Topeka Presbyterian Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Topeka, Kansas.
- Location
- 4712 Sw 6th Ave, Topeka, Kansas 66606
- CMS Provider Number
- 175297
- Inspections on file
- 21
- Latest survey
- June 17, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Topeka Presbyterian Manor during CMS and state inspections, most recent first.
A resident with Alzheimer's disease and a history of wandering exited the facility unsupervised by following a visitor out the main entrance before the door's lock engaged. Although the resident wore a Wanderguard bracelet and had a care plan identifying elopement risk, staff did not prevent the resident from leaving, and the alarm system was only triggered after the exit. The resident was found outside and returned safely, but the incident revealed a lapse in supervision and exit monitoring.
The facility failed to provide consistent weekend activities on Saturdays, as revealed by a review of the Activity Calendar for October, November, and December 2024. The Resident Council reported long and boring weekends, with residents often staying in their rooms watching TV. Staff interviews confirmed the lack of activities, with efforts underway to recruit volunteers. The facility's Life Enrichment Programs policy was not adhered to, placing residents at risk for decreased psychosocial well-being.
The facility failed to secure hazardous areas and materials, placing residents at risk for accidents. Unsecured closets and rooms contained cleaning chemicals and unlocked electrical panels. A resident with Alzheimer's fell in an unsecured shower room due to inadequate supervision, while another resident's wheelchair was not placed as per their care plan, increasing fall risk. Staff interviews confirmed these areas should have been locked and care plans followed.
The facility did not complete a yearly performance evaluation for a CNA who had been employed for over 12 months. This was confirmed by an administrative staff member who admitted the facility was behind on evaluations. The facility also lacked a policy for yearly staff performance reviews, placing residents at risk for inadequate care.
The facility failed to maintain sanitary standards in the dining room, with dirty plates left from previous meals and an uncovered food thickener container. A CNA placed dome covers directly on food and did not perform hand hygiene between tasks. Staff interviews confirmed inconsistent adherence to hand hygiene protocols, contrary to the facility's policy on maintaining clean food service areas.
The facility failed to implement an effective system for alerting staff and visitors about Enhanced Barrier Precautions (EBP) needs, with PPE stored in rooms without visible signage. Staff interviews revealed a lack of awareness about EBP indicators. Additionally, proper hand hygiene was not followed during wound care, and oxygen equipment was improperly stored, increasing infection risk.
The facility failed to ensure agency staff received required resident rights training, as revealed by a review of training records for CNAs and LNs. Interviews with agency staff indicated inconsistent training practices, and Administrative Nurse D admitted there was no system to verify training completion. This deficiency placed residents at risk for impaired care and decreased quality of life.
The facility failed to ensure agency staff received required infection control training, risking resident care quality. Training records lacked documentation for agency CNAs and an LN, and there was no system to verify training completion. Some agency staff reported completing in-services through their agencies, but the facility relied on agencies to ensure training, contrary to its education policy.
The facility failed to ensure the use of foot pedals during wheelchair transport for three residents, leading to their feet sliding on the floor. Staff interviews confirmed the expectation for foot pedals to be used, but no policy was provided. This oversight placed residents at risk for preventable accidents.
A resident with severe cognitive impairment and multiple health conditions was not properly assisted with grooming, resulting in matted and unkempt hair. Despite staff acknowledging their responsibility to ensure residents are presentable, the facility lacked a policy for ADLs, and the resident's consistent refusals for showering were documented without adequate intervention.
A resident with multiple health conditions, including hemiplegia and obesity, was at high risk for pressure ulcers. The facility failed to set the resident's low air-loss mattress at the correct weight, as specified in the care plan, which was crucial for pressure ulcer prevention. Observations showed the mattress was set at 320 pounds instead of the required 190-210 pounds. Staff interviews revealed inconsistent monitoring and documentation practices, despite the facility's policy emphasizing preventative measures for skin integrity.
A facility failed to ensure a resident had a safety assessment for side rails used with a low air-loss mattress. The resident, with severe cognitive impairment and a history of falls, was fully dependent on staff for transfers and ADLs. The facility's policy required an assessment of risks associated with side rails and low air-loss mattresses, but staff did not conduct this assessment, placing the resident at risk for uninformed decisions and impaired safety.
A facility failed to ensure a resident had a CMS-approved indication or required physician-documented rationale, including risk versus benefits, for the use of Zyprexa. The resident, with severe dementia and other conditions, was receiving hospice services and had a severely impaired cognition. Despite the facility's policy requiring documentation and monitoring of psychoactive medications, the EMR lacked documentation of nonpharmacological interventions attempted and failed, placing the resident at risk for unnecessary medication administration and possible adverse side effects.
