The Shepherd's Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cimarron, Kansas.
- Location
- 101 Cedar Ridge Drive, Cimarron, Kansas 67835
- CMS Provider Number
- 175570
- Inspections on file
- 15
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at The Shepherd's Center during CMS and state inspections, most recent first.
The facility did not complete required annual performance evaluations for two of five sampled CNAs, as shown by missing or outdated evaluation records in their personnel files.
A facility failed to employ a full-time certified dietary manager with appropriate credentials to oversee food and nutrition services for its residents. The current Dietary Manager did not have certification or prior food handling experience and was only enrolled in certification classes at the time of the survey. Administrative staff were unaware of the requirement for certification or specialized training, and the facility could not provide a relevant policy or evidence of adequate training.
Surveyors found that food was not stored or handled according to sanitary standards, with undated and expired items, frost-covered vegetables, and missing freezer temperature logs in multiple kitchens. Administrative staff confirmed that required procedures for dating, discarding, and monitoring food were not followed, resulting in unsanitary conditions.
The facility did not complete a thorough facility-wide assessment to identify specific staffing levels, shift requirements, or contingency staffing plans needed to care for all residents during daily operations and emergencies. The assessment lacked details on the number of RNs, LPNs, CMAs, and CNAs required for each unit and shift, and did not include plans for staffing during events that could impact resident care.
The facility did not complete a required QAPI PIP within the past year, with administrative staff unable to provide evidence of any recent PIP activity and stating the last one was completed about a year and a half ago, contrary to facility policy.
The facility did not maintain required infection and antibiotic surveillance logs, and the Infection Preventionist was unable to provide documentation of infection data collection or analysis. Instead, infection monitoring was limited to daily EMR reviews for new antibiotic orders and verbal reporting at QA meetings, contrary to facility policy requiring systematic documentation and analysis.
Staff did not maintain required antibiotic and infection surveillance logs, and the Infection Preventionist had no records to show tracking or analysis of antibiotic use or lab reports. Instead, antibiotic monitoring was limited to daily EMR review and verbal reporting at QA meetings, contrary to facility policy requiring comprehensive documentation and analysis.
The facility did not complete or submit comprehensive MDS assessments on time for multiple residents, with delays ranging from several days to over a month, and in one instance, an assessment remained incomplete. This was confirmed by review of medical records and staff interviews, despite facility policy requiring timely and accurate MDS completion.
A resident with a history of frequent falls and stroke was discharged without receiving written notification or a completed recapitulation of stay. The facility did not provide or have the resident or responsible party sign any discharge paperwork, and staff interviews confirmed that required discharge documentation was not completed in the electronic medical record.
A resident with anxiety, depression, and insomnia was administered multiple psychotropic medications, including an antipsychotic and a hypnotic, but the MDS assessment failed to document the use of these medications during the required lookback period. Staff interviews and record reviews confirmed the omission, which was not in accordance with facility policy for accurate MDS completion.
A resident admitted with a history of myocardial infarction and major depression did not have a Baseline Care Plan developed within 48 hours of admission, as required by facility policy. Review of the electronic medical record and staff interviews confirmed the absence of this initial care plan, which is intended to guide immediate care and ensure staff communication.
A resident with a history of myocardial infarction and major depression, who was cognitively intact and independent in ADLs but exhibited care rejection behaviors, did not have a comprehensive care plan documented in the EMR as required by facility policy. This omission was confirmed by administrative staff.
A resident with a pressure ulcer did not have wound care interventions included in their care plan, despite physician orders for wound treatment. The care plan only addressed cardiac issues, and a nurse confirmed the omission. Facility policy requires individualized care plans, but this was not followed for the resident's wound care needs.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete the required annual performance evaluations for two out of five sampled Certified Nursing Aides (CNAs). Review of personnel files showed that one CNA, hired in August 2023, had a performance evaluation dated July 2024 with no subsequent evaluation documented. Another CNA, hired in December 2020, had a performance evaluation dated May 2024 with no further evaluation recorded. This deficiency was identified through interviews and record reviews, confirming that the facility did not ensure timely completion of annual evaluations as required.
Lack of Certified Dietary Manager for Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee the food and nutrition services for its 20 residents. During interviews, the current Dietary Manager stated she did not possess a CDM certificate or prior experience with food handling before assuming the position and was only currently enrolled in CDM classes. Administrative staff confirmed that the Dietary Manager was placed in the role without knowledge of the certification, specialized training, or experience requirements. Additionally, the facility was unable to provide evidence of adequate training credentials for the Dietary Manager or a policy regarding the employment of a Certified Dietary Manager.
