Sunporch Of Dodge City
Inspection history, citations, penalties and survey trends for this long-term care facility in Dodge City, Kansas.
- Location
- 501 W Beeson Road, Dodge City, Kansas 67801
- CMS Provider Number
- 175207
- Inspections on file
- 15
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Sunporch Of Dodge City during CMS and state inspections, most recent first.
A resident with vascular dementia, anxiety, delirium, major depressive disorder, and severe cognitive impairment was placed in a bed with rails without a documented bed rail safety assessment or informed consent from the resident or representative. Despite multiple residents having beds with at least one rail, nursing staff reported that no bed rail safety assessments had been completed, and maintenance logs showed only general safety checks without specific bed rail inspections. This occurred even though the facility’s bed safety policy required attempts at alternatives, IDT evaluation, resident assessment, and informed consent before using bed rails.
The facility did not complete required annual performance reviews or skills check-offs for two CNAs, as confirmed by administrative staff and employee file review. Both CNAs missed the scheduled skills check-off and had not completed a make-up session, and the facility could not provide a relevant policy when asked.
Multiple residents receiving psychotropic medications did not have timely or appropriate physician responses to pharmacy recommendations for gradual dose reductions, with staff uncertain about escalation procedures and the facility lacking a specific GDR policy, resulting in continued use of potentially unnecessary medications.
Surveyors found that opened food items in the kitchen, freezers, and walk-in cooler were not labeled with open dates, including bread, dairy products, and various frozen foods. The Dietary Manager acknowledged the issue and was unaware of the requirement to label and date opened freezer items. The facility's policy did not specify labeling and dating procedures for opened items.
Staff failed to follow infection control protocols, including proper hand hygiene before and after glove use, correct removal of PPE, and appropriate cleaning of nebulizer equipment after each use. Soiled linens were placed on the floor, and staff did not consistently use required eye protection when handling catheter drainage bags. These lapses were confirmed by staff interviews and direct observation.
Medication and treatment carts containing prescription drugs, narcotics, insulins, and topical medications were found unlocked and unattended in areas accessible to residents, including hallways and an open nurse's office. Nursing staff confirmed the carts should have been locked when not in direct line of sight, and the facility's policy required all medication storage to be secured when not in use. The facility had several residents who were confused and independently mobile at the time of the deficiency.
Three residents experienced significant incidents, including elopement and multiple falls, but their care plans were not promptly revised to reflect new risks or interventions. One resident with Alzheimer's had repeated exit-seeking behaviors and left the facility multiple times before interventions were added to the care plan. Another resident with dementia had several falls, with interventions like fall mats used by staff but not documented in the care plan. A third resident with dementia and Parkinson's disease had multiple falls without appropriate fall investigations or care plan updates. Staff and administrative interviews confirmed delays and inconsistencies in care plan documentation.
The facility did not properly assess or care plan for a resident's smoking safety despite cognitive impairment and failed to conduct thorough fall investigations or implement new interventions for two residents with repeated falls. Staff were unclear about supervision requirements, and required assessments and care plan updates were not completed in a timely manner, resulting in deficiencies in accident prevention.
Nursing staff did not properly clean nebulizer equipment after each medication administration for two residents requiring respiratory care. Instead, equipment was only cleaned once daily, leaving visible liquid residue and not following facility policy or infection control standards.
The facility did not maintain documentation showing that COVID-19 and pneumococcal vaccines were offered or declined for two residents. Administrative staff confirmed the absence of records and the lack of a policy outlining the vaccination process.
Failure to Assess Bed Rail Safety and Obtain Informed Consent
Penalty
Summary
The deficiency involves the facility’s failure to assess a resident for safety related to bed rail use and to obtain informed consent prior to using bed rails. The resident had diagnoses including vascular dementia, anxiety, delirium, and major depressive disorder, with documentation of severe cognitive impairment, memory problems, and being never or rarely understood per the MDS and CAA. The resident’s care plan noted an alteration in musculoskeletal status related to broken bones in the left wrist/forearm, and the facility documented that his bed was replaced with one without bed rails following an incident. However, the resident’s EHR contained no bed rail risk assessment from admission onward, and there was no evidence that the resident or his representative had been provided information about risks and benefits or had given informed consent for bed rail use. Surveyor interviews and record reviews showed that, prior to the incident involving this resident, the facility had no nursing bed rail safety assessment process in place, despite having 25 residents with at least one bed rail attached to their beds. The Administrative Nurse acknowledged that no nursing bed rail safety assessments had been conducted since her hire and confirmed that no informed consent had been obtained for this resident’s bed rail use. Maintenance staff reported performing general safety checks and provided inspection logs that referenced checking for safety and fall risks but did not specifically address bed rails, and there were no inspection logs specific to bed rails. The facility’s own Bed Safety and Bed Rails policy required attempts to use alternatives, IDT evaluation, resident assessment, and informed consent before bed rail use, but these steps were not carried out or documented for this resident.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete an annual performance review or skills check-off for two Certified Nurse Aides (CNAs) within a 12-month period, as required. Review of employee files revealed that these two CNAs, who had been employed for over a year, did not have documented performance evaluations or skills check-offs. Administrative staff confirmed that all CNA staff were required to complete an annual skills check-off in lieu of a performance evaluation, and if a CNA was unable to perform required tasks, remediation would be provided. However, the two CNAs in question missed the most recent skills check-off and had not completed a make-up session as intended. Additionally, the facility was unable to provide a policy related to annual performance evaluations or skills check-off evaluations for CNA staff when requested.
