Swan Health At Overland Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Overland Park, Kansas.
- Location
- 6505 W 103rd Street, Overland Park, Kansas 66212
- CMS Provider Number
- 175240
- Inspections on file
- 18
- Latest survey
- September 18, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Swan Health At Overland Park during CMS and state inspections, most recent first.
A resident with complex medical needs and dependent on enteral nutrition experienced ongoing and significant weight loss, with no documented interventions or increased monitoring by staff until the loss became severe. Despite facility policy requiring prompt response to weight changes, staff failed to adjust feeding regimens or increase the frequency of weight checks in a timely manner, and no dietary assessments were completed during the period of decline.
The facility did not ensure consistent RN coverage for eight consecutive hours each day as required, with staffing records and schedules showing multiple days without documented RN presence. Administrative staff reported covering some shifts, but these hours were not accurately reflected in the official documentation, and timecard data for the missing days could not be retrieved due to a system change.
The facility did not conduct a comprehensive assessment to determine specific staffing needs for day, night, and weekend shifts, instead only documenting total daily staffing requirements. Payroll data showed consistently low weekend staffing, and administrative staff confirmed the assessment lacked shift-specific details, affecting all residents.
The facility failed to submit accurate PBJ staffing data to CMS, particularly for weekend coverage, despite internal records and staff interviews indicating adequate staffing and administrative nurse coverage for call-offs. The facility's assessment did not specify required nursing hours for different shifts, contributing to the inaccurate reporting.
The facility did not implement an effective antibiotic stewardship program or track antibiotic use, resulting in a lack of identification and monitoring of possible infection outbreaks. The Infection Preventionist confirmed that antibiotic use was not tracked, and the infection control log did not identify facility-acquired infections.
Three medication carts containing resident and stock medications, as well as medicated ointments, were observed unlocked and unsupervised in a hallway. Nursing staff confirmed the carts should have been locked when not in use, but failed to do so, contrary to facility policy requiring all medications to be secured.
Two residents received unnecessary psychotropic medications, including antipsychotics prescribed for non-approved indications such as depression and insomnia, and PRN orders without required stop dates or proper clinical justification. Nursing and administrative staff acknowledged these practices were inconsistent with facility policy and regulatory requirements, resulting in the risk of chemical restraint.
Two residents did not have required Care Area Assessment (CAA) analyses completed after their admission MDS triggered multiple care areas, including functional abilities, urinary incontinence, pressure ulcers, psychotropic drug use, falls, and nutritional status. Administrative nursing staff were unable to explain the missing analyses, despite facility policy assigning this responsibility to an RN.
A resident with multiple medical conditions, including depression and quadriplegia, was prescribed Seroquel, an antipsychotic, for depression. The Consultant Pharmacist identified that Seroquel could not be used for depression but did not address that depression is not a CMS-approved indication for antipsychotic use. Nursing and administrative staff confirmed antipsychotics should not be used for depression, and facility policy required the pharmacist to review and report such irregularities. Despite this, the medication continued to be administered for an unapproved indication.
Two residents did not receive care in accordance with physician orders regarding medication administration and monitoring. One resident with diabetes and heart failure had multiple blood glucose readings outside the ordered parameters without physician notification or documentation. Another resident with hypertension received antihypertensive medication outside the prescribed blood pressure parameters on several occasions, also without required documentation. Staff interviews confirmed expectations for following orders and documenting deviations, but these were not met.
Dietary staff did not follow approved recipes when preparing pureed meals for a resident, instead using water as an additive and inconsistently adding thickener. Staff admitted to not following recipes, and the facility could not provide a policy for altered diet preparation.
Surveyors found that the facility did not update its daily posted nurse staffing information, with documentation remaining unchanged for several days. Staff confirmed that the posting should be updated daily by nursing administrators, but this was not done when the responsible administrator was absent, resulting in outdated staffing information being displayed.
A resident in a persistent vegetative state with a PEG tube experienced neglect when the facility failed to provide adequate monitoring and timely care for her feeding tube site, leading to an infection. Despite signs of infection and displacement, staff delayed appropriate intervention, resulting in the resident's condition worsening. The resident was eventually transferred to the hospital, where it was discovered that the PEG tube was outside of the stomach, and she had a severe abdominal wall infection. The resident passed away the same day, and the facility's actions were deemed neglectful, placing the resident in immediate jeopardy.
