Tonganoxie Terrace
Inspection history, citations, penalties and survey trends for this long-term care facility in Tonganoxie, Kansas.
- Location
- 1010 East Street, Tonganoxie, Kansas 66086
- CMS Provider Number
- 175215
- Inspections on file
- 21
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Tonganoxie Terrace during CMS and state inspections, most recent first.
A resident was not adequately prepared for a safe transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences, resulting in a deficiency related to transfer/discharge planning.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
The facility failed to implement a water management program to prevent Legionella disease and did not ensure adequate infection control practices related to catheter care. Staff were unaware of the water management requirement, and multiple observations revealed improper handling of urinary catheters, including lack of privacy bags, inadequate disinfection, and poor hand hygiene. These deficiencies placed residents at increased risk for infection.
The facility failed to provide the required 12 hours of in-service education for CMAs and CNAs, placing residents at risk of receiving impaired care. This deficiency was confirmed by the Director of Nursing and was in violation of the facility's Competency of Nursing Staff policy.
The facility failed to ensure a safe environment and prevent accidents for residents. One resident burned his fingers while smoking due to inadequate safety assessments and preventive actions. Another resident with severe cognitive impairment was not re-evaluated for smoking safety for over two years. Additionally, the facility did not investigate or implement interventions to prevent falls and injuries for two residents, placing them at risk for further harm.
The Consultant Pharmacist failed to identify and report medications administered outside of physician-ordered parameters for several residents, including blood pressure medications and insulin. This oversight placed residents at risk for adverse side effects and unnecessary medications. Additionally, the CP did not address the inappropriate use of Seroquel for a resident with Alzheimer's.
The facility failed to properly label and manage insulin medications for three residents, leading to potential risks for ineffective medication administration. Insulin flex pens for two residents were not dated when opened, and an outdated insulin vial for another resident was not discarded. Administrative Nurse D confirmed that the facility's protocol requires nurses to date insulin when opened and discard it when outdated.
The facility failed to identify and investigate injuries of unknown origin in a resident with severe cognitive impairment and multiple medical conditions. The resident sustained two skin tears on separate occasions, but no investigation was conducted to determine the cause of the injuries, placing the resident at risk for ongoing abuse and/or neglect.
The facility failed to investigate two injuries of unknown origin for a resident with multiple health conditions, including dementia and congestive heart failure. Despite the facility's policy requiring investigation and reporting of all incidents, no investigation was conducted, placing the resident at risk for unidentified and ongoing abuse or neglect.
The facility failed to develop comprehensive care plans for three residents, leading to impaired care due to uncommunicated care needs. One resident's care plan lacked interventions for managing diabetes and preventing falls, another resident's care plan did not address behaviors and mood, and a third resident's care plan did not include smoking safety measures after a burn injury.
The facility failed to review and revise care plans for a resident with chronic pain and another with skin tears, leading to inadequate pain management and increased risk of injuries. The care plans lacked necessary interventions, and the facility did not investigate incidents or document alternative measures, resulting in uncommunicated care needs and impaired care.
The facility failed to provide necessary bathing services for three residents, leading to extended periods without showers and placing them at risk for impaired health. Despite being scheduled for regular showers, documentation showed multiple refusals without follow-up or reapproach by staff. Observations confirmed the residents' unkempt appearances, and staff verified the lack of adherence to the facility's policy on documenting refusals and follow-up actions.
The facility failed to provide appropriate catheter care and infection control practices for two residents, leading to increased risk of infection and other catheter-related complications. Observations revealed improper handling of urinary catheter bags, lack of privacy covers, and failure to disinfect catheter ports, contrary to the facility's policies.
The facility failed to provide non-medicinal pain relief measures and promote effective pain management for a resident with chronic pain. Despite receiving scheduled and PRN pain medications, the resident reported inadequate pain control. The care plan lacked direction for non-medication pain relief measures, and staff did not consistently offer or attempt alternative pain interventions. This placed the resident at risk for ongoing severe pain and impaired quality of life.
The facility failed to provide necessary dementia care and services for two residents, leading to unmanaged aggressive behaviors and expressions of wanting to die. The care plans lacked specific interventions, and staff were not adequately informed or trained to manage the residents' conditions effectively, placing them at risk for abuse and decreased quality of life.
The facility failed to notify the physician of abnormal blood sugars and did not monitor blood pressure before administering medication for a resident. Another resident received blood pressure medication and insulin despite physician orders to hold them if certain parameters were not met. These actions placed the residents at risk for adverse medication effects.
