for the victim.
Removal Plan
- R1 was placed on one-on-one supervision until psychiatric evaluation can be completed.
- The facility identified all at-risk residents on the unit.
- Staff were provided in-service on abuse, neglect, and exploitation with comprehensive testing.
- Safe survey conducted on female residents of unit.
- Psychiatric evaluation will be completed.
Failure to Implement Preventative Interventions for Resident's Sexual Behaviors
Penalty
Summary
The facility failed to implement effective preventative interventions to manage a resident's sexual behaviors, which placed female residents at risk. The resident in question, identified as R1, had a history of sexual behaviors related to psychiatric illness, as noted in his medical records. Despite this, his care plan lacked specific interventions to address his sexual behaviors towards female residents, and there was insufficient supervision and monitoring when he was outside his room. The care plan did not include necessary precautions such as supervision around female residents or monitoring while he was out of his room. Multiple incidents were documented where R1 engaged in inappropriate sexual behaviors towards female residents. These incidents included inappropriate touching and physical aggression, which were not adequately addressed in his care plan or through staff supervision. For instance, R1 was observed touching a female resident inappropriately during meal service, and another incident involved him touching a female resident's arm despite her attempts to push him away. These behaviors were not consistently documented or monitored in his electronic medical records, indicating a lack of effective intervention and oversight. Interviews with staff revealed inconsistencies in the understanding and implementation of monitoring and reporting procedures for R1's behaviors. Staff members were aware of R1's history but did not consistently document or monitor his behaviors as required. The facility's policy on abuse, neglect, and exploitation emphasized the need for resident safety and dignity, yet the facility failed to protect female residents from R1's inappropriate behaviors. This deficiency placed R2 and 19 other female residents at risk, highlighting a significant lapse in the facility's duty to provide a safe environment.
Inadequate Behavioral Monitoring and Interventions for Resident
Penalty
Summary
The facility failed to implement effective behavioral monitoring and interventions for a resident with a history of sexual behaviors related to psychiatric illness. The resident, who had diagnoses including chronic obstructive pulmonary disease and depression, exhibited sexually inappropriate behaviors towards female residents. Despite having a care plan that noted these behaviors, the plan lacked specific triggers, coping strategies, and supervision requirements necessary to prevent such behaviors. The resident's electronic medical records and care plan did not adequately document or address these behaviors, leading to repeated incidents. Multiple incidents were documented where the resident engaged in inappropriate touching and aggressive behaviors towards female residents. These incidents were recorded in the resident's progress notes, but there was a lack of consistent monitoring and documentation in the electronic medical records, particularly in the Tasks and Treatment Administration Report sections. The facility's policy required ongoing behavioral monitoring and supervision for cognitively impaired residents, but this was not effectively implemented for the resident in question. Interviews with facility staff revealed inconsistencies in the understanding and execution of the care plan. Staff were aware of the resident's history and the need for monitoring, but the care plan did not clearly outline the necessary interventions and supervision. The facility's failure to provide adequate behavioral health care and services placed the resident at risk for continued behavioral episodes and unmet care needs.
Inadequate Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment, dated [DATE], did not specify the facility's resident capacity, nor did it include input from residents and their representatives. Additionally, it lacked details on the specific staffing needs for each unit based on the resident population and did not identify the competencies and skill sets required by nursing staff to adequately care for the residents. An administrative nurse mentioned that the assessment was recently revised, but the facility could not provide a policy related to the assessment when requested. This oversight placed all 115 residents at risk for inadequate care.
Failure to Provide Required Communication Training for Agency Staff
Penalty
Summary
The facility, with a census of 115 residents, failed to ensure that agency staff received the required communication training, which is essential for providing quality care. During a review on September 11, 2024, the facility could not provide proof of training records for agency staff, including Licensed Nurses K and L, and Certified Nurse's Aide OO. Administrative Nurse D mentioned that the facility typically reviews training records online or receives information over the phone about the training or classes completed by agency staff. However, the facility was unable to provide the requested training records by September 18, 2024. According to the facility's Nursing Services and Sufficient Staffing policy, revised in October 2022, the facility is responsible for ensuring sufficient staffing with appropriate training, competencies, and skill sets to assure resident safety and the highest level of resident care. The failure to complete the required communication training for staff providing care in the facility placed residents at risk for impaired care and decreased quality of life.
