The Cedars
Inspection history, citations, penalties and survey trends for this long-term care facility in Mcpherson, Kansas.
- Location
- 1021 Cedars Drive, Mcpherson, Kansas 67460
- CMS Provider Number
- 175380
- Inspections on file
- 19
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at The Cedars during CMS and state inspections, most recent first.
A resident with moderately impaired cognition had their blood glucose checked by an LN at a dining room table in the presence of other residents, staff, and a visitor. After obtaining the reading from the resident’s finger, the LN announced that the blood sugar was high and that the MD might need to be contacted to start insulin. Administrative nursing staff later acknowledged that such procedures should occur in a private area, and facility policy stated that residents have the right to be treated with dignity and respect.
The facility failed to provide required Notice of Medicare Non-Coverage (NOMNC) forms to two residents when their skilled services ended. In both cases, there was no documentation that the residents or their representatives received Form CMS-10123, which explains non-coverage and the appeal process. An administrative staff member confirmed the forms were not given as required, and the facility could not produce a policy for Beneficiary Notices when requested by surveyors.
Surveyors found that the facility did not ensure appropriate indications and documentation for psychotropic medications. A resident with dementia, depression, Parkinson’s disease, and encephalopathy received an antipsychotic for dementia with agitation without a documented physician rationale, nonpharmacological interventions, or risk–benefit analysis as required by facility policy. Two other residents with dementia, depression, and anxiety had PRN antianxiety medications ordered without 14-day stop dates or specified durations, and their records lacked the required physician rationale for extended PRN use, despite staff acknowledging that such orders should include a 14-day limit and reassessment.
A resident with dementia, acute blood loss anemia, and a lower GI bleed, who required partial staff assistance with ADLs and had moderately impaired cognition per MDS BIMS, was admitted for care and later discharged home with a spouse. The care plan identified discharge as an outcome and directed staff to support the resident and family through care plan conferences, discharge planning, and discussion of alternative care options. Despite this, the clinical record did not contain a recapitulation summarizing the resident’s stay and course of treatment at discharge, and facility leadership confirmed that this required discharge documentation was not completed, contrary to the facility’s discharge planning policy.
Surveyors found that the facility failed to implement appropriate care planning and clinical parameters for two residents. A resident with DM who was dependent for mobility and received daily insulin had a care plan that only directed staff to provide a nighttime protein snack, with no further diabetes-related guidance, and the EMR lacked physician-ordered blood glucose parameters despite orders for pre-meal and bedtime checks; nursing staff and a CMA confirmed there were no parameters in the current EMR and that they relied on nursing judgment. Another resident with dementia, anxiety, severely impaired cognition, and a history of repeated falls was identified as high fall risk, yet the care plan contained only general directions such as determining causative factors, promoting exercise, and obtaining PT and pharmacy reviews, without specific individualized fall interventions. Multiple fall investigations documented the resident repeatedly scooting onto the floor in her room, with immediate responses limited to adding a fall mat and posting reminder signs, while staff reported frequent falls, use of a Wander Guard, and the practice of keeping the resident in common areas for observation.
Two residents at high risk for falls experienced multiple falls when staff did not consistently follow fall-prevention care plans and safe transfer practices. One resident with dementia and Parkinson’s disease, who required staff assistance and had a history of falls, continued to ambulate in shoes that were too large, leading to a fall with laceration, hematoma, and skin tear during assisted walking, despite a care-plan directive for properly fitting footwear. The same resident had several prior unwitnessed falls from a recliner in his room, with at least one fall lacking a documented investigation in the EMR, contrary to facility fall-reporting policy. Another resident with severe cognitive impairment, macular degeneration, and weakness, care-planned for two-person assistance with a sit-to-stand lift, slid out of the sling and fell to the bathroom floor on two occasions during sit-to-stand transfers; investigations identified incorrect sling application and use of only one staff member during one event, inconsistent with the care plan and facility policies requiring appropriate interventions and documentation after falls.
A resident with diabetes who was dependent on staff for care and received daily insulin had blood sugars checked four times per day without any physician-ordered blood glucose parameters documented in the EMR or care plan. Nursing staff reported relying on personal judgment to determine when to notify the physician, and a CMA stated she did not know what the parameters should be, noting that they were present in a prior computer system but not in the current one. An administrative nurse acknowledged that physician-ordered parameters and clear care plan directions for diabetes management were lacking, and the facility could not provide a blood sugar management policy when requested.
