The Healthcare Resort Of Kansas City
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Kansas.
- Location
- 8900 Parallel Parkway, Kansas City, Kansas 66112
- CMS Provider Number
- 175548
- Inspections on file
- 23
- Latest survey
- August 6, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at The Healthcare Resort Of Kansas City during CMS and state inspections, most recent first.
A resident receiving enteral nutrition experienced an 11.74% weight loss due to the facility's failure to consistently monitor her weight and adjust her nutritional regimen. Despite being at risk, the resident's nutritional needs were not adequately assessed or addressed, and there was a lack of communication and documentation among staff regarding her condition.
The facility failed to ensure agency direct care staff received required communication training, risking impaired care and decreased quality of life for residents. A review revealed that three CNAs lacked evidence of completed communication training. Administrative Staff A assumed the staffing agency ensured completion of required in-services, which was not the case. The curriculum covered various topics but omitted communication, resident rights, and dementia training.
The facility failed to ensure agency CNAs received required resident rights training, as revealed by a review of training records. Administrative Staff A assumed the staffing agency handled this training, but it was not completed, risking impaired care and decreased quality of life for residents.
The facility did not ensure agency CNAs received required dementia training, risking resident care quality. Training records for three CNAs lacked evidence of completed in-service training. Administrative Staff A assumed the staffing agency handled this, leading to missing training in communication, resident rights, and dementia care.
The facility failed to maintain a safe environment by leaving cleaning chemicals accessible, an unsecured CO2 canister, and an unlocked oxygen storage room. Additionally, fall prevention interventions were not followed for two residents, leading to a fall incident. An unsecured oxygen canister was also left in a resident's room, posing a risk for injury.
The facility failed to secure medication and treatment carts, leaving medicated lotions and medications like Cefdinir and Junuvia unsecured. An LN confirmed that carts should be locked when unsupervised, and the facility's policy required safe storage of medications. This deficiency placed residents at risk for medication errors.
The facility failed to follow infection control standards, risking resident safety. Observations showed improper handling of soiled laundry and PPE, with items left on floors and carts. CMAs and CNAs neglected hand hygiene during medication administration and personal care. Staff interviews confirmed these practices violated the facility's infection control policy, which requires routine training.
A resident with a complex medical history, including hemiparesis and cognitive impairment, was not provided with foot pedals for her wheelchair, leaving her vulnerable to injury. Staff interviews confirmed that pedals should have been used when the resident was being pushed by staff, as per the facility's policy on accommodating individual needs.
A resident with a history of hemiplegia and intact cognition threw hot coffee on another resident during a seating disagreement in the dining room. The incident was reported, but no immediate further action was taken to prevent future harm. The facility's policy on abuse prevention was not adequately followed, resulting in a deficiency in protecting residents from abuse.
A resident with intact cognition and mobility impairments threw hot coffee on another resident during a disagreement over seating in the dining room. The facility failed to fully investigate the incident or implement interventions to prevent further occurrences, despite having policies on abuse prevention. This inaction placed residents at risk of harm.
A resident with a UTI and other conditions experienced a delay in care due to the facility's failure to obtain STAT labs as ordered and notify the physician of the delay. Despite multiple attempts to contact the lab, the labs were not collected promptly, and the resident's condition was not adequately monitored or documented. Staff interviews revealed a lack of communication and follow-up, contributing to the delay in treatment.
A resident with multiple medical conditions, including hemiparesis, did not have her leg/ankle brace applied as ordered when out of bed, risking worsening contractures. Despite a physician's order and no documented refusals, staff failed to apply the brace, with a CNA admitting lack of knowledge on how to do so. Interviews confirmed the brace should have been applied, highlighting a deficiency in following care protocols.
A resident with a history of UTIs did not receive proper perineal care due to inadequate hand hygiene by a CNA. The CNA failed to wash hands between glove changes while assisting the resident, contrary to facility procedures. Staff interviews revealed a lack of ongoing hand hygiene training, contributing to the deficiency.
A facility failed to consistently communicate a resident's medical condition before and after hemodialysis, risking adverse outcomes. The resident, with multiple health issues including end-stage renal disease, was not properly assessed on several occasions. Despite a care plan requiring daily checks and communication with the dialysis center, the facility's process was inadequate, leading to incomplete documentation.
A resident with cognitive impairment and aggressive behaviors was not provided with adequate non-pharmacological interventions, as documented in the facility's records. Despite having a care plan and staff training, the facility failed to document or implement strategies to manage the resident's refusal of care and aggression, and did not notify the medical provider of these behaviors.
