Southwind At Spearville
Inspection history, citations, penalties and survey trends for this long-term care facility in Spearville, Kansas.
- Location
- 102 N Pine Street, Spearville, Kansas 67876
- CMS Provider Number
- 175568
- Inspections on file
- 10
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Southwind At Spearville during CMS and state inspections, most recent first.
Surveyors observed a dietary staff member plating meals while wearing the same pair of gloves to handle multiple food items, including ready-to-eat bread, and then touching her face and glasses before continuing to plate food without changing gloves or washing hands. The staff member reported she had been trained to serve in this manner and usually changed gloves several times during the process. These practices did not follow the facility’s hand hygiene policy, which requires handwashing in designated sinks, appropriate glove use when handling ready-to-eat food, and handwashing before distributing meals.
The facility used an admission packet containing an Arbitration Provision that did not inform residents or their representatives of their right to rescind the agreement within 30 days or that signing it was not a condition of admission. All residents had signed arbitration agreements, and staff reported that the provision in the packet was the only written information provided, with explanations given verbally at admission. Administrative staff and an administrative nurse indicated that the provision had been created by a previous company and possibly altered by current leadership, and they were not aware of the specific regulatory language required to be included in the arbitration agreement.
The facility used an admission packet arbitration provision for all 22 residents that did not inform residents or their representatives of their right to participate in selecting a neutral arbitrator or a mutually convenient venue. Administrative staff reported that the arbitration provision in the admission packet was the only written information provided and that they verbally explained it at admission, but they were not aware of the specific language required to be included. The arbitration language had been created under a previous company and may have been altered by the current board and administrator, yet it still lacked the required provisions, resulting in a deficiency related to the arbitration process.
A resident with atrial fibrillation and moderately impaired cognition had a care plan and physician order indicating DNR status, but the signed DNR document was missing from the EMR. During transfer from assisted living to LTC, the signed DNR did not carry over into the current chart, and an administrative nurse acknowledged there was no process in place to monitor or verify changes to advance directives, contrary to the facility’s Advance Directives policy requiring supporting documentation with a DNR order.
Surveyors found that the beauty shop was left unlocked and unattended while containing accessible hazardous items, including disinfectant sprays, shampoo, hair spray, curling irons, and an electric razor, with an unlocked cabinet holding additional disinfectant spray. This occurred despite the presence of cognitively impaired but independently mobile residents and despite a facility policy stating a commitment to eliminate and control hazardous chemicals and meet safety standards for hazards and potential hazards.
A resident with a colostomy and history of intestinal obstruction, who was cognitively intact, had a care plan and an ostomy policy requiring staff to monitor and document bowel sounds and bowel movements, including stool output, consistency, and color each shift. Staff did not document any bowel movement information in progress notes or tasks, and continence was left unrated due to the colostomy without recording amount, frequency, or consistency. A CNA was observed emptying the colostomy bag directly into the trash without measuring or documenting the stool and reported that staff do not monitor or report bowel movement details to nurses, while an RN confirmed that this resident’s bowel movements were not included in the usual bowel report process.
A resident with HTN and CHF, prescribed multiple antihypertensives and diuretics with specific BP and pulse parameters, did not receive valsartan, metoprolol, furosemide, or hydrochlorothiazide during a morning medication pass when a CMA obtained a BP in the low 100s systolic and 40s diastolic and reported it to an LN. The LN instructed the CMA to hold all ordered medications based on nursing judgment and did not notify the physician, despite orders outlining when to contact the provider. Documentation in the EMR and MAR reflected that the medications were held per nursing judgment, and no physician notification occurred.
The facility failed to submit complete and accurate staffing information through PBJ, resulting in multiple instances where Licensed Nursing Coverage was not reported as 24 hours a day, despite adequate hours being indicated in the nursing schedule and clocking sheets. An outside agency was responsible for the inaccurate data submission prior to November 1, 2023.
The facility failed to revise care plans for four residents related to falls and nebulizer use. Observations and interviews revealed that nebulizer equipment was not properly stored or cleaned, and care plans were not updated with new interventions after falls. The facility also failed to provide a policy regarding care plans when requested.
The facility failed to conduct a criminal background check for a CNA hired on 07/08/22. The Administrative Nurse confirmed the lack of background check information, which is required by the facility's policy on abuse prevention. This failure had the potential to negatively affect resident care.
The facility failed to ensure a safe environment for a resident with severe cognitive impairment and a history of falls. Despite multiple falls and a high fall risk score, the care plan lacked effective interventions, and staff did not adequately follow the facility's accident prevention policy. This resulted in repeated falls for the resident.
The facility failed to provide necessary respiratory care for two residents, including improper storage and cleaning of nebulizers, and lacked a policy on respiratory care. Observations and staff interviews confirmed these deficiencies.