Unsanitary Food Storage and Handling Practices Identified
Penalty
Summary
Surveyors observed that the facility failed to prepare and serve food under sanitary conditions, as required by professional standards and facility policy. During inspections of the main pantry and two satellite kitchens, they found a dented can of refried beans, bags of carrots with significant frost accumulation, and hash browns without a date. In the satellite kitchens, there were bags of hot dogs—one with an expired date and another with no date—as well as additional bags of carrots with frost. The mini freezer temperature logs were not maintained for several days, and upon re-inspection, the logs still had not been updated. Additionally, neither of the two kitchens had foot-activated trash cans available, contrary to sanitary best practices. Interviews with administrative staff confirmed that staff were expected to date food items when opened and discard outdated items, and that freezer temperatures were to be checked and logged daily. Facility policy also required that food items be checked, dated, and stored properly, and that food from dented cans or with abnormal appearance be discarded immediately. The observed failures to follow these procedures resulted in unsanitary food storage and handling practices, placing residents at risk for foodborne illness.
Incomplete Facility-Wide Assessment for Staffing and Resource Needs
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources required to care for its 20 residents competently during both routine operations and emergencies. The assessment provided did not specify the required staffing levels for each unit, nor did it detail the number of RNs, LPNs, CMAs, and CNAs needed based on patient acuity and census. Additionally, the assessment lacked information on staffing requirements for each shift, including evenings and weekends, and did not include contingency staffing plans for situations that could impact resident care but did not necessitate activation of the emergency plan. During interviews, administrative staff acknowledged that while some staffing information had been updated, the assessment did not include all required elements such as specific staffing levels, contingency staffing plans, or staff recruitment plans. The facility's own policy requires an annual evaluation of resident population and identification of necessary resources, including sufficient staff and appropriate competencies for all shifts, as well as contingency planning for events affecting resident care. However, the assessment reviewed did not meet these requirements, affecting all residents in the facility.
Failure to Complete Required Quality Assurance and Performance Improvement Program
Penalty
Summary
The facility failed to complete a Quality Assurance and Performance Improvement Program (PIP) within the past year, as required by its own policy. Upon request, the facility was unable to provide evidence of any PIP completed in the last year. During an interview, an administrative staff member stated that she expected the administrative nurse to complete all PIPs and believed the last PIP was completed approximately one and a half years ago. The facility's policy indicated that PIPs should be developed and maintained to address care and service areas needing attention, based on data-driven indicators and prioritization tools. However, no documentation or evidence of such activities was available for the past year.
Failure to Maintain Infection Surveillance and Documentation
Penalty
Summary
The facility failed to implement a comprehensive infection prevention and control program for its 20 residents. Specifically, the facility did not maintain antibiotic and infection surveillance logs, and the Infection Preventionist was unable to provide any electronic or paper records documenting the collection and analysis of infection data. Instead, the Infection Preventionist relied on daily reviews of the Electronic Medical Record for new antibiotic orders and provided only verbal reports of infections and antibiotic use during Quality Assurance meetings. This practice was inconsistent with the facility's own policy, which required systematic monitoring, documentation, and analysis of infection data through a monthly infection control log and ongoing surveillance.
Failure to Monitor and Document Antibiotic Stewardship
Penalty
Summary
The facility failed to ensure staff adhered to the principles of antibiotic stewardship by not monitoring the appropriate use of antibiotics prescribed to residents, which is necessary to prevent antibiotic resistance and the spread of multidrug resistant organisms. The facility, with a census of 20 residents and a sample of 13, was unable to provide antibiotic and infection surveillance logs upon request. During an interview, the Infection Preventionist stated there were no electronic or paper records documenting the collection and analysis of data to track or monitor antibiotics ordered and laboratory reports received. Instead, the Infection Preventionist relied on daily review of the Electronic Medical Record for new antibiotic orders and provided only verbal reports of infections and antibiotic use at Quality Assurance meetings. The facility's policy required the Infection Preventionist to monitor every antibiotic ordered, complete antibiotic time-outs, summarize antibiotic use and resistance, and track outcome measures, but these actions were not documented or evidenced.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments in a timely manner for six residents, as required by regulation. Specifically, the MDS assessments for these residents were either completed or submitted late, with delays ranging from 9 to 52 days, and in one case, the assessment was still in progress and not completed or submitted as required. The issue was confirmed through review of electronic medical records and interviews with the facility's MDS Nurse and another administrative nurse, both of whom acknowledged that MDS assessments were in progress or completed late. The facility's own policy states a commitment to ensuring the accuracy, timeliness, and completeness of all MDS assessments, referencing the RAI manual.
