Smoky Hill Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Salina, Kansas.
- Location
- 1007 Johnstown Avenue, Salina, Kansas 67401
- CMS Provider Number
- 175185
- Inspections on file
- 36
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at Smoky Hill Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia and diabetes experienced a marked decline in function, including increased weakness, inability to ambulate, decreased ability to feed herself, lethargy, and frequent urination. Staff documentation over two days showed missing food and fluid intake records, escalating assistance needs for transfers and ambulation, and notes of excessive weakness, but no complete vital signs or blood glucose checks were obtained despite an order for PRN glucose monitoring and a care plan identifying hyperglycemia risk. Nursing staff focused on a presumed UTI, requested and started an antibiotic without a documented urine specimen, and did not consider or assess for hyperglycemia or dehydration. The resident was later sent to the ED with a cold, pale, non-blanchable foot and was found to be obtunded with a blood glucose of 1020 mg/dL and significant lab abnormalities, and the failure to properly assess and respond to her change in condition was cited as neglect and immediate jeopardy.
A resident with COPD, respiratory failure, CHF, and atrial fibrillation, who required continuous O2 and nighttime Bi-Pap per recent hospital discharge orders, returned to the facility without being placed on Bi-Pap despite the facility having told the hospital that a functional Bi-Pap was available. Staff later discovered the in-house Bi-Pap was nonfunctional and, after being told a replacement would arrive that evening, the resident remained without Bi-Pap overnight. An ABG drawn at the facility showed markedly elevated CO2, and the resident was readmitted to the hospital with acute hypercapnic respiratory failure and mucous plugging. Interviews confirmed nursing "dropped the ball" in ensuring Bi-Pap availability and use, and the facility could not provide a relevant respiratory care policy.
Several residents who were dependent on staff for ADL assistance did not receive regular bathing as required by their care plans, resulting in poor hygiene, soiled clothing, and strong odors. Staff interviews revealed challenges in completing scheduled baths, especially on shifts staffed by agency personnel who reportedly refused to perform bathing duties. Documentation confirmed infrequent bathing for these residents, contrary to facility policy.
A resident with significant physical and cognitive impairments was left in a hallway for an extended period with a leaking colostomy bag, resulting in soiled clothing and a foul odor. Multiple staff members passed by without providing assistance, despite care plan directives for regular colostomy care and hygiene. The resident was unable to communicate his needs or move himself, and staff interviews confirmed the lapse in timely care.
Surveyors found extensive unsanitary conditions in the kitchen, including dirty floors, food splatters on walls and equipment, contaminated utensils, and unclean storage areas. Staff confirmed the lack of cleaning and failure to follow the facility's sanitation policy, resulting in all meals being prepared and served in an environment that did not meet professional standards.
A deficiency was found when a section of mopboard in the dining room was detached from the wall and partially lying on the floor, creating unsanitary and unhomelike conditions for residents who dined there. Maintenance staff were aware of the issue and had attempted to block access with a table, but the problem persisted.
Staff did not securely store medications or dispose of expired drugs as required. Expired aspirin, biotin, magnesium chloride, and folic acid were found in medication carts and the medication room. A nurse treatment cart was left unlocked and unattended with medications accessible, and staff confirmed these practices were not in line with facility policy.
Two residents with incontinence and significant care needs were repeatedly left exposed in their briefs and visible from the hallway due to staff failing to provide adequate privacy and assistance. Staff did not consistently cover the residents, ensure call lights were within reach, or position them safely for meals, resulting in compromised dignity and privacy in violation of facility policy.
Two residents were not given the required CMS Form 10055 Advanced Beneficiary Notice when skilled services were ending, and instead received an incorrect form that did not meet regulatory requirements. The facility also could not provide a Medicare beneficiary policy when requested, and staff reported discontinuing the correct form based on corporate direction.
A resident with chronic kidney disease and other comorbidities was placed on a physician-ordered fluid restriction, but the care plan was not updated to reflect this order. Staff were not consistently aware of the restriction, and fluid intake was not being monitored or documented as required, resulting in the resident having unrestricted access to fluids at the bedside.
Two residents with significant medical and functional needs did not receive adequate ADL support, including assistance with positioning, hygiene, and meal setup. Both were left in undignified or unsafe conditions, such as being exposed or unable to reach their call light, and staff failed to ensure privacy or provide timely help. Care plans and facility policies lacked necessary detail or were not provided when requested.
A resident with an indwelling urinary catheter and significant medical needs was observed on multiple occasions with catheter tubing resting on the floor while seated in a wheelchair, contrary to facility policy and the resident's care plan. This failure was confirmed by an administrative nurse, who stated staff were expected to keep tubing off the floor.