A resident with Alzheimer's received Seroquel without appropriate indication or documented physician rationale, including unsuccessful attempts for nonpharmacological symptom management. The facility's policy required addressing all potential causes of behavioral symptoms before considering antipsychotic medications, but this was not followed, placing the resident at risk for adverse side effects.
A resident with multiple health conditions received midodrine and metoprolol outside of physician-ordered blood pressure parameters multiple times over three months. Staff lacked understanding and proper communication regarding medication orders, and the facility failed to perform competency checks despite re-education efforts.
Failure to Ensure Resident-Centered and Safe Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not completed, resulting in a deficiency related to resident-centered care and safe transition planning.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from facility staff, resulting in unmet care needs for those individuals. No additional details about the specific residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Water Management Program and Inadequate Catheter Care
Penalty
Summary
The facility failed to implement a water management program to prevent Legionella disease, as required by the Centers for Medicare and Medicaid Services (CMS). Maintenance and administrative staff were unaware of the requirement, and the facility had no current program in place. This failure placed residents at risk of contracting Legionella pneumonia, particularly those over the age of 50 or with weakened immune systems, chronic lung disease, or heavy tobacco use. Additionally, the facility did not ensure adequate infection control practices related to catheter care. Observations revealed that staff did not use privacy bags for urinary catheter drainage bags, allowing urine to be visible from the hall. Staff also placed measuring containers on bare floors, did not disinfect catheter ports, and failed to change gloves or wash hands between handling different types of catheters. These practices were observed with multiple residents, including one who had recently completed antibiotic treatment for a urinary tract infection. Interviews with various staff members confirmed that the observed practices were not in line with the facility's policies. Staff acknowledged that catheter bags should not be placed on the floor, should be kept in privacy bags, and that proper hand hygiene and disinfection protocols should be followed. The facility's policies directed staff to maintain a clean technique, keep catheter tubing and drainage bags off the floor, and prevent contact of the drainage spigot with nonsterile containers. The failure to adhere to these policies placed residents at increased risk for infection.
Failure to Provide Required In-Service Education for Nursing Staff
Penalty
Summary
The facility failed to provide the required 12 hours of in-service education for Certified Medication Aides (CMAs) and Certified Nursing Assistants (CNAs). Specifically, CMAs R, RR, and SS, as well as CNA P, lacked documentation of the required training. This deficiency was identified through a review of the facility's annual in-service documentation and was confirmed by Administrative Nurse D, who has been serving as the Director of Nursing since November 2023. Administrative Nurse D acknowledged the absence of evidence showing that the sampled CNA staff had completed the required 12 hours of in-service education. The facility's Competency of Nursing Staff policy mandates that all nursing staff meet specific competency requirements as defined by state law, including annual and facility-specific competencies. Despite this policy, the facility did not ensure that the required in-service education was provided. This failure placed residents at risk of receiving impaired care, as the staff may not have been adequately trained to meet the residents' needs as identified through assessments and care plans.
Failure to Ensure Safe Environment and Prevent Accidents
Penalty
Summary
The facility failed to ensure an environment free from preventable accident hazards for a resident who burned his fingers while smoking. The resident, who had intact cognition and several medical conditions including neuromuscular dysfunction of the bladder, diabetes mellitus, and pneumonia, was not properly assessed for smoking safety upon admission. Despite a care plan that required supervision and the use of a cigarette holder and smoking apron, the resident burned his fingers twice due to a lack of feeling in his fingers. The facility did not conduct a timely smoking safety assessment or implement preventive actions to prevent future burns, placing the resident at risk for injuries and pain related to burns. Another resident with bilateral above-the-knee amputations, diabetes mellitus, dementia, and anxiety was also not properly assessed for smoking safety. The resident's last smoking safety assessment was conducted over two years ago, and the facility failed to re-evaluate the resident's ability to smoke safely on a quarterly basis as required by their policy. This oversight placed the resident at risk for preventable accidents and related injuries. Additionally, the facility failed to investigate and implement interventions to prevent falls and injuries for two other residents. One resident with congestive heart failure, diabetes mellitus, osteoporosis, dementia, and anxiety experienced multiple skin tears, but the facility did not investigate the incidents or develop preventive measures. Another resident with dementia, diabetes mellitus, and hypertension had a history of falls but lacked care-planned interventions to prevent further falls. The facility did not complete a fall investigation for one of the resident's falls and failed to implement resident-centered interventions to prevent falls, placing the resident at risk for further injuries.