The facility failed to complete annual performance reviews for three CNAs employed for over 12 months, as confirmed by administrative staff. This lapse was identified during a review of employee files, revealing a lack of performance evaluations to ensure adequate care and services for residents.
Improper Glove Use and Hand Hygiene During Meal Service
Penalty
Summary
Surveyors identified a deficiency in food preparation and service sanitation when observing the noon meal service for a census of 22 residents from the facility’s main kitchen. During the meal, a dietary staff member wearing gloves plated food by removing the lid from a roasting pan and using utensils to serve meat, potatoes, and spinach, then used the same gloved hand to pick up a roll and continued plating. While still wearing the same gloves, she touched her face and glasses and then resumed the plating process without removing the gloves or washing her hands. In a subsequent interview, the dietary staff member stated she had been trained to serve in that manner and typically changed her gloves about three times during the process. The facility’s written hand hygiene policy for food handlers requires that hands always be washed in designated handwashing sinks, that gloves be worn when serving residents on transmission-based precautions or when touching ready-to-eat food, and that staff perform handwashing prior to distributing meals.
Arbitration Agreement Lacked Required Rescission and Non-Condition of Admission Language
Penalty
Summary
The facility failed to ensure its arbitration agreement informed residents or their representatives of their right to rescind the agreement within 30 days of signing and that signing the agreement was not a condition of admission. With a census of 22 residents, all 22 had signed arbitration agreements, and there were no residents in active arbitration. Review of the admission packet showed that Exhibit E, titled Arbitration Provision, did not contain language notifying residents or representatives of the 30-day rescission right or that the arbitration agreement was optional and not required for admission. During interviews, an administrative staff member stated that the Arbitration Provision in the admission packet was the only information provided about the agreement and that she verbally explained it to new admissions when they signed, but there was no indication that the required language was included in writing. Another administrative nurse reported that the previous company had written the Arbitration Provision and that the current board and administrator might have modified it, and she was not aware of the specific language required to be included. A separate administrative staff member also stated they followed whatever the admission agreement said about the Arbitration Provision and acknowledged not being aware of the required elements of the provision. These findings demonstrate that the facility’s written arbitration documents, as provided to all residents at admission, lacked the federally required notifications regarding the right to rescind within 30 days and the non-mandatory nature of signing the arbitration agreement for admission, and that key administrative personnel were unaware of these specific regulatory requirements.
Deficient Arbitration Agreement Lacking Neutral Arbitrator and Venue Provisions
Penalty
Summary
The facility failed to ensure its arbitration agreement provided for the selection of a neutral arbitrator agreed upon by both parties and for the selection of a venue convenient to both parties. At the time of survey, the facility had a census of 22 residents, all of whom had signed the arbitration agreement, and there were no residents in active arbitration. Record review of the admission packet, specifically Exhibit E Arbitration Provision, showed it did not notify residents or their representatives of their right to participate in selecting a neutral arbitrator or a mutually convenient venue. During interviews, an administrative staff member stated that the Arbitration Provision in the admission packet was the only information provided about the agreement and that she verbally explained it to new admissions when they signed it. Another administrative nurse reported that the previous company that operated the facility had written the Arbitration Provision and that the current board and administrator might have modified it, and she was not aware of the specific language required in the provision. A further administrative staff member stated the facility followed whatever was written in the admission agreement regarding arbitration and acknowledged not being aware of the required elements for the Arbitration Provision. These combined actions and inactions—using an admission arbitration form that lacked required language about neutral arbitrator and venue selection, having all residents sign this form, and administrative staff’s lack of awareness of the required arbitration language—led to the identified deficiency.
Failure to Maintain Signed DNR Documentation in Clinical Record
Penalty
Summary
The facility failed to ensure that a resident’s documented Do Not Resuscitate (DNR) status was supported by a signed DNR document in the clinical record. The resident had a diagnosis of atrial fibrillation and an admission MDS showing a BIMS score of 12, indicating moderately impaired cognition. Her care plan documented that she chose to be a DNR and stated that the DNR order would be part of the medical record and reviewed with the care plan. The EMR also contained a physician’s order for a DNR. However, the EMR lacked evidence of the actual signed DNR document that was required to accompany the physician’s order. During the survey, the resident was observed in the dining room visiting with another resident. Administrative Nurse D reported that during the resident’s transfer from assisted living to long-term care, the signed DNR did not transfer into the current chart. Administrative Nurse D also stated that the facility did not have a process or system in place to monitor or verify changes for advance directives. The facility’s undated Advance Directives policy stated that a physician’s DNR order would be accompanied by supporting documentation in the resident’s clinical record, but this supporting documentation was not present for this resident.
