The Nicol Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Glasco, Kansas.
- Location
- 303 E Buffalo St, Glasco, Kansas 67445
- CMS Provider Number
- 175473
- Inspections on file
- 14
- Latest survey
- September 16, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at The Nicol Home during CMS and state inspections, most recent first.
The facility failed to submit accurate direct care staffing information to CMS through the PBJ system, resulting in suppressed metrics for RN hours and LN coverage. Despite having LN and RN coverage according to the nursing schedule and timesheet payroll, the facility's submission for FY 2023 Quarter 4 was inaccurate, and the deadline for FY 2024 Quarter 2 was missed. This placed residents at risk for unidentified issues with inadequate staffing.
The facility failed to ensure appropriate indications and documentation for psychotropic medications for several residents, placing them at risk for adverse side effects. A resident was prescribed Rexulti without a documented rationale or evidence of nonpharmacological interventions. Another resident received Ativan without a 14-day stop date and Risperdal without appropriate indication. Additionally, a resident was given Olanzapine without an approved indication, and another was prescribed Quetiapine without proper documentation or a gradual dose reduction attempt.
The facility failed to develop comprehensive care plans for several residents, leading to uncommunicated care needs. A resident with multiple diagnoses had wounds not documented in the care plan, leaving staff without guidance for treatment. Another resident on Ativan lacked a care plan for non-pharmacological interventions, and a resident with chronic UTIs had no care plan addressing long-term antibiotic use. Additionally, a resident with diabetes using an insulin pump lacked a diabetes care plan, placing them at risk for impaired care.
A resident with diabetes, anxiety, edema, and hypertension experienced multiple skin tears, yet the care plan was not updated to address these issues. Despite frequent bruises and skin tears, staff were unaware of the resident's current condition, and the care plan lacked specific interventions for prevention or treatment, leading to a deficiency in care.
The facility failed to implement necessary skin care interventions for two residents, leading to multiple skin tears and sores. One resident experienced frequent skin tears due to fragile skin, while another had untreated sores from scratching. The facility did not follow care plans or policies, resulting in inadequate communication and documentation of the residents' skin conditions.
The facility failed to implement effective fall prevention interventions for two residents, leading to multiple falls. One resident, with a history of falls and cognitive impairment, had no documented interventions in their care plan. Another resident, diagnosed with dementia, experienced repeated falls without a root cause analysis being conducted. The facility did not adhere to its policy on managing falls, resulting in inadequate person-centered interventions.
A resident with severe cognitive impairment and multiple health issues was not provided with appropriate mental health support before being administered psychotropic medications. The care plan lacked specific interventions for emotional and social needs, and there was no evidence of nonpharmacological interventions. Staff interviews confirmed the absence of social service involvement or mental health support, and the facility lacked a policy for behavioral or mental health services.
The facility's Consultant Pharmacist failed to identify and report medication irregularities for several residents, including the lack of stop dates for PRN antianxiety medications and unapproved indications for antipsychotic use. This oversight placed residents at risk for inappropriate medication use.
A facility failed to implement antibiotic use protocols, leading to inappropriate antibiotic use for two residents. One resident, with a history of various health conditions, was prescribed antibiotics for chronic UTIs despite only one documented infection in the past year. Another resident, with multiple diagnoses, was given nitrofurantoin without active infections or a physician's rationale. The facility's Antibiotic Stewardship policy was not followed, placing residents at risk for adverse effects and antibiotic resistance.
Inaccurate PBJ Submission Leads to Staffing Deficiency
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare & Medicaid Services (CMS) through the Payroll-Based Journal (PBJ) system. This deficiency was identified during a review of the PBJ report for Fiscal Year (FY) 2024 Quarter 2, which showed that the metrics for Registered Nurse (RN) hours and Licensed Nurse (LN) coverage 24 hours per day were suppressed for the facility. Additionally, the PBJ report for FY 2023 Quarter 4 documented 13 dates on which the facility did not have LN coverage. However, a review of the nursing schedule and timesheet payroll for these periods revealed that LN and RN coverage was indeed present. Administrative Staff A, who was responsible for submitting the PBJ information, confirmed that there was an inaccurate submission for FY 2023 Quarter 4 and that the submission deadline for FY 2024 Quarter 2 was missed. The facility's policy on Reporting Direct Care Staffing Information, dated August 2022, requires that staffing information be reported electronically to CMS no less frequently than quarterly, with submissions due no later than 45 days after the end of the reporting quarter. The failure to submit accurate information placed the residents at risk for unidentified issues with inadequate staffing.