The facility failed to coordinate hospice services for two residents, leading to inadequate end-of-life care. The care plans lacked specific instructions on hospice services, causing confusion among staff. Interviews revealed staff uncertainty about hospice services, highlighting a gap in care coordination.
A resident consented to receive the PCV20 pneumococcal vaccine in August 2024 but did not receive it until December 2024, despite the facility's policy requiring timely vaccination. The delay was confirmed through EMR review and staff interviews, with no explanation provided for the oversight.
A resident with multiple health conditions, including osteoporosis and COPD, sustained fractures to both ankles due to improper transfer methods by staff. The resident's care plan required a sit-to-stand lift with two staff members, but an unsafe arm-in-arm transfer was used instead. The facility's investigation was inadequate, failing to identify all involved staff and not adhering to the policy on safe transfers.
Elopement Due to Inadequate Supervision and Exit Monitoring
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, moderate cognitive impairment, and a history of wandering was able to elope from the facility. The resident's care plan identified him as being at risk for elopement, required the use of a Wanderguard bracelet, and instructed staff to check its placement and functionality regularly. The care plan also noted that the resident would often wait by the facility entrance for his wife and required redirection and supervision. Despite these interventions, the resident was able to exit the facility by following a visitor out the main entrance before the door's lock could engage. The Wanderguard alarm system was triggered, and staff found the resident outside the main entry, leaning against a brick wall. The resident was assessed and found to have no injuries before being redirected back inside. Interviews with staff confirmed that the resident's Wanderguard was checked each shift and that he was known to be confused and required supervision when outside. The facility's policy required close monitoring of residents at risk for elopement and adherence to individualized care interventions, but the resident was able to leave the building unsupervised due to a lapse in monitoring at the entrance.
Inconsistent Weekend Activities for Residents
Penalty
Summary
The facility failed to provide consistent weekend activities on Saturdays, which are essential for promoting socialization among residents. The review of the facility's Activity Calendar for October, November, and December 2024 revealed a lack of scheduled activities on several Saturdays. Specifically, no activities were recorded on 10/19/24, 10/26/24, 11/02/24, 11/09/24, 11/30/24, and throughout December. This inconsistency in providing activities was confirmed by the Resident Council, which reported that weekends were long and boring, with residents often staying in their rooms watching TV. Interviews with facility staff further corroborated the deficiency. Activities Staff Z acknowledged the absence of consistent weekend activities and mentioned efforts to recruit volunteers from churches and staff to address this issue. CNA Q was unaware of any weekend activities, indicating a lack of communication or implementation of such programs. Administrative D stated that while volunteers were available on Sundays, the nursing staff could facilitate weekend activities, but there was no evidence of this occurring. The facility's Life Enrichment Programs policy emphasizes the importance of group activities for residents' well-being, yet the facility failed to adhere to this policy, placing residents at risk for decreased psychosocial well-being, boredom, and isolation.
Failure to Secure Hazardous Areas and Supervise Residents
Penalty
Summary
The facility failed to secure hazardous areas and materials, placing residents at risk for preventable accidents and injuries. During a walk-through, it was observed that housekeeping and linen closets in the 580's hallway were unsecured, containing cleaning chemicals with warning labels and unlocked electrical panels marked with high voltage warnings. Additionally, a storage closet in the 560's hallway and the Spa room were found unsecured, with the latter containing unsecured sanitary bleach wipes. Staff interviews confirmed that these areas should have been locked to prevent resident access, especially for the ten cognitively impaired, independently mobile residents. Resident 33, diagnosed with Alzheimer's disease and other conditions, was at risk for falls due to cognitive and physical impairments. Despite a care plan indicating the need for extensive assistance and supervision, R33 was found in a shower room after a fall, which should have been locked. The facility's investigation revealed that R33 attempted to toilet herself, leading to the fall. Staff interviews highlighted that R33 was impulsive and required supervision, yet the necessary precautions were not consistently implemented, resulting in her accessing the unsecured shower room. Resident 43, with multiple diagnoses including anxiety and Parkinson's disease, was also at risk for falls. The care plan required R43's wheelchair to be placed next to her to prevent falls. However, it was observed that R43's wheelchair was folded and out of reach, contrary to the care plan. Staff interviews indicated that while care plans were accessible, they were not always reviewed or followed, leading to R43's fall. The facility's failure to adhere to the care plan and ensure proper supervision and equipment placement contributed to the risk of falls and injuries for R43.