A resident with dementia exhibited behaviors such as throwing food and pouring hot food on herself, resulting in a burn injury. Despite having a care plan noting her behavioral history, the facility failed to identify a pattern of these behaviors and implement effective interventions. Staff interviews indicated awareness of the behaviors, but the facility lacked a specific dementia care policy, leading to inadequate supervision and intervention during mealtimes.
A facility failed to monitor a resident's blood pressure and pulse as ordered by a physician before administering metoprolol succinate, an antihypertensive medication. The resident, with a history of congestive heart failure and other conditions, was at risk of unnecessary medication administration due to the lack of monitoring. Interviews with staff confirmed that monitoring should have occurred, but the facility's policy was not followed, as shown by missing records in April, May, and June 2024.
The facility did not post daily nurse staffing data with the required information and failed to retain these records as required. Observations showed outdated postings and missing census numbers. Staffing sheets from earlier months were incomplete, and recent sheets lacked census data. Responsibility for posting was divided among staff, but no specific policy was in place, leading to unawareness of the omissions.
A resident with diabetes and amputations did not receive timely and appropriate wound care, leading to a severe infection and the surgical removal of a toe. The facility failed to monitor and treat the wound promptly, resulting in the resident's condition worsening.
Failure to Monitor and Adjust Enteral Nutrition Leads to Significant Weight Loss
Penalty
Summary
The facility failed to consistently monitor the weight of a resident, identified as R27, who was receiving enteral nutrition through a PEG tube due to severe cognitive impairment and medical conditions such as aphasia, dysphagia, and hemiplegia. Upon admission, R27 weighed 155 pounds and was dependent on staff for all activities of daily living. Despite being at risk for complications related to her PEG tube, the facility did not trigger a Nutrition Care Area Assessment upon her admission, and her care plan did not adequately address her nutritional needs. R27 experienced a significant, unplanned weight loss of 11.74% over 37 days, dropping to 136.8 pounds. The facility's records showed a lack of consistent weight monitoring and documentation, with no follow-up from the medical provider or registered dietician despite the resident's continued weight loss. The facility's policy required weekly weigh-ins for at-risk residents, but this was not adhered to, and the resident's nutritional regimen was not adjusted in response to the weight loss. Interviews with staff revealed that there was a breakdown in communication and documentation regarding R27's nutritional status and weight loss. The registered dietician was on maternity leave, and a temporary dietician was not adequately informed of the resident's condition. The facility's failure to monitor and adjust R27's enteral nutrition regimen in a timely manner led to the significant weight loss, highlighting deficiencies in the facility's nutritional management practices.
Lack of Communication Training for Agency Staff
Penalty
Summary
The facility failed to ensure that agency direct care staff received the required communication training, which placed residents at risk for impaired care and decreased quality of life. During a review of the training records for agency CNAs, it was found that the credentialing files for three CNAs lacked evidence of completed communication training. Administrative Staff A acknowledged that during orientation, the curriculum covered various topics such as timekeeping, meal breaks, smoking policy, cell phone and social media use, dress code, dietary services, fall prevention, infection control, abuse, customer service, and information related to protected health information and electronic medical records. However, it was assumed that the staffing agency ensured the completion of required in-services for nurse aides, which was not the case. Administrative Staff A stated that communication, resident rights, and dementia training would be added to the curriculum for agency staff.
Deficiency in Resident Rights Training for Agency Staff
Penalty
Summary
The facility, with a census of 66 residents, failed to ensure that agency direct care staff received the required training on resident rights. This deficiency was identified through a review of the training records for agency CNAs P, Q, and LL, which revealed a lack of evidence that these staff members completed the necessary resident rights training. During an interview, Administrative Staff A acknowledged that the orientation for agency employees covered various topics, including timekeeping, meal breaks, smoking policy, cell phone and social media use, dress code, dietary services, fall prevention, infection control, abuse, customer service, and information related to protected health information and electronic medical records. However, it was assumed that the staffing agency ensured the completion of required in-services for nurse aides, which was not the case. This oversight placed residents at risk for impaired care and decreased quality of life.
