Tallgrass Creek, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Overland Park, Kansas.
- Location
- 13760 Metcalf Avenue, Overland Park, Kansas 66223
- CMS Provider Number
- 175541
- Inspections on file
- 16
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Tallgrass Creek, Inc during CMS and state inspections, most recent first.
The facility failed to ensure a safe environment free from hazardous materials for nine cognitively impaired residents and did not follow proper transfer practices, resulting in an injury to a resident during a Hoyer lift transfer.
The facility failed to ensure an accurate reconciliation of controlled medications was completed consistently, as the daily controlled medication record log lacked evidence of two nurse signatures on 10 of 72 opportunities. This placed residents at risk of medication misappropriation, diversion, and ineffective medication regimens.
The facility failed to ensure proper food storage, preparation, and service, placing residents at risk of foodborne illness and cross-contamination. Observations included improperly stored chicken strips, a leaking freezer unit, and inadequate sanitization of food processing equipment.
The facility failed to follow infection control standards during the use of shared equipment, transport of clean linens, and storage of a resident's oxygen therapy equipment. Staff did not sanitize shared equipment between uses, and clean linens were transported uncovered, placing residents at risk for infectious diseases.
A resident with severe cognitive impairments was left uncovered and exposed for an extended period, despite the facility's policy requiring regular checks. This failure to monitor and cover the resident appropriately compromised her dignity and quality of life.
The facility failed to ensure proper preparation of pureed foods, resulting in runny and unattractive food items. Dietary staff used an unmeasured amount of water and did not follow recipes, compromising the appearance and palatability of the food. This placed residents at risk of decreased palatability and impaired nutritional status.
A resident with dementia and Alzheimer's disease was not provided with the prescribed nectar thick liquids, receiving thin liquids instead on multiple occasions. Staff acknowledged the error, and the facility's policy on thickened liquids was not consistently followed, placing the resident at risk for complications.
Failure to Ensure Safe Environment and Proper Transfer Practices
Penalty
Summary
The facility failed to ensure a safe environment free from hazardous materials for nine cognitively impaired independently mobile residents. During an initial walkthrough, it was observed that the west hall's laundry room door was unlocked, and a bottle of Oxivir-TB spray was left on top of the washing machine. Additionally, the west hall's spa room was found unlocked with an unlocked cabinet containing disposable ice packs and alcohol cleaning wipes. In the east hallway's activity area, an unsupervised supplemental oxygen storage rack with 10 oxygen cylinders was found, three of which were pressured above 1000 PSI. These hazardous materials were accessible to residents, posing a risk for preventable accidents and injuries. Staff interviews confirmed that hazardous materials should be locked and inaccessible to residents, and the facility's policy required staff to ensure the environment remains free from potential risks of accidents and falls. However, these protocols were not followed, leading to the deficiency observed during the survey. The facility also failed to ensure an environment free from avoidable accidents for a resident (R15) who was injured during a lift-assisted transfer. R15, who had severe cognitive impairment and required extensive assistance for transfers, suffered a quarter-size skin tear on his left hand when it got caught between two moving levers of a Hoyer lift. The incident report indicated that R15 often became agitated or anxious during care, which contributed to the accident. Staff interviews revealed that R15's hands should be securely placed on his chest during transfers, and one of the assisting staff should monitor his hand placement. However, these safety measures were not adequately followed, resulting in the injury. The facility's policies on incident reporting and investigation, as well as lift, transfers, and bed mobility, were not adhered to, leading to the deficiencies observed. The failure to lock hazardous materials and ensure safe transfer practices placed residents at risk for preventable accidents and injuries. The facility's staff acknowledged the lapses in following protocols, which contributed to the unsafe environment and the injury sustained by R15.
Failure to Ensure Accurate Reconciliation of Controlled Medications
Penalty
Summary
The facility failed to ensure an accurate reconciliation of controlled medications was completed consistently. Observations revealed that the daily controlled medication record log from 04/20/24 to 05/06/24 lacked evidence of two nurse signatures indicating a reconciliation was completed on 10 of 72 opportunities. This was confirmed by a Licensed Nurse who stated that the count sheet should be signed by the off-going nurse and the on-coming nurse at the beginning and the end of each shift after the narcotic count had been completed and the medication room keys exchanged. An Administrative Nurse confirmed that the two nursing staff were expected to sign the narcotic count shift sheet at the beginning and the end of each shift to indicate the count was completed as required. The facility's policy dated May 2021 documented that narcotic/controlled substances were to be counted on a regular basis by the off-going and on-coming nurse/care associate. Despite these policies and reminders posted in the medication rooms, the facility failed to ensure an accurate reconciliation of controlled medications, placing residents at risk of medication misappropriation, diversion, and ineffective medication regimens.