Consultant Pharmacist Fails to Identify and Report Medication Errors
Penalty
Summary
The Consultant Pharmacist (CP) failed to identify and report medications administered outside of physician-ordered parameters for several residents, placing them at risk for adverse side effects and unnecessary medications. For Resident 15, the CP did not report that midodrine was administered 29 times when the resident's blood pressure was above the ordered parameters. Despite the pharmacist's recommendation to obtain hold parameters for another medication, there was no mention of the errors related to midodrine administration. This oversight was confirmed by the administrative nurse and a certified medication aide who admitted to not understanding the symbols indicating when to hold the medication. For Resident 31, the CP did not identify that staff failed to obtain blood pressure readings before administering lisinopril, a medication for hypertension, 78 times. The administrative nurse verified this oversight and expressed confusion as to why the pharmacist had not identified the issue. The facility's policy required the CP to perform a thorough medication regimen review to prevent and resolve medication-related problems, but this was not adhered to in this case. Resident 6 also experienced similar issues, with blood pressure medications and insulin being administered multiple times when the physician's orders indicated they should be held. The CP's monthly reviews did not note these discrepancies, and the administrative nurse confirmed the oversight. Additionally, Resident 4 was given Seroquel for an inappropriate indication (Alzheimer's), and the CP failed to recommend an appropriate indication for its continued use. The administrative nurse verified that the pharmacist had sent monthly reviews but did not address the inappropriate use of Seroquel.
Failure to Properly Label and Discard Insulin
Penalty
Summary
The facility failed to properly label and manage insulin medications for three residents, leading to potential risks for ineffective medication administration. Specifically, the insulin flex pens for two residents were not dated when opened, and an outdated insulin vial for another resident was not discarded. These observations were made during a survey of the facility's medication carts, where it was found that the Humalog flex pens for two residents lacked both an open date and a discard date. Additionally, a Lantus vial for another resident had an open date that indicated it should have been discarded but was still present in the medication cart. Administrative Nurse D confirmed that the facility's protocol requires nurses to date insulin when opened and discard it when outdated. The facility's Insulin Administration policy also mandates that the expiration date be recorded on the vial when opened. The failure to adhere to these protocols was verified by the administrative nurse, who acknowledged that the night nurse should check for expired medications and that every nurse administering medications should ensure they are not outdated. This lapse in protocol placed the residents at risk for receiving ineffective medications.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure staff identified injuries of unknown origin as potential allegations of abuse and report them to the administrator for investigation. This deficiency was observed in the case of a resident with severe cognitive impairment and multiple medical conditions, including congestive heart failure, diabetes mellitus, osteoporosis, dementia, and anxiety. The resident, who was dependent on staff for most activities of daily living and used a wheelchair for mobility, sustained two skin tears on separate occasions. The first injury was a large skin tear on the right lower extremity, and the second was a skin tear on the right lateral calf. Despite these injuries, the facility's records lacked any investigative notes, and administrative staff were unaware of how the injuries occurred, indicating that no investigation was completed to determine the cause of the injuries. The facility's policy on Accident and Incidents-Investigating and Reporting required that all accidents or incidents involving residents be investigated and reported to the administrator. However, the facility staff failed to follow this policy, as evidenced by the lack of investigation into the resident's injuries. The administrative nurse confirmed that the facility did not investigate the incidents to determine their cause. This failure to identify and investigate injuries of unknown origin placed the resident at risk for unidentified and ongoing abuse and/or neglect.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to investigate two injuries of unknown origin for a resident, which could have ruled out possible abuse or neglect. The resident had a history of congestive heart failure, diabetes mellitus, osteoporosis, dementia, and anxiety, and was dependent on staff for most activities of daily living. The resident's medical records documented a large skin tear on the right lower extremity on one occasion and a skin tear on the right lateral calf on another occasion. Despite these injuries, the facility did not conduct any investigation to determine the cause of the injuries, as confirmed by the administrative nurse. The facility's policy required that all accidents or incidents involving residents be investigated and reported to the administrator, with specific data included in the report. However, the facility did not follow this policy for the resident's injuries. The lack of investigation placed the resident at risk for unidentified and ongoing abuse or neglect. The facility's failure to investigate these injuries was a clear violation of their own policies and procedures, as well as a failure to ensure the safety and well-being of the resident.