Via Christi Village Pittsburg
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburg, Kansas.
- Location
- 1502 E Centennial, Pittsburg, Kansas 66762
- CMS Provider Number
- 175465
- Inspections on file
- 19
- Latest survey
- November 19, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Via Christi Village Pittsburg during CMS and state inspections, most recent first.
The facility failed to conduct required care plan meetings for four residents, including those with end-stage renal disease, hemiplegia, Alzheimer's, and colon cancer. Care plans were updated without resident or representative involvement, contrary to facility policy.
The facility failed to maintain resident equipment in a clean and safe condition, as observed with a toilet seat riser that had rusty legs and a cracked seat. Housekeeping/Maintenance staff acknowledged the need for replacement, but the facility lacked a policy for equipment maintenance.
The facility failed to maintain a clean environment in one of its neighborhoods, as surveyors observed dirty and stained privacy curtains in a shower room. Housekeeping staff confirmed responsibility for curtain cleanliness and acknowledged the need for washing or replacement. The facility also lacked a policy for maintaining and cleaning shower curtains.
A resident with severe cognitive impairment had a personal humidifier with a heavy build-up of a hardened, white substance, but the care plan lacked instructions for its maintenance. Staff interviews revealed confusion about responsibility for the humidifier's care, and the facility's policy requires care plans to include specific care needs, which was not followed.
The facility failed to update care plans for two residents with dementia, resulting in improper use of wheelchair footrests. Observations showed residents' feet skimming the floor or dangling between footrests during transport. Staff acknowledged the issue but did not revise care plans to include necessary instructions, violating facility policy.
Two residents with hemiplegia and cognitive impairments did not receive adequate grooming assistance, as observed in a LTC facility. One resident was not shaved on designated bath days, while another had food substances left on her face after meals. Staff interviews confirmed expectations for personal hygiene care, but these were not met, violating the facility's dignity policy.
Two residents with dementia in an LTC facility were improperly positioned in their wheelchairs due to the absence or misuse of footrests during staff-assisted transport. Despite facility policy requiring footrests, staff failed to ensure residents' feet were properly supported, leading to deficiencies in care.
A resident with severe cognitive impairment had a humidifier in their room that was not properly cleaned or maintained, leading to a build-up of a hardened, white substance. Facility staff were unclear about who was responsible for the humidifier's care, and the facility's water management policy was not adhered to.
A resident with end-stage renal disease receiving dialysis three times a week was not adequately assessed and monitored by the facility. Despite instructions in the care plan and facility policy, staff failed to consistently perform and document pre-dialysis and post-dialysis assessments, leading to a deficiency in care.
A resident with end-stage renal disease and moderate cognitive impairment received Midodrine outside the physician-ordered parameters, which specified administration only if systolic blood pressure was below 140 mmHg. The facility's staff administered the medication multiple times despite higher blood pressure readings, as confirmed by administrative nurses, violating the facility's policy on medication administration.
A facility failed to assess a resident for adverse effects of Olanzapine, an antipsychotic medication prescribed for violent behaviors. Despite the resident's severe cognitive impairment and the care plan's instructions to monitor for side effects, the necessary AIMS assessments were not conducted as required. Observations indicated potential adverse effects, such as tearfulness and nonsensical mumbling, which were not addressed, highlighting a lapse in following the facility's policy on behavioral assessments and monitoring.
A resident with severe cognitive impairment and at high risk for pressure ulcers developed a stage II ulcer. During wound care, a nurse failed to change gloves and perform hand hygiene after cleansing the wound, contrary to facility policy. This deficiency was confirmed by another staff member.
A cognitively impaired resident was found on the floor by a CMA, who administered medications and left without reporting the incident. The resident remained on the floor for four hours until discovered by a CNA, resulting in a left hip fracture requiring surgical repair.
A resident received two doses of oxycodone within two hours due to a nurse's failure to document the administration of a PRN dose in the EHR. The resident had a history of pneumonia and pain, with moderately impaired cognition. The facility's policy required proper documentation, which was not followed, leading to the medication error.