Failure to Ensure Timely Physician Response to Pharmacy Medication Reviews
Penalty
Summary
The facility failed to ensure that physicians responded in a timely manner to monthly medication regimen reviews (MRR) and pharmacy recommendations for gradual dose reductions (GDR) of psychotropic medications for multiple residents. For several residents with diagnoses such as dementia, Parkinson's disease, Alzheimer's disease, and major depressive disorder, the consultant pharmacist made recommendations for GDRs or medication changes, but the attending physicians either did not respond or provided inadequate responses without appropriate rationale. In some cases, the facility made multiple attempts to contact the physicians, but timely follow-up was not achieved, and there was uncertainty among staff regarding the procedures to escalate these issues to the medical director when the attending physician was unresponsive. For example, one resident with moderate cognitive impairment and a history of falls was prescribed antipsychotic and antidepressant medications. The pharmacist recommended a GDR, but the physician did not respond to repeated requests. Another resident with severe cognitive impairment and Alzheimer's disease was on multiple psychotropic medications, and the pharmacist recommended a GDR, but again, there was no documented physician response. In another case, a resident with dementia and anxiety was prescribed antipsychotic, antidepressant, and anti-anxiety medications, and the physician's only response to a GDR recommendation was a brief disagreement without further explanation. The facility's policies stated that if a physician did not respond to MRR recommendations, the consultant pharmacist should contact the medical director or administrator. However, staff interviews revealed a lack of clarity and consistent follow-through on these procedures. Additionally, the facility was unable to provide a policy specific to the GDR process when requested. As a result, the facility did not ensure that residents' medications were free from unnecessary drugs due to the lack of timely and appropriate physician responses to pharmacy recommendations.
Failure to Label and Date Opened Food Items in Storage Areas
Penalty
Summary
Surveyors observed multiple instances of improper food storage in the facility's kitchen and food storage areas. Specifically, two bread bags were found opened without a date, and several items in the freezers, such as bread, rolls, spinach, french fries, onion rings, beef tips, and chicken tenders, were not labeled with an open date. Additionally, items in the walk-in cooler, including a gallon of milk, a container of half and half, grape jelly, ketchup, half of an onion, and a tray of blueberry muffins, were also not labeled with an open date. During an interview, the Dietary Manager confirmed that the undated food items in the refrigerator and the opened bread were unacceptable and admitted to being unaware that freezer items required labeling and dating when opened. The facility's policy addressed safe food expiration guidelines and proper rotation by expiration dates but did not specify the requirement to label and date items when opened in the refrigerator and freezer. No dry food storage policy was provided.
Infection Control Deficiencies in Hand Hygiene, PPE Use, and Equipment Cleaning
Penalty
Summary
Facility staff failed to maintain effective infection control practices during the provision of care to multiple residents. During incontinent care, staff did not perform hand hygiene before donning gloves or after removing gloves and before applying new gloves. Soiled linens were placed directly on the floor instead of on a barrier, and personal protective equipment (PPE) was removed improperly, with gowns and gloves being discarded together without proper technique. Staff interviews confirmed awareness of the correct procedures but acknowledged that these steps were not followed during the observed care. When providing respiratory care, staff did not rinse nebulizer equipment after each medication administration, contrary to facility expectations and professional standards. Instead, nebulizer equipment was only cleaned once daily on the night shift, and used equipment was stored with visible liquid residue in the chamber. Staff interviews confirmed that the expected practice of rinsing and air-drying the equipment after each use was not being followed. Additionally, staff failed to use appropriate PPE, such as eye protection, when emptying or changing catheter drainage bags. Catheter bags were observed resting on the floor, and staff did not follow proper cleaning protocols when this occurred. The facility's own policies required hand hygiene after glove removal and the use of eye protection for splash hazards, but these were not consistently implemented during care.
Unattended and Unlocked Medication and Treatment Carts
Penalty
Summary
Surveyors observed that both a medication cart and a nurse treatment cart containing prescription medications, narcotics, over-the-counter medications, insulins, topical ointments, medicated creams, and wound care supplies were left unlocked and unattended in resident-accessible areas. On one occasion, the medication cart was found in a hallway with keys hanging from the locking mechanism, and the treatment cart was also unlocked and unattended, with multiple staff members passing by without securing them. Licensed nursing staff confirmed that these carts contained controlled substances and other medications and acknowledged that the carts should be locked when not in direct line of sight of the responsible nurse. Further observations revealed that the nurse treatment cart was left unlocked and unattended in the nurse's office, with the door open and accessible from resident hallways. Interviews with nursing staff confirmed that the carts should remain locked when not within arm's reach, regardless of their location. The facility had 12 residents identified as confused and independently mobile. The facility's own policy required all medication storage compartments to be locked when not in use and not left unattended if open or accessible to others. The failure to secure these carts resulted in a deficiency related to the safe storage of drugs and biologicals.
