Sunset Home Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Concordia, Kansas.
- Location
- 620 Second Avenue, Concordia, Kansas 66901
- CMS Provider Number
- 175422
- Inspections on file
- 22
- Latest survey
- May 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sunset Home Inc during CMS and state inspections, most recent first.
The facility did not employ a full-time certified dietary manager to oversee food and nutrition services, with the current dietary manager lacking certification and only recently starting relevant coursework. Administrative staff confirmed the absence of certification, and the facility could not provide a policy for qualified dietary managers, resulting in noncompliance for all residents receiving meals from the kitchen.
A CNA wore a protective gown and gloves in the hallway while assisting a resident and handling facility equipment, removing the PPE only after leaving the resident care area, contrary to the facility's EBP policy. The facility also did not have a properly implemented infection monitoring surveillance plan in place until recently, resulting in lapses in infection identification and control.
Surveyors found expired bisacodyl suppositories and aspirin/diphenhydramine tablets in the medication room, as well as an opened, undated glargine insulin pen on a nurse treatment cart. Nursing and administrative staff confirmed that medications should be checked for expiration and insulin pens dated when opened, as per facility policy. The failure to remove expired medications and properly date the insulin pen resulted in a deficiency.
Nursing staff conducted blood glucose testing and administered insulin injections to two residents in the dining room in the presence of other residents, staff, and visitors. One resident expressed discomfort about the procedure, and staff confirmed that such practices occurred in communal areas, despite facility policy requiring care to be provided in a manner that maintains resident dignity and privacy.
A resident with left-sided hemiplegia and a history of falls was transported to the facility in a regular wheelchair without proper support, resulting in repeated sliding and the need for frequent repositioning. During the transport, the transportation aide became frustrated and verbally abusive, yelling and cursing at the resident. The incident was documented in the grievance log, but there was no evidence of a formal investigation or reporting to the state agency as required by facility policy.
A resident with significant mobility impairments reported being verbally abused by a transportation aide during a van ride, including being yelled at and cursed at for sliding out of a wheelchair. The incident was documented in the grievance log and acknowledged by the aide, but staff did not immediately report the allegation to the administrator or state agency as required by policy, resulting in a failure to investigate the abuse allegation.
A resident with left-sided hemiplegia and a history of falls reported being verbally abused by a transportation aide during a van ride to the facility, including being yelled at and cursed for sliding out of a wheelchair. The facility documented the complaint and the aide's admission of frustration but did not conduct a thorough investigation or report the allegation to the state agency, as required by policy.
A resident with dementia and a left heel pressure ulcer did not have the required wound dressing applied after a morning shower and before a wound clinic appointment. Staff transferred and assisted the resident without a dressing in place, and a new dressing was only applied after consulting with the wound clinic. The facility could not provide a policy for pressure ulcer treatment.
A resident with a neurogenic bladder, indwelling catheter, and multiple comorbidities did not receive the physician-ordered daily fluid intake, as staff failed to monitor and document intake as required. Dietary and nursing staff were unclear about their responsibilities, and the facility lacked a urinary tract infection prevention policy, resulting in the resident being placed at risk for ongoing UTIs.
A resident with heart failure, chronic kidney disease, diabetes, and a neurogenic bladder did not receive the physician-ordered daily fluid intake, as staff failed to monitor and document intake as directed in the care plan. Staff interviews revealed confusion about responsibility for tracking fluids, and the facility lacked a urinary tract infection prevention policy. This resulted in the resident not receiving the required fluids, with recent hospitalizations for dehydration and urinary tract infection.
A consultant pharmacist did not notify the DON or physician about a resident's blood pressure not being monitored as ordered while the resident continued to receive losartan. The resident, with a history of hypertension, TIA, and anemia, had an active order requiring blood pressure checks before medication administration, but only received weekly monitoring. Facility policy required the pharmacist to review and communicate medication regimen issues monthly, but this was not done.
A resident with hypertension, TIA, and anemia received losartan without staff consistently monitoring blood pressure as ordered by the physician. Staff only checked blood pressure weekly, despite orders to hold the medication if certain parameters were not met, resulting in a failure to follow physician orders and facility policy.
A resident with severe cognitive impairment was forced to go to bed by two CNAs despite his protests, leading to agitation and physical resistance. The resident, who had a history of cognitive decline and required assistance for daily activities, was found with multiple bruises following the incident. The facility failed to respect the resident's right to choose and maintain his dignity, resulting in psychosocial impairment and decreased quality of life.