Failure to Provide Required Resident Rights Training for Agency Staff
Penalty
Summary
The facility, with a census of 115 residents, failed to ensure that agency staff received the required resident rights training, which is essential for providing proper care and maintaining the quality of life for residents. During a review on 09/11/24, the facility could not provide proof of training records for agency staff, including Licensed Nurses K and L, and Certified Nurse's Aide OO. Administrative Nurse D mentioned that the facility typically reviews training records online or receives information over the phone regarding the training or classes completed by agency staff. However, the facility was unable to provide the necessary training records when requested on 09/18/24. According to the facility's Nursing Services and Sufficient Staffing policy, revised in October 2022, the facility is required to provide sufficient staffing with appropriate training, competencies, and skill sets to ensure resident safety and achieve the highest level of resident care. The failure to complete the required resident rights training for staff who provided care in the facility placed residents at risk for impaired care and decreased quality of life.
Failure to Ensure Infection Control Training for Agency Staff
Penalty
Summary
The facility, with a census of 115 residents, failed to ensure that agency staff received the required infection control training, which is a part of its infection prevention and control program. During a review on 09/11/24, the facility was unable to provide proof of training records for agency staff, specifically for Licensed Nurse (LN) K, LN L, and Certified Nurse's Aide (CNA) OO. Administrative Nurse D mentioned that the facility would typically review records online or receive information over the phone regarding the training or classes completed by agency staff. However, the facility was unable to provide the required training records as requested on 09/18/24. The facility's Nursing Services and Sufficient Staffing policy, revised in 10/2022, indicated that the facility would provide sufficient staffing with appropriate training, competencies, and skill sets to ensure resident safety and achieve the highest level of resident care. The failure to ensure the completion of the required infection control training for staff who provided care in the facility placed the residents at risk for impaired care and decreased quality of life.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to maintain the dignity of several residents during meal assistance and personal care. Two residents, R17 and R41, were observed being fed by staff who stood over them, which is against the facility's policy of sitting with residents during meals. Another resident, R92, experienced an incontinent accident in the dining room, and staff delayed in addressing the situation, leading to other residents noticing and commenting on the incident. Additionally, R35 was left exposed during personal care with the room door open, compromising privacy. In the Memory Unit, staff failed to treat R108 with respect during mealtime. Activity Z made a derogatory comment about R108's eating habits, which led to R108 refusing to eat and moving away from the table. Furthermore, staff referred to R35 as a "feeder" in a loud manner in the hallway, which is disrespectful and against the facility's dignity policy. Interviews with staff confirmed that these actions were not in line with the expected standards of care, which emphasize maintaining resident dignity and privacy.
Failure to Accommodate Dietary Preferences in Memory Care Unit
Penalty
Summary
The facility failed to accommodate the dietary preferences of its residents, particularly in the Memory Care Unit. Multiple residents expressed dissatisfaction with the lack of meal options, specifically during breakfast. One resident repeatedly requested pancakes and toast but was denied and given Cheerios instead. Another resident asked for a different type of cereal but was told only Cheerios were available. Additionally, residents were informed that seconds were not available, and coffee requests were delayed until the arrival of the breakfast cart. The Resident Council also reported that alternative meal options were not provided for breakfast, and pancakes were only served on Saturdays. Staff interviews revealed inconsistencies in the availability of food and beverages. A CNA mentioned that coffee was always available but required a call to the kitchen, and alternative menus were only offered for lunch and dinner. An administrative nurse stated that staff should communicate with the kitchen for additional items, and units should have drinks and snacks available. However, a dietary staff member indicated that alternatives for breakfast could not be provided, although pancakes, coffee, and cereal options were available upon request. The facility's Food Preferences policy stated that residents' dietary needs and preferences should be assessed and accommodated, but this was not effectively implemented, leading to the deficiency.