Failure to Conduct Required Care Plan Meetings
Penalty
Summary
The facility failed to conduct care plan meetings for four residents, as required by their policy. Resident 2, who has end-stage renal disease and receives dialysis, was not included in care plan meetings, as confirmed by Social Service Staff X. The resident's care plan was updated without the involvement of the resident or their representative, despite the facility's policy that encourages participation in care planning. Resident 13, diagnosed with hemiplegia after a stroke, also did not have care plan meetings conducted with their involvement. The resident, who requires extensive assistance with daily activities, had a care plan updated without their or their representative's participation. This was confirmed by Social Service Staff X, who acknowledged the omission of care plan meetings. Resident 7, with severe cognitive impairment due to Alzheimer's disease and dementia, and Resident 57, with colon cancer, were similarly affected. Resident 7's care plan was updated without a meeting, and Resident 57 had not had a care plan meeting since early in the year, missing scheduled meetings due to the absence of a social worker. The facility's policy mandates quarterly care plan meetings, which were not adhered to for these residents.
Deficiency in Maintenance of Resident Equipment
Penalty
Summary
The facility failed to ensure that all resident equipment in the C Court neighborhood was maintained in a clean and safe condition. During an environmental tour, a toilet seat riser was observed to have multiple rusty areas on all four legs, and the plastic toilet seat was cracked at the area where it met residents' buttocks. Housekeeping/Maintenance Staff U acknowledged that the toilet seat riser needed to be discarded and mentioned that the facility had extra toilet seat risers available for replacement. However, the facility lacked a policy for the maintenance and upkeep of resident equipment, contributing to the deficiency.
Deficiency in Cleanliness of Shower Room Curtains
Penalty
Summary
The facility failed to maintain a clean environment in one of its four neighborhoods, specifically in a shower room on C Court. During an environmental tour, surveyors observed two privacy curtains that were dirty and stained. Housekeeping/Maintenance Staff U confirmed that housekeeping was responsible for ensuring the cleanliness of the privacy curtains in the shower rooms and acknowledged that the curtains needed to be washed or replaced. Additionally, the facility lacked a policy regarding the maintenance and cleaning of the shower curtains.
Failure to Include Humidifier Maintenance in Resident Care Plan
Penalty
Summary
The facility failed to complete a comprehensive care plan for a resident, identified as R27, regarding the care and maintenance of her personal humidifier. The resident, who has a diagnosis of dementia with severe cognitive impairment, was observed with a humidifier in her room that had a heavy build-up of a hardened, white substance in the spout and nebulizer chamber. Despite the presence of the humidifier and its condition, the care plan for the resident, revised on 10/14/24, did not include any staff instructions for the care and maintenance of the humidifier. Interviews with facility staff revealed a lack of clarity and responsibility regarding the maintenance of the resident's humidifier. A Certified Medication Aide (CMA) believed that the night shift staff was responsible for the humidifier's care, while another CMA was unsure of who was responsible. An Administrative Nurse confirmed that the care plan should have included staff instructions for the care and maintenance of personal humidifiers. The facility's policy on care plans, revised in 10/2021, mandates that comprehensive care plans should include resident-specific care needs with measurable goals and outcomes, which was not adhered to in this case.
Failure to Revise Care Plans for Wheelchair Footrest Use
Penalty
Summary
The facility failed to review and revise the care plans for two residents, R59 and R70, regarding the use of footrests for their wheelchairs. Resident 59, diagnosed with dementia and severe cognitive impairment, utilized a wheelchair for mobility and required varying levels of staff assistance. Despite this, her care plan lacked instructions for the use of footrests while being propelled by staff. Observations revealed that her feet skimmed the floor during transport, as her wheelchair lacked footrests. Staff members stated that footrests were not used because the resident sometimes self-propelled. Similarly, Resident 70, also diagnosed with dementia and severe cognitive impairment, required substantial to maximal assistance with mobility. Her care plan did not include instructions for the use of appropriate footrests. Observations showed that her feet dangled between the footrests or rested improperly, indicating a lack of support. Staff acknowledged the issue but had not addressed it in the care plan. The facility's policy required ongoing assessments and revisions of care plans as residents' conditions changed. However, the care plans for both residents were not updated to include necessary instructions for footrest use, leading to deficiencies in their care. The facility's failure to ensure proper footrest use while residents were being propelled by staff was confirmed by both staff and administrative personnel.