Failure to Maintain Food Safety Standards
Penalty
Summary
The facility failed to ensure proper food storage, preparation, and service in accordance with professional standards, placing residents at risk of foodborne illness and cross-contamination. During an initial tour of the kitchen, surveyors observed an opened box and bag of breaded chicken strips in the walk-in freezer that were not sealed and lacked an open date. Additionally, frozen water icicles were found to have dropped onto an opened box of food below in the freezer unit. These observations indicate a failure to maintain the freezer unit properly and to store food items safely. Further deficiencies were noted during food preparation. Dietary Staff CC did not properly wash and sanitize the Robo coupe container and lid between each food item that was pureed. Dietary Staff EE admitted to not being aware of the leaking freezer unit and stated that food containers should be either run through the dishwasher or washed and sanitized in the three-bin wash sinks. The facility's Standard Operating Procedure (SOP) for Food Preparation and Service, dated February 2024, mandates strict food preparation procedures, including cleaning and sanitizing sinks, slicing machines, and cutting boards after each use. The facility's failure to adhere to these procedures compromised food safety and increased the risk of cross-contamination and foodborne illness among residents.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure infection control standards were followed during the use of shared equipment, transport of clean linens, and storage of a resident's oxygen therapy equipment. Specifically, an inspection revealed that a resident's supplemental oxygen face mask and two oxygen connector ports were stored on a paper towel on a shared sink. Additionally, a nurse failed to sanitize shared blood pressure equipment between taking the vitals of two residents. Staff also did not sanitize a Hoyer lift before or after transferring a resident, and a large, uncovered cart carrying brown towels was transported through the facility's east hall. Interviews with staff confirmed that all laundry should be covered during transport, and shared equipment should be sanitized between uses. Oxygen tubing and masks should be stored in clean bags when not in use. The facility's Infection Prevention and Control Surveillance and Monitoring policy indicated that safe infection control practices should be implemented to prevent contamination and infections. However, the facility did not adhere to these standards, placing residents at risk for infectious diseases.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to provide a dignified care environment for Resident 23, who had severe cognitive impairments due to dementia and aphasia. The resident required maximal assistance with daily activities and was at risk for falls and injuries. On the morning of May 6, 2023, Resident 23 was observed sleeping in her bed with her lower body exposed and only an incontinence brief covering her. Her room door was open, making her visible from the hallway. This situation persisted for approximately 1.5 hours, during which multiple residents and staff walked by her room without addressing her exposed state. Staff interviews revealed that the facility's policy required residents to be checked at least every two hours, but some staff preferred to check every 30 minutes. Despite this, Resident 23 was left uncovered and exposed for an extended period. The facility's Resident Rights policy emphasized the importance of treating residents with respect and ensuring their dignity, which was not upheld in this instance. The failure to monitor and cover Resident 23 appropriately placed her at risk for impaired dignity and quality of life.
Failure to Ensure Proper Preparation of Pureed Foods
Penalty
Summary
The facility failed to ensure that dietary staff prepared pureed food that conserved the nutritive value, flavor, and appearance. Observations revealed that the dietary staff used an unmeasured amount of water to puree baked tilapia, lima beans, and barbecued pulled pork, resulting in runny and unattractive food items. The dietary staff did not follow any recipes, as the facility had recently implemented a new policy that did not require recipes for pureed foods. This new policy aimed to achieve a pudding-thick consistency by adding water to the original cooked foods, but it compromised the appearance and palatability of the pureed items. Interviews with dietary staff and a consultant confirmed that the new standard operating procedure did not require recipes and involved adding water to achieve the desired consistency. The consultant claimed that the nutritive value and flavor would not be compromised, but observations indicated otherwise. Additionally, the dietary staff had difficulty distinguishing between different pureed food items due to a lack of labeling. The facility's failure to follow proper procedures for preparing pureed foods placed residents at risk of decreased palatability and impaired nutritional status.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide a resident's therapeutic diet as ordered by his physician, placing the resident at risk for complications including choking. The resident, who had diagnoses of dementia and Alzheimer's disease, required a pureed diet with nectar thick liquids due to difficulty or pain with swallowing. Despite this, observations on multiple occasions revealed that the resident was provided with thin liquids instead of the prescribed nectar thick liquids. Staff interviews confirmed that the resident's care plan, which included the dietary order, was accessible in the resident's room and the dining room, and that staff had been educated on the importance of adhering to these dietary orders. On several occasions, thin liquids were observed in the resident's room, contrary to the prescribed nectar thick liquids. Staff members, including a CNA and a licensed nurse, acknowledged the presence of incorrect fluid consistency and indicated that it might have been placed by the night shift. The facility's policy on thickened liquids, revised in March 2020, stated that thickened liquids should be provided as ordered to promote ease of swallowing and prevent choking and aspiration. Despite this policy and staff education, the facility did not consistently adhere to the resident's dietary orders, resulting in a deficiency that placed the resident at risk for serious health complications.
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Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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