Inadequate Infection Control Measures
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by several deficiencies observed during a survey. The facility did not provide appropriate signage or indicators to alert staff and visitors of residents on Enhanced Barrier Precautions (EBP), which are necessary to reduce the transmission of resistant organisms. Specifically, rooms of residents with medical conditions such as percutaneous endoscope gastrostomy tubes, open wounds, and suprapubic catheters lacked protective equipment and signage indicating EBP. Additionally, shared equipment like the Hoyer lift was not sanitized between uses, and staff did not perform adequate hand hygiene during resident care, as observed when a CNA failed to change soiled gloves before touching clean items. The facility also failed to maintain a sanitary environment, as evidenced by improper trash storage and uncleaned spills. Large trash bags containing soiled items were left on the floor across from the nurse's station, and a brown substance was found in a dining room cabinet. Administrative Nurse D confirmed that signs should be posted for residents requiring EBP, and staff should adhere to hand hygiene protocols. The facility's Infection Prevention and Control Program, dated 11/01/19, was not effectively implemented, placing residents at risk for infectious diseases.
Resident's Call Light Inaccessible
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which left the resident vulnerable to unmet care needs. The resident, identified as R37, had multiple medical conditions including sleep apnea, diabetes mellitus, hypertension, congestive heart failure, bipolar disorder, depressive disorder, Parkinson's disease, chronic obstructive pulmonary disease, dysphagia, and end-stage renal disease. The resident was documented as having moderately impaired cognition and was dependent on staff for activities of daily living, including eating, showering, and personal hygiene. Observations on two separate occasions revealed that the resident's call light was on the floor, out of reach, while the resident was either in bed or in a wheelchair. Interviews with facility staff, including a licensed nurse, a certified nurse's aide, and an administrative nurse, confirmed that call lights should be within reach of residents at all times. The facility's policy on the accommodation of needs also stated that reasonable accommodations should be made for individual resident needs and preferences. Despite these guidelines, the facility did not ensure that the resident's call light was accessible, resulting in a deficiency in care.
Failure to Update Resident's Care Plan Post-Catheter Removal
Penalty
Summary
The facility failed to update the care plan of a resident, identified as R106, to reflect his current toileting needs after the discontinuation of his Foley catheter. R106 was admitted with a Foley catheter, which was removed shortly after admission. Despite this change, the care plan continued to indicate the presence of the catheter and did not provide updated instructions for his toileting needs. This oversight was identified during a review of the resident's care plan, which lacked necessary updates to reflect his ability to independently manage his toileting and personal hygiene. Observations and interviews with staff revealed that the care plan should have been updated to reflect the resident's current needs. A CNA and a licensed nurse both acknowledged that the care plan was outdated and should have been revised to remove references to the Foley catheter. The administrative nurse confirmed that care plans should be reviewed and updated regularly, including when there are changes in a resident's condition. The failure to update the care plan placed the resident at risk for impaired care due to uncommunicated care needs.
Failure to Utilize Translation Services for Non-English Speaking Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R99, received appropriate supportive care and services to maintain her quality of life. R99, who has severe cognitive impairment, dementia, general anxiety disorder, and a cognitive communication disorder, was not provided with adequate tools or strategies to communicate her needs, wants, or feelings. Despite her care plan indicating the need for an interpreter and the use of translation services, staff did not utilize these resources effectively, leading to multiple incidents where R99 was unable to understand or be understood by staff. On several occasions, R99 was observed wandering the Memory Care Unit and entering other residents' rooms, causing confusion and distress. Staff attempted to redirect her using English, which she did not understand, and failed to use available translation services or cue cards to communicate with her. This lack of communication led to incidents where R99 inadvertently disturbed other residents, such as attempting to assist another resident during lunch, which resulted in a verbal altercation. The facility's failure to implement the necessary communication strategies as outlined in R99's care plan placed her at risk for decreased quality of life, isolation, and impaired dignity. Despite having policies in place for communication with residents with limited English proficiency, staff did not consistently apply these measures, contributing to the deficiency identified in the report.