Lack of Certified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager to oversee the food and nutrition services for all 39 residents. During an observation in the kitchen, it was found that the staff member acting as the dietary manager had only recently started and was not certified, though she had begun coursework to become a Certified Dietary Manager. Administrative staff confirmed that the current dietary manager was not certified. Additionally, the facility was unable to provide a policy regarding qualified dietary managers. These actions resulted in the facility not meeting the requirement to have a certified dietary manager responsible for the nutritional needs of the residents.
Failure to Follow PPE Protocols and Maintain Infection Surveillance
Penalty
Summary
Certified Nurse Aide (CNA) M was observed wearing a yellow protective gown and gloves while pushing a resident in a wheelchair to the dining room and then opening a closet, all while still wearing the PPE. CNA M stated that the gown was worn in the hallway so the surveyor would recognize her in it. The PPE was removed only after entering the service hall next to the dining room, rather than before exiting the resident's room as required by facility policy. This practice was not in accordance with the facility's Enhanced Barrier Precautions (EBP) policy, which specifies that PPE should be discarded before leaving a resident's room to prevent the spread of infection. Additionally, the facility failed to maintain an effective infection monitoring surveillance plan prior to January 2025. The infection tracking system was not correctly implemented until that time, as verified by the Administrative Nurse. This lapse meant that the facility did not have a consistent method for identifying, reporting, investigating, and controlling infections and communicable diseases for all individuals in the facility, as required by their Infection Prevention and Control Program.
Expired Medications and Undated Insulin Pen Found During Survey
Penalty
Summary
Surveyors observed that expired medications, including bisacodyl suppositories with an expiration date of November 2024 and a container of aspirin/diphenhydramine tablets expired December 2024, were present in the facility's medication room. Additionally, an opened glargine insulin pen on the nurse treatment cart was found to be undated. Licensed nursing staff confirmed the presence of expired medications and acknowledged that the insulin pen should have been dated when opened. Administrative staff verified that facility policy requires staff to date insulin pens upon opening and to check expiration dates when transferring medications from the medication room to the medication cart for administration. The facility's policy also mandates weekly audits of medication inventories to ensure all medications are properly dated and not expired. Despite these protocols, expired medications remained accessible and an insulin pen was not dated, resulting in a deficiency related to medication storage and labeling.
Insulin Administration in Dining Room Compromises Resident Dignity
Penalty
Summary
Licensed nursing staff performed blood glucose testing and administered insulin injections to two residents in the facility's dining room while other residents, staff, and visitors were present. One resident verbally expressed discomfort about needles during the procedure, and insulin was injected at the dining table in view of others. Another resident received insulin at a table with two other residents and a visitor present. These actions were observed by surveyors during meal times. Interviews with nursing staff confirmed that insulin administration and blood sugar checks were sometimes performed in the dining room, and staff indicated that residents could receive these procedures privately if they wished. The facility's policy stated that care should be provided in a manner that maintains and enhances each resident's dignity and respect. However, the observed practice did not ensure privacy or dignity for the residents involved, as required by facility policy.
Failure to Prevent Verbal Abuse During Resident Transport
Penalty
Summary
A resident with a history of cerebral infarction resulting in left-sided hemiplegia, cerebral edema, and muscle weakness was admitted to the facility and required total assistance for mobility, including the use of a mechanical lift and a specialized Broda chair to prevent sliding. During transport to the facility via the facility van, the resident was placed in a regular wheelchair without a pommel, which did not adequately prevent him from sliding forward. The transportation aide had to stop multiple times to reposition the resident, who repeatedly slid out of the wheelchair during the trip. During the transport, the resident reported being verbally abused by the transportation aide, who became frustrated and yelled and cursed at him for sliding out of the wheelchair. The resident stated that he was told, in explicit language, that the aide was tired of stopping to reposition him. The aide later acknowledged feeling angry and frustrated during the transport but denied cursing. The incident was documented in the facility's grievance log, and the resident also informed his family about the treatment he received during the ride. The facility's records indicated that the previous facility did not communicate the resident's risk of sliding forward, and the transportation aide was not provided with this information. The facility's policy required that all allegations of abuse be reported and investigated, but there was no evidence that the incident was reported to the state agency or that a formal investigation was conducted at the time. The only documentation available was the grievance log and the aide's statement.