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to impaired care due to uncommunicated care needs. Resident 31, diagnosed with dementia, diabetes mellitus, and hypertension, had a care plan that lacked interventions for managing diabetes and preventing falls. Despite multiple falls and blood sugar levels outside the ordered parameters, the care plan did not provide adequate direction to staff, and the physician was not notified of abnormal blood sugar levels on numerous occasions. Observations revealed that Resident 31 was often left unattended, increasing the risk of falls and further injury. Resident 77, with diagnoses including vascular dementia, depressive disorder, and diabetes mellitus, exhibited behaviors such as refusing care, expressing a desire to die, and urinating on the floor. The care plan did not address these behaviors or provide interventions for managing the resident's mood and verbalizations of wanting to die. Despite multiple incidents of aggressive behavior and statements about self-harm, the facility did not follow up with psychiatric evaluations or implement consistent safety checks. Staff were aware of the resident's behaviors but did not take appropriate actions to address them in the care plan. Resident 29, admitted with neuromuscular dysfunction of the bladder, diabetes mellitus, and pneumonia, began smoking at the facility but did not have a comprehensive care plan for smoking safety. After burning his finger while smoking, the resident's care plan was updated to include supervision and the use of a cigarette holder and smoking apron. However, the facility failed to perform a smoking assessment when the resident started smoking and did not document the burn on the skin assessment. Staff did not reassess the resident's smoking practices after the incident, leading to continued risk of injury.
Failure to Review and Revise Care Plans for Pain Management and Skin Tear Prevention
Penalty
Summary
The facility failed to review and revise the care plan for a resident with chronic pain, leading to inadequate pain management. The resident, who had diagnoses including alcohol dependence, chronic pain in the right shoulder, and dorsalgia, reported constant severe pain that interfered with sleep and activities. Despite receiving scheduled and PRN pain medications, the care plan lacked non-medication pain relief measures. Observations and interviews revealed that the resident's pain was not adequately managed, and alternative pain relief interventions were not offered or documented by the staff. The facility's care planning policy was not followed, resulting in uncommunicated care needs and impaired care for the resident. Another resident with diagnoses including congestive heart failure, diabetes mellitus, osteoporosis, dementia, and anxiety experienced skin tears that were not adequately addressed in the care plan. The resident, who had severely impaired cognition and was dependent on staff for most activities of daily living, had a care plan that directed staff to use pressure-reducing measures and provide substantial assistance with transfers. However, after skin tears occurred, the care plan was not updated with new interventions to prevent further injuries. The facility also failed to investigate the incidents, leaving the causes of the skin tears unknown. Observations and interviews confirmed that the facility did not follow its care planning policy, resulting in uncommunicated care needs and increased risk of injuries for the resident. The facility's failure to review and revise care plans for pain management and skin tear prevention led to impaired care for the residents. The care plans did not include necessary interventions, and the facility did not investigate incidents or document alternative measures. This lack of communication and adherence to care planning policies placed the residents at risk for inadequate care and further injuries.
Failure to Provide Necessary Bathing Services
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene, including bathing, for three residents, placing them at risk for impaired health and decreased psychosocial well-being. Resident 4, diagnosed with Alzheimer's, major depressive disorder, congestive heart failure, and atrial fibrillation, required substantial assistance for most activities of daily living, including bathing. Despite being scheduled for showers twice a week, documentation revealed multiple instances where the resident refused showers without any follow-up or reapproach by staff, resulting in the resident not receiving a shower for extended periods. Resident 41, with diagnoses including bilateral above-the-knee amputations, diabetes mellitus, dementia, and anxiety, also required extensive assistance for bathing. The resident's records showed numerous refusals of showers without follow-up or reapproach, leading to significant gaps between showers. Observations confirmed the resident's unkempt appearance, and staff verified the lack of documentation and follow-up for missed showers. Resident 30, who had chronic pain and dorsalgia, required partial moderate assistance for bathing. Despite having intact cognition and no rejection of care behavior, the resident's records indicated consistent refusals of showers without evidence of reapproach or alternative hygiene options being offered. Staff interviews revealed a lack of coordination and follow-up for missed showers, and observations confirmed the resident's unclean state. The facility's policy required documentation of refusals and follow-up actions, which were not adhered to, resulting in the failure to provide necessary care and bathing services for these residents.