A facility failed to protect residents' trust funds from misappropriation by an administrative staff member responsible for managing these accounts. The investigation revealed unauthorized withdrawals and checks written from the resident trust account without proper documentation or authorization. This lack of oversight placed all residents with trust accounts at risk for financial instability and impaired rights.
A resident with a PEG tube and anoxic brain damage developed cellulitis around the tube site, requiring antibiotic treatment. The facility failed to notify the resident's representative of this new medication order, leading to a risk of miscommunication. Staff interviews indicated an expectation to notify representatives of changes, but the facility's policy did not address this requirement.
The facility failed to report suspected misappropriation of resident funds to the State Agency and law enforcement within the required timeframe. An investigation revealed discrepancies involving large checks written to an administrative staff member and unauthorized withdrawals from resident accounts. Despite identifying these issues, the facility delayed reporting, placing residents with trust accounts at risk.
Failure to Implement Timely Interventions for Significant Weight Loss in Enteral-Fed Resident
Penalty
Summary
The facility failed to implement timely and appropriate interventions to address ongoing and significant weight loss in a resident who was dependent on enteral nutrition via PEG tube. The resident, who had a complex medical history including nontraumatic subarachnoid hemorrhage, conversion disorder, dysphagia, cerebral edema, and ventilator dependence, experienced a weight loss of 3.85% within the first month of admission, which progressed to a significant loss of 8.85% by the second month. Despite these documented losses, there was no evidence in the medical record of any interventions or responses from the facility until over two months after admission, when the weight loss had reached 11.15%. The resident's care plan and physician orders directed monthly weights and specified enteral feeding regimens, but there was no documented adjustment to the feeding orders or increased monitoring in response to the early weight loss. The resident's electronic medical record lacked evidence of dietary assessments or progress notes addressing the weight loss between admission and the point when the loss became significant. Staff interviews revealed that weights were typically obtained monthly, and that the dietitian was responsible for monitoring and making dietary adjustments. However, both the dietitian and administrative staff acknowledged that interventions, such as increasing the frequency of weight monitoring and adjusting feeding methods, should have been implemented sooner when the initial weight loss was observed. The dietitian also noted that no dietary assessments were completed in July when the first weight loss was documented, and that the resident remained on monthly weights despite ongoing decline. Facility policy required staff to report significant weight changes and for the dietitian to monitor and recommend interventions for residents receiving enteral nutrition. Despite this, the resident's weight loss was not addressed in a timely manner, and there was a lack of documentation of any interventions or increased monitoring until the weight loss became severe. Staff interviews confirmed that the process for monitoring and responding to weight loss was not followed as required, contributing to the continued decline in the resident's nutritional status.
Failure to Maintain Consistent RN Coverage
Penalty
Summary
The facility failed to provide consistent Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week, as required. A review of the facility's Payroll Based Journaling (PBJ) Staffing Data Report revealed that there was no RN coverage on twelve occasions, and for eight of those days, there were no accounted RN hours according to the facility's working schedules and daily posted staffing. The facility was unable to provide documentation for the missing RN coverage on these days when requested. Administrative staff stated that they sometimes covered shifts, but the hours may not have been accurately reflected in the PBJ documentation, and the administrator was unable to retrieve timecard data for the missing days due to a system changeover. The facility's own policy required an RN to be on duty at least eight consecutive hours every 24 hours, seven days a week.
Failure to Conduct Comprehensive Facility-Wide Resource Assessment
Penalty
Summary
The facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. The assessment provided by administrative staff was updated annually and identified required staffing needs per day, but did not specify staffing needs for day, night, and weekend shifts. Review of the facility's Payroll Based Journaling (PBJ) data revealed excessively low weekend staffing in all four quarters reviewed. Additionally, administrative staff confirmed that the assessment did not separate required hours by shift, only showing total required hours. The facility's policy required a documented assessment to determine necessary resources for resident care during daily operations, but this was not fully implemented.