A resident with chronic kidney disease, hypertension, and other comorbidities was not properly monitored for a physician-ordered fluid restriction. The care plan did not include the restriction, staff were unaware or unable to recall the specific order, and fluid intake was not documented as required. The resident had access to fluids beyond the prescribed limit, and facility policy for fluid restriction was not followed.
A resident with significant care needs and moderately impaired cognition was admitted to hospice, but the facility did not include essential hospice service details—such as visit frequency, medications, equipment, and contact information—in the care plan. Staff confirmed this information was missing from the facility's documentation, despite policy requiring a coordinated plan of care with the hospice provider.
A resident with a urinary catheter was observed when a CNA allowed the catheter drainage bag and tubing to come into contact with the floor during wheelchair transport. Despite facility policy and care plan instructions to keep catheter equipment off the floor, staff did not immediately change out the contaminated items, resulting in a failure to follow infection control protocols.
Three residents were not offered or did not have documentation of being offered the pneumococcal PCV20 vaccine, as required by CDC guidance. In each case, either only a previous Prevnar 13 dose was recorded with no further documentation, or there was no record of pneumococcal vaccination information at all. An administrative nurse was unaware of the updated CDC recommendations, and facility policy requiring adherence to current CDC guidance was not followed.
A resident admitted for rehabilitation after a hip replacement did not receive appropriate pain management due to the facility's failure to obtain prescribed oxycodone and incorrect entry of acetaminophen orders. The resident experienced significant pain and distress, as the staff administered ineffective Norco instead. This impacted the resident's ability to participate in rehabilitation and affected her well-being.
A resident experienced significant medication errors when the facility failed to obtain prescribed as-needed pain medication following a hip replacement. The resident's acetaminophen was incorrectly entered as needed instead of scheduled, and oxycodone was not provided, leading to unalleviated pain and impaired rehabilitation participation.
A resident with a history of hemiplegia and stroke was neglected by staff, leading to a severe injury. The resident was left without a call light, preventing him from calling for help. After being left to eat breakfast lying flat, the resident attempted to communicate his need for assistance by showing a ball of feces to a CMA, who failed to help. The resident fell from the bed, hitting his head, resulting in a severe brain injury. Staff delayed in providing assistance and failed to offer comfort measures, placing the resident in immediate jeopardy.
A resident on antiplatelet therapy fell from bed, hitting his head, and did not receive adequate post-fall care. Staff failed to perform a thorough assessment, including a neurological exam, and left the resident on the floor while preparing his bed. The resident showed signs of distress and potential injury throughout the day, but staff did not conduct proper assessments or closely monitor his condition. The resident was later found lethargic and vomiting, leading to a hospital transfer where he was diagnosed with a severe brain injury and subsequently died.
A resident with significant medical conditions and a high fall risk was left without adequate supervision and safety measures, leading to a fall and fatal injury. Staff failed to ensure the resident's call light was within reach and did not perform necessary assessments or provide timely care, resulting in the resident's death from a hemorrhagic brain bleed.
A resident with severe cognitive impairment and a high fall risk fell from a wheelchair, sustaining a broken nose and head laceration, due to inadequate supervision and intervention by staff. Despite being redirected verbally, the resident's repeated unsafe behavior of leaning forward was not sufficiently addressed, leading to the fall.