Deficiency in Dementia Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that agency direct care staff received the required dementia training for nurse aides, which placed residents at risk for impaired care and decreased quality of life. During a review of the training records for agency CNAs, it was found that the credentialing files for three CNAs lacked evidence of completed in-service training. Administrative Staff A acknowledged that the orientation for agency employees covered various topics, but assumed that the staffing agency ensured the completion of required in-services for nurse aides. This oversight resulted in the absence of necessary training in communication, resident rights, and dementia care for agency staff.
Failure to Maintain a Safe Environment and Follow Fall Prevention Interventions
Penalty
Summary
The facility failed to maintain a safe environment free from potential hazards for its residents, particularly those who are cognitively impaired and independently mobile. During an inspection, it was observed that cleaning chemicals and Microkill wipes were left accessible in the main lobby's kitchenette, posing a risk to residents. Additionally, a pressurized carbon dioxide canister was found unsecured under a sink, and an oxygen storage room was left unlocked with several pressurized canisters inside. Furthermore, a large leak in the west dining hall was covered with soiled wet towels without a 'Wet Floor' sign, creating a slip hazard. The facility also failed to follow fall prevention interventions for two residents, R29 and R58. R29, who has moderate cognitive impairment and is at risk for falls, was found with a low air-loss mattress that was supposed to be discontinued due to safety concerns. Despite the care plan indicating the removal of this mattress, it remained in place, and staff were unable to verify if it was supposed to be there. Similarly, R58, who requires two-person assistance for transfers due to weakness, experienced a fall during a shower transfer when only one staff member was assisting him. This incident highlights the failure to adhere to the care plan interventions designed to prevent falls. Additionally, the facility did not ensure R6's room was free from physical hazards. R6, who is legally blind and has multiple medical conditions, had an unsecured oxygen canister left in his room. The canister was not in a holder or secured, contrary to the facility's policy on oxygen handling and storage. This oversight placed R6 at risk for injuries, as unsecured oxygen tanks can pose significant hazards. The facility's failure to secure the oxygen canister and adhere to its own policies contributed to the unsafe environment.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to secure its medication and treatment carts, which placed residents at risk for unnecessary medication and administration errors. During an inspection on the East Hall nursing station, an unlocked skin treatment cart was found containing assorted medicated lotions with warnings to avoid ingestion and contact poison control. Additionally, at the [NAME] Hall station, an unsecured medication cart was observed with pill packs of Cefdinir and Junuvia left on top of the cart. These medications were not secured, and the cart stored both stock and prescription medications for residents in the [NAME] Hall. Licensed Nurse J verified the unsecured medications and carts, acknowledging that they should be locked when unsupervised and that medication should never be left unattended. Administrative Nurse D confirmed that the facility's policy required medication carts to be locked when not in use or supervised. The facility's Medication Access and Storage policy indicated that all medications and biologicals should be stored safely, following the manufacturer's storage recommendations, and properly labeled with expiration dates. The failure to adhere to these protocols resulted in the deficiency noted in the report.
Infection Control Deficiencies in Handling Laundry and Hand Hygiene
Penalty
Summary
The facility failed to adhere to sanitary infection control standards, which placed residents at risk for infectious diseases. Observations revealed multiple instances of improper handling of soiled laundry, such as soiled towels and bed linens being placed on the floor in various locations, including a kitchenette and resident rooms. Additionally, used personal protective equipment (PPE) was found discarded improperly, such as a soiled glove and broken facemask left on an Enhanced Barrier Precautions (EBP) cart, and used PPE on the floor of a resident's room. These actions indicate a lack of compliance with infection control protocols regarding the proper disposal of contaminated materials. Further deficiencies were noted in the administration of medications and hand hygiene practices. Certified Medication Aides (CMAs) failed to perform hand hygiene during medication preparation and administration, increasing the risk of contamination. A Certified Nurse's Aide (CNA) was observed not performing hand hygiene between glove changes and after providing personal care to a resident, despite acknowledging the importance of hand hygiene. Interviews with staff, including a Licensed Nurse and an Administrative Nurse, confirmed that hand hygiene should be performed frequently and that soiled laundry should not be placed on the floor. The facility's Infection Control and Surveillance policy, revised in October 2023, mandates routine infection control training, yet staff reported a lack of recent education on hand hygiene practices.