Inadequate Documentation and Indication for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure appropriate indications and documentation for the use of psychotropic medications for several residents, placing them at risk for adverse side effects. Resident 4 was prescribed Rexulti, an atypical antipsychotic, for dementia without a documented physician rationale or evidence of unsuccessful nonpharmacological interventions. Despite the resident's pleasant demeanor and lack of aggressive behaviors, the medication was continued based on family requests and without proper documentation of risk versus benefit analysis. Resident 13 was administered Ativan, an antianxiety medication, without a 14-day stop date, and Risperdal, an antipsychotic, without appropriate indication or documentation of nonpharmacological interventions. The resident, who had advanced dementia and was resistant to care, received these medications without a comprehensive assessment or documented rationale for their continued use, contrary to the facility's policy. Resident 12 received Olanzapine, an antipsychotic, without an approved indication and without documentation of nonpharmacological interventions. The resident's PRN Ativan also lacked a stop date, and there was no documentation of nonpharmacological interventions prior to its use. Similarly, Resident 2 was prescribed Quetiapine, an antipsychotic, without appropriate indications or documentation of nonpharmacological interventions, and without a gradual dose reduction attempt or physician rationale for its continued use.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive care plans for several residents, leading to uncommunicated care needs and potential risks for impaired care. Resident 17 had multiple diagnoses, including muscle weakness, atrial fibrillation, and dementia, and was dependent on staff for care. Despite having wounds on the left heel and great toe, these were not documented in the care plan, leaving staff without proper guidance for treatment. Observations revealed that the resident was dependent on staff for all care, and the administrative nurse confirmed the omission of wound care instructions in the care plan. Resident 12, who had severe cognitive impairment and was on multiple medications, including Ativan for anxiety, did not have a care plan that included non-pharmacological interventions before administering the medication. The care plan also lacked a stop date for the PRN Ativan, and staff did not document the use of non-pharmacological interventions. This oversight placed the resident at risk for impaired care due to uncommunicated needs. Resident 5, with a history of diabetes mellitus and chronic UTIs, was on long-term antibiotic treatment, but the care plan did not address this ongoing medication use. The resident was able to report UTI symptoms to staff, but the care plan did not reflect the long-term antibiotic use. Similarly, Resident 26, who had diabetes and used an insulin pump, did not have a diabetes care plan in place, leaving staff without direction for managing the insulin pump. These deficiencies in care planning placed the residents at risk for impaired care due to uncommunicated needs.
Failure to Revise Care Plan for Resident's Skin Tears
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R3, to reflect their current health needs, specifically regarding skin tears. R3 had a history of diabetes mellitus type 2, anxiety, edema, and hypertension, and required varying levels of assistance for daily activities. Despite having intact cognition and no documented skin issues in the most recent Minimum Data Set, R3 experienced multiple skin tears over a period of time. These incidents included a skin tear from a dog during pet therapy and another from bumping a hand on a drawer. Observations and interviews revealed that R3 frequently experienced bruises or skin tears, yet the care plan lacked specific directions for the prevention or treatment of these skin issues. The facility's policy required care plans to be reviewed and revised when there was a significant change in condition, yet this was not done for R3. Interviews with staff, including a Certified Nurse Aide and an Administrative Nurse, indicated a lack of awareness and communication regarding R3's current skin condition. The care plan did not incorporate necessary interventions to prevent further skin tears, placing R3 at risk for impaired care due to uncommunicated care needs. The facility's failure to update the care plan as per their policy contributed to this deficiency.