Failure to Assess Change in Condition and Evaluate for Hyperglycemia in Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a resident’s significant change in condition, resulting in neglect. The resident had diagnoses including diabetes mellitus with circulatory complications, dementia with severe cognitive impairment, hyperlipidemia, and a cognitive communication deficit, and resided on a secure unit. Her care plan identified her as at risk for hyperglycemia and directed staff to observe, document, and report signs and symptoms such as increased thirst, frequent urination, fatigue, and other indicators. Laboratory data showed an elevated HbA1c placing her at risk for diabetes, and the MAR included an order for PRN blood glucose monitoring with instructions to notify the provider if blood sugar was below 70 mg/dL or above 400 mg/dL. In the days leading up to the event, documentation showed a decline in the resident’s functional status and intake that was not fully assessed. On one day, EMR task documentation lacked information on the amount of food consumed at breakfast and lunch, noted that she required staff assistance for eating and transfers, and showed she did not ambulate or required total staff assistance for ambulation, with no fluid intake documented. The following day, documentation again lacked food intake for breakfast and lunch, showed she required extensive assistance from two staff for transfers and ambulation, and still lacked fluid intake documentation. A health status note recorded that she had excessive weakness, could no longer ambulate independently or with assistance, and required two staff to pivot her from chair to wheelchair, but the EMR did not contain a complete set of vital signs or any blood glucose value associated with this change. Later that same day, staff faxed the physician reporting that the resident had shakes, was more sleepy, not as awake as usual, and had frequent urination, and requested an antibiotic for a presumed UTI, noting unsuccessful attempts to obtain a urine specimen, including straight catheterization, though the EMR lacked documentation of these attempts. The physician ordered Macrobid, and a health status note documented administration of the first dose and continued weakness and cognitive decline, with the resident non-verbal and requiring staff to feed her. Again, the EMR lacked a complete set of vital signs and a blood glucose measurement despite documentation that vital signs were within normal limits. Early the next morning, staff reported the resident’s foot was cold and colorless; the nurse found it pale, cold, and non-blanchable, notified the on-call physician, and the resident was sent to the emergency department. In the ED, she was obtunded, with a point-of-care glucose reading “HI” and a laboratory glucose of 1020 mg/dL, along with a sodium level of 158 mEq/L and urine showing very high glucose but negative for bacteria and nitrites. Interviews with facility staff revealed that they believed the resident had a UTI, did not obtain or document complete vital signs, did not perform blood glucose checks, and did not consider hyperglycemia or dehydration as potential causes of her symptoms, despite her diagnosis and risk factors. The facility’s own Acute Condition Changes Protocol required comprehensive assessment and data collection, including vital signs and evaluation of possible causes, which were not carried out. This failure to assess and respond to the resident’s change in condition, including failure to consider and evaluate for hyperglycemia or dehydration, was determined to be neglect and placed the resident in immediate jeopardy.
Removal Plan
- Upon change of condition of any resident, Smoky Hill Nurses will complete a Change of Condition Form and notify the resident physician immediately.
- Any resident with a diabetes diagnosis will be assessed for hypo/hyperglycemia and labs as ordered by the physician.
- Nursing staff will be in-serviced on hypo/hyperglycemia and other conditions (frequent urination, lethargy, weakness, inability to ambulate, inability to feed self) as associated with diabetes.
- All residents with diabetes will be assessed for signs and symptoms of dehydration or hypo/hyperglycemia or any other changes associated with diabetes.
- The facility will monitor changes in condition 7 days a week and 5 days a week for 3 weeks.
Failure to Provide Functional Bi-Pap and Required Respiratory Support
Penalty
Summary
The deficiency involves the facility’s failure to provide required respiratory care and equipment for a resident with significant pulmonary and cardiac comorbidities. The resident had diagnoses including COPD, respiratory failure, CHF, and atrial fibrillation, required continuous oxygen, and needed extensive assistance with ADLs. The resident’s care plan documented the need for oxygen at all times and monitoring for signs and symptoms of respiratory distress. Following a hospitalization for hypercapnia and pneumonia, the hospital discharge instructions specified that the resident was to receive 3 L of oxygen continuously and use Bi-Pap at night. Upon discharge from the hospital, the resident’s primary care physician documented that the resident was supposed to be on Bi-Pap when he returned to the facility and that the facility had told the hospital they had a functioning Bi-Pap available. However, the physician noted that as of the time of his dictation, the resident had not been placed on Bi-Pap and that the facility would need to see if they could acquire one. The physician also documented that an ABG was needed to evaluate CO2 retention and that, if the facility could not obtain a Bi-Pap in a timely manner and the resident’s CO2 continued to rise, he would likely need to return to the emergency room. A subsequent health status note recorded that an ABG drawn at the facility showed a CO2 level of 85, and the resident was sent to the emergency room. Hospital records from the readmission documented that the resident presented with elevated CO2 and was diagnosed with mucous plugging, left pleural effusion, acute hypercapnic respiratory failure, and decreased responsiveness. The hospital noted that the resident had been discharged two days earlier with orders for Bi-Pap ventilation and that the hospital had kept him an extra day so the facility could arrange Bi-Pap, but for some reason he did not have access to a Bi-Pap machine after return. A pulmonology consult documented recurrent acute hypercapnic respiratory failure requiring Bi-Pap and noted that the resident’s mentation was already improving with Bi-Pap. Facility staff interviews revealed that the facility had informed the hospital they had an in-house Bi-Pap, but when staff attempted to set it up, they could not program the settings and were later told by the equipment company that the machine was no longer functional. Staff stated a replacement Bi-Pap was expected that evening, but one nurse reported she did not know until the next morning that the new machine had not been delivered and that the resident had been without Bi-Pap overnight. The facility was unable to provide a Respiratory Care Policy applicable to this practice.