Failure to Provide Wheelchair Pedals for Resident
Penalty
Summary
The facility failed to provide a resident, identified as R39, with foot pedals for her wheelchair, which left her vulnerable to possible injury. R39 has a complex medical history, including dysarthria, a pacemaker, transient ischemic attack, diabetes mellitus, hemiparesis/hemiplegia, difficulty in walking, cerebral infarction, depression, and cerebrovascular accident. Her cognitive function is moderately impaired, as indicated by a BIMS score of eight, and she is dependent on staff for certain activities, such as putting on and taking off footwear. The care plan for R39 notes a contracture of her right upper and lower extremity, which further complicates her mobility. On a specific morning, R39 was observed rolling herself to breakfast using her left hand, without wearing her foot/ankle brace, and her right foot hit the floor twice while being propelled by a CNA. Interviews with staff, including a CNA, a Licensed Nurse, and an Administrative Nurse, confirmed that wheelchair pedals should have been provided to prevent injury when staff were pushing R39. The facility's policy on accommodating needs states that residents have the right to receive services with reasonable accommodation of individual needs, which was not adhered to in this instance.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect residents from abuse when a resident, identified as R31, threw hot coffee on another resident, R40. R31, who has a history of hemiplegia, diabetes, hypertension, and peripheral vascular disease, was documented to have intact cognition and was independent in his functional abilities, using a motorized wheelchair for mobility. The incident occurred in the dining room when R31 became upset over a seating disagreement with R40, leading to R31 throwing coffee on R40's abdomen and thighs. R40 was assessed by a licensed nurse, who noted wet clothing but no immediate injury, although tiny raised areas were observed on R40's thigh the following day. The facility's investigation revealed that R31 had a history of becoming upset if he felt his prayer group time was impeded upon, and staff were instructed to approach him calmly and redirect him if necessary. However, during the incident, R31 expressed that the coffee spill was accidental, although he later made a comment suggesting intentionality. The facility's policy on abuse prevention emphasizes the right of residents to be free from abuse and the importance of staff intervention to protect residents' rights and safety. Despite this, no immediate further action was taken with R31 following the incident, as it was believed he posed no further threat. Interviews with staff indicated that the incident was reported immediately, but there was a lack of immediate intervention to prevent further harm. The facility's policy requires oversight and monitoring to prevent abuse, yet the actions taken were insufficient to ensure the safety and well-being of all residents. The failure to implement appropriate interventions and monitor residents with behaviors that might lead to conflict resulted in a deficiency in protecting residents from abuse.
Failure to Investigate and Prevent Resident-to-Resident Altercation
Penalty
Summary
The facility failed to fully investigate and implement interventions following a resident-to-resident altercation, where one resident threw hot coffee on another. The incident involved a resident with intact cognition and a history of hemiplegia, diabetes, hypertension, and peripheral vascular disease, who used a motorized wheelchair for mobility. This resident became upset when another resident did not move from a preferred spot in the dining room, leading to the altercation. Despite the incident, the facility did not take further action to address the behavior of the resident who threw the coffee. The facility's investigation report documented that the incident was reported to administrative staff, and the affected resident was assessed for injuries, which were minimal. However, the facility did not implement any interventions to prevent further incidents or address the behavior of the resident who initiated the altercation. The staff involved did not witness the incident directly but were informed by other staff members. The resident who threw the coffee claimed it was an accident, and no further actions were taken by the facility to ensure the safety of other residents. The facility's policy on abuse prevention emphasizes the right of residents to be free from abuse and the importance of taking action to prevent such incidents. Despite this policy, the facility did not take adequate steps to investigate the incident thoroughly or implement measures to prevent future occurrences. This lack of action placed residents at risk of harm and did not align with the facility's stated policies on abuse prevention and resident safety.
Failure to Obtain STAT Labs and Notify Physician
Penalty
Summary
The facility failed to ensure that staff obtained physician-ordered labs for a resident, identified as R45, and did not notify the physician of the delay in obtaining these labs. R45 had diagnoses of hypertension, a urinary tract infection, and a compression fracture of the lumbar vertebra. The resident required partial assistance for functional abilities and was dependent on staff for toileting and bathing. On a specific date, R45 presented with an altered mental status and heavy sweating, prompting an order for immediate labs, including urinalysis, a complete metabolic panel, and a complete blood count with differential. However, the labs were not obtained in a timely manner, and there was no documentation of further monitoring of R45's condition from the time the labs were ordered until they were eventually reviewed. The nursing notes indicated that staff attempted to contact the lab company multiple times to request a STAT lab draw, but the labs were not collected until several days later. During this period, R45's condition was not adequately monitored or documented, and the physician was not informed of the delay in obtaining the lab results. When the lab results were finally reviewed, they showed abnormal findings, and an order for an antibiotic was placed. However, there was a lack of documentation regarding the resident's condition and any signs or symptoms from the time the labs were ordered until the results were reviewed. Interviews with facility staff revealed a lack of communication and follow-up regarding the delay in obtaining the STAT labs. A licensed nurse acknowledged that the resident had not been followed up on appropriately, and the administrative nurse admitted to being unaware of the delay and the lack of physician notification. The facility did not provide a policy regarding quality of care, and the failure to obtain the STAT labs as ordered resulted in a delay in care and treatment for R45's urinary tract infection.