A resident with dementia, metabolic encephalopathy, DM, atrial fibrillation, and chronic pain experienced a decline in ADLs and was admitted to hospice for senile degeneration of the brain. The MDS documented hospice services and increased need for assistance, but the facility’s care plan did not include any information that the resident was on hospice or reflect coordination with hospice services. An administrative nurse confirmed the omission, despite a facility end-of-life policy requiring interdisciplinary care planning for hospice and end-of-life care.
The facility did not employ a full-time certified dietary manager while providing meals to 33 residents. A dietary staff member preparing meals confirmed she was not certified and was still completing coursework and testing for certification, yet was responsible for managing specialized diets, including pureed diets for two residents and minced and moist diets for three residents. Administrative staff later verified that this staff member was not certified, despite facility policy requiring sufficient competent personnel in the food and nutrition services department.
A facility failed to report an allegation of rough care as potential abuse to the LNHA and SA. A resident with severe cognitive impairment and other medical conditions was reportedly handled roughly by a CMA during a transfer, leading to the resident yelling out. Despite a CNA witnessing and reporting the incident, it was not immediately reported to the LNHA or SA, placing the resident at risk for ongoing mistreatment.
A resident with severe cognitive impairment and multiple medical conditions was allegedly handled roughly by a CMA during a transfer, leading to the resident yelling out. Despite the report of potential abuse, the facility did not immediately suspend the involved staff member or conduct a thorough investigation, as required by policy. This delay in action placed the resident at risk for continued abuse.
Public Blood Glucose Testing and Discussion Compromised Resident Dignity
Penalty
Summary
The facility failed to protect and promote the dignity of Resident 23, who had a Brief Interview for Mental Status (BIMS) score of 11 indicating moderately impaired cognition, when obtaining and discussing blood glucose results in a public setting. On 01/21/26 at 7:55 AM, a licensed nurse checked the resident’s blood sugar using a glucometer while the resident was seated at a dining room table, with five other residents, staff, and a visitor present. After obtaining the reading from the resident’s right index finger, the nurse verbally stated in the dining room that the resident’s blood sugar was high and that the physician might need to be contacted to start insulin. Administrative staff later confirmed that blood sugar checks should not be performed in the dining room and that residents should be taken to their room or a private area, and facility policy on resident rights documented that residents have the right to be treated with dignity and respect. This conduct, occurring in a communal dining area in the presence of other residents, staff, and a visitor, constituted a failure to provide care in a manner that maintained Resident 23’s dignity and respected their right to privacy regarding personal health information.
Failure to Provide Required Medicare Non-Coverage Notices to Beneficiaries
Penalty
Summary
The facility failed to provide required Medicare beneficiary notices to two residents whose skilled services were ending, resulting in a deficiency related to lack of Notice of Medicare Non-Coverage (NOMNC) Form CMS-10123. For one resident, skilled services ended on 11/20/25, and for the other resident, skilled services ended on 01/13/26; in both cases, the facility lacked documentation that the resident or their representative received Form 10123, which should have included a detailed explanation of non-coverage and the appeal process. During an interview on 01/23/26 at 1:40 PM, an administrative staff member confirmed that Form 10123 was not provided to these two residents and acknowledged that it should have been given to the resident or representative. Additionally, when requested on 01/23/26, the facility was unable to provide a policy for Beneficiary Notices.
Failure to Ensure Appropriate Indications and 14-Day Limits for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate indications and documentation for psychotropic medication use, including antipsychotic and PRN antianxiety drugs. One resident with diagnoses of dementia, depression, Parkinson’s disease, and encephalopathy was admitted post-hospitalization and had severely impaired cognition, requiring staff assistance with most ADLs. This resident received Seroquel 25 mg twice daily for a diagnosis of dementia with agitation. The care plan documented monitoring for side effects and effectiveness, but the electronic medical record lacked a documented physician rationale for the continued use of Seroquel, including documentation of unsuccessful attempts at nonpharmacological symptom management and a risk-versus-benefit analysis. An administrative nurse confirmed that the resident was receiving an antipsychotic with a diagnosis of dementia, which was identified as an inappropriate indication under facility policy, and that the physician and consultant pharmacist had recognized the need for a different diagnosis. The facility’s own Antipsychotic Medication Administration policy required that antipsychotics only be used when necessary to treat a specific, documented condition and that orders include a diagnosis, condition, or indication for use from a defined list of acceptable conditions. The policy also required comprehensive assessment, routine dose reduction, and behavioral interventions unless clinically contraindicated. Despite these requirements, the documentation for the resident on Seroquel did not include the necessary physician rationale or evidence of nonpharmacological interventions attempted prior to or alongside antipsychotic use, as required by the policy. The deficiency also includes failures related to PRN antianxiety medications for two other residents with dementia, depression, and anxiety diagnoses and severely impaired cognition. One resident had a physician’s order for alprazolam 0.5 mg by mouth every eight hours PRN for anxiety, and another had an order for lorazepam 0.5 mg by mouth every four hours PRN for anxiety. Both orders lacked a 14-day stop date or any specified duration. Their electronic medical records did not contain evidence of a physician’s rationale for extended PRN use, including a risk-benefit rationale statement and duration, as required by the facility’s Psychotropic Medication Use policy. Nursing staff acknowledged that PRN psychotropic orders were supposed to have a 14-day stop date and that the physician should reassess the residents to determine ongoing need, but this had not been implemented in these cases.