Inaccurate PBJ Staffing Data Submission for Weekend Coverage
Penalty
Summary
The facility failed to submit accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) through Payroll Based Journaling (PBJ), specifically regarding weekend staffing coverage hours. A review of the facility's PBJ data for multiple fiscal quarters showed that the facility triggered for excessively low weekend staffing. However, examination of the facility's working schedules, time sheets, and posted staffing hours did not reveal any gaps or loss of hours, and weekend call-offs were documented as being covered by administrative nurses. Further review of the facility's updated Facility Assessment indicated that it did not differentiate required nursing hours for day, evening, and weekend shifts. Interviews with nursing staff and administrative nurses confirmed that the facility was typically well-staffed on weekends, with administrative nurses covering any call-offs. Despite this, the PBJ data submitted to CMS did not accurately reflect the actual staffing coverage, resulting in a deficiency for failing to report complete and accurate staffing information as required by facility policy.
Failure to Implement Antibiotic Stewardship and Infection Tracking
Penalty
Summary
The facility failed to develop and implement the core elements of an antibiotic stewardship program as part of its infection prevention and control efforts. Review of the Infection Control Log from May 2024 through April 2025 showed no evidence of tracking or identifying possible infection outbreaks, and the log did not identify facility-acquired infections. During an interview, the facility's Infection Preventionist confirmed that antibiotic use was not being tracked to monitor for potential infection outbreaks. The facility's Infection Prevention Plan policy outlined the need for surveillance and reporting of infectious agents, but these practices were not followed as required.
Unsecured Medication Carts Found Unattended
Penalty
Summary
Three medication carts were found unlocked and unsupervised on the facility's 200 hallway during an inspection, with resident medications, stock medications, and medicated ointments stored inside. Licensed nurses acknowledged that the carts should have been locked when not in use or supervised, but had left them unsecured for a period of time. The facility's policy required all medications and biologicals to be locked and secured to prevent tampering or exposure, but this protocol was not followed during the observed incident.
Failure to Prevent Unnecessary Psychotropic Medication and Chemical Restraint
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications and chemical restraints for two residents. One resident with quadriplegia, severe cognitive impairment, and total dependence on staff was administered Seroquel, an antipsychotic, for depression, despite the absence of a psychiatric or mood disorder diagnosis and no CMS-approved indication for antipsychotic use in depression. The resident also received PRN Lorazepam for anxiety with an indefinite order lacking a required stop date. The consultant pharmacist identified these issues, noting the inappropriate use of Seroquel for depression and the need for a defined duration for Lorazepam, but the orders were not appropriately updated or discontinued as required. Another resident with paraplegia and intact cognition received antipsychotic medications, including Diazepam and Seroquel, for muscle spasms and insomnia, respectively. The Diazepam orders were PRN without a 14-day stop date or specific duration, and Seroquel was prescribed for insomnia, which is not an approved indication for antipsychotic use. The consultant pharmacist recommended clinical rationale and duration for Diazepam and questioned the indication for Seroquel, but the facility was unable to provide appropriate physician documentation for the use of antipsychotics with non-approved indications. Interviews with nursing staff and administrative nurses confirmed that antipsychotic medications should not be used for depression or insomnia and that PRN psychotropic medications require a 14-day stop date and physician evaluation for continued use. The facility's own policy also required these safeguards, but they were not followed. These actions and inactions resulted in the administration of unnecessary psychotropic medications and the risk of chemical restraint for the affected residents.
Failure to Complete CAA Analyses for Two Residents
Penalty
Summary
The facility failed to complete the Care Area Assessment (CAA) analysis of findings for two residents following their admission, as required by the Comprehensive Minimum Data Set (MDS) process. For one resident, the Admission MDS triggered CAAs for functional abilities, urinary incontinence and indwelling catheter, pressure ulcer, and nutritional status, but none of these CAAs included a completed analysis of findings. For another resident, the Admission MDS triggered CAAs for functional abilities, urinary incontinence and indwelling catheter, pressure ulcer, psychotropic drug use, falls, and nutritional status, with all triggered CAAs also lacking the required analysis. Interviews with administrative nursing staff revealed they were unable to provide information regarding the missing analyses. The facility's policy states that a registered nurse is responsible for conducting and coordinating the completion of the resident assessment.