Deficiencies in ADL Assistance for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, leading to deficiencies in care. Resident 92, who had diagnoses of quadriplegia, dementia, and encephalopathy, was dependent on staff for all ADLs, including toileting. Despite being on a two-hour check schedule, Resident 92 was observed with urine leaking from his brief onto the dining room floor, indicating a failure to provide timely incontinence care. Staff interviews revealed that Resident 92 was not checked and changed as required, especially before meals, which was a directive in his care plan. Resident 68, who had severe cognitive impairment and was dependent on staff for all ADLs, was left without toileting or incontinence checks for over four hours while sitting in a Broda chair. This lack of attention to his toileting needs was contrary to his care plan, which required regular checks and changes to maintain dignity and prevent skin breakdown. Staff interviews confirmed that Resident 68 should have been checked every two hours and provided with bathroom opportunities after meals. Resident 37, with multiple diagnoses including sleep apnea, diabetes, and Parkinson's disease, was dependent on staff for eating and other ADLs. On one occasion, Resident 37 was left in bed with his breakfast tray out of reach, and he was unable to eat without assistance. Despite his request to be taken to the dining room, he was not assisted due to a lack of available staff. This resulted in Resident 37 being unable to consume his meal, as observed when his tray was removed with most of the food untouched. Staff interviews indicated that there should have been enough staff to assist with his needs, but this was not provided, leading to a deficiency in care.
Improper Setting of Low Air-Loss Mattress for Resident
Penalty
Summary
The facility failed to ensure that a resident's low air-loss (LAL) mattress pump was set correctly according to the resident's weight, which is crucial for pressure ulcer prevention and care. The resident, who had multiple sclerosis, heart failure, and a history of pressure ulcers, was dependent on staff for all functional abilities and was incontinent of both bladder and bowel function. The resident's care plan included the use of a LAL mattress to prevent skin breakdown, but the mattress was found to be set at 220 lbs, which was inappropriate for the resident's actual weight of 137 lbs. The deficiency was identified through observations, record reviews, and interviews. The resident's electronic medical record (EMR) and treatment administration record (TAR) documented the requirement for the LAL mattress to be checked every shift to ensure it was set correctly based on the resident's weight. However, the TAR lacked documentation of the resident's weight or the setting of the LAL machine. Interviews with staff revealed a lack of knowledge regarding the correct setting for the LAL mattress, with both a certified nurse aide and a licensed nurse unable to specify the appropriate setting. The facility's policy on the use of support surfaces required that such devices be utilized according to the manufacturer's recommendations and checked each shift for proper functioning. Despite this policy, the resident's LAL mattress was not set according to the physician's order or the resident's weight, placing the resident at risk for complications related to skin breakdown and pressure ulcers.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement the fall intervention of anti-rollback devices for a resident, identified as R41, as per his care plan. R41 had severe cognitive impairment and was dependent on staff assistance for various activities of daily living. Despite being at risk for falls due to his medical conditions and limited mobility, his wheelchair lacked the necessary anti-rollback device, which was observed during a survey. Staff members, including a CNA and a licensed nurse, were unsure if the device had ever been placed on the wheelchair, indicating a lapse in following the care plan. Another deficiency was noted when a resident, identified as R36, was found with her bed left in a high position, posing a risk for falls. R36 had severely impaired cognition and was dependent on staff for mobility and other daily activities. Observations showed that her bed was elevated three feet off the floor, and she was unable to lower it herself. Staff members, including a CNA and a licensed nurse, acknowledged that the bed should not have been left in such a position, highlighting a failure to ensure a safe environment. The facility's policies on accidents and supervision were not adequately followed, as evidenced by the lack of implementation of individualized interventions to minimize fall risks for both residents. The care plans for R41 and R36 were not effectively executed, placing them at risk for preventable accidents and injuries. The facility's failure to adhere to its own policies and care plans resulted in these deficiencies, as noted by the surveyors.
Failure to Communicate Resident's Condition with Dialysis Center
Penalty
Summary
The facility failed to consistently communicate a resident's medical condition with the dialysis center, which led to a deficiency in providing safe and appropriate dialysis care. The resident, who required hemodialysis due to end-stage renal disease, had multiple medical conditions including sleep apnea, diabetes mellitus, hypertension, congestive heart failure, bipolar disorder, depressive disorder, Parkinson's disease, chronic obstructive pulmonary disease, and dysphagia. The resident's care plan specified that dialysis was to be conducted three times a week, with specific instructions for pre- and post-dialysis assessments and communication with the dialysis center. However, the facility's records lacked evidence of pre-hemodialysis assessments on several specified dates and post-hemodialysis assessments on other dates. Interviews with nursing staff revealed that there was an expectation for nurses to fill out and send pre-dialysis communication sheets with the resident and ensure post-dialysis sheets were completed and returned. Despite these expectations, the facility's failure to consistently follow these procedures placed the resident at risk of potential adverse outcomes and physical complications related to dialysis.
