Spring View Manor Healthcare And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Conway Springs, Kansas.
- Location
- 412 S 8th Street, Conway Springs, Kansas 67031
- CMS Provider Number
- 175504
- Inspections on file
- 13
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Spring View Manor Healthcare And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found multiple sanitation issues in the kitchen, including improperly stored frozen and refrigerated foods such as open bags of food with ice crystals, an unsealed bag of meat, and an opened package of cheese. Dietary staff were observed delivering meals while placing their thumbs on the eating surfaces of plates. Dishwasher temperatures were measured below the level a staff member stated was needed for proper disinfection, and prior service reports showed low wash and final rinse temperatures. A staff member reported that the water heater pilot light went out at times and that staff were expected to monitor temperatures, while the written dishwashing policy lacked specific temperature requirements for cleaning and sanitizing dishware and cookware.
The facility did not ensure that all CNAs received the required minimum of 12 hours of annual in-service training, including topics such as dementia care and abuse prevention. Review of records for several CNAs employed more than one year showed that two CNAs had only seven and eight documented training hours over the prior year. An administrative nurse confirmed the 12-hour annual requirement and the absence of additional training records for these CNAs, and the facility was unable to provide a policy outlining its CNA in-service training program.
The facility failed to issue required CMS-10055 SNF Advanced Beneficiary Notices of Non-Coverage (ABN), including estimated costs, to two Medicare Part A beneficiaries when their skilled coverage ended and they remained for custodial care. Review of electronic medical records showed that both residents had defined Medicare Part A episodes followed by continued custodial stays, but there was no documentation that ABNs were provided. The facility’s own Advance Beneficiary Notice policy required timely notification of Medicare eligibility, coverage, and potential liability for payment before providing items or services that may not be covered, such as custodial care. An interview with social services staff revealed unawareness of the need to complete and issue the ABN, and the facility could not produce evidence that the CMS-10055 form was given to either resident.
A resident with obesity, O2 dependence, cognitive communication deficit, and skin cancer experienced respiratory symptoms and was transferred to the hospital after nursing staff documented shortness of breath, productive cough, and low O2 saturation, with a phone message left for the responsible party. Although the EMR showed a bed-hold assessment with verbal confirmation and the resident later returned for skilled therapy, there was no written notice explaining the reason for transfer provided to the resident or representative, nor was a copy sent to the ombudsman. Interviews with the resident, social services, and an administrative nurse revealed that staff were unaware or unsure of written notification requirements and that the facility had not been consistently issuing written transfer notices or ombudsman notifications, contrary to its own transfer/discharge policy requiring detailed written notice and appeal information.
Surveyors found that dietary staff did not follow the approved recipe for pureed green beans, using tap water instead of an appropriate hot liquid, which altered the food’s nutritive content. Staff also failed to consistently monitor and maintain required food temperatures, with pureed spaghetti and cooked spaghetti served below the facility’s 135°F hot holding standard and an Italian tossed salad served above the 41°F cold holding standard. A resident reported that tray-delivered meals were only “kind of warm,” and a dietary staff member acknowledged that they do not routinely take temperatures of cooked or pureed foods before service, despite facility policy requiring specific hot and cold holding temperatures.
Surveyors identified multiple infection control failures, including staff entering a resident’s room on EBP wearing gloves without prior hand hygiene and continuing incontinence care while wearing soiled gloves, then changing gloves without hand hygiene. Two residents’ nebulizer masks and equipment were found lying directly on bedside tables, one with residual fluid, and not stored in sanitary containers between treatments. An RN performed an enteral dressing change without a gown, used gloves taken from a pants pocket, and placed a new syringe plunger into a soiled container. The same RN performed wound care for another resident while repeatedly leaving and re-entering the room, assisting the roommate, kneeling on the floor, handling dressings, and completing the wound care without changing gloves or performing hand hygiene, despite facility policies requiring proper hand hygiene, glove changes between soiled and clean tasks, appropriate PPE, and sanitary storage of nebulizer equipment.
A resident’s EMR lacked required documentation showing that an influenza (flu) vaccine was offered, accepted, declined, or contraindicated, despite the facility’s policy to offer annual flu immunizations. During review, there was no record in the immunization section of the EMR of a flu vaccine, a documented offer, a legal representative’s informed declination, or a physician-documented contraindication. The IP, who tracks immunizations, reported having contacted the resident’s legal representative and stated the vaccine was declined, but this was not documented in the EMR in accordance with facility policy.