Failure to Apply Leg Brace for Resident with Contractures
Penalty
Summary
The facility failed to ensure that a resident's leg/ankle brace was applied when she was out of bed, which was necessary to prevent the worsening of her contractures. The resident, identified as having multiple medical conditions including hemiparesis and a history of cerebrovascular accident, was dependent on staff for assistance with activities of daily living, including the application of her leg brace. Despite a physician's order for the brace to be applied every shift when the resident was out of bed, observations revealed that the brace was not applied, and the resident reported that the CNA did not know how to put it on. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that the brace should have been applied and that there were no documented refusals from the resident regarding the application of the brace. The facility's policy on contracture documentation emphasized the importance of providing appropriate treatment to prevent a decrease in range of motion. However, the failure to apply the brace as ordered placed the resident at risk for worsening contractures and decreased mobility.
Deficient Perineal Care and Hand Hygiene Practices
Penalty
Summary
The facility failed to provide the standard of care for a resident with a history of urinary tract infections (UTIs). The resident, who had multiple medical conditions including moderately impaired cognition, was dependent on staff for all toileting hygiene. During an observation, a Certified Nurse's Aide (CNA) did not perform proper hand hygiene while assisting the resident with toileting. The CNA did not wash hands between changing gloves after cleaning the resident's back and front peri areas, which is against the facility's procedure for perineal care. This lack of proper hand hygiene placed the resident at risk for further UTIs. Interviews with staff revealed that the CNA acknowledged the mistake and admitted that the facility had not provided hand hygiene education since her hiring. A Licensed Nurse confirmed that the CNA should have washed her hands when transitioning from cleaning the back to the front peri area. An Administrative Nurse also stated that staff had not received follow-up in-service training on hand hygiene, only initial check-offs at hiring. The facility's failure to ensure proper hand hygiene during perineal care was a deficiency that increased the resident's vulnerability to UTIs.
Failure to Communicate Dialysis Condition
Penalty
Summary
The facility failed to consistently communicate a resident's medical condition prior to and post-hemodialysis, which placed the resident at risk of potential adverse outcomes and physical complications related to dialysis. The resident, who had a history of diabetes mellitus, hypotension, end-stage renal disease requiring dialysis, peripheral vascular disease, hypertension, muscle weakness, repeated falls, cognitive communication deficit, difficulty in walking, unsteadiness on feet, and dysphagia, was not properly assessed before and after dialysis sessions on multiple dates. The resident's care plan required nursing staff to check the dialysis fistula daily, monitor for signs of infection, and obtain pre- and post-dialysis vitals, but these assessments were not consistently documented. The facility's process for handling dialysis communication sheets was inadequate, as evidenced by the lack of completed pre- and post-dialysis assessments in the resident's clinical record. Licensed Nurse G and Administrative Nurse D acknowledged issues with obtaining communication sheets from the dialysis center, which were supposed to be filled out and returned to the facility. Despite attempts to improve the process by sending sheets in a binder, the facility's policy to assist residents in maintaining homeostasis and ensuring ongoing communication with the dialysis center was not effectively implemented, leading to the deficiency.
Failure to Address Behavioral Health Needs
Penalty
Summary
The facility failed to adequately meet the behavioral health needs of Resident 46, who was diagnosed with metabolic encephalopathy, cognitive-communication disorder, and other conditions that contributed to her moderate cognitive impairment. The resident exhibited verbal and physically aggressive behaviors, which were documented in her Minimum Data Set (MDS) and Behavioral Symptoms Care Area Assessments (CAA). Despite these assessments indicating a need for interventions, the care plan lacked specific strategies to address her continued refusal or resistance to care. Throughout the report, multiple instances were noted where the resident displayed aggressive and verbally abusive behavior towards staff, including refusing medications and treatments. Progress notes in the Electronic Medical Records (EMR) repeatedly lacked documentation of non-pharmacological interventions being offered or attempted to calm the resident. Additionally, there was no evidence that the medical provider was notified of the resident's behaviors, which is a critical step in managing such situations. Interviews with staff, including a Certified Nurse Aide (CNA), a Licensed Nurse (LN), and an Administrative Nurse, revealed that while there were care-planned interventions and mandatory training for handling behaviors, these were not consistently documented or followed. The facility's Behavioral Health Services policy emphasized the need for non-pharmacological interventions, yet the failure to implement these effectively placed the resident at risk for continued behavioral episodes and unmet care needs.