Failure to Provide Dementia-Related Care Services
Penalty
Summary
The facility failed to provide appropriate dementia-related care services for a resident, identified as R99, who was diagnosed with dementia, general anxiety disorder, and cognitive communication disorder. The resident's care plan indicated the need for an interpreter due to her non-English language communication and required staff to encourage her independence while ensuring supervision, especially when outside. Despite these instructions, staff did not utilize translation services or cue cards to communicate effectively with R99 during incidents of confusion and wandering. On multiple occasions, R99 exhibited behaviors such as wandering into other residents' rooms and attempting to assist them, which led to confusion and distress among the residents. Staff interventions were inadequate as they attempted to redirect R99 in English, which she did not understand, and failed to use available translation services. This lack of effective communication and supervision resulted in R99's continued wandering and interactions with other residents, which were not appropriately managed. The facility's policy required staff to provide assistance and services as outlined in each resident's care plan and to monitor and update care plan interventions as needed. However, the staff did not adhere to these guidelines, as evidenced by their failure to use translation services and adequately supervise R99, leading to a deficiency in providing dementia-related care. This deficiency placed R99 at risk for decreased quality of life, isolation, and impaired dignity.
Failure to Reconcile Controlled Substances Between Shifts
Penalty
Summary
The facility failed to ensure that controlled substances were properly accounted for and reconciled between shifts, as evidenced by missing signatures on the Narcotic Hand Off Count Sheets for multiple dates in July, August, and September 2024. Specifically, there were missing signatures for either the on-coming or off-going nurse during both morning and evening shifts on several occasions. This lack of documentation was observed in the medication rooms and carts on the 100 halls, indicating a failure to adhere to the facility's policy requiring narcotic counts and signatures at each shift change. Interviews with facility staff, including a Certified Medication Aide and a Licensed Nurse, confirmed that narcotics were supposed to be counted and documented with signatures at each shift change. The facility's policy on Controlled Substance Administration and Accountability, dated January 1, 2020, mandates safeguards to prevent loss, diversion, or accidental exposure of controlled substances. Despite this policy, the facility did not ensure accurate reconciliation of controlled medications, placing residents at risk for medication misappropriation and diversion.
Failure to Address Medication Regimen Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported missing dosage and application location for a physician-ordered medication for a resident, referred to as R92. R92 had multiple diagnoses, including quadriplegia, dementia, and encephalopathy, and required significant assistance for daily activities. The resident's medication orders for diclofenac sodium external gel lacked specific dosage amounts and application locations, which were not identified or reported by the CP during monthly medication regimen reviews from May 2024 to August 2024. This oversight placed the resident at risk for unnecessary medication side effects. Additionally, the facility did not ensure that the CP's recommendations for another resident, referred to as R35, were submitted to the attending physician for review. R35 had severe cognitive impairment and multiple diagnoses, including diabetes mellitus, depressive disorder, atrial fibrillation, and hypertension. The resident's electronic medical record showed that recommendations were made by the CP in March and May 2024, but there was no evidence that these recommendations were reviewed or addressed by the attending physician. This failure to act on the CP's recommendations placed R35 at risk for unnecessary medication use and potential side effects. Interviews with facility staff revealed a lack of clarity and action regarding pharmacy recommendations. Licensed Nurse J stated she was not involved with pharmacy recommendations, and Administrative Nurse D confirmed that the facility could not locate documentation showing that the physician had reviewed the CP's recommendations for R35. The facility's Medication Regimen Review policy required thorough evaluation and documentation of medication regimens, but these procedures were not followed, leading to the deficiencies identified in the report.
Deficiency in Medication Administration for a Resident
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary drugs, specifically regarding the administration of diclofenac, a topical medication used to treat pain and swelling. The resident, identified as R92, had a physician's order for diclofenac sodium external gel 1% to be applied to the affected area three times a day for pain. However, the order lacked a specified dosage amount and did not indicate the specific location for application. This oversight placed the resident at risk of unnecessary medication administration and potential adverse side effects. R92's medical history included diagnoses of quadriplegia, dementia, and encephalopathy, with a documented severely impaired cognition. The resident required substantial to total assistance for functional abilities and was always incontinent of both bladder and bowel. During the survey, it was observed that the licensed nurse applied the medication without a specified dosage, and the administrative nurse confirmed that all orders should indicate the amount and area for application. The facility was unable to provide a policy regarding physician's orders when requested, highlighting a deficiency in ensuring proper medication administration for R92.