Unlocked Beauty Shop With Accessible Chemicals and Heating Devices
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment by leaving the beauty shop, which contained heating devices and chemicals, unlocked and unattended. The facility had a census of 22 residents, including three residents who were cognitively impaired but independently mobile. On 01/27/26 at 10:06 AM, surveyor observation showed the beauty shop door unlocked and open with two cans of Clippercide spray (liquid disinfectant chemical), shampoo, hair spray, two curling irons, and an electric razor on the counter, and an unlocked cabinet containing a can of Lysol spray disinfectant, with no staff present in the room. On 01/28/26 at 02:09 PM, Administrative Staff D stated she expected the beauty shop to be closed and locked when no one was in it. The facility’s undated “Control of Hazardous Chemicals” policy stated the facility is committed to eliminating and controlling hazards that could cause injury or illness to elders and to meeting safety standards where there are specific rules about hazards or potential hazards in the facility. These observations and statements show that hazardous chemicals and heating devices were accessible in an unsecured area despite the presence of cognitively impaired but mobile residents and despite the facility’s stated policy on controlling hazardous chemicals.
Failure to Monitor and Document Colostomy Output
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document bowel movements for a resident with a colostomy as required by the care plan and facility policy. The resident’s EMR documented diagnoses of colostomy and intestinal obstruction, and the admission MDS showed intact cognition with a BIMS score of 15. The resident’s care plan, initiated for dehydration or potential fluid deficit related to diuretic use, directed staff to monitor and document bowel sounds and the frequency of bowel movements. However, progress notes lacked any documentation of bowel movement monitoring, and the task documentation indicated continence was not rated due to the colostomy, with no recorded amount, frequency, or consistency of stool. During observation, a CNA was seen emptying the resident’s colostomy bag into a plastic trash bag and discarding it without any measurement or documentation of the stool. The CNA stated that staff did not monitor or document the frequency, amount, or consistency of the resident’s bowel movements and did not report this information to the nurse, although the CNA noted the stool was loose. A nurse confirmed that while night shift runs a bowel movement report for residents to check for constipation, staff did not document or monitor this resident’s bowel movements. An administrative nurse stated she expected staff to document and monitor the resident’s bowel movements, and the facility’s ostomy care policy required stool output, consistency, and color to be documented in the chart every shift, which was not done for this resident.
Failure to Administer Ordered Antihypertensives/Diuretics and Notify Physician of Medication Hold
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors and to notify the physician when ordered medications were withheld. The resident had diagnoses of HTN and CHF and was prescribed multiple antihypertensive and diuretic medications, including valsartan 320 mg daily, metoprolol tartrate 50 mg twice daily, furosemide 40 mg daily, and hydrochlorothiazide 12.5 mg daily, all with specific parameters to notify the physician if SBP was less than 90 mm/Hg or greater than 180 mm/Hg, DBP less than 40 mm/Hg or greater than 100 mm/Hg, or pulse less than 50 or greater than 110 on two consecutive checks two hours apart. The resident’s care plan directed staff to administer medications as ordered and monitor blood pressure, holding medications per physician-set parameters. On the date in question, the Medication Administration Record documented that none of the four ordered medications were given, and the EMR notes show that the CMA recorded each medication as held per nursing judgment. According to staff interviews, the CMA obtained a blood pressure reading of approximately 111/49 mm/Hg, rechecked it with the diastolic still in the 40s, and reported this to the nurse. The nurse instructed the CMA to hold the medications based on nursing judgment and confirmed that the physician was not notified. Administrative nursing staff later stated that the nurse did not notify the physician because the blood pressure was not within the parameters requiring provider notification, despite the physician’s orders specifying when to notify. The facility’s Medication Administration Policy stated that medications shall be administered safely as ordered by the physician, but the ordered antihypertensive and diuretic medications were not administered and the physician was not contacted regarding the decision to hold them.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to electronically submit complete and accurate staffing information to the federal regulatory agency through Payroll-Based Journaling (PBJ). Specifically, the facility did not accurately submit hourly staffing data for all nursing personnel for multiple dates across three fiscal quarters in 2023. The review of the PBJ Staffing Data reports for Quarter 2, Quarter 3, and Quarter 4 of 2023 revealed that the facility did not have Licensed Nursing Coverage 24 hours a day on numerous specified dates. Despite the nursing schedule and clocking sheets indicating adequate hours for 24-hour nursing coverage, the data submitted was inaccurate. An interview with Administrative Nurse B on March 27, 2024, revealed that an outside agency contracted by the previous ownership company was responsible for the submission of payroll data prior to November 1, 2023. The administrative nurse was unable to provide an explanation for the inaccurate data. The facility's policy on the mandatory submission of uniform format staffing information (PBJ) stated that the facility would electronically submit complete and accurate direct care staffing information based on payroll and other verifiable and auditable data. The facility administrator was responsible for ensuring the accuracy and timeliness of the submitted data.