Failure to Complete Yearly Performance Evaluation for CNA
Penalty
Summary
The facility failed to complete a yearly performance evaluation for one of the five Certified Nurse Aides (CNA) reviewed, specifically CNA N, who had been employed for over 12 months. This oversight was identified during a review of the facility's staffing list and confirmed through an interview with Administrative Staff A. The staff member acknowledged that CNA N's performance evaluation had not been completed, citing that the facility was behind in conducting these evaluations. Additionally, the facility was unable to provide a policy related to yearly staff performance reviews. This deficiency placed the residents at risk for inadequate care.
Sanitary Standards Violation in Dining Room
Penalty
Summary
The facility failed to maintain a sanitary environment for food storage and meal service, as observed in the Cedar View dining room. Dirty plates were left on a table next to the kitchenette's serving window from the previous evening's meal service. A large, uncovered container of instant food thickener was found on the condiment shelf, with residue covering the countertop. Despite being moved, the thickener container remained uncovered at various times, indicating a lack of adherence to sanitary standards. Additionally, a CNA was observed placing dome covers directly on food, pushing it downward, and delivering it to residents without proper hand hygiene between tasks. Staff interviews revealed that hand hygiene protocols were not consistently followed, as CNAs were expected to sanitize hands before, during, and after assisting residents with meals. The facility's policy on equipment storage, cleaning, and sanitizing emphasized the importance of maintaining clean and sanitary food service areas, yet these standards were not met. The failure to adhere to these protocols placed residents at risk of food-borne illnesses and compromised food safety.
Inadequate Infection Control and EBP Signage
Penalty
Summary
The facility failed to develop and implement an effective system to alert staff and visitors of Enhanced Barrier Precautions (EBP) needs for residents identified as requiring such precautions. During inspections, it was observed that personal protective equipment (PPE) was stored in residents' rooms without any visible signage or indicators for EBP, leaving staff and visitors unaware of the necessary precautions. Interviews with staff revealed a lack of awareness regarding the indicators for EBP, with some staff members unaware of the blue dots on door plates meant to signify EBP rooms. This lack of clear communication and signage compromised the facility's ability to effectively manage infection control. Additionally, the facility failed to adhere to proper hand hygiene protocols during wound care and did not ensure the sanitary storage of oxygen therapy equipment. Observations showed that a licensed nurse did not change gloves or perform hand hygiene between handling soiled and clean dressings during a resident's wound care. Furthermore, oxygen equipment, such as nebulizer masks and nasal cannulas, were found improperly stored on surfaces like coffee tables and beds, rather than in clean storage bags as required by the facility's policy. These practices increased the risk of infectious disease transmission among residents.
Deficiency in Resident Rights Training for Agency Staff
Penalty
Summary
The facility failed to ensure that agency staff received the required resident rights training, which is essential for providing proper care and maintaining the quality of life for residents. The deficiency was identified during a review of training records for agency staff, including Certified Nurses Aids (CNAs) and Licensed Nurses (LNs). Specifically, the credentialing files for CNA O and LN I lacked documentation of completed resident rights training. Although LN I's file indicated she had received training on abuse, neglect, and exploitation, the absence of resident rights training was noted. Interviews with agency staff, such as CNA Q and LN H, revealed that while some in-services were completed through their staffing agencies, there was no consistent system in place at the facility to ensure all agency staff had completed the necessary training. Administrative Nurse D acknowledged the expectation that the staffing agency would ensure their staff completed the required in-services. However, she admitted there was no system in place at the facility to verify that agency staff had received the necessary training. The facility's education policy, dated August 2022, outlined the goal of ensuring all staff received appropriate training to guarantee resident safety and well-being, utilizing an electronic learning management system and other educational resources. Despite this policy, the lack of documented resident rights training for agency staff placed residents at risk for impaired care and decreased quality of life.
Failure to Ensure Infection Control Training for Agency Staff
Penalty
Summary
The facility failed to ensure that agency staff received the required infection control training, which placed residents at risk for impaired care and decreased quality of life. During a review of training records, it was found that the credentialing files for agency CNAs and a Licensed Nurse lacked documentation of completed infection control training. Although some agency staff reported completing in-services through their staffing agencies, there was no system in place at the facility to verify that these trainings were completed. Interviews with agency staff revealed that while some had attended in-services at the facility, there was an expectation from the Administrative Nurse that the staffing agency would ensure the completion of required in-services. The facility's education policy aimed to ensure all staff received appropriate training for resident safety and well-being, utilizing an electronic learning management system and other educational resources. However, the lack of documented infection control training for agency staff indicated a failure to meet this goal.