Failure to Address Dementia-Related Behaviors in Resident
Penalty
Summary
The facility failed to identify a pattern of dementia-related behaviors for a resident, referred to as R29, and implement meaningful interventions to promote her quality of life. R29 had a medical diagnosis of dementia, cognitive communication deficit, insomnia, and dysphagia. Her Minimum Data Set (MDS) indicated moderate cognitive impairment and required substantial assistance with daily activities. Despite having a care plan that noted her history of behaviors such as verbal aggression and banging on things, the facility did not effectively address her behaviors during mealtimes, which included throwing food, spitting food down her shirt, and pouring hot food on herself, resulting in a burn injury. Interviews with staff revealed that while they were aware of R29's behaviors and the need for supervision during meals, the facility did not have a specific policy related to dementia care. The facility's Behavioral Health Services policy emphasized the need for non-pharmacological interventions, but there was no evidence of a consistent approach to managing R29's behaviors. The lack of a structured plan and failure to monitor and intervene appropriately during mealtimes placed R29 at risk for preventable injuries and hindered her ability to maintain her highest practicable level of functioning.
Failure to Monitor Antihypertensive Medication Parameters
Penalty
Summary
The facility failed to ensure that staff followed physician-ordered parameters for monitoring a resident's antihypertensive medication, specifically metoprolol succinate. The resident, who had a history of congestive heart failure, myocardial infarction, diabetes mellitus, and chronic kidney disease, was at risk of unnecessary medication administration due to the lack of proper monitoring. The resident's care plan did not include specific directions for antihypertensive medications, and the medication administration records for April, May, and June 2024 showed a lack of blood pressure and pulse monitoring prior to administering the medication. Interviews with licensed nurses and administrative staff revealed that blood pressure and pulse should have been monitored before administering the medication, and the medication should have been held if the parameters were not met. However, the facility's policy on medication administration was not followed, as evidenced by the absence of monitoring records. This oversight placed the resident at risk for unnecessary medication administration and potential adverse side effects.
Failure to Post and Retain Daily Nurse Staffing Data
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily with the required information and did not retain the posted daily staffing data as mandated. During an initial tour, it was observed that the staffing hours posted were outdated, and the facility census number was missing. Upon request, the facility could only provide staffing sheets from December 2023 onwards, with notable gaps in March and April 2024. Additionally, the sheets from May 2024 onwards lacked the daily facility census number. Interviews revealed that the responsibility for posting staffing hours was divided between front desk staff and the floor charge nurse on weekends. However, there was no specific policy in place for daily posted staffing hours, and the administrative staff was unaware of the omissions in the census number.
Failure to Provide Appropriate Wound Care for Resident with Diabetes and Amputations
Penalty
Summary
The facility failed to ensure that a resident with a history of diabetes mellitus (DM) and amputations received appropriate wound care and services to prevent complications from his medical conditions. The resident, who had severe cognitive impairment and required assistance with various activities, developed a wound on his left third toe that was not properly monitored or treated in a timely manner. Despite the resident's known risk factors, including DM and peripheral vascular disease (PVD), the facility did not follow its own policies for skin and wound monitoring and management. The resident's electronic medical record (EMR) documented that on 02/15/24, the resident's second toe on his left foot had moist, loose skin, which was cleaned and wrapped with gauze by a nurse. However, there was no evidence of follow-up monitoring, treatment orders, or physician notification until 02/21/24, when the resident was seen by a physician for a new open area on the third toe with a possible infection. The physician ordered antibiotics and wound care, but the delay in addressing the initial concern allowed the wound to worsen. By the time the resident was transferred to the hospital on 03/14/24, the wound had become severely infected, leading to the surgical removal of the third toe. Interviews with facility staff revealed inconsistencies in documentation and communication regarding the resident's wound care. The facility's failure to adhere to its policies and promptly address the resident's wound contributed to the deterioration of the resident's condition and the need for surgical intervention.
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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