Failure to Ensure CMS-Approved Indication for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) recommended a Centers for Medicare and Medicaid Services (CMS) approved indication for an antipsychotic medication prescribed to a resident. The resident had a history of depression, quadriplegia, muscle weakness, dysphagia, and COPD, and was completely dependent on staff for all activities of daily living. The resident's medical record included an order for Seroquel, an antipsychotic, to be administered via gastrostomy tube at bedtime for depression. The CP's medication regimen review noted that Seroquel could not be used for depression, but did not acknowledge that depression is not an accepted CMS indication for antipsychotic use. The medical provider noted a failed gradual dose reduction, but the documentation did not address the lack of an appropriate indication for the medication. Interviews with nursing staff and administrative nurses confirmed that antipsychotic medications should not be used for depression and are intended for mental disorders such as behavioral and mood disorders. The facility's policy required the CP to complete monthly medication reviews and report irregular findings, including making recommendations based on medication indications. Despite these requirements, the CP did not ensure that the antipsychotic was prescribed for a CMS-approved indication, resulting in the continued administration of the medication for an unapproved use.
Failure to Follow Physician Orders for Medication Administration and Monitoring
Penalty
Summary
The facility failed to ensure that physician orders regarding medication administration and monitoring were followed for two residents. For one resident with diagnoses of congestive heart failure and diabetes mellitus, the physician had ordered blood glucose monitoring four times daily, with instructions to notify the physician if blood sugar levels were less than 30 or greater than 350. Over a 94-day period, this resident's blood sugar was outside the ordered parameters on twelve occasions, but there was no documentation that the physician was notified as required. Both nursing staff and administrative staff confirmed that physician notification and documentation were expected when blood sugars were outside the specified range. The facility was unable to provide a policy related to following physician orders. For another resident with chronic respiratory failure, hypoxia, hypertension, and muscular dystrophy, the physician ordered Metoprolol to be administered twice daily for hypertension, with instructions to hold the medication if systolic blood pressure was less than 110 mmHg. Review of the medication administration record showed that Metoprolol was given outside the ordered parameters on ten occasions, with no documentation explaining why the medication was administered despite the blood pressure being below the threshold. Nursing and administrative staff confirmed that medication parameters should be followed and that any deviations should be documented, including the reason for administering medication outside of parameters if instructed by the physician. The facility's medication monitoring policy indicated that medications should be given per physician orders and that irregular medication findings should be reported and corrected. However, the observed practices for these two residents did not align with the policy or physician instructions, as required notifications and documentation were not completed.
Failure to Follow Approved Recipes for Pureed Diets
Penalty
Summary
Dietary staff failed to follow nutritionally approved recipes during the preparation of pureed meals for a resident on a puree textured diet. Observations showed that staff used water as an additive in the food processor when pureeing cooked parmesan chicken, spaghetti with marinara sauce, and peas, and also added thickener inconsistently, rather than following the prescribed recipes. When questioned, the dietary staff member admitted to not following the recipes, citing experience as the reason. Another dietary staff member confirmed that water should not be used as an additive and that recipes should be followed for altered diets. The facility was unable to provide a policy related to altered diet preparation.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to update its daily posted nurse staffing information as required. During inspections on multiple days, surveyors observed that the staffing documentation posted in the cafeteria area was dated several days prior and had not been updated daily. Staff interviews confirmed that the form should be updated each day by nursing administrators, but this had not occurred since the administrator responsible had been off work. The facility's policy requires daily posting and maintenance of staffing records, but this procedure was not followed, resulting in inaccurate and outdated staffing information being displayed.
Neglect of Resident with PEG Tube Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to prevent the neglect of a resident, identified as R1, who was dependent on staff for her activities of daily living due to her persistent vegetative state and required a feeding tube for nutrition. The deficiency arose when staff did not provide adequate monitoring and timely care for R1's percutaneous endoscopic gastrostomy (PEG) tube site, which led to an infection. The infection caused R1's abdomen to become swollen and inflamed, with darkening and bruising noted on her right lower abdomen. Despite the presence of these symptoms, the facility's staff did not take immediate and appropriate action to address the complications. R1's medical records indicated that she had a history of anoxic brain damage and was in a persistent vegetative state, requiring tube feeding for more than half of her daily caloric intake. The facility's care plan for R1 included directives for staff to monitor and report any signs of infection or complications related to the PEG tube. However, the staff failed to adhere to these directives, as evidenced by the lack of timely intervention when R1's PEG tube site showed signs of infection and displacement. The staff's inaction resulted in R1 developing cellulitis around the PEG tube site, which was not promptly addressed, leading to further complications. The situation escalated when R1's condition deteriorated, with her abdomen becoming distended and tender, and the PEG tube balloon appearing displaced. Despite these alarming signs, there was a delay in sending R1 to the hospital for further evaluation. When R1 was finally transferred to the hospital, it was discovered that the PEG tube was outside of the stomach, and she had a severe abdominal wall infection. Unfortunately, R1 passed away the same day at the hospital. The facility's failure to provide necessary monitoring and treatment for R1's PEG tube complications constituted neglect and placed R1 in immediate jeopardy.