Failure to Complete Discharge Recapitulation for Resident Stay
Penalty
Summary
The deficiency involves the facility’s failure to complete a recapitulation of a resident’s stay and course of treatment upon discharge. The resident had diagnoses of dementia, acute blood loss anemia, and a lower gastrointestinal bleed, and an admission 5-Day Medicare MDS documented a BIMS score of nine, indicating moderately impaired cognition. The resident required partial staff assistance with toileting hygiene, showers, dressing, personal hygiene, and transfers. The care plan documented that the resident was to be discharged from the facility and directed staff to encourage verbalization of fears and concerns, clarify misconceptions, and provide the resident and family with opportunities to attend care plan conferences, participate in discharge planning, and consider alternative care options. Nurse’s notes documented that the resident was admitted with a lower gastrointestinal bleed and anemia and later discharged home with her husband. However, the clinical record lacked a completed recapitulation summarizing the resident’s stay and course of treatment in the facility. On interview, the Administrative Nurse confirmed that a recapitulation upon discharge was not completed for this resident. The facility’s Discharge Planning policy stated that discharge planning is part of the comprehensive care plan and that all discharge planning activities are to be documented in the resident’s clinical record, but the required recapitulation was not present in this case.
Failure to Implement Diabetes Management Parameters and Individualized Fall Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate care planning and clinical parameters for a resident with diabetes mellitus. One resident with a documented diagnosis of diabetes had an admission MDS showing intact cognition and dependence on staff for toileting hygiene, mobility, and transfers, and received daily insulin. The resident’s care plan directed staff only to provide a nighttime protein snack to keep blood sugars even and did not include any further direction related to diabetes management. A physician order required blood sugars to be obtained before meals and at bedtime for diabetes, but the medical record did not contain any blood sugar parameters. A licensed nurse confirmed there were no parameters and stated he would use his own nursing judgment to decide when to notify the physician, and a CMA reported not knowing what the parameters should be, noting that parameters had existed in a prior computer system but were absent in the new one. An administrative nurse stated the resident should have physician-ordered blood sugar parameters and that the care plan should direct staff on what to monitor for regarding the resident’s diabetes. The deficiency also includes failure to implement individualized fall interventions for another resident with dementia, anxiety, repeated falls, and severely impaired cognition. This resident was dependent on staff for ambulation, toileting hygiene, and lower-body dressing, and required substantial assistance for mobility and supervision with transfers. The admission MDS documented that the resident was at risk for falls, had no functional impairment, and had experienced two or more falls since admission. The care plan instructed staff to determine and address causative factors of falls, provide exercise and strength-building activities, obtain a PT consult for strength and mobility, and request a pharmacist medication review, but did not include specific, individualized fall interventions beyond these general directions. Multiple fall assessments and investigations documented that the resident was at high risk for falls and had several episodes of being found on the floor after scooting herself in her room, often near the room door, with falls described as unwitnessed and without injury. Immediate interventions documented in the fall investigations included obtaining a fall mat and placing signs in the room to remind the resident to call for help before attempting to transfer. Observations showed the resident in a low bed with a fall mat, able to stand with a gait belt and ambulate steadily with a walker, and staff reported she had numerous falls in her room, wore a Wander Guard that alarmed frequently, and was often placed in a recliner in the dayroom so staff could watch her. An administrative nurse stated that the resident had many falls in her room and that staff should have put interventions in place for those falls, and further confirmed that all the incidents where she scooted on the floor in her room were considered falls. The facility’s Resident Care Plan policy required evaluation by the interdisciplinary team, initiation of a care plan within 48 hours of admission, and review and revision of the care plan when resident needs changed, but the documented care plans did not reflect individualized interventions for the resident’s repeated falls.