The facility did not ensure that daily nurse staffing sheets accurately reflected actual hours worked by RNs, LPNs, and CNAs. On the day reviewed, the posted staffing form, observed twice near the nurse’s station with a census of 40 residents, lacked actual hours worked per shift for licensed and unlicensed staff providing resident care. An LN and administrative nurses reported that nurses did not update the posted sheet when staff were late or absent and that the business office added actual hours at the end of the week, contrary to facility policy requiring real-time updates after each shift.
The facility did not conduct required annual evaluations for four CNAs and CMAs employed for over a year. Personnel files lacked documentation of these evaluations, contrary to the facility's policy. This was confirmed through a review and an interview with a consultant.
The facility failed to submit accurate direct care staffing information to CMS for the second and fourth quarters of 2023. The Payroll Base Journal (PBJ) submissions did not include agency staff used on weekends, leading to reports of excessively low weekend staffing. The facility lacked a policy for PBJ submission, contributing to the inaccurate reporting.
The facility failed to provide adequate education for informed decision-making regarding influenza, pneumococcal, and COVID-19 vaccinations for several residents. Medical records lacked documentation of education or evidence of vaccine receipt or declination, contrary to facility policies. Interviews confirmed the absence of proper documentation, leading to deficiencies in vaccine administration.
A resident with severe cognitive impairment and physical limitations did not receive adequate grooming, as staff failed to shave him regularly despite his discomfort with facial hair. The resident, who required assistance with ADLs, was observed with several days' worth of facial hair growth. Staff were unaware of his last shower, and the facility's grooming policy was not followed, affecting the resident's well-being.
The facility failed to follow physician orders and provide timely lab reporting for two residents. One resident did not have labs obtained promptly, delaying treatment for nausea and vomiting. Another resident did not receive medications as prescribed for weight gain and hypertension, with staff administering Lisinopril despite low blood pressure readings. The facility lacked a policy for following physician orders.
A facility failed to follow infection control practices during medication and insulin administration for two residents. A nurse did not sanitize a gastrostomy tube or syringe before administering medications to a resident with a swallowing disorder. Additionally, the same nurse did not perform hand hygiene between administering insulin to two residents, contrary to facility policy.
The facility did not ensure daily staff postings included actual hours worked, as required. A review of postings from February to April 2024 showed missing hours, confirmed by an interview with an administrative staff member. The business office recorded hours via a computer program, and the facility lacked a policy for daily staff posting.
Unsanitary Food Storage, Handling, and Dishwashing Practices
Penalty
Summary
Surveyors identified deficiencies in the facility’s food storage and preparation practices. During an initial kitchen tour with dietary staff, three open plastic bags of food were observed in the freezer with ice crystals formed directly on the food items, along with one unsealed bag of meat and one opened package of cheese. These items were not properly sealed, indicating improper storage of frozen and refrigerated foods. Additional observations showed dietary staff handling resident meal plates by placing their thumbs on the eating surfaces of the plates while delivering meals to residents. Surveyors also found deficiencies in dishwashing and sanitization practices. A dietary staff member measured the dishwasher water temperature at 103°F, and stated that the water temperature should be 120°F to properly disinfect and sanitize dishware and cookware. Review of recent kitchen service reports showed that both the wash and final rinse temperatures of the dishwasher had been recorded at 122–123°F on prior dates. Another staff member reported that the pilot light on the water heater went out at times and that staff were expected to monitor dishwasher temperatures and not run dishes if the temperature was below 120°F. The facility’s written dishwashing policy from 2020 did not specify required temperatures for cleaning, disinfecting, or sanitizing dishware and cookware.
Failure to Ensure Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to develop, implement, and permanently maintain an in-service training program for CNAs that ensured at least 12 hours of annual education with required topics such as dementia care and abuse prevention. During a survey with a reported census of 40 residents, review of training records for five CNAs employed more than one year showed that two CNAs had less than 12 hours of documented in-service training in the previous 12 months. One CNA, employed since 12/20/23, had eight hours of documented training, and another CNA, employed since 07/22/24, had seven hours of documented training. The Administrative Nurse confirmed that all CNAs were required to have 12 hours of training annually and acknowledged there were no additional training records for these CNAs, and the facility did not provide a policy governing the in-service training program. These findings demonstrate that the facility did not ensure all CNAs received and had documentation of the minimum required annual in-service training hours, nor did it provide evidence of a formal policy to support and maintain the required training program.