Failure to Use Foot Pedals During Wheelchair Transport
Penalty
Summary
The facility failed to ensure the appropriate use of foot pedals during wheelchair transports for three residents, placing them at risk for preventable accidents and injuries. On multiple occasions, staff were observed transporting residents without foot pedals in place, causing the residents' feet to slide along the floor. Specifically, a resident with upper and lower extremity impairments was wheeled without foot pedals to the medication cart, and two other residents, one severely cognitively and physically impaired, were transported in similar conditions. Interviews with staff, including a Licensed Nurse and a Certified Nurse Aide, confirmed that the expectation was for foot pedals to be in place during transport. However, the facility did not provide a policy related to the accommodation of needs or assistive devices for wheelchairs, indicating a lack of procedural guidance. This oversight in ensuring the proper use of assistive devices during resident transport was identified as a deficiency by the surveyors.
Failure to Assist Resident with Grooming
Penalty
Summary
The facility failed to ensure staff assisted a resident, identified as R4, with grooming, which placed the resident at risk for impaired dignity and a further decline in activities of daily living (ADL). R4's medical history included severe cognitive impairment, heart disease, kidney disease, and Alzheimer's disease, among other conditions. The resident's care plan indicated a need for staff assistance with grooming and other ADLs, but observations revealed that R4's hair was matted and unkempt, indicating a lack of proper grooming assistance. Interviews with facility staff, including a licensed nurse and a certified nurse's aide, confirmed that it was the responsibility of the staff to ensure residents were clean and presentable before leaving their rooms. However, the facility did not provide a policy for ADLs, and R4's medical record documented consistent refusals for showering. Despite these refusals, staff were expected to assist R4 with grooming, but failed to do so, as evidenced by the resident's appearance during observations.
Failure to Set Low Air-Loss Mattress Correctly for Resident
Penalty
Summary
The facility failed to ensure that a resident's low air-loss mattress was set at the appropriate weight setting, which is crucial for preventing pressure ulcers. The resident, identified as R32, had a range of medical conditions including hemiplegia, muscle wasting, obesity, and Alzheimer's disease, and was at high risk for pressure ulcers as indicated by a Braden Scale score of 10. Despite having a care plan that specified the mattress should be set between 190-210 pounds, observations revealed that the mattress was set at 320 pounds, which was not in accordance with the resident's weight of 201.8 pounds. This discrepancy was not documented or monitored in the resident's electronic medical record (EMR), and there was no evidence of regular checks to ensure the mattress was set correctly. Interviews with facility staff revealed a lack of consistent monitoring and documentation practices regarding the low air-loss mattress settings. A licensed nurse acknowledged that the mattress should be set according to the resident's current weight but was unable to find any record of monitoring in the EMR. Additionally, a certified nursing aide stated that she would notify a charge nurse if the pump was beeping but did not adjust the settings herself. The administrative nurse claimed that nursing staff checked each mattress daily and signed off on the Treatment Administration Record (TAR) each shift, but this was not reflected in the documentation. The facility's Skin Integrity policy emphasized the importance of evaluating skin integrity and implementing preventative measures, yet the failure to set the mattress correctly placed the resident at increased risk for pressure ulcer development.
Failure to Assess Side Rail Safety with Low Air-Loss Mattress
Penalty
Summary
The facility failed to ensure that a resident, identified as R33, had a safety assessment for the use of side rails that acknowledged the risks when used with a low air-loss mattress. R33's medical history included Alzheimer's disease, a history of fractures related to falls, hearing loss, age-related physical debility, fatigue, urinary retention, and age-related macular degeneration. The resident was severely cognitively impaired, fully dependent on staff for transfers and activities of daily living, and had a history of falls. Despite these conditions, the facility did not conduct a comprehensive safety assessment that considered the interaction between the side rails and the low air-loss mattress, which is crucial to prevent entrapment and ensure safety. Observations and interviews revealed that the facility's staff did not assess the side rails in relation to the low air-loss mattress, as required by the facility's policy. The Assistive Device for Bed Screening form completed for R33 failed to acknowledge the use of the low air-loss mattress, and the facility's policy indicated that such mattresses should be included in the evaluation of potential risks. Interviews with staff confirmed that while they checked for gaps in the bed rails, they did not assess the specific risks associated with the combination of side rails and low air-loss mattresses. This oversight placed R33 at risk for uninformed decisions and impaired safety related to the use of side rails.