Failure to Provide Regular Bathing and Hygiene Care
Penalty
Summary
The facility failed to provide bathing care according to residents' care plans and preferences for four residents who were dependent on staff for activities of daily living. Observations revealed that multiple residents had greasy, matted hair, strong body odors, and soiled clothing, indicating a lack of regular bathing and hygiene care. One resident had not received a bath in 39 days, another had only two baths in 34 days since admission, and others had similarly infrequent bathing documented. Residents expressed feeling dirty, unclean, and neglected, with one stating that bathing did not seem to be a priority in their care. Staff interviews confirmed difficulties in completing scheduled baths, particularly on the evening shift, which was staffed entirely by agency personnel who reportedly refused to perform bathing duties. Documentation reviewed supported the lack of regular bathing for the affected residents. The facility's own policy required regular bathing to promote cleanliness and comfort, but this was not followed, resulting in the observed deficiencies.
Failure to Maintain Resident Dignity and Hygiene Due to Unaddressed Colostomy Leak
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis, major depressive disorder, and cognitive communication deficit was observed sitting in a hallway in a wheelchair for approximately 45 minutes with a visibly leaking colostomy bag. The resident's t-shirt and sweatpants were soiled with a brown liquid substance consistent with bowel movement, and there was a foul odor present. Multiple staff members walked past the resident during this time without providing assistance or addressing the resident's hygiene needs. The resident was unable to move himself or communicate his needs effectively due to his medical conditions. The resident's care plan documented the need for staff to provide care to the colostomy site every shift and as needed, and to ensure the resident was clean, well-groomed, and appropriately dressed. Despite these directives, staff failed to recognize and respond to the resident's condition in a timely and dignified manner. Staff interviews confirmed that the resident was left in the hallway as a reminder to get him into bed after breakfast, but his hygiene needs were not addressed during the observed period. Facility policy required the provision of a safe, clean, and comfortable environment with person-centered care, which was not upheld in this instance.
Widespread Kitchen Sanitation Failures Compromise Food Safety
Penalty
Summary
Surveyors observed widespread unsanitary conditions in the facility's kitchen, affecting the preparation, storage, and serving of meals for all 61 residents. During the initial kitchen tour, dried dirt, food splatters, and debris were found throughout the kitchen, including on the tiled floors, dishwashing area walls, and food serving areas. Clean dish carts and utensils were contaminated with food debris, and equipment such as microwaves, ovens, and refrigerators contained old, dried, and burned food residues. The food storage bins, can opener, and food scales were also found to be dirty and covered in food debris or grease. Trash cans were greasy and uncovered, and the dried food storage area was littered with packets and onion skins. Additionally, kitchen vents lacked covers, exposing air filters, and the walk-in refrigerator had food debris on the floor and door. Interviews with dietary and administrative staff confirmed the uncleanliness of the kitchen, with staff attributing the lack of cleaning to the evening shift and acknowledging the unsanitary conditions. The facility's own sanitation policy requires all kitchen and dining areas, equipment, and utensils to be kept clean and in good repair, but these standards were not met. The failure to maintain sanitary conditions in the kitchen placed all residents at risk for food-borne illnesses, as all meals were prepared and served from this environment.
Dining Room Environmental Deficiency Due to Damaged Mopboard
Penalty
Summary
A deficiency was identified when approximately 2-3 feet of mopboard at the west end of the dining room was observed coming away from the wall, with about 6 inches of it lying on the floor. Maintenance staff confirmed awareness of the issue and stated that a table had been placed in front of the damaged area, but it had been moved. The facility was in the process of replacing all mopboards, and staff were expected to report environmental issues through the TELS system. The facility's policy required the maintenance supervisor to ensure the building and equipment were maintained in a safe and operable manner. The failure to promptly repair the mopboard resulted in unsanitary and unhomelike conditions for residents dining in the main dining room.
Failure to Secure and Timely Dispose of Medications
Penalty
Summary
Facility staff failed to store medications securely and did not dispose of expired medications in a timely manner. Observations included a nurse treatment cart containing an expired bottle of aspirin and an undated insulin pen, as well as a medication cart with an expired bottle of biotin. Additionally, the medication room contained expired stock medications, including magnesium chloride and multiple bottles of folic acid. These expired medications were confirmed by licensed staff and had not been removed or disposed of as required by facility policy. Further, a nurse treatment cart on one hall was found unlocked and unattended, with warfarin, insulin pens, and other medications accessible for at least two minutes without licensed staff present. Staff interviews confirmed that medication carts should be locked when not in use and that expired medications should be removed and disposed of according to policy. The facility's own policy requires that discontinued or outdated drugs be destroyed or returned to the pharmacy and that all medication storage areas be locked when not in use.
