The Healthcare Resort Of Leawood - Iron Horse Hlth
Inspection history, citations, penalties and survey trends for this long-term care facility in Leawood, Kansas.
- Location
- 5401 W 143rd Street, Leawood, Kansas 66224
- CMS Provider Number
- 175558
- Inspections on file
- 21
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 23 (1 serious)
Citation history
Health deficiencies cited at The Healthcare Resort Of Leawood - Iron Horse Hlth during CMS and state inspections, most recent first.
The facility failed to prevent two CNAs from bringing firearms into the building and engaging in gunfire on a resident unit, resulting in bullets traveling down a resident hallway and striking a doorframe and wall near occupied rooms. One CNA unlocked an exit door, returned toward the nurses’ station, drew a gun from his jacket, and fired multiple shots into the dining room at another CNA, who then returned fire down the hall where multiple residents resided. Staff reported hearing gunshots, seeing shell casings and smoke near the nurses’ station, and then calling 911 and checking on residents, while two residents in wheelchairs described being awakened and startled by the shots. Interviews indicated that one CNA had earlier felt uneasy about the other and retrieved a gun from his car without reporting his concern, and that an escalating argument with demeaning and vulgar comments preceded the shooting, despite an employee handbook that prohibited workplace violence and weapons on the premises.
A CNA did not have a required annual performance evaluation completed, as confirmed by record review and staff interview. Facility policy mandates yearly evaluations to identify employee strengths and training needs, but documentation for this CNA was missing.
Surveyors found that dietary staff did not wear hairnets, and multiple food items in the kitchen and walk-in refrigerator were not labeled or dated. The convection oven was dirty and had a bucket on the floor catching water from a broken pipe, and the facility could not provide a policy for foodborne illness or food storage.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report notes that safety standards were not met and supervision was lacking, but does not provide further specifics.
Surveyors found two unlocked treatment carts containing medical ointments and wound cleansers in separate units, as well as improperly labeled and expired tuberculin serum vials in a medication storage refrigerator. Nursing staff confirmed that carts should be locked when not in use, and facility policy required all medications and biologicals to be secured.
Surveyors found that clean linens were improperly stored on a PPE cart, soiled linens were left on the floor, and respiratory equipment such as a nebulizer mask and nasal cannula were not stored in a sanitary manner. Additionally, a nurse failed to use a barrier when placing an Accu-Check machine on various surfaces. Staff interviews confirmed these actions were not in line with the facility's infection control policies.
The facility did not obtain or document consent or declination for the PCV20 pneumococcal vaccine for two residents, and there was no evidence that the vaccine was offered or previously administered. An administrative nurse was unable to confirm which immunizations were offered, and the facility lacked a policy for immunizations.
A resident with muscle weakness, cognitive impairment, and a history of falls was found to have her call light placed out of reach while in bed, despite care plan instructions and facility policy requiring it to be accessible at all times. Staff interviews confirmed the expectation for call lights to be within reach, but observations showed this was not followed, resulting in a deficiency in accommodating the resident's needs.
A resident with multiple complex medical needs was discharged without a required summary of her stay or care provided. Despite the care plan and nursing notes indicating significant ADL assistance and ongoing skilled services, the medical record lacked a discharge summary, which staff confirmed was their responsibility to complete.
A resident with dementia, cognitive communication disorder, muscle weakness, and diabetes required varying levels of staff assistance for ADLs, as indicated by assessments. However, the care plan did not document the resident's current level of functioning or the specific assistance needed for tasks such as bathing, dressing, and mobility. Staff interviews confirmed that this information should be included in care plans, but it was missing in this case.
A resident with CHF and multiple comorbidities did not have daily and weekly weights obtained and documented as ordered by the physician. Staff interviews confirmed that the process for ensuring weights were taken and recorded was not followed, resulting in a lack of required documentation in the MAR, TAR, and EMR.
A resident with impaired mobility and incontinence, identified as at risk for pressure ulcers, did not have a physician-ordered pressure-reducing cushion in their wheelchair. Despite care plan documentation and staff acknowledgment of the need for such devices, repeated observations showed the cushion was not in place, and staff were unclear about their responsibilities regarding pressure-reducing devices.
A resident with multiple medical conditions and a physician order for nebulizer treatments was observed to have their nebulizer mask left on the bedside table instead of being stored in a clean, dated plastic bag as described by staff. The care plan lacked instructions for nebulizer use or mask storage, and the facility did not provide a policy for proper storage, resulting in unsanitary respiratory care practices.
A deficiency was identified when laboratory records in a resident's medical file were found to be incomplete and lacking required dates.
A resident receiving hospice care, with multiple chronic conditions and significant ADL needs, did not have a coordinated plan of care between the facility and hospice services. Staff relied on a separate hospice binder and verbal communication for updates, and key hospice information was not integrated into the facility's care plan, contrary to facility policy and staff expectations.