Failure to Follow Fall-Prevention Care Plans and Safe Transfer Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and follow fall-prevention care plans for two residents at high risk for falls. One resident (R9) had dementia without behavioral disturbance and Parkinson’s disease, with documented high fall risk and multiple prior falls. His care plan included multiple fall-prevention interventions, including a directive for the family to provide properly fitting shoes. Despite this, R9 continued to use shoes that were too big, and during an assisted walk with a gait belt and walker he tripped over his feet and fell, sustaining a laceration to the left eyebrow, a hematoma, and a skin tear to the left elbow, requiring emergency room evaluation and wound closure. The fall investigation specifically identified that his shoes were too big, and an administrative nurse acknowledged that the oversized shoes contributed to the fall and that staff should have followed the fall care plan intervention. R9’s records also showed repeated falls in his room and from his recliner prior to the injury fall. On multiple occasions, staff heard a crash from his room and found him on the floor next to his recliner or air conditioner/heater unit after he attempted to get up or prepare his bed. Although his care plan directed staff to place the call light and personal items within reach, educate him to use the call light for assistance, offer a urinal every two hours, and encourage use of the dayroom for supervision when restless, he continued to experience falls in his room. One nurse’s note documented a fall from his recliner with staff then moving him to the dayroom for visualization, but the electronic medical record lacked a corresponding fall investigation for that event, despite facility policy requiring completion of a Fall Report and further investigation after any fall. The second resident (R43) had dementia with severely impaired cognition, macular degeneration, repeated falls, and weakness, and was assessed as high risk for falls. Her care plan included use of a fall mat, staff education on proper sling placement, and a requirement for two staff with a sit-to-stand lift for transfers. She experienced two separate falls during sit-to-stand lift transfers to or from the toilet. In the first incident, her knees gave out and she slid out of the sling onto the bathroom floor. In the second incident, she let go of the lift, slid through the belt on the sling, and fell onto her bottom. In both cases, the fall investigations identified issues with the use of the sit-to-stand lift and sling, including that the sling was not put on correctly and that only one staff member was present during one of the falls, contrary to the care plan directive for two-person assistance. Staff interviewed later were unaware of these prior sit-to-stand falls and described her as a one-to-two-person transfer who could use the sit-to-stand lift if needed, indicating that the care plan directions and fall history were not consistently followed in practice. Facility policies on Falls-Accident Reporting and the Resident Fall Checklist required that after any fall, licensed staff complete a Fall Report, perform a head-to-toe assessment before assisting the resident off the floor, notify the physician and responsible party, determine appropriate interventions to prevent further falls, update the care plan, obtain witness statements for falls with injury or possible injury, and document progress notes every shift for three days. The documented events for R9 and R43 show that falls occurred in the context of high fall risk, existing fall-prevention care plans, and specific policy requirements, yet the facility did not consistently implement the care-planned interventions (such as ensuring properly fitting shoes and two-person sit-to-stand transfers) or fully document and investigate all falls as required by its own policies.
Lack of Physician-Ordered Blood Glucose Parameters for Insulin-Dependent Diabetic Resident
Penalty
Summary
Surveyors identified a deficiency related to unnecessary drugs and inadequate blood glucose management for one resident with diabetes mellitus. The resident had a diagnosis of diabetes, was cognitively intact with a BIMS score of 13, and was dependent on staff for toileting hygiene, mobility, and transfers. The MDS documented that the resident received insulin daily, and the care plan directed staff to provide a nighttime protein snack to keep blood sugars even, but the care plan did not include specific directions related to diabetes management. A physician order directed staff to obtain blood sugars before meals and at bedtime, yet the medical record lacked any physician-ordered blood sugar parameters. During interviews, a licensed nurse confirmed that there were no blood sugar parameters for the resident and stated he relied on his own nursing judgment to decide when to notify the physician if blood sugars seemed too high. A CMA reported that she did not know what the resident’s blood sugar parameters should be and stated that parameters had existed in a previous computer system but were absent in the new system. An administrative nurse acknowledged that the resident should have physician-ordered blood sugar parameters and that the care plan should provide direction to staff regarding the resident’s diabetes. When requested, the facility was unable to provide a policy for blood sugar management.