Deficient Catheter Care and Infection Control Practices
Penalty
Summary
The facility failed to provide appropriate care and services to prevent potential infection of the urinary system for two residents, R29 and R17, during care for their urinary catheters. For R29, the facility did not maintain proper infection control practices. Observations revealed that the urinary catheter bag was frequently placed on the floor without a privacy cover. Additionally, staff did not use disinfectant wipes on the catheter port and placed a measuring canister on a visibly soiled floor. These actions were contrary to the facility's policy, which required maintaining a clean technique and ensuring the catheter tubing and drainage bag were kept off the floor. R29 had a history of neuromuscular dysfunction of the bladder, diabetes mellitus, and recurrent urinary tract infections, which placed him at higher risk for complications. Despite these conditions, the facility's staff failed to adhere to proper catheter care protocols, leading to an increased risk of infection and other catheter-related complications for R29. Similarly, R17's care was compromised due to improper handling of the urinary catheter and nephrostomy bags. Observations showed that the urinary catheter drainage bag was hung on the side of the bed without a privacy bag, making the urine visible from the hall. Staff placed a measuring container on the bare floor and did not disinfect the catheter port before and after emptying the urine. Additionally, staff did not change gloves or wash hands between handling the Foley and nephrostomy bags. These actions were inconsistent with the facility's policy, which required maintaining a clean technique, using alcohol wipes on the port, and changing gloves between tasks. R17 had a history of diabetes mellitus, obstructive and reflux uropathy, paraplegia, and recurrent urinary tract infections, making her particularly vulnerable to infections. The facility's failure to follow proper catheter care protocols placed R17 at increased risk for infection and other catheter-related complications. The facility's policies on catheter care, dated 2014, directed staff to maintain an accurate record of daily output, keep the tubing free of kinks, and always position the drainage bag lower than the bladder. Staff were also required to maintain a clean technique when handling or manipulating the catheter, tubing, or drainage bag, and to ensure the catheter tubing and drainage bag were kept off the floor. Despite these clear guidelines, the facility failed to ensure appropriate catheter care and services for both R29 and R17, leading to deficiencies in infection control practices and placing the residents at risk for catheter-related complications.
Failure to Provide Non-Medicinal Pain Relief Measures
Penalty
Summary
The facility failed to provide non-medicinal pain relief measures and promote effective pain management for a resident (R30) who experienced almost constant severe pain. R30 had diagnoses of alcohol dependence, chronic pain in the right shoulder, and dorsalgia. Despite receiving scheduled and PRN pain medications, including Tylenol and oxycodone, R30 reported that his pain control was inadequate. The care plan for R30 lacked direction for non-medication pain relief measures, and the EMR did not show evidence that staff consistently offered or attempted non-pharmacological interventions to treat pain. Observations and interviews revealed that R30 was not offered alternative pain interventions such as heat or cold therapy, aromatherapy, or music therapy, and staff primarily relied on medication to manage his pain. R30's care plan directed staff to administer analgesia per orders, evaluate the effectiveness of pain interventions, and notify the physician if interventions were unsuccessful. However, the care plan did not include specific non-medication pain relief measures. The facility's Pain-Clinical Protocol policy stated that staff should provide elements of a comforting environment and appropriate physical and complementary interventions, but this was not consistently implemented for R30. The resident's pain level remained high, and he frequently sought pain medication, indicating that the current pain management strategies were ineffective. Interviews with staff members, including a CNA and a licensed nurse, confirmed that non-medication pain relief interventions were not consistently offered to R30. The administrative nurse acknowledged that staff should have offered alternative pain relief measures and documented their attempts. The facility's failure to provide non-medicinal pain relief measures and promote effective pain management for R30 placed the resident at risk for ongoing severe pain and impaired quality of life.