Failure to Issue Required ABNs When Medicare Part A Coverage Ended
Penalty
Summary
The facility failed to provide required CMS-10055 Skilled Nursing Facility (SNF) Advanced Beneficiary Notices of Non-Coverage (ABN), including estimated costs for continued services, to two Medicare Part A beneficiaries when their skilled coverage ended and they remained for custodial care. Record review showed that one resident had a Medicare Part A episode from 09/18/25 to 10/20/25 and then remained in the facility for custodial care, but the electronic medical record contained no evidence that an ABN was issued. Another resident had a Medicare Part A episode from 10/25/25 to 12/24/25 and also remained for custodial care, with no documentation in the electronic medical record that an ABN was provided. The facility’s policy on Advance Beneficiary Notices, reviewed 05/07/25, required timely notices regarding Medicare eligibility and coverage and informing beneficiaries of potential liability for payment, including issuing a liability notice upon admission or during the stay before providing items or services that may not be covered because they are not medically reasonable and necessary or are custodial care. Interviews confirmed that the responsible social services staff member was not aware of the requirement to complete and issue the ABN, and the facility was unable to produce evidence that the CMS-10055 form was given to either resident.
Failure to Provide Required Written Transfer and Bed-Hold Notifications
Penalty
Summary
Surveyors identified a failure to provide required written notification of transfer for a resident who was hospitalized. The resident had diagnoses including obesity, dependence on supplemental oxygen, cognitive communication deficit, and skin cancer. On 12/11/25, nursing notes documented the resident was short of breath, coughing up yellow sputum, and had an oxygen saturation of 88%, leading to new medication, lab orders, and a mobile chest X-ray. Later that day, a nurse documented leaving a message for the responsible party that the resident was going to the hospital, and that the resident left with emergency services. The resident returned to the facility on 12/22/25 and was to receive skilled therapy services. The EMR contained a bed-hold assessment with verbal confirmation but lacked documentation of written notification to the resident and/or representative explaining the reason for the transfer to the hospital. During interviews, the resident stated he was supposed to sign the bed hold but was not given it before leaving for the hospital. Social Service staff reported that one social worker obtained bed holds when a resident left, but they were not aware of or unsure about sending written letters to residents or representatives or notifying the ombudsman. Administrative nursing staff confirmed the facility had not been sending written notifications to families with the reason for transfer, nor sending notifications to the ombudsman, noting that an email had been sent one month prior but not since. This practice was inconsistent with the facility’s Transfer and Discharge policy, which requires that a transfer/discharge notice be provided to the resident and representative, including the specific reason for transfer, effective date, destination, appeal rights and procedures, and contact information for the state appeal entity, ombudsman, and protection and advocacy agencies where applicable.
Failure to Follow Puree Recipe and Maintain Safe Food Temperatures
Penalty
Summary
Surveyors identified a deficiency related to food preparation and service temperatures. During observation of meal preparation, a dietary staff member added tap water to green beans while pureeing them, despite the facility’s recipe specifying that, if thinning was needed, staff should gradually add an appropriate hot liquid such as broth, gravy, milk, or reserved cooking liquid. This deviation from the recipe altered the nutritive content of the pureed green beans. The facility’s written recipe and procedures did not authorize the use of tap water for this purpose. Additional observations showed that staff did not consistently ensure hot and cold foods were served at safe and appetizing temperatures. Pureed spaghetti delivered to the dining room was measured at 127°F, and a plated hall tray of cooked spaghetti delivered to a resident’s room was measured at 130°F, both below the facility’s required hot holding/serving temperature of 135°F or higher. The Italian tossed salad on the same tray was measured at 52°F, above the required cold holding/serving temperature of 41°F or below. A resident reported that food served to their room was not hot but “kind of warm.” One dietary staff member stated they do not obtain temperatures on cooked food or cooked pureed food before sending it to the dining room, while another dietary staff member acknowledged the facility’s expectations that hot foods be maintained at 135°F or above and cold foods at 41°F or below, as outlined in the facility’s 2020 Monitoring Food Temperatures for Meal Service policy.