Failure to Provide Adequate Grooming Assistance
Penalty
Summary
The facility failed to provide adequate grooming assistance to two residents, R13 and R37, who were dependent on staff for personal hygiene. R13, who had hemiplegia following a stroke and moderate cognitive impairment, was observed with several days' worth of facial hair, indicating a lack of grooming. Despite being cooperative with bathing, the resident was not shaved on his designated bath days, as confirmed by interviews with staff members. The facility's policy on Quality of Life-Dignity emphasized the importance of maintaining residents' dignity through personal care, which was not adhered to in this case. R37, who also had hemiplegia and dementia, required extensive assistance with activities of daily living due to a recent diagnosis of Parkinson's disease. Observations revealed that the resident had food substances on her face after meals, which were not cleaned by staff members, including a Certified Medication Aide and a Licensed Nurse. The resident preferred to feed herself, but staff were expected to assist with personal hygiene afterward, which was not consistently done. This neglect in providing necessary personal hygiene care was contrary to the facility's policy aimed at enhancing residents' dignity and quality of life. Interviews with the Administrative Nurse confirmed that staff were expected to provide personal hygiene care to residents. However, the observations and interviews indicated a failure to meet these expectations, resulting in a deficiency in the care provided to these residents. The facility's inability to ensure proper grooming and hygiene assistance compromised the residents' comfort and dignity, as outlined in their care plans and the facility's policies.
Improper Wheelchair Positioning for Residents with Dementia
Penalty
Summary
The facility failed to properly position two residents, R59 and R70, in their wheelchairs, which led to deficiencies in their care. Resident R59, diagnosed with dementia and severe cognitive impairment, required assistance with mobility and used a wheelchair. Despite the care plan indicating independence with the wheelchair, observations showed that R59's feet skimmed the floor during transport due to the absence of footrests. Staff members, including CNAs and a CMA, acknowledged that footrests were not used because the resident sometimes self-propelled. However, the facility's policy required footrests during staff-assisted transport, which was not adhered to. Resident R70, also diagnosed with dementia and severe cognitive impairment, required substantial to maximal assistance with mobility. Observations revealed that R70's feet were not properly supported on the wheelchair footrests, with instances of feet dangling or resting improperly. Staff, including a CNA, failed to notice the improper positioning of the resident's feet. The facility's policy mandated that residents' feet should rest comfortably on footrests during transport, which was not followed in R70's case. Interviews with staff, including a Licensed Nurse and an Administrative Nurse, confirmed the expectation that footrests should be used during transport to ensure residents' feet are properly positioned. The facility's policy for safe patient transport in wheelchairs, approved earlier in the year, was not implemented effectively, resulting in the improper positioning of both residents during transport.
Failure to Maintain Resident's Humidifier
Penalty
Summary
The facility failed to provide proper respiratory care for a resident, identified as R27, by not maintaining and cleaning a humidifier in the resident's room. The resident, who has a diagnosis of dementia with severe cognitive impairment, was observed with a humidifier that had a heavy build-up of a hardened, white substance in the spout and nebulizer chamber. This condition persisted over several days, indicating a lack of maintenance and cleaning of the device. Interviews with facility staff revealed confusion and uncertainty regarding the responsibility for the care and cleaning of the resident's humidifier. Certified Medication Aides were unsure of who was responsible, and the Administrative Nurse did not know how often the humidifiers should be cleaned. The facility's policy on water management to reduce Legionella exposure was not followed, as it included guidelines for maintaining devices like humidifiers to prevent the growth and spread of Legionella.