Failure to Report Allegation of Verbal Abuse During Resident Transport
Penalty
Summary
A deficiency occurred when staff failed to immediately report an allegation of verbal abuse made by a resident against a transportation aide to the facility administrator and the state agency. The resident, who had a history of stroke with left-sided hemiplegia, cerebral edema, and muscle weakness, was dependent on staff for mobility and required a specialized wheelchair to prevent sliding. Upon admission, the resident reported being yelled at and cursed at by the transportation aide during the van ride to the facility, particularly after repeatedly sliding out of the wheelchair due to his physical limitations. The incident was documented in the facility's grievance log, where the resident described the aide's use of profanity and expressed distress over being blamed for something he could not control. The transportation aide acknowledged feeling frustrated during the transport and confirmed that she had to stop multiple times to reposition the resident, eventually requiring assistance from facility staff. However, there was no evidence that the allegation of verbal abuse was reported to the administrator or the state agency as required by facility policy. Facility records, including the grievance log and witness statements, confirmed the resident's complaint and the aide's account of the incident. Despite the facility's policy mandating immediate reporting and investigation of all abuse allegations, the required notifications and investigation were not completed. This failure to follow protocol placed the resident at risk for ongoing abuse or mistreatment.
Failure to Investigate Allegation of Verbal Abuse During Resident Transport
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse made by a newly admitted resident. The resident, who had a history of cerebral infarction resulting in left-sided hemiplegia, cerebral edema, and muscle weakness, was dependent on staff for mobility and required a specialized wheelchair to prevent sliding. Upon admission, the resident reported being verbally abused by a transportation aide during the van ride to the facility, stating that the aide yelled and cursed at him multiple times because he kept sliding out of his wheelchair. The resident also informed his family about the incident. Documentation in the facility's grievance log confirmed the resident's complaint, and a witness statement from the transportation aide acknowledged frustration during the transport but denied cursing. The aide described having to stop several times to reposition the resident and eventually required assistance from facility staff. Despite the resident's report and the aide's admission of frustration, the facility's only documented response was to educate the aide on abuse, neglect, and exploitation. There was no evidence of a thorough investigation, witness interviews, or a written report as required by the facility's abuse policy. Administrative staff later verified that the allegation was not reported to the state agency and that no formal investigation was conducted. The only documentation available was the grievance log entry and the aide's note. The facility's policy mandates immediate reporting and investigation of all abuse allegations, including obtaining witness statements and filing a written report, which was not followed in this case.
Failure to Maintain Pressure Ulcer Dressing on Resident's Heel
Penalty
Summary
A resident with dementia and a history of left hip fracture was identified as having an open pressure ulcer (PU) on her left heel. The resident required moderate to maximum staff assistance for activities such as bathing and dressing. Physician orders directed staff to dress the left heel wound with saline-moistened promogram prisma followed by a mepilex border dressing. The resident's care plan also instructed staff to monitor and document the wound's size, depth, granulation, and healing progress, and to notify the physician as needed. On the day of the incident, after the resident's early morning shower and prior to a scheduled wound clinic appointment, staff observed that the resident's left heel PU was not covered with any dressing as ordered. The resident was transferred multiple times and participated in activities without a dressing on the wound. Staff only applied a new dressing after consulting with the wound clinic later that morning. Interviews confirmed that open wounds should be covered at all times unless otherwise ordered by a physician. The facility was unable to provide a policy for pressure ulcer treatment.
Failure to Ensure Physician-Ordered Fluid Intake and UTI Prevention
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including heart failure, neuromuscular dysfunction of the bladder, diabetes mellitus, chronic kidney disease, and a neurogenic bladder with an indwelling catheter, did not receive the physician-ordered daily fluid intake of two quarts (1920 cc) of water. The resident's care plan directed staff to monitor and document intake and output, and to report signs or symptoms of urinary tract infection to the physician. However, review of the electronic medical record showed that the resident's fluid intake consistently fell short of the ordered amount over a period of several weeks. Interviews with dietary and nursing staff revealed confusion and lack of awareness regarding responsibility for tracking fluid intake, with dietary staff stating they were not keeping track of anyone's fluid intake and nursing staff unaware of the specific fluid order for the resident. Additionally, the facility was unable to provide a urinary tract infection prevention policy. These actions and inactions resulted in the resident not receiving the prescribed fluid intake, placing them at risk for ongoing urinary tract infections.