Failure to Revise Care Plans for Falls and Nebulizer Use
Penalty
Summary
The facility failed to revise the care plans for four residents, specifically related to falls and the use of nebulizer equipment. For Resident 1, the care plan did not include interventions or staff guidance related to nebulizer treatment for respiratory care, despite physician orders indicating the need for such treatments. Observations revealed that the nebulizer equipment was not properly stored or cleaned between treatments, and interviews with staff indicated a lack of knowledge on how to update care plans using the facility's software program. The facility also failed to provide a policy regarding care plans when requested. For Resident 3, the care plan similarly lacked interventions or staff guidance regarding nebulizer treatments, despite physician orders and observations confirming the need for such treatments. Staff interviews revealed that nebulizers were not being washed between treatments, and there was a general lack of understanding on how to update care plans. The facility again failed to provide a policy regarding care plans when requested. Residents 5 and 13 had multiple falls, but their care plans were not updated with new interventions to prevent further falls. Resident 5 had several falls documented, but the care plan lacked new interventions after each fall. Similarly, Resident 13 had multiple falls, but the care plan was not revised to include new interventions to prevent further incidents. Interviews with staff confirmed that care plans were not being updated, and the facility failed to provide a policy regarding care plan revisions when requested. This deficiency led to additional falls and had the potential for physical and psychosocial injuries for the residents involved.
Failure to Conduct Criminal Background Check for Staff Member
Penalty
Summary
The facility failed to conduct a criminal background check for one of three staff members reviewed, specifically a Certified Nurse Aide (CNA) hired on 07/08/22. During a review of employee files, it was found that the CNA's file lacked any criminal background check information. This was confirmed by the Administrative Nurse, who admitted that she did not know if a background check had been conducted prior to or since the CNA's employment began. The facility's policy on Abuse, Neglect, Exploitation, and Misappropriation Prevention Program mandates that background checks be performed before extending employment offers. The failure to conduct this check had the potential to negatively affect the care delivered to residents.
Failure to Prevent Falls for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident, identified as R13, who had a history of falls and severe cognitive impairment. Despite multiple documented falls and a high fall risk score, the care plan lacked effective interventions to prevent further falls. The resident had several falls within the facility, including incidents where the resident was found on the floor in various locations such as the bathroom, beside the bed, and in front of a recliner. The facility's investigations into these falls often lacked a root cause analysis, and the care plan was not updated with new interventions to prevent additional falls. The care plan for R13 included several interventions, such as ensuring the call light was within reach, placing body pillows on both sides of the bed, and using a video camera at night. However, these interventions were either not effectively implemented or not updated following each fall. Staff interviews revealed that care should be driven by the care plan available in the Electronic Health Record (EHR), but there was a disconnect between the documented care plan and the actions taken by the staff. The facility's policy on accident prevention was not adequately followed, leading to repeated falls for R13. Administrative staff confirmed that the care plan lacked necessary interventions related to each fall and that the facility did not conduct interdisciplinary team meetings or fall huddles to address the issue. The facility's failure to provide a safe environment and adequate supervision resulted in multiple falls for R13, highlighting a significant deficiency in the facility's fall prevention and care planning processes.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care consistent with professional standards of practice for two residents, R1 and R3, regarding the use and cleaning of nebulizers. For R1, the physician's orders included the use of a nebulizer for chronic obstructive pulmonary disease (COPD), but the care plan did not include interventions related to the use and care of the nebulizer. Observations revealed that R1's nebulizer tubing and medication chamber/mouthpiece were improperly stored, and interviews with staff confirmed that the nebulizer was not rinsed between treatments as required. The facility also failed to provide a policy regarding respiratory care when requested. For R3, who had diagnoses of COPD and pleural effusion, the care plan similarly lacked interventions regarding nebulizer treatments. Observations and staff interviews indicated that the nebulizer was not washed between treatments. The facility again failed to provide a policy on respiratory care when requested. These deficiencies highlight the facility's failure to adhere to professional standards of care in providing respiratory treatments to residents.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete an annual performance review at least once every 12 months for three Certified Nurse Aides (CNA) to ensure adequate and appropriate care and services were provided to the residents. The facility reported a census of 13 residents. During a review of employee files, it was found that there were no performance evaluations for three CNAs who had been employed for over 12 months. This was confirmed by the Administrative Nurse and Administrative Staff, who acknowledged that it was their expectation to perform annual performance evaluations but admitted that these evaluations were not completed. The facility provided an undated and untitled document indicating that performance evaluations were to be performed at an unknown frequency to measure employee effectiveness and set goals for future performance and professional growth.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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