Failure to Prevent Armed Workplace Violence Between CNAs on Resident Unit
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision to prevent accidents, specifically by failing to prevent two CNAs from bringing firearms into the building and engaging in gunfire on a resident unit. On the night of the incident, one CNA (CNA M) walked down the Northeast (NE) corridor, unlocked an exit door, then returned toward the nurses’ station. He reached into his jacket, turned toward the dining room where another CNA (CNA N) was located, and fired multiple shots into the dining room. Video surveillance reviewed by administrative staff showed this sequence of events, including CNA M unlocking the NE corridor door, returning toward the nurses’ station, drawing a gun from his jacket, firing into the dining room, and then fleeing out the NE corridor door. In response to the gunfire from CNA M, CNA N returned an unknown number of rounds down the East Hall, where nine residents resided. A bullet grazed the wall near the room of one resident (R2), leaving a four- to six-inch graze mark, and a bullet, possibly the same one, struck the doorframe of another resident’s room (R1). Subsequent observation of the East Hall revealed a round indentation on the lower part of R1’s doorframe and a graze mark on the wall near R2’s room. In the dining room across from the East Hall, there were two bullet holes in the window and two to three bullet holes in the wall. Staff on duty reported hearing gunshots and screams, seeing smoke and shell casings near the nurses’ station, and then moving to call 911 and check on residents. Residents described being awakened and startled by the gunfire. R1, seated in a wheelchair in his room, reported initially thinking the sounds were pots and pans clanging, then realizing they were three to four shots, one of which hit his doorframe; he thought the shooter might be coming into his room for him. R2, also in a wheelchair in his room, stated that the gunshots startled him awake and that he was scared for a few seconds. Staff interviews revealed that earlier in the shift, CNA N felt uneasy about CNA M and went out to his car to retrieve his gun, which he then brought into the facility without reporting his concern to anyone. Another nurse (LN I) and a CNA (CNA O) described an escalating verbal argument between CNA M and CNA N in the dining area, including demeaning and vulgar comments, with CNA M pacing and attempting to leave while CNA N continued to pull him back into the conversation, before CNA M walked down the NE hall, returned, and began firing. The facility’s employee handbook, in effect at the time, prohibited acts or threats of violence and the possession of weapons of any kind on the property, but both CNAs nonetheless possessed guns inside the facility and engaged in gunfire on the East unit, placing residents in immediate jeopardy.
Removal Plan
- The facility began staff education on workplace violence, reporting protocols, security, anti-harassment and anti-retaliation protections, and technology and social media controls (education ongoing).
- The facility contracted with a security agency for a nighttime security guard.
- The facility notified the residents' representatives of the incident.
- The facility had a psychologist visit with residents possibly affected by the incident.
Annual Performance Evaluation Not Completed for CNA
Penalty
Summary
The facility failed to complete the required annual performance evaluation for one of five reviewed Certified Nurse Aides (CNA), specifically for a CNA hired on 10/11/23. During a review of performance evaluation and in-service training records, it was found that no yearly performance evaluation was available for this CNA when requested. An administrative nurse confirmed that the evaluation had not been completed, despite facility policy requiring annual performance reviews for all employees to identify strengths, goals, and training needs. This deficiency was identified through record review and staff interview.
Failure to Maintain Sanitary Food Storage and Preparation Practices
Penalty
Summary
Surveyors observed multiple failures to follow sanitary dietary standards in the facility's kitchen and kitchenettes. Dietary staff were seen working without hairnets, and several food items in the walk-in refrigerator, including hot dogs, hamburgers, cut-up watermelon, lettuce, and corn salad, were found covered but not labeled or dated. In the walk-in freezer, French-fried potatoes were stored in an unlabeled and undated canister. The top of the convection oven was dirty and cluttered with black gloves and dirty pan cover sheets, and a white plastic bucket was placed on the floor to catch dirty water from a broken pipe above the oven. The facility was unable to provide a policy for foodborne illness or food storage when requested.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents. Specific details regarding the actions or inactions of staff, or the condition of residents at the time, are not provided in the report.
Failure to Secure Treatment Carts and Properly Label Medication
Penalty
Summary
Surveyors observed that two treatment carts in separate units were left unlocked, one in the back nurses' station of the Hallbrook unit and another in the hallway of the Bridgewood unit. Both carts contained medical ointments and wound cleansers. Additionally, in the medication storage room on the Hallbrook unit, a refrigerator inspection revealed two vials of tuberculin serum, one of which was opened without any dates indicating when it was opened or when it should expire, and the other had been opened and was past its 30-day expiration date. Interviews with nursing staff confirmed that carts were expected to be locked when not in use and that staff were responsible for securing carts and patient information when stepping away. The facility's policy required all medications and biologicals to remain locked and secured to prevent tampering or exposure.