Failure to Document Rationale for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident, identified as R41, had a Centers for Medicare and Medicaid Services (CMS) approved indication or the required physician-documented rationale, including risk versus benefits and nonpharmacological attempts, prior to the use of the antipsychotic medication Zyprexa. R41's electronic medical record documented diagnoses of vascular dementia with irritation, depression, anxiety, and delirium. Despite these conditions, the facility did not complete a gradual dose reduction, and there was no physician documentation that a gradual dose reduction was contraindicated for R41. The resident was receiving hospice services and had a severely impaired cognition with a BIMS score of three. Observations and interviews revealed that R41 was at risk for unnecessary medication administration and possible adverse side effects due to the lack of documented rationale for the use of Zyprexa. The resident's care plan directed staff to monitor for side effects, but the EMR lacked documentation of nonpharmacological interventions attempted and failed. The facility's policy on psychoactive medications required that such medications not be used unless necessary to treat medical symptoms and that they be monitored by the interdisciplinary team. However, the facility did not ensure compliance with this policy, placing R41 at risk.
Failure to Coordinate Hospice Services for Residents
Penalty
Summary
The facility failed to ensure coordinated care and services between the facility and hospice providers for two residents, R43 and R38, who were receiving hospice services. For R43, the care plan lacked specific instructions on the services provided by hospice, including the frequency and type of support visits, supplies, medical equipment, medications covered by hospice, and hospice contact information. Despite being newly readmitted to hospice services, R43's care plan did not reflect the necessary coordination, leaving staff uncertain about the hospice services provided. Similarly, R38's care plan was deficient in detailing the services and medications provided by hospice. Although the care plan mentioned that hospice would provide durable medical equipment and that hospice staff would visit per the hospice plan of care, it did not specify the services hospice staff would provide or the medications covered. This lack of detailed information in the care plan led to confusion among staff about the hospice services available to R38. Interviews with facility staff, including a Licensed Nurse, a Certified Nursing Aide, and an Administrative Nurse, revealed a lack of clarity and communication regarding the hospice services provided to the residents. Staff members were unsure where to find information about hospice services if it was not included in the care plan, indicating a gap in the coordination of care. The facility's Care Management policy emphasized systematic and comprehensive management of resident care, yet the failure to coordinate care with hospice providers placed the residents at risk for inadequate end-of-life care.
Failure to Administer Pneumococcal Vaccine Timely
Penalty
Summary
The facility failed to ensure that a resident, identified as R51, received the pneumococcal vaccine after consenting to it. The resident had previously received pneumococcal vaccinations (PPSV23 in 2014 and PCV13 in 2016) but had not been offered or given the newer PCV20 or PCV21 vaccinations since his admission to the facility in 2023. Despite consenting to the PCV20 vaccination on August 28, 2024, the resident did not receive it until December 11, 2024. This delay in vaccination was confirmed through a review of the resident's electronic medical record (EMR) and interviews with the resident and facility staff. The deficiency was identified during a review of influenza and pneumococcal immunizations for a sample of residents, including R51. The facility's policy, revised in July 2024, required that all residents be screened for pneumococcal vaccinations, with assessments of each resident's history, health status, and preferences. However, the facility did not adhere to this policy, as evidenced by the lack of timely administration of the vaccine to R51. The administrative nurse was unable to provide an explanation for the delay in vaccination, which placed the resident at risk for complications from pneumococcal disease.
Failure to Ensure Safe Transfers Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident, identified as R1, remained free from avoidable accident hazards. The deficiency occurred when staff did not adhere to the resident's care plan, which required the use of a sit-to-stand lift with the assistance of two staff members for transfers. Instead, R1 was transferred using an unsafe arm-in-arm method without a gait belt, leading to fractures in both ankles and lower legs. R1's medical history included conditions such as malignant neoplasm of the lower right lung, COPD, osteoporosis, thrombocytopenia, long-term use of anticoagulants, and hypertension. R1 required substantial to maximal assistance for transfers and was assessed as having a moderate risk for falls. Despite these needs, the facility's staff did not follow the prescribed transfer procedures, resulting in significant injuries to R1. The facility's investigation into the incident was inadequate, as it failed to identify all staff involved in the transfer. The investigation relied solely on the account of one CNA, who reported that another unidentified CNA assisted in the transfer. However, other staff interviews contradicted this account, indicating that the transfer was conducted by only one CNA. The facility's policy on lifting and transferring residents was not followed, contributing to the accident and subsequent injuries sustained by R1.
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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