Failure to Maintain Resident Privacy and Dignity During Personal Care
Penalty
Summary
Staff failed to provide adequate privacy and assistance to two residents who wore incontinent briefs, resulting in their exposure to staff, visitors, and other residents from the hallway. One resident, who had multiple comorbidities including diabetes, morbid obesity, chronic pain, and respiratory failure, was observed on several occasions with her lower body uncovered and her incontinent brief exposed while lying in bed with her leg hanging off the mattress. The resident was dependent on staff for bed mobility, positioning, and use of the call light, which was often not within reach. Staff did not consistently assist with covering the resident or adjusting her bed for meals, leaving her in unsafe positions for eating and drinking, and her privacy was not maintained as required by facility policy. Another resident, with diagnoses including hypertension, stroke, chronic kidney disease, and major depressive disorder, was also observed without adequate privacy. This resident, who required supervision and assistance with mobility and toileting, was seen standing in her room wearing only a blue incontinent brief while staff left the door open, making her visible to those passing in the hallway. The room also had a strong odor of urine, and the resident's clothing was on the floor, indicating a lack of timely assistance with personal hygiene and dressing. Facility policy required staff to promote and protect residents' privacy and dignity, including bodily privacy during personal care. Despite this, staff actions and inactions led to repeated instances where both residents' privacy and dignity were compromised. Administrative staff acknowledged that staff should assist residents to protect their privacy by closing doors and covering them, but these practices were not consistently followed, resulting in the observed deficiencies.
Failure to Provide Required Medicare Liability Notices
Penalty
Summary
The facility failed to provide two residents with a fully completed Advanced Beneficiary Notice (ABN) using the required CMS Form 10055 when skilled services were ending. Instead, the facility issued CMS Form 10124, which is not the appropriate form for this situation. The ABN is intended to inform residents or their representatives about potential Medicare non-coverage for continued skilled therapy services and to provide an estimated cost of those services. The forms given to the residents did include options for the beneficiary to choose whether to receive the therapy and how billing should be handled, but did not meet the regulatory requirement for the specific form and content. Additionally, when requested, the facility was unable to provide a Medicare beneficiary policy. Administrative staff reported that the use of CMS Form 10055 had been discontinued based on corporate direction. This failure to use the correct form and provide the necessary policy documentation resulted in residents not being properly informed about their potential financial liability for services not covered by Medicare.
Failure to Update Care Plan with Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to update a resident's care plan to include a physician-ordered fluid restriction, despite clear documentation in the medical record and physician orders. The resident had multiple diagnoses, including hypertension, chronic kidney disease, and a history of stroke, and was under a fluid restriction of three liters per day as ordered by the physician. The care plan, however, did not reflect this restriction, and staff were not consistently aware of or monitoring the fluid intake as required. The dietary and nursing departments had specific instructions for fluid provision, but these were not incorporated into the care plan, and intake was not being documented for the resident. Observations revealed that the resident had access to a 600-cc jug of ice water at the bedside, contrary to the fluid restriction order. Interviews with staff indicated a lack of awareness regarding the fluid restriction, and the responsible nurse had not documented the resident's fluid intake. The facility's policy required the interdisciplinary team to develop individualized care plans, but this was not followed in the case of the resident with a fluid restriction.
Failure to Provide Adequate ADL Support and Maintain Resident Dignity
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) support for two residents who required staff assistance. One resident had multiple diagnoses including diabetes mellitus, morbid obesity, major depressive disorder, delusional disorder, restless leg syndrome, chronic pain, lymphedema, and chronic respiratory failure. This resident was documented as dependent on staff for bed mobility, transfers, toileting hygiene, bathing, and dressing. Observations revealed that the resident was frequently left in unsafe or undignified positions, such as having a leg hanging off the bed and being exposed from the waist down, with the incontinent brief visible from the hallway. The resident was also left without assistance to adjust the bed for safe eating and drinking, resulting in coughing episodes, and the call light was often out of reach. Staff failed to provide timely assistance with positioning, covering, and meal setup, and the bed controls were found to be nonfunctional without prompt repair. Another resident, with diagnoses including hypertension, stroke, chronic kidney disease, angina, delusional disorder, anxiety disorder, localized edema, and major depressive disorder, was also observed to have unmet ADL needs. This resident was frequently incontinent and required supervision and setup assistance with eating and toileting, as well as a scheduled toileting program. Observations showed the resident remained in bed in soiled clothing, with a strong urine odor in the room, and was left standing in only an incontinent brief while staff and visitors could see into the room. Staff failed to ensure the resident was dressed or covered, and the door was left open, compromising privacy and dignity. The care plan for this resident lacked documentation of a physician-ordered fluid restriction, despite a progress note indicating a three-liter fluid restriction was in place. The facility's policies and care plans were found to be insufficient or lacking in specificity regarding the level of staff assistance required for these residents' functional abilities. The facility failed to provide a policy for activities of daily living support when requested. Additionally, the facility's repositioning policy outlined the need for individualized care plans and consistent repositioning programs, but observations indicated these were not consistently implemented for the residents in question. These failures resulted in ongoing unmet needs for ADL support, lack of privacy, and inadequate assistance with positioning, hygiene, and meal setup.