Infection Control Deficiencies in Linen and Equipment Handling
Penalty
Summary
Surveyors identified multiple infection control deficiencies during their review of the facility. Clean linens, including towels, washcloths, and a bed sheet, were observed placed on top of a personal protective equipment (PPE) cart in the hallway, rather than being stored in a sanitary manner. In one instance, soiled linen was found on the floor of a resident's room. Additionally, respiratory equipment such as a nebulizer mask and nasal oxygen tubing were not stored properly; the nebulizer mask was left on a bedside table and the nasal cannula was thrown on top of an oxygen canister at the bottom of a resident's bed, rather than being kept in a clean, dated plastic bag as required by facility policy. Further deficiencies were observed in the handling of blood glucose monitoring equipment. A licensed nurse was seen placing the Accu-Check machine directly onto various surfaces, including a medication cart, a shower room counter, and the arm of a Broda chair, without using a barrier as required. Staff interviews confirmed that these practices were inconsistent with facility infection control policies, which mandate the use of barriers for equipment and proper storage of linens and respiratory devices to prevent contamination.
Failure to Document and Offer Pneumococcal Vaccinations and Lack of Immunization Policy
Penalty
Summary
The facility failed to obtain consent or declination for the Pneumococcal Conjugate Vaccine (PCV20) for two residents, despite reviewing their immunization status as part of a sample of five residents. For one resident, the clinical record showed declinations for PCV13 and PPSV23, but lacked documentation that PCV20 was offered, declined, or previously administered. For another resident, records indicated administration of PPSV23 and PCV13, but again lacked documentation regarding PCV20 being offered, declined, or historically administered. Additionally, an administrative nurse was unable to confirm which immunizations were offered at the facility, and the facility did not provide a policy for immunizations.
Failure to Ensure Call Light Accessibility for Resident with High Fall Risk
Penalty
Summary
A deficiency occurred when staff failed to ensure a resident had access to her call light, which was required for her to communicate her needs. The resident had multiple medical diagnoses, including muscle weakness, overactive bladder, a need for assistance with personal care, a history of falling, and a cognitive communication disorder. Her care plan specifically instructed staff to keep the call light within reach at all times due to her high risk for falls and need for substantial to maximal assistance with activities of daily living. Despite these documented needs and instructions, observations showed that the resident's soft-touch call light was placed on a bedside table across the room, out of her reach, while she was in bed on multiple occasions. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that the expectation was for call lights to be within reach of residents at all times and checked each shift. The facility's Fall Management System policy also required appropriate equipment and interventions to ensure resident safety and prevent falls. The failure to follow these protocols and care plan instructions resulted in the resident being unable to communicate her needs, constituting a deficiency in reasonably accommodating her needs and preferences.
Failure to Document Resident Discharge Summary
Penalty
Summary
The facility failed to provide a final summary of a resident's status at discharge, as required. The resident in question had multiple diagnoses, including infection and inflammatory reaction due to a knee prosthesis, MRSA, pain, cognitive decline, major depressive disorder, and dysphagia. Documentation showed the resident required significant assistance with activities of daily living (ADLs) such as eating, oral hygiene, toileting, transfers, and bed mobility. The care plan indicated ongoing skilled services to help the resident regain strength and return home, with identified risks including further ADL decline, falls, incontinence, skin breakdown, and pain. On the day of discharge, the resident's husband arrived to take her home, and nursing staff notified the physician of the discharge. However, the medical record did not contain a summary of the resident's stay or a recompilation of her care, as required by facility policy. Interviews with nursing staff confirmed that it was the responsibility of the nurse in charge, or the DON if not completed, to document this summary, but it was not done in this case.
Failure to Document Resident's Required ADL Assistance in Care Plan
Penalty
Summary
The facility failed to identify and document the specific level of care assistance required for activities of daily living (ADLs) for a resident with multiple medical diagnoses, including dementia, cognitive communication disorder, muscle weakness, and diabetes mellitus. The resident's Minimum Data Set (MDS) indicated she needed partial to moderate assistance with lower body dressing, footwear, bathing, toileting, and oral hygiene, and supervision or touch assistance with upper body dressing, personal hygiene, bed mobility, and walking. The Functional Abilities Care Area Assessment (CAA) also indicated a need for staff assistance with ADLs and self-care. However, the care plan did not specify the resident's current level of functioning or the required level of assistance for bathing, transfers, dressing, oral hygiene, meals, and bed mobility. Observations showed the resident was able to walk with a walker and prepare for meals independently, and she reported no concerns about her care. Interviews with staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that care plans should include detailed information about each resident's level of functioning and assistance needs. The facility's policy required comprehensive assessments and individualized interventions, with care plans reviewed and updated as needed, but this was not reflected in the resident's care plan documentation.