Failure to Implement Skin Care Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent skin tears for Resident 3, who had a history of fragile skin and frequent skin tears. Despite the care plan directing staff to inspect the resident's skin during showers, there was no specific guidance on preventing or treating skin tears. The resident experienced multiple skin tears, including one from a dog during pet therapy and another from bumping his hand on a drawer. Observations revealed additional skin tears, and staff were unaware of the current skin tear, indicating a lack of communication and documentation regarding the resident's skin condition. Resident 29, who had diagnoses including diabetes mellitus type 2 and chronic pain, also experienced inadequate skincare. The care plan required skin inspections during showers, but the resident had multiple sores on his arms, which were not addressed in the medical record or through specific treatment orders. The resident reported itching and scratching his arms, leading to sores, yet staff only applied lotion after showers without further intervention. The facility's policy required obtaining physician orders and reviewing care plans for skin issues, which was not followed for this resident. The facility's failure to provide appropriate skin care and implement preventive measures for both residents placed them at risk for further skin injuries and complications. The lack of communication, documentation, and adherence to care plans and facility policies contributed to these deficiencies, as staff were not adequately informed or equipped to address the residents' skin care needs.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to identify and implement interventions to prevent falls for two residents, R25 and R13, which placed them at risk for further falls and injuries. R25 had a history of unspecified falls, altered mental status, weakness, unsteadiness, and major depressive disorder. Despite being at high risk for falls due to confusion, gait, and balance problems, R25's care plan lacked documentation of falls or immediate actions to prevent further incidents. Multiple falls were recorded for R25, but the facility did not conduct a root cause analysis or update the care plan with effective interventions. R13, diagnosed with dementia and repeated falls, also experienced multiple falls without sustaining injuries. The care plan for R13 included various updates to assist with toileting and ambulation, but the facility did not perform a root cause analysis to determine the reasons for the falls. Despite being at high risk for falls, the interventions were not adequately tailored to address R13's specific needs, such as her gait imbalance and incontinence issues. The facility's policy on managing falls and fall risk required staff to identify interventions based on the resident's specific risks and causes. However, the facility did not adhere to this policy, as evidenced by the lack of root cause analysis and the failure to implement meaningful, person-centered interventions for both R25 and R13. This oversight placed both residents at continued risk for falls and potential injuries.
Failure to Provide Mental Health Support Before Medication
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident, identified as R2, who displayed signs of mental disorder and psychosocial adjustment difficulties. R2 had a history of chronic kidney disease, polyosteoarthritis, weakness, and a displaced fracture of the humerus. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment without delirium or psychosis, and R2 was on multiple medications, including antipsychotics and antidepressants, without any documented attempt at gradual dose reduction or physician documentation of contraindications. R2's care plan, dated June 6, 2024, lacked specific interventions to address her emotional and social needs, particularly her difficulty adjusting to the facility and loss of independence. Progress notes documented R2's tearfulness, refusal to engage with staff, and expressions of distress, including a desire to die. Despite these observations, there was no evidence of nonpharmacological interventions or actions taken to address R2's emotional and psychological needs before the administration of psychotropic medications. Interviews with facility staff revealed a lack of social service involvement or mental health support for R2 prior to the initiation of medication treatment. The facility did not provide a policy for behavioral or mental health services, indicating a systemic failure to address the resident's mental health needs adequately. This deficiency placed R2 at risk for unmet mental health care needs, as the facility did not ensure the highest practicable mental and psychosocial well-being for the resident.
Consultant Pharmacist Fails to Identify Medication Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities in the medication regimens of several residents, specifically regarding the use of antianxiety and antipsychotic medications. For Resident 12, the CP did not report the lack of a stop date for the PRN Ativan prescribed for agitation, nor did they identify the unapproved indication for the use of olanzapine, an antipsychotic medication. The resident's care plan noted the potential adverse effects of these medications, including increased confusion and risk of falls, yet the CP's reviews consistently failed to address these issues. Resident 2's medication regimen also exhibited deficiencies, as the CP did not identify the inappropriate indication for the use of quetiapine, an antipsychotic prescribed for anxiety. The CP recommended a gradual dose reduction (GDR) but did not document the reason for continued use without a GDR. The resident's care plan lacked evidence of nonpharmacological interventions or documentation of the risks versus benefits of continued antipsychotic use without a GDR. For Resident 13, the CP failed to address the absence of a stop date for the PRN Ativan prescribed for agitation. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, was at risk for inappropriate use of psychotropic medication due to this oversight. The facility's policy required the CP to help comply with legal and regulatory requirements related to medication management, but the CP did not fulfill this role effectively, leading to potential risks for the residents involved.