Removal Plan
- The facility educated all LN in an in-service provided by Administrative Nurse D on PEG tubes, notification of changes, and abuse/neglect/exploitation.
- Administrative Nurse D rounded on all 23 residents with PEG tubes to ensure proper placement.
- Administrative Nurse D or designee rounded daily using the PEG Tube Nursing Audit Tool.
- Administrative Nurse D reviewed the information from the audits and reported findings to the Quality Committee.
Misappropriation of Resident Trust Funds by Administrative Staff
Penalty
Summary
The facility failed to protect residents' trust funds from misappropriation by Administrative Staff B, who was responsible for managing these accounts. The investigation revealed that several large checks were written from the resident trust account to Administrative Staff B, with withdrawals not matching the written checks. Additionally, there were multiple transactions from residents' accounts that lacked proper documentation, such as signed withdrawal receipts and records, indicating a lack of oversight and control over the funds. The investigation into the misappropriation began when credit card fraud was discovered on the company credit card, attributed to Administrative Staff B. This led to a deeper audit of the Resident Funds Management Systems (RFMS), uncovering unauthorized withdrawals from the accounts of three residents. The facility identified that checks were written from the RFMS account without being linked to specific residents, and withdrawals were made without the necessary receipts or signatures from the residents or Administrative Staff B. The facility's policies required that no funds be disbursed without appropriate written authorization from the resident or their legal representative. However, the lack of adherence to these policies allowed for the misappropriation to occur, placing all residents with trust accounts at risk. The facility's failure to ensure proper management and documentation of resident funds resulted in financial instability and impaired rights for the affected residents.
Failure to Notify Resident's Representative of Care Plan Changes
Penalty
Summary
The facility failed to notify Resident 1's representative of changes in the plan of care, specifically regarding a new medication order for cellulitis around the PEG tube site. Resident 1, who had a history of anoxic brain damage and required tube feeding due to dysphagia, developed a swollen abdomen with a palpable mass and signs of infection at the PEG tube site. Despite the initiation of an antibiotic treatment (Augmentin) for cellulitis, there was no documented evidence that the resident's representative was informed of this new order. Interviews with nursing staff revealed that they were expected to notify the resident's representative of any new orders or changes in condition, and to document these notifications in the electronic medical record (EMR). However, the facility's policy on physician notification of change in condition did not address the requirement for notifying the resident's representative. This oversight led to a risk of miscommunication between the resident, their representative, and the facility.
Failure to Timely Report Misappropriation of Resident Funds
Penalty
Summary
The facility failed to report the suspicion of misappropriation of resident funds to the State Agency (SA) and law enforcement within the required timeframe. The issue was identified when the facility initiated an investigation on 12/11/24 after discovering credit card fraud on the company credit card linked to Administrative Staff B. During the investigation, several large checks from the resident funds account were found to be written to Administrative Staff B, with withdrawals not matching the written checks. Further discrepancies were identified on 12/17/24, including withdrawals from the accounts of three residents without receipts signed by them and checks written from the RFMS account not linked to any specific resident. Despite these findings, the facility delayed reporting the incident to the SA until 01/16/25 and to law enforcement until 01/22/25. The facility's policy, last revised in February 2020, required immediate reporting of any suspected or actual abuse, neglect, or exploitation to the SA and law enforcement. The delay in reporting placed all residents with trust accounts managed by the facility at risk for unidentified and ongoing misappropriation. The facility's actions, including the suspension and eventual resignation of Administrative Staff B, did not mitigate the failure to report the incident in a timely manner, as required by their policy.
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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