Failure to Follow Physician's Orders for Weight Monitoring in CHF Patient
Penalty
Summary
The facility failed to follow a physician's order for daily and weekly weights for a resident diagnosed with congestive heart failure (CHF), among other conditions. The resident's electronic medical record (EMR) included orders for daily weights for three consecutive days and weekly weights thereafter, which were not documented as completed on the specified dates. The July Medication Administration Record (MAR), Treatment Administration Record (TAR), and Weights/Vital Signs tab lacked evidence of daily weights for three days and weekly weights for two separate weeks. Interviews with staff confirmed that the process for obtaining and documenting weights involved communication between CNAs and nurses, with the charge nurse responsible for ensuring orders were followed and weights were recorded in the EMR. The resident had a history of CHF, overactive bladder, pain, dementia, cellulitis, lack of coordination, communication deficit, need for assistance with personal care, a healing fracture, and Parkinson's disease. The care plan required nursing staff to administer medications as ordered and monitor for side effects, with specific mention of monitoring for adverse effects of medication every shift. Despite these directives, the required weights were not obtained or documented as ordered, resulting in a failure to provide care in accordance with the physician's orders and the facility's policy.
Failure to Provide Ordered Pressure-Reducing Device for At-Risk Resident
Penalty
Summary
A deficiency occurred when a resident, identified as being at risk for pressure ulcers due to impaired mobility and incontinence, did not have a physician-ordered pressure-reducing cushion in place on their wheelchair. The resident's medical record documented diagnoses including difficulty walking, dementia, lack of coordination, muscle weakness, and a need for assistance with personal care. The care plan and assessments indicated the resident was at risk for pressure-related injuries and required monitoring and assistance with turning and repositioning. Despite a physician order for a cushion to be used in the wheelchair, multiple observations over several days found the resident's wheelchair lacked the required cushion, and no cushion was present in the room. Interviews with staff revealed inconsistent understanding and implementation of responsibilities regarding pressure-reducing devices. Certified Nurse Aides and Licensed Nurses stated that ensuring pressure-reducing devices were in place was a shared responsibility, and that such devices should be listed on the resident's care plan or Kardex. However, there was uncertainty among staff about which residents required these devices, and the ordered cushion was not in use as required by the resident's care plan and physician order. The facility's policy required pressure-reducing devices for individuals restricted to a chair, but this was not followed for the resident in question.
Failure to Store Nebulizer Mask in a Sanitary Manner
Penalty
Summary
A deficiency was identified when a resident's nebulizer mask was repeatedly observed stored in an unsanitary manner, specifically left on the bedside table rather than in a clean, designated container. The resident had multiple medical conditions, including hypertension, peripheral vascular disease, bilateral below-knee amputations, a colostomy, muscle weakness, and required significant assistance with activities of daily living. The resident was prescribed Ipratropium-Albuterol nebulizer treatments three times daily for wheezing. Despite staff interviews indicating that nebulizer masks should be rinsed, air dried, and stored in a dated plastic bag, direct observations on multiple occasions showed the mask left out on the bedside table. The resident's care plan did not include instructions for nebulizer use or mask storage, and the facility was unable to provide a policy regarding proper storage of nebulizer masks. These actions and omissions led to the failure to ensure safe and sanitary respiratory care for the resident.
Incomplete and Undated Laboratory Records
Penalty
Summary
The facility failed to keep complete, dated laboratory records in the resident's record. This deficiency was identified through review of documentation, which revealed that laboratory records were either incomplete or missing required dates. The lack of proper documentation was directly observed in the resident's medical record.
Failure to Coordinate Hospice and Facility Care Plans
Penalty
Summary
The facility failed to ensure a coordinated plan of care between the facility and hospice services for a resident who was admitted to hospice. The resident had multiple diagnoses, including fibromyalgia, hypertension, peripheral vascular disease, major depressive disorder, diabetes mellitus, muscle weakness, and senile degeneration of the brain, and required significant assistance with activities of daily living. The resident's care plan documented admission to hospice and outlined comfort measures, maintenance of dignity, and the provision of supplies by hospice. However, review of records and staff interviews revealed that information regarding hospice services, such as supplies provided and the schedule of hospice staff, was not consistently included in the facility's care plan. Instead, this information was maintained separately in a hospice binder at the nurse's station, and staff relied on verbal communication and the binder for updates. Certified Nursing Aides and Licensed Nurses reported that they did not believe hospice information was integrated into the facility's care plan, and the Administrator confirmed that while communication with hospice was good, the care plans between the facility and hospice should match. The facility's policy required individualized, interdisciplinary plans to address residents' needs, but the lack of a unified, coordinated care plan placed the resident at risk for inappropriate end-of-life care. The deficiency was identified through observation, record review, and staff interviews, which demonstrated a failure to develop and maintain a coordinated plan of care as required.
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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