Failure to Provide Physician-Ordered Fluid Intake for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to ensure that a resident with multiple complex medical conditions, including heart failure, chronic kidney disease, diabetes mellitus, neurogenic bladder, and a history of urinary tract infections, received the physician-ordered daily fluid intake of two quarts (1920 cc) of water. The resident's care plan directed staff to monitor and document intake and output, and to report signs or symptoms of urinary tract infection to the physician. Despite these directives, review of the electronic medical record showed that the resident did not consistently receive the ordered amount of fluids over a period of several weeks. The resident had recently returned from the hospital with diagnoses of acute and chronic renal failure, dehydration, and a urinary tract infection, and subsequently required another hospitalization for a urinary tract infection. Interviews with dietary and nursing staff revealed confusion and lack of awareness regarding responsibility for tracking fluid intake, with dietary staff stating they were not currently monitoring anyone's fluid intake and nursing staff unaware of the specific fluid order for the resident. The facility was unable to provide a urinary tract infection prevention policy, and the existing hydration policy only generally stated that residents at risk for dehydration should receive appropriate interventions. These failures resulted in the resident not receiving the physician-ordered fluid intake, placing the resident at risk for ongoing dehydration and urinary tract infections.
Consultant Pharmacist Failed to Report Lack of Blood Pressure Monitoring
Penalty
Summary
The facility's consultant pharmacist did not notify the director of nursing or the physician regarding the lack of blood pressure monitoring for a resident who had an active order for losartan, a blood pressure medication. The physician's order specified that the medication should be held if the resident's systolic blood pressure was less than 100 mmHg or diastolic less than 60 mmHg, and required monitoring to assess the medication's effectiveness. Despite this, the resident's blood pressure was only documented weekly over a period of several months, while the order and medication administration remained unchanged. The resident involved had diagnoses of hypertension, transient cerebral ischemic attack, and anemia, and was receiving multiple medications including an antihypertensive, antidepressant, diuretic, and opioid. The resident's care plan directed staff to consult with a pharmacist as needed and to monitor and report adverse reactions to medication therapy. The facility's policy required the consultant pharmacist to review medication regimens monthly and communicate findings and recommendations to the physician and care team. However, the consultant pharmacist failed to report the lack of required blood pressure monitoring, as confirmed by the administrative nurse.
Failure to Monitor Blood Pressure as Ordered During Antihypertensive Administration
Penalty
Summary
Staff failed to monitor a resident's blood pressure as ordered by the physician to assess the effectiveness and safety of her antihypertensive medication, losartan. The physician's order specified that losartan should be held if the resident's systolic blood pressure was less than 100 mmHg or diastolic blood pressure was less than 60 mmHg. Despite this, staff only obtained the resident's blood pressure weekly over several months, while the order remained active and the medication continued to be administered. The resident had diagnoses of hypertension, transient cerebral ischemic attack, and anemia, and was receiving multiple medications including an antihypertensive, antidepressant, diuretic, and opioid. The facility's policy required medications to be administered as ordered and for staff to monitor residents' responses to medications. However, staff did not consistently check blood pressure with each administration of losartan as required, resulting in a failure to follow physician orders and facility policy.
Resident's Rights Violated During Forced Bedtime Transfer
Penalty
Summary
The facility failed to uphold a resident's right to choose and respect his wishes, leading to a situation where the resident was forced to go to bed against his will. On the evening of December 5th, two CNAs attempted to transfer the resident from his wheelchair to his bed despite his protests. The resident, who had a history of cognitive decline and required assistance for daily activities, became agitated and resistant during the transfer, resulting in a physical struggle. The CNAs reported that their primary concern was preventing the resident from falling, but the situation escalated, causing the resident to become combative. The resident's medical records indicated he had severe cognitive impairment and required assistance for most activities, except eating. Despite this, the care plan noted that he was alert and able to communicate his needs, although he required cues for care. During the incident, the resident's oxygen was reportedly off, and he was short of breath, which may have contributed to his confusion and agitation. The CNAs involved claimed they were trying to ensure the resident's safety by putting on his oxygen, but their actions were perceived as coercive by another CNA who intervened. Following the incident, the resident was found to have multiple bruises on his hands and arms, which he could not recall how they occurred. The bruising was documented over several days, and the resident's representative expressed concern about the situation, noting that the resident did not typically go to bed early due to breathing difficulties when lying down. The facility's policy on resident rights emphasizes the importance of respecting residents' choices and ensuring their dignity, which was not upheld in this case, leading to psychosocial impairment and a decrease in the resident's quality of life.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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