Failure to Follow Hand Hygiene, PPE, and Nebulizer Storage Practices Under EBP
Penalty
Summary
The deficiency involves failures in infection prevention and control practices, including improper hand hygiene, PPE use, and storage of nebulizer equipment. Surveyors observed that two staff members entered a resident’s room on Enhanced Barrier Precautions (EBP) wearing gloves but without performing hand hygiene. During incontinence care, one staff member continued to pull up the resident’s pants while still wearing soiled gloves, then removed and reapplied gloves without hand hygiene. In separate observations, two residents’ nebulizer masks and equipment were found lying directly on bedside tables, one with residual fluid in the chamber, and not stored in sanitary containers between treatments, contrary to facility expectations. Additional observations showed a nurse performing dressing changes without adhering to EBP and infection control standards. For one resident with an enteral feeding site, the nurse used gloves taken from his pants pocket, did not don a gown for the dressing change, and placed a new syringe plunger into a soiled container without cleaning it. For another resident receiving wound care, the same nurse donned gloves from his pocket and a gown, left and re-entered the room multiple times without changing gloves or performing hand hygiene, assisted the roommate while wearing the same gloves, knelt on the floor, handled dressing supplies, cleansed and dressed the wound, and used a marker from his pocket to date the dressing, all without changing contaminated gloves. Facility leadership and the Infection Preventionist later confirmed that nebulizers should be bagged between treatments, PPE (including gowns) should be worn for dressing changes, gloves should be changed between soiled and clean tasks, and hand hygiene should be performed between glove changes, as required by the facility’s hand hygiene and EBP policies.
Failure to Document Influenza Vaccination Offer and Declination
Penalty
Summary
The deficiency involves the facility’s failure to follow its influenza vaccination policy by not properly documenting the offer, consent, declination, or contraindication for an influenza vaccine for Resident 28. The facility had a census of 40 residents, with a sample of 12 residents and 5 reviewed for immunization status. Record review of Resident 28’s EMR under the Immunization tab showed no documentation that the influenza vaccine was offered or declined, and no record of a historical influenza vaccination or a physician-documented contraindication, despite the resident’s admission earlier in the month. Although the facility later provided a declination form for the annual influenza vaccination dated the day after the record review, this documentation was not present at the time of the initial review. During an interview, the Infection Preventionist, who was responsible for tracking immunizations, stated she had left a message with the resident’s legal representative regarding immunizations and reported that the legal representative had declined the influenza vaccination, but this declination was not documented in the EMR as required by facility policy. The facility’s written Influenza Vaccination policy stated that it was the policy of the facility to minimize the risk of acquiring, transmitting, or experiencing complications from influenza by offering annual influenza immunization to residents, staff, and volunteers, but the required documentation of this process was not completed for Resident 28.
Failure to Post Accurate Daily Nurse Staffing Hours
Penalty
Summary
The facility failed to ensure that the posted daily nurse staffing sheets contained accurate and identifiable information, specifically the actual hours worked per shift by licensed and unlicensed staff providing resident care. On the survey date, the posted nurse staffing form for that day, observed near the nurse’s station, did not include the actual hours worked for RNs, LPNs/LVNs, and CNAs. The form was observed twice on the same day and on both occasions lacked the required actual hours worked per shift. The facility census at the time was 40 residents. Staff interviews confirmed that actual hours were not being updated on the posted staffing sheets as required by facility policy. An LN reported that nurses do not change the time or add actual hours on the posted sheet, even when staff arrive late, and that the business office updates the information later. An administrative nurse stated she placed the staffing sheet out and that the office added actual hours at the end of the week, with no adjustments made before then. Another administrative nurse stated that nurses should be entering the actual hours on the posted staffing sheet after the start of each shift. This practice conflicted with the facility’s written Nurse Staffing Posting Information policy, which required daily posting of staffing sheets with actual hours worked and updates after the start of each shift to reflect staff absences and call-outs.
Failure to Conduct Annual Evaluations for CNAs and CMAs
Penalty
Summary
The facility failed to ensure that four out of five Certified Nurse Aides (CNA) and Certified Medication Aides (CMA/CNA) who were employed for over a year received their required annual evaluations. The personnel files of these staff members, specifically CNA N, CNA M, CNA O, and CMA R, lacked documentation of annual evaluations. This deficiency was identified during a review of personnel files and confirmed through an interview with consultant GG, who stated that she expected staff to have evaluations annually. The facility's policy, implemented in December 2019, mandates a formal written evaluation of employees' work performance annually, which was not adhered to in these cases.
Inaccurate PBJ Submission for Weekend Staffing
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the second and fourth quarters of 2023. Specifically, the facility did not accurately report weekend staffing, as the Payroll Base Journal (PBJ) submissions did not include agency staff used to supplement the nursing staff employed by the facility. This resulted in the PBJ triggering for excessively low weekend staffing for both quarters. The facility lacked a policy for PBJ submission, which contributed to the inaccurate reporting of hours. An interview with Administrative Staff A revealed that the corporate office was responsible for submitting the PBJ, and the omission of agency staff led to the deficiency.