Failure to Provide Written Discharge Notification and Complete Discharge Documentation
Penalty
Summary
The facility failed to provide a resident with a written notification of discharge and did not complete a recapitulation of the resident's stay as required. The resident, who had a history of frequent falls and cerebral infarction, was admitted with intact cognition and required maximal assistance with bathing and dressing, but was independent with ambulation. The resident's goal was to discharge back into the community, and an active discharge plan was documented. However, the electronic medical record lacked both a baseline and comprehensive care plan. Physician orders indicated discharge from physical therapy and a potential discharge home, and a progress note documented the resident leaving the facility with family members. Interviews with nursing staff revealed confusion and inconsistency regarding who was responsible for completing discharge paperwork. It was confirmed that the recapitulation of stay and discharge summary were not completed in the electronic medical record, and the facility did not provide or have the resident or responsible party sign any discharge paperwork. The facility's policy required informing residents or their representatives about discharge policies and documenting discharge planning and arrangements, but this was not followed in the resident's case.
Inaccurate MDS Documentation of Psychotropic Medication Administration
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for one resident, specifically regarding the documentation of psychotropic medications administered during the assessment lookback period. The resident in question had diagnoses of anxiety, depression, and insomnia, and was prescribed multiple psychotropic medications, including an antipsychotic (Abilify) and a hypnotic (trazodone). However, the MDS assessment did not record the administration of antipsychotic and hypnotic medications, despite evidence from the electronic medical record, care plan, and physician orders that these medications were given during the lookback period. Interviews with facility staff confirmed that the MDS should have indicated the use of antipsychotic and hypnotic medications, but this was not done. The facility's policy requires accuracy, timeliness, and completeness in all MDS assessments, referencing the RAI manual. The deficiency was identified through observation, record review, and staff interviews, which revealed the omission in the MDS documentation for the resident who was receiving several psychotropic medications as part of their treatment plan.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a Baseline Care Plan for a resident who was admitted with diagnoses of myocardial infarction and major depression. The resident's electronic medical record did not contain a Baseline Care Plan, despite facility policy requiring an initial person-centered care plan to be completed within 48 hours of admission. The omission was confirmed through record review and an interview with administrative staff, who stated that a baseline care plan assessment is expected upon admission. The lack of a Baseline Care Plan was identified during a review of the resident's records and was not in accordance with the facility's stated procedures for ensuring continuity of care and communication among staff.
Failure to Develop Comprehensive Care Plan for Resident with Cardiac and Mental Health Diagnoses
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident diagnosed with myocardial infarction and major depression. The resident's electronic medical record indicated a history of heart attack and persistent mood disorder, with an admission MDS showing intact cognition and documented behaviors such as rejection of care. Despite being independent in all activities of daily living, the resident's EMR did not contain a comprehensive care plan as required. Facility policy mandates an individualized, person-centered interdisciplinary plan of care for all residents, but this was not completed in a timely manner for the resident in question, as confirmed by administrative staff.
Care Plan Lacked Wound Care Interventions for Pressure Ulcer
Penalty
Summary
The facility failed to revise the care plan for a resident with a pressure ulcer. The resident's electronic medical record showed that the care plan, dated 08/17/23, did not include any wound care interventions, despite physician orders being in place to cleanse and dress open areas on the bilateral buttocks. The care plan only addressed cardiac complications and congestive heart failure, with interventions such as monitoring lung sounds, labored breathing, labs, vital signs, and signs of edema, but omitted any mention of wound care for the pressure ulcer. During the survey, a licensed nurse confirmed that the care plan lacked information regarding wound care for the resident. The resident was observed in her recliner and refused wound care observation. Administrative staff stated that care plans were expected to be completed in a timely manner. The facility's policy requires individualized, person-centered care plans based on the resident's needs, but this was not followed in the case of the resident with a pressure ulcer.
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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