Failure to Provide Adequate Dementia Care and Behavioral Health Services
Penalty
Summary
The facility failed to provide the necessary dementia care and services to attain or maintain the highest level of practicable physical, mental, and psychosocial well-being for two residents, R26 and R77. R26 had diagnoses of mild cognitive impairment, cognitive communication deficit, and cerebral infarction. Despite displaying aggressive behaviors such as hitting, biting, and attempting to pull her roommate out of bed, the facility did not investigate the incident to identify potential triggers or causative factors. Additionally, R26's care plan lacked specific interventions related to her cognitive impairment and behaviors, and staff were not adequately informed or trained to manage her behaviors effectively. R77 had diagnoses of vascular dementia, depressive disorder, cerebral infarction, hemiparesis/hemiplegia, epilepsy, and diabetes mellitus. Despite multiple instances of expressing a desire to die, refusing care, and displaying aggressive behaviors such as kicking and scratching staff, the facility did not provide adequate person-centered interventions. The care plan for R77 lacked direction regarding his mood and verbalizations of wanting to die. The facility also failed to follow up with a Geri-Psych hospital for placement and did not implement consistent safety checks or alternative interventions when R77 refused to see a therapist. The facility's Behavioral Health Services policy stated that residents would receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being. However, the facility did not adhere to this policy for both R26 and R77. The lack of person-centered interventions and failure to investigate and address the residents' behaviors placed them at risk for abuse and decreased quality of life.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to notify the physician of blood sugars outside of ordered parameters for Resident 31 and did not monitor Resident 31's blood pressure before administering medication for high blood pressure. Resident 31 had diagnoses of dementia, diabetes mellitus, and hypertension. The care plan for Resident 31 lacked interventions or directions for monitoring side effects from medications related to diabetes and hypertension. The Treatment Administration Record (TAR) documented multiple instances where blood sugars were outside the ordered parameters, and the physician was not notified. Additionally, there was no documentation of blood pressure being checked before administering lisinopril for 78 administrations since the start of the medication. The facility also failed to hold blood pressure medication and insulin when the medication was out of the physician-ordered parameters for Resident 6. Resident 6 had diagnoses of hypertension and diabetes mellitus and was independent for most activities of daily living. The Medication Administration Record (MAR) documented several instances where blood pressure medications and insulin were administered despite the physician's orders to hold them if certain parameters were not met. Specifically, hydralazine, Cozaar, and metoprolol were administered multiple times when the systolic blood pressure was less than 110 mmHg, and Humalog insulin was administered when the finger stick blood sugar was less than 110 mg/dL. Observations and interviews with staff confirmed these deficiencies. Administrative Nurse D verified that the care plan for Resident 31's diabetes should have been completed and that blood sugars outside of the ordered parameters were not reported to the physician. Additionally, it was confirmed that staff had not obtained Resident 31's blood pressure before administering blood pressure medication. For Resident 6, it was verified that staff should have held the insulin and blood pressure medications as ordered when the parameters were not met. The facility's policies on administering medications and monitoring vital signs were not followed, placing the residents at risk for adverse medication effects.
Inappropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure an appropriate indication or a documented physician rationale for the continued use of antipsychotic medication for a resident diagnosed with Alzheimer's. The resident's electronic medical record lacked documentation of unsuccessful attempts for nonpharmacological symptom management and a risk versus benefits analysis for the continued use of Seroquel. The resident's care plan noted the use of antipsychotic medication and the need for monitoring side effects, but the physician's order did not provide a valid indication for the medication's use. Observations revealed that the resident received Seroquel despite spitting out other medications, and the administrative nurse confirmed the inappropriate indication for the antipsychotic medication. The facility's policy on antipsychotic medication use required that all potential causes of behavioral symptoms be identified and addressed before considering such medications. However, the facility did not adhere to this policy, as evidenced by the lack of documented rationale and nonpharmacological interventions for the resident. This failure placed the resident at risk for adverse medication side effects, as the facility did not ensure the antipsychotic medication was used appropriately and with proper documentation.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to prevent significant medication errors for a resident diagnosed with end-stage renal disease, hypertension, diabetes mellitus, hypotension, and heart failure. The resident's care plan required staff to administer medications as ordered and monitor for side effects. However, the resident's Medication Administration Records (MAR) for January, February, and March 2024 documented multiple instances where the resident received midodrine and metoprolol outside of the physician-ordered blood pressure parameters. Specifically, midodrine was administered 74 times when the resident's blood pressure was above the ordered parameters, and metoprolol was administered three times when the resident's blood pressure was below the ordered parameters. These errors were not consistently identified or corrected by the staff, despite education and recommendations from the pharmacist regarding the errors in February 2024. Interviews with staff revealed a lack of understanding and proper communication regarding the medication orders and blood pressure parameters. A Certified Medication Aide admitted to not understanding the symbols indicating when to hold the medication, and a Licensed Nurse stated that he did not always check the MAR for blood pressure readings before administering medication. The Administrative Nurse acknowledged that re-education had been provided but no competency checks were performed on the staff who made the errors. The facility's policy required immediate action in the event of significant medication errors, but this was not effectively implemented, placing the resident at risk for adverse medication reactions and physical decline.
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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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