Failure to Maintain Catheter Tubing Off the Floor
Penalty
Summary
Staff failed to provide proper urinary catheter care for a resident with a history of cerebral infarction, neuromuscular bladder dysfunction, and an infection related to an indwelling urinary catheter. The resident's care plan required staff to change the catheter as ordered, check for patency and urinary output every shift, observe for pain or discomfort, ensure the catheter tubing was free of kinks, and keep the catheter bag and tubing below the level of the bladder and off the floor. The facility's policy also directed staff to keep the catheter tubing and drainage bag off the floor. Despite these directives, observations on two separate occasions found that the resident's catheter tubing was resting on the floor while the resident was seated in a wheelchair in the dining room. On one occasion, approximately four inches of tubing were on the floor, and on another, about one inch was on the floor. An administrative nurse confirmed that staff were expected to prevent tubing from resting or dragging on the floor, indicating a failure to follow established protocols for catheter care.
Failure to Monitor and Implement Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to monitor and implement a physician-ordered fluid restriction for a resident with multiple comorbidities, including hypertension, chronic kidney disease, angina, and a history of stroke. The physician's order specified a daily fluid restriction of three liters, with detailed instructions for the distribution of fluids by shift and department. However, the resident's care plan did not include the fluid restriction, and staff were not consistently aware of or following the order. Observations revealed that the resident had access to a 600-cc jug of ice water at the bedside, contrary to the restriction, and staff interviews confirmed a lack of awareness and documentation regarding the fluid restriction and intake monitoring. Further review of facility policy indicated that staff were expected to follow specific instructions for fluid restrictions, including removing water pitchers from the room and recording intake. Despite these guidelines, nursing staff had not documented the resident's fluid intake, and the care plan lacked the necessary information about the restriction. The failure to implement and monitor the fluid restriction as ordered placed the resident at risk for complications related to hydration status, particularly given the resident's cardiac and renal conditions.
Failure to Communicate and Document Hospice Services in Resident Care Plan
Penalty
Summary
The facility failed to ensure a communication process between the hospice provider and the facility for a resident who was admitted to hospice care. The resident, who had diagnoses of sarcopenia and a transient ischemic attack and demonstrated moderately impaired cognition, required extensive assistance with most activities of daily living. The care plan documented the need for staff to work cooperatively with the hospice team but did not include specific instructions regarding the services provided by hospice, such as the frequency and type of support visits, supplies, medical equipment, medications covered by hospice, or hospice contact information. Record review and staff interviews confirmed that the care plan lacked essential details about hospice services, and this information was not incorporated into the facility's care plan, even though it was available in the hospice care plan kept at the nurse's station. The facility's policy required a coordinated plan of care between the facility, hospice agency, and resident/family, but this was not reflected in the resident's care plan documentation.
Failure to Maintain Catheter Bag and Tubing Off the Floor
Penalty
Summary
Staff failed to maintain a sanitary environment to prevent the development and transmission of infections when a resident's urinary catheter tubing and drainage bag were allowed to come into contact with the floor. The resident, who had diagnoses of obstructive and reflux uropathy and used a urinary catheter, was observed in a wheelchair when a CNA turned the wheelchair, causing the catheter drainage bag to fall out of its privacy bag and land on the floor. The CNA then placed the drainage bag back into the privacy bag and moved the resident to the dining room, with the catheter tubing still touching the floor. The resident's care plan instructed staff to keep the catheter bag and tubing below the level of the bladder and off the floor, and the facility's policy required that catheter tubing and drainage bags be kept off the floor. The administrative nurse confirmed that staff were expected to change out the catheter drainage bag and tubing if they touched the floor. Despite these instructions and policies, staff did not follow proper infection control procedures during the incident.