Failure to Monitor Antibiotic Use in Residents
Penalty
Summary
The facility failed to implement antibiotic use protocols effectively, leading to unnecessary and inappropriate antibiotic use for two residents, R5 and R12. R5's medical records indicated a history of diabetes mellitus, chronic atrial fibrillation, major depressive disorder, chronic kidney disease, and morbid obesity. Despite having only one documented urinary tract infection (UTI) in the past year, R5 was prescribed Macrodantin for chronic UTIs and cefdinir for a UTI that occurred in May. The care plan did not address the ongoing use of antibiotics, and staff failed to monitor the effectiveness and appropriateness of the antibiotic regimen. R12's medical records showed diagnoses of hypertension, major depressive disorder, peripheral vascular disease, dementia, anxiety disorder, and other conditions. Despite no active infections found in urine analyses conducted in March and May, R12 was prescribed nitrofurantoin for urinary health without a documented rationale or benefits statement from a physician. The care plan did not mention the antibiotic use, and there was no evidence of monitoring or evaluation of the necessity of the ongoing antibiotic treatment. The facility's Antibiotic Stewardship policy, dated December 2016, emphasized the importance of monitoring antibiotic use to prevent adverse effects and antibiotic resistance. However, the facility failed to adhere to this policy, as evidenced by the lack of identification and addressing of ongoing antibiotic use for R5 and R12 without signs and symptoms of infections. This oversight placed both residents at risk for complications related to antibiotic use, including the development of antibiotic-resistant organisms.
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.
The facility failed to coordinate hospice services within the care plans for two residents receiving hospice. Both residents had severe cognitive impairment and extensive ADL needs, and their MDS assessments documented hospice care. Their care plans included general directions about ADL assistance, pain monitoring, and consulting with hospice or the physician, but omitted key hospice-specific details such as hospice contact information, visit schedules, services to be provided, and what supplies, equipment, and medications hospice would furnish. Clinical record review and interviews with an administrative nurse confirmed that there was no documented coordination between hospice and facility care plans, contrary to the facility’s hospice policy requiring an interdisciplinary plan integrating hospice and facility services.
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 Coordinate Hospice Services in Resident Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain a coordinated hospice plan of care that integrated hospice services with facility services for two residents receiving hospice. For one resident with Alzheimer’s disease, CAD, and atrial fibrillation, the Significant Change MDS documented severely impaired cognition and extensive assistance needs for bed mobility and transfers, and indicated the resident was receiving hospice services. The resident’s care plan noted a terminal prognosis due to Alzheimer’s, directed staff to adjust ADL care, consult the physician for hospice care in the facility, and monitor and treat pain, but it did not include instructions on hospice services such as hospice staff visit schedules, supplies, medical equipment, or medications covered by hospice. The clinical record showed the resident had been admitted to hospice care months earlier, yet there was no documented evidence of coordination of care between hospice and the facility. For the second resident, diagnosed with PVD, DM, HTN, and atherosclerotic heart disease, the Significant Change MDS showed severe cognitive impairment with a BIMS score of two and dependence on staff for most ADLs, and documented that the resident received hospice services. The resident’s care plan recorded admission to hospice and directed staff to adjust ADL provision, encourage participation as desired, assess coping, respect wishes, and consult with the physician and hospice for continuing hospice care, as well as monitor for pain and notify the physician and hospice for breakthrough pain. However, the care plan lacked a hospice contact number, information on what supplies, equipment, and medications hospice would provide, and details on when hospice staff would be in the building and what care they would deliver. Observations and staff interviews confirmed these omissions. One resident was observed in bed receiving eye drops from a CMA, and during record review, the Administrative Nurse acknowledged that the facility care plan lacked specific information coordinating with the hospice care plan. For the second resident, the Administrative Nurse verified that the care plan did not contain information regarding hospice visits, phone numbers, or medical supplies provided by hospice, and stated that such information should be on the resident’s care plan. These findings were inconsistent with the facility’s Hospice Services policy, which required an interdisciplinary care plan integrating facility and hospice services, including coordination of services and supplies provided by the hospice provider.
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