Failure to Coordinate Facility and Hospice Care in Resident Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure coordinated care and services between the facility and hospice for a resident receiving hospice services. The resident had diagnoses including dementia, metabolic encephalopathy, DM, atrial fibrillation, and chronic pain, and a Significant Change MDS showed a BIMS score of eleven, indicating moderately impaired cognition. The MDS documented that the resident required extensive staff assistance with toilet hygiene and supervision with oral hygiene, personal hygiene, and other ADLs, and that the resident was receiving hospice services. The ADL care plan noted a decline in the resident’s ability to care for herself after a fall in assisted living, with increased confusion, several falls, and increased need for staff assistance with most ADLs. Despite the resident’s admission to hospice on 11/14/25 with a diagnosis of senile degeneration of the brain, review of the clinical record showed that the facility’s care plan did not contain any information indicating that the resident was on hospice services. On observation, the resident was seen dressed in street clothes and eating breakfast at the dining room table. During an interview, an administrative nurse confirmed that the facility care plan lacked any indication that the resident was receiving hospice services and verified that the resident had been on hospice since 11/14/25. The facility’s End of Life policy stated that end-of-life care, including hospice, should be provided through an interdisciplinary approach with a care plan developed by the team to address actual and potential problems, but this coordination with hospice was not reflected in the resident’s care plan.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to provide the services of a full-time certified dietary manager for 33 residents who received their meals from the kitchen. During observation of lunch meal preparation, a dietary staff member confirmed she was not a certified dietary manager, reported she was still taking the course and had not yet taken the certification test, and was functioning in the kitchen despite this. She also identified that two residents were on a pureed diet and three residents were on a minced and moist diet. Later, administrative staff confirmed that this dietary staff member was not certified. The facility’s Personnel policy stated that the food and nutrition services department would be staffed with sufficient competent personnel to carry out departmental functions, but the facility did not have a certified dietary manager in place. No additional resident-specific medical histories or conditions beyond the need for pureed and minced and moist diets were documented in the report.
Failure to Report Alleged Rough Care as Potential Abuse
Penalty
Summary
The facility failed to ensure that staff identified and reported an allegation of rough care as potential abuse immediately to the Licensed Nursing Home Administrator (LNHA) and the State Agency (SA) as required. This deficiency was identified during a survey involving a resident with severe cognitive impairment, dementia, hypertension, and other medical conditions. The resident was dependent on staff for various aspects of personal care and had a history of verbal behaviors and care refusal. On a specific date, a Certified Nurse Aide (CNA) witnessed a Certified Medication Aide (CMA) handling the resident roughly during a transfer, which resulted in the resident yelling out. The CNA reported the incident to a Licensed Nurse (LN), who then informed Administrative Nurse D via email. However, the incident was not reported to the LNHA or the SA immediately, as required by the facility's policy on abuse, neglect, and exploitation prevention. The failure to report the incident promptly placed the resident at risk for ongoing abuse and mistreatment. Despite the CNA's report and the subsequent examination of the resident, which found no new bruising, the facility did not take the necessary steps to ensure the allegation was addressed according to regulatory requirements. This oversight highlights a significant lapse in the facility's abuse reporting protocol.
Failure to Investigate and Protect Resident from Alleged Abuse
Penalty
Summary
The facility failed to initiate protective measures and fully investigate an allegation of abuse involving a resident with severe cognitive impairment and multiple medical conditions, including dementia and major depressive disorder. The resident was dependent on staff for various aspects of care and had a history of verbal behaviors and care refusal. On a specific date, a Certified Nurse Aide (CNA) reported witnessing a Certified Medication Aide (CMA) potentially handling the resident roughly during a transfer, which was followed by the resident yelling out in distress. Despite the report of potential abuse, the facility did not immediately suspend the involved staff member or conduct a thorough investigation. The incident was initially reported to a Licensed Nurse (LN), who noted typical bruising on the resident's arms but did not find any new bruising. The LN communicated the concern to an Administrative Nurse, but the information was not promptly relayed to the appropriate administrative staff for further action. This delay in communication and action resulted in the staff member continuing to work with residents until a later date when the issue was escalated. The facility's policy required immediate reporting and suspension of staff involved in alleged abuse, but these procedures were not followed. The failure to adhere to the policy and promptly address the allegation placed the resident at risk for continued abuse. The lack of immediate protective measures and a comprehensive investigation highlights a significant deficiency in the facility's handling of abuse allegations.
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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