Failure to Offer and Document Pneumococcal PCV20 Vaccinations per CDC Guidance
Penalty
Summary
The facility failed to offer or document the offering of pneumococcal PCV20 immunizations to three residents, as required by current CDC guidance. Specifically, one resident's electronic medical record (EMR) showed receipt of a single Prevnar 13 dose in 2015, but lacked documentation regarding any subsequent offer or refusal of further pneumococcal vaccinations. Another resident's EMR also indicated a single Prevnar 13 dose in 2015, with no documentation of additional offers or refusals. A third resident's EMR lacked any information about pneumococcal vaccination or whether the vaccine was offered or refused. During an interview, an administrative nurse acknowledged being unaware of the CDC guidance related to the PCV20 immunization. The facility's policy stated that all residents would be offered pneumococcal vaccines in accordance with current CDC recommendations, but the records reviewed did not reflect compliance with this policy.
Inadequate Pain Management for Post-Surgical Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who was admitted for rehabilitation following a total hip replacement. The resident was prescribed oxycodone 5 mg as needed and acetaminophen 1000 mg every six hours on a scheduled basis. However, the facility did not obtain the prescribed oxycodone until several days after admission and incorrectly entered the acetaminophen order as 'as needed' in the Electronic Medical Record (EMR), requiring the resident to request the medication. Upon admission, the facility did not attempt to obtain the oxycodone until the following day, and when the local pharmacy did not have it in stock, they did not check with other pharmacies. Instead, the medical director prescribed Norco 5/325 mg, which the resident had previously indicated was ineffective for her pain. Despite the resident's repeated complaints and requests for oxycodone, the staff continued to administer Norco, resulting in the resident experiencing significant pain and distress over the weekend. The resident expressed dissatisfaction with the pain management, stating that the Norco did not alleviate her pain and that she was in tears and unable to sleep due to the pain. The facility's failure to follow the discharge orders and obtain the correct medication led to the resident's pain being inadequately managed, impacting her ability to participate in rehabilitation and affecting her overall well-being.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to obtain the prescribed as-needed pain medication for a resident following a total hip replacement, leading to significant medication errors. The resident, who had diagnoses of postoperative care following joint replacement, anxiety, and depression, was admitted to the facility for a Medicare-covered stay. The resident's care plan required the administration of pain medication per physician orders, but the facility did not follow the discharge orders for acetaminophen to be given on a scheduled basis. Instead, the order was incorrectly entered into the Electronic Medical Record (EMR) as needed, requiring the resident to request the medication. The resident's Medication Administration Record (MAR) showed discrepancies in the administration of pain medications. The resident was prescribed Norco and oxycodone for pain management, but the facility failed to provide the oxycodone as needed, and the acetaminophen was not administered as scheduled. The resident expressed dissatisfaction with the pain management, stating that Norco was ineffective and that she was in tears due to pain, which affected her ability to participate in rehabilitation and sleep. The facility's administrative staff acknowledged the errors, noting that the resident's pain was not adequately managed over the weekend due to issues with obtaining the prescribed oxycodone from a local pharmacy. The facility's Medication Monitoring and Management Policy emphasized the importance of optimizing medication therapy and minimizing adverse consequences, but the facility did not adhere to these guidelines, resulting in the resident experiencing unalleviated pain and psychosocial impairment.
Neglect Leads to Severe Injury in Resident
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in a series of events that led to a severe injury. The resident, who had a history of right-sided hemiplegia, cerebrovascular accident, aphasia, dysphagia, and repeated falls, was left without a call light within reach, preventing him from calling for assistance. On the morning of the incident, a Certified Nurse Aide (CNA) entered the resident's room, patted the resident's brief without gloves, and left without ensuring the call light was accessible. Later, the resident was left to eat breakfast lying flat in bed, which led to food spillage and further discomfort. Throughout the morning, the resident attempted to communicate his need for assistance by showing a ball of feces to a Certified Medication Aid (CMA), who failed to provide help and left the room. The resident, unable to reach his call light or wheelchair, attempted to adjust his bed pad, resulting in a fall from the bed. The resident hit his head on the floor, leading to a severe brain injury. Despite the resident's cries for help, staff delayed in providing immediate assistance and failed to offer comfort measures, such as placing a pillow under his head. The facility's neglect was further evidenced by the lack of proper toileting and incontinent care, as the resident's bed pad and linens were found soaked and covered with feces. The staff's failure to conduct timely neurological assessments and provide necessary care after the fall contributed to the resident's deteriorating condition, which included an acute hemorrhagic brain bleed. The facility's actions and inactions placed the resident in immediate jeopardy, highlighting a significant deficiency in the care provided.