Lack of Collaboration with Hospice Services
Penalty
Summary
The facility failed to ensure proper collaboration and communication between the nursing home and hospice services for two residents, R20 and R5, who were receiving hospice care. For R20, the facility did not document a comprehensive care plan that included the medications covered by hospice, personal care items provided, and the frequency of hospice visits. The hospice communication book also lacked a current hospice care plan, physician order with admitting diagnosis, and a list of medications covered by hospice. This lack of documentation and communication created a risk of missed opportunities for services and delayed addressing of physical, mental, and psychosocial needs. R20's medical history included dementia, major depressive disorder, diabetes mellitus, and chronic obstructive pulmonary disease. Observations noted that R20 had severely impaired cognition and required assistance with activities of daily living. Despite being admitted to hospice care, the facility's care plan did not reflect the necessary coordination with the hospice provider, as evidenced by the absence of detailed documentation regarding hospice services. Similarly, for R5, the facility's care plan did not specify the services provided by hospice, such as medication, equipment, and supplies, or the schedule of hospice worker visits. R5's medical conditions included convulsions, bipolar disorder, depressive disorder, anxiety, cerebral infarction, Bell's palsy, protein-calorie malnutrition, weakness, dysphagia, and congestive heart failure. Despite receiving hospice services, the facility failed to ensure a collaborative process was in place to communicate necessary information regarding R5's care, which had the potential for negative outcomes.
Failure to Obtain Informed Declination for PCV20 Vaccine
Penalty
Summary
The facility failed to offer and/or obtain an informed declination for the Pneumococcal Conjugate Vaccine (PCV20) for two residents, identified as R35 and R75. Both residents' Electronic Medical Records (EMR) documented a refusal for the PCV20 vaccination, yet their clinical records lacked evidence of an informed declination. This deficiency was identified during a review of the facility's immunization practices, which included a sample of 26 residents out of a census of 115. The facility's Vaccine Information Statement, revised on 06/01/22, mandates that a copy of the most current vaccine information statement be provided to the resident or their legal representative before vaccine administration, and that a signed consent form be placed in the individual's permanent medical record. However, the facility was unable to provide evidence of informed declinations for R35 and R75, placing them at increased risk for complications related to pneumonia.
Failure to Post Daily Staffing Information and Maintain Records
Penalty
Summary
The facility failed to comply with the requirement to post daily staffing information, including the census, and to maintain these records for 18 months. During an inspection on 09/16/24, it was observed that the staffing sheet displayed in the main lobby was dated 09/13/24 and did not include the census. The following day, the posted staffing sheet had the correct date but still lacked the census information. A review of the facility's records from 04/01/23 to 09/16/24 revealed multiple missing daily posted staffing records between 07/12/23 and 12/01/23. Administrative Nurse D confirmed the requirement to post daily staffing hours with the census and maintain these records for 18 months. The facility was unable to provide a policy related to the posting of staffing information.
Failure to Prevent Falls and Provide Post-Fall Care
Penalty
Summary
The facility failed to identify and implement appropriate, resident-centered interventions to prevent falls for a cognitively impaired resident. Despite multiple falls and documented interventions, the resident continued to fall, indicating that the interventions were ineffective. The resident's care plan included measures such as staff education, medication review, and placing signs in the resident's room, but these did not prevent further falls. On one occasion, the resident experienced an unwitnessed fall that resulted in head trauma. The facility failed to ensure that the resident received post-fall care, including neurological evaluations and nursing assessments. Although initial neurological checks were performed, there was a lack of evidence that these checks were continued as required. The resident was later found to have nasal bone fractures and multiple rib fractures. Interviews with staff revealed inconsistencies in the implementation of post-fall protocols. One nurse did not check if the resident was on anticoagulant medication, which would have necessitated immediate hospital transfer. Another nurse did not receive a callback from the on-call provider and did not attempt to call again. These lapses in care placed the resident at risk for increased pain and other complications.
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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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