Deficiency in Vaccine Education and Documentation
Penalty
Summary
The facility failed to ensure that residents received proper education for informed decision-making regarding vaccinations, leading to deficiencies in the administration of influenza, pneumococcal, and COVID-19 vaccines. Specifically, two residents, R21 and R11, did not receive education for the 2023 influenza vaccine, and R21 also lacked education for the pneumococcal vaccine. Additionally, three residents, including R21 and R3, did not receive education for informed decision-making regarding the COVID-19 vaccine. The medical records for these residents lacked documentation of education provided for informed decision-making or evidence of receipt or declination of the vaccines. The facility's policies on influenza, pneumococcal, and COVID-19 vaccinations, implemented in 2019 and 2022, instructed staff to offer and educate residents about these vaccines. However, interviews with the administrative nurse confirmed the absence of documented declinations or undated declinations for the residents involved. This lack of documentation and education resulted in the facility's failure to provide residents with the opportunity to make informed decisions about their vaccinations, as required by the facility's policies.
Failure to Provide Adequate Grooming for Resident
Penalty
Summary
The facility failed to provide adequate personal grooming for a resident with severe cognitive impairment and physical limitations. The resident, who had a history of hemiplegia, hemiparesis, cerebral vascular accident, and major depressive disorder, was assessed as requiring staff assistance with activities of daily living, including personal hygiene. Despite the care plan indicating the resident was dependent on staff for bathing and personal hygiene, observations revealed the resident had several days' worth of facial hair growth, which he did not desire and found uncomfortable. Interviews with staff indicated that the resident was typically shaved on shower days, but there was a lack of awareness regarding the resident's last shower. The resident had refused showers on several occasions during the evening shift, and staff confirmed he needed a shave. The facility's policy on grooming facial hair instructed staff to assist residents in maintaining proper hygiene, yet the resident did not receive grooming opportunities according to his preferences, impacting his sense of well-being.
Failure to Follow Physician Orders and Timely Lab Reporting
Penalty
Summary
The facility failed to provide timely pharmaceutical services for two residents, leading to deficiencies in care. For one resident with chronic respiratory and heart failure, diabetes, and kidney failure, the facility did not obtain laboratory values in a timely manner. Despite the physician's instructions to obtain a Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) due to the resident's ongoing nausea and vomiting, the facility delayed obtaining these labs by two days. This delay was attributed to the laboratory's failure to provide a phlebotomist promptly. Additionally, the facility did not report the laboratory results to the physician on the day they were obtained, further delaying necessary medical intervention. Another resident with hypertension, heart failure, and chronic kidney disease did not receive medications as per physician orders. The facility failed to administer Bumex for weight gain as instructed, despite documented weight increases that met the criteria for administration. Furthermore, the facility administered Lisinopril for hypertension even when the resident's blood pressure readings were below the parameters set by the physician. These failures were compounded by the absence of a facility policy for following physician orders, leading to non-compliance with prescribed medical care.
Infection Control Lapses in Medication and Insulin Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during the administration of medications and insulin for two residents. For Resident 1, who had a history of cerebral vascular accident and a swallowing disorder, a Licensed Nurse (LN) was observed administering medications through a percutaneous gastrostomy tube without cleaning or sanitizing the tube or syringe. The syringe was placed directly on a paper towel on the resident's bedside table, which did not adhere to the facility's policy requiring infection control precautions to minimize contamination risk. In another instance, a Licensed Nurse was observed administering insulin to a resident with diabetes without performing hand hygiene between residents. The nurse picked up an insulin pen and prepared to administer insulin without sanitizing her hands, although she later verified the need to do so. This action was contrary to the facility's policy, which required hand hygiene and glove use before and after insulin administration. These lapses in infection control practices could potentially lead to the spread of infections among residents.
Failure to Record Actual Staff Hours on Daily Postings
Penalty
Summary
The facility failed to ensure that the daily staff postings included the actual hours worked by staff, as required. During a review of the daily staff postings from February, March, and April 2024, it was found that the postings lacked the actual hours worked for staff members. An interview with Administrative Staff A confirmed that the facility did not record the actual hours worked on the daily staff posting sheets. Instead, the business office documented these hours through a computer program. Additionally, the facility did not have a policy in place for daily staff posting, contributing to the deficiency.
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Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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