Failure to Provide Adequate Post-Fall Care for Resident on Antiplatelet Therapy
Penalty
Summary
The facility failed to provide adequate post-fall treatment for a resident, identified as R1, who was on antiplatelet therapy and had a history of cerebrovascular accident, hemiplegia, and repeated falls. On the morning of the incident, R1 fell from his bed, hitting his head on the floor. Despite being on blood thinners, the staff did not perform a thorough assessment for injuries, including a neurological examination, after the fall. Instead, they left R1 on the floor while they prepared his bed, and when they eventually assisted him back to bed, they did so without using a gait belt or assessing for potential fractures or injuries. Throughout the day, R1 exhibited signs of distress and potential injury, such as yelling in pain and later becoming lethargic and vomiting. However, staff failed to conduct proper neurological assessments or monitor R1's condition closely. The video footage revealed that staff did not enter R1's room for several hours after he was last seen at lunch, during which time R1 showed signs of discomfort and eventually vomited. The documented neurological assessments in R1's electronic medical record were not consistent with the video evidence, indicating that these assessments were not actually performed. The facility's policies on assessing falls and conducting neurological assessments were not followed, as staff did not adequately evaluate R1 for head injuries or other complications following the fall. This lack of appropriate care and monitoring led to R1 being found in a deteriorated state later in the day, ultimately resulting in his transfer to a hospital where he was diagnosed with a severe brain injury and subsequently died.
Failure to Prevent Resident Fall Resulting in Fatal Injury
Penalty
Summary
The facility failed to implement safety interventions to prevent falls for a resident with significant medical conditions, including right-sided hemiplegia, cerebrovascular accident, aphasia, dysphagia, and a history of repeated falls. The resident required substantial assistance for daily activities and was identified as a high fall risk. Despite these needs, the resident was left without a call light within reach, and the bed was not in the lowest position, contributing to a fall that resulted in a fatal injury. On the morning of the incident, the resident was left unattended for extended periods, with staff failing to ensure the call light was accessible or that the resident was positioned safely. The resident attempted to manage personal hygiene needs independently, leading to a fall from the bed. The fall was unwitnessed by staff, and the resident suffered a hemorrhagic brain bleed after hitting his head on the floor. The facility's documentation and video footage revealed that staff did not perform necessary neurological assessments or provide adequate supervision and assistance. The resident was left without proper care and monitoring for several hours after the fall, during which time his condition deteriorated, ultimately leading to his death. The facility's failure to adhere to care plans and safety protocols placed the resident in immediate jeopardy.
Removal Plan
- Re-educate all nursing staff on policies including Quality Care Documentation, Notifying Primary Care Physician (PCP) and Family, Neurological Assessments and Vital Signs, Change in Condition, Gait Belt Use, Falls, Using a Lift, Abuse, Neglect, and Exploitation Recognition and reporting.
- Implement a Quality Assurance and Performance Improvement (QAPI) review of the incidents.
- Conduct one-on-one disciplinary counseling with direct care staff on duty.
- Terminate the involved nurses.
- Complete audits to identify residents at risk and ensure all appropriate actions/interventions are implemented.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and intervention for a resident, identified as R1, who exhibited unsafe behaviors that led to a fall and subsequent injuries. R1, who had a history of cerebrovascular accident, depression, and atrial fibrillation, was documented to have severe cognitive impairment and required significant assistance for daily activities. Despite being identified as a high fall risk, R1 was observed leaning forward in his wheelchair multiple times on the day of the incident, which eventually resulted in him falling headfirst to the floor, causing a broken nose and a head laceration. The incident occurred when a Certified Nurse Aide (CNA) was cleaning the dining hall and momentarily turned away from R1, who then fell. The CNA and a Licensed Nurse (LN) responded to the fall, and R1 was subsequently sent to the hospital for evaluation. The facility's records indicated that R1 had been leaning forward in his wheelchair throughout the morning, and staff had verbally redirected him, but no further interventions were implemented to prevent the fall. The facility's policy on managing falls and fall risk emphasized the need for staff to identify and implement appropriate interventions based on a resident's specific risks. However, in this case, the facility did not adequately supervise or intervene to prevent R1's fall, despite his known high fall risk and repeated unsafe behavior. This lack of supervision and intervention directly contributed to the incident and R1's injuries.
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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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