Failure to Revise and Update Care Plans After Elopement and Falls
Penalty
Summary
The facility failed to accurately revise and update care plans for three residents following significant changes in their conditions and incidents, as observed through record review, staff interviews, and direct observation. One resident with Alzheimer's disease and severely impaired cognition exhibited increased exit-seeking behaviors and experienced actual elopements on multiple occasions. Despite repeated incidents of wandering and leaving the facility, the care plan was not updated to include appropriate interventions for exit-seeking and elopement behaviors until after several events had already occurred. Staff interviews confirmed that care plan updates were not always timely, and administrative staff were sometimes unaware of incidents that should have triggered care plan revisions. Another resident with dementia and severely impaired cognition experienced multiple falls, including one that resulted in a large hematoma and hospitalization. Although immediate interventions such as increased monitoring and toileting assistance were implemented following these falls, these interventions were not promptly incorporated into the resident's care plan. Staff interviews revealed that some interventions, such as the use of a fall mat, were being provided but were not documented in the care plan, leading to inconsistencies in communicated care needs. Administrative staff acknowledged that delays of up to 30 days in updating care plans after a fall were unacceptable. A third resident with dementia and Parkinson's disease experienced several falls, some with minor injuries, but the facility failed to conduct appropriate fall investigations or develop and document root cause analyses and immediate or permanent care plan interventions. Progress notes and fall reports lacked documentation of interventions to mitigate fall risks, and care plans were not revised to reflect new or ongoing risks. Staff interviews confirmed that while immediate interventions were discussed and sometimes implemented, these were not consistently documented in the care plan, resulting in uncommunicated care needs.
Failure to Assess and Care Plan for Smoking and Fall Risks
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents. One resident with a history of depression, repeated falls, hypotension, and cognitive impairment was not properly assessed for smoking safety upon admission. There was no documentation of a smoking evaluation or care plan for this resident's smoking privileges until 78 days after admission, despite evidence that the resident was a current smoker and had access to cigarettes and a lighter. Staff interviews revealed confusion and lack of clarity regarding the resident's smoking status and required supervision, with some staff believing supervision was needed and others allowing independent smoking without proper assessment or care planning. The facility's own policy required a smoking evaluation and care plan upon admission, which was not followed in this case. Another resident with diagnoses including dementia and Parkinson's disease experienced multiple falls, but the facility failed to conduct appropriate fall investigations or implement and document new interventions to mitigate the risk of further falls. Several falls were reported in the resident's record, but the associated fall reports lacked root cause analysis, immediate interventions, and updates to the care plan. Staff interviews confirmed that while there was an expectation for immediate intervention and care plan updates after a fall, these actions were not consistently documented or implemented. Administrative staff acknowledged that fall investigation reports were incomplete and that care plan interventions were not always entered in a timely manner. The facility's policies required timely assessment, investigation, and care planning for both fall prevention and resident smoking safety. However, the records and staff interviews demonstrated that these procedures were not consistently followed. The lack of timely and thorough assessments, investigations, and care plan updates for residents at risk for falls and those who smoke resulted in deficiencies that could potentially lead to injury.
Failure to Clean Nebulizer Equipment After Each Use
Penalty
Summary
Licensed nurses failed to properly clean nebulizer equipment after each use for two residents who required respiratory care. Observations showed that after administering breathing treatments, staff placed used nebulizer equipment into bags without rinsing them, leaving visible liquid residue in the chambers. Interviews with nursing staff confirmed that the nebulizer equipment was only cleaned and rinsed once daily during the night shift, rather than after each medication administration as required by facility policy and infection control standards. The facility's policy specified that nebulizer containers should be rinsed with fresh tap water and dried on a clean paper towel or gauze sponge after each use. However, both direct observation and staff interviews revealed that this procedure was not followed. The infection control nurse stated that her expectation was for nurses to rinse the nebulizer after each use and allow it to air dry, but this was not being done. This failure to adhere to proper cleaning protocols for respiratory equipment constituted a deficiency in providing safe and appropriate respiratory care.
Failure to Document and Offer Required Vaccinations
Penalty
Summary
The facility failed to provide proper documentation regarding the administration or declination of COVID-19 and pneumococcal vaccines for two residents. Specifically, the electronic health record for one resident did not contain evidence that the COVID-19 vaccine was offered or declined, and for another resident, there was no documentation of either the pneumococcal or COVID-19 vaccines being administered or declined. Administrative staff confirmed that the required documentation could not be located, and one resident was not offered the COVID-19 vaccine because they were not present in the facility when it was administered. Additionally, the facility was unable to provide a policy specific to the process for administering or documenting pneumococcal or COVID-19 vaccines when requested by surveyors.
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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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