Failure to Monitor Dialysis Patient
Penalty
Summary
The facility failed to provide adequate assessment and monitoring for a resident with end-stage renal disease who required dialysis three times a week. The resident, who had moderate cognitive impairment, was at risk for nutritional and fluid volume imbalance. The care plan instructed staff to assess the dialysis access site for bleeding and ensure stable blood pressure before the resident resumed activity. However, the facility did not consistently perform or document pre-dialysis and post-dialysis assessments as required. Specifically, the Dialysis Communication forms from late September to mid-October lacked pre-dialysis and post-dialysis assessments on multiple occasions. The Nurse's Progress Notes also lacked documentation of these evaluations. Interviews with staff confirmed that assessments should have been conducted and documented, but this was not done consistently. The facility's policy required staff to assess the access site and document the resident's condition before and after dialysis, but these procedures were not followed, leading to a deficiency in care.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary drugs, specifically regarding the administration of Midodrine, a medication used to increase blood pressure. The resident, who had end-stage renal disease and was receiving dialysis, had a physician's order to administer Midodrine only if the systolic blood pressure (SBP) was less than 140 mmHg. However, the Medication Administration Record (MAR) showed multiple instances where staff administered Midodrine despite the resident's SBP being above the ordered threshold, ranging from 142 mmHg to 175 mmHg. The resident's medical records indicated moderate cognitive impairment and a risk for nutritional and fluid volume imbalance due to dialysis treatments. Despite these considerations, the facility's staff did not adhere to the physician's parameters for administering Midodrine, as confirmed by interviews with administrative nurses. The facility's policy required staff to record medication and any specified parameters, but this was not followed, leading to the administration of Midodrine outside the prescribed limits.
Failure to Monitor Antipsychotic Side Effects
Penalty
Summary
The facility failed to adequately assess a resident, identified as R44, for adverse effects of an antipsychotic medication, specifically Olanzapine, which was prescribed for violent behaviors. The resident, who has a history of dementia with behavioral disturbances, anxiety, and pseudobulbar affect, was noted to have severe cognitive impairment with a BIMS score of one. Despite the care plan's instructions to monitor for adverse effects due to the medication's Black Box warning, the facility did not perform the necessary assessments using the AIMS tool to check for extrapyramidal side effects. The last documented AIMS assessment was completed several months prior, and the facility's policy required such assessments every three months. Observations of the resident showed signs of potential adverse effects, such as tearfulness, flat affect, and nonsensical mumbling, which were not adequately addressed by the facility. An interview with Administrative Nurse E confirmed the expectation for regular assessments using the AIMS tool, which had not been met. The facility's policy on Behavioral Assessments, Intervention, and Monitoring emphasized the need for minimal complications through both nonpharmacological and pharmacological interventions, yet the interdisciplinary team failed to review and discuss the necessary interventions and findings for this resident.
Failure in Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during wound care for a resident identified as R27. The resident, who has a diagnosis of dementia and severe cognitive impairment, was at high risk for developing pressure ulcers. Despite having no unhealed pressure ulcers at the time of the initial assessment, the resident developed a stage II pressure ulcer on the coccyx, which was being treated according to a physician's order. During a dressing change, Administrative Nurse F did not change gloves or perform hand hygiene after cleansing the wound and before measuring it, which was against the facility's wound care policy. The facility's policy, revised in May 2023, clearly stated that staff should remove gloves, perform hand hygiene, and don clean gloves after cleansing a wound. However, during an observation on October 16, 2024, Administrative Nurse F admitted to not following this protocol. This lapse in procedure was confirmed by another staff member, Administrative Nurse D, who stated that the expectation was for staff to change gloves and perform hand hygiene after cleansing a wound and before measuring it. This failure to perform proper hand hygiene during wound care was a deficiency identified by the surveyors.
Failure to Prevent Neglect of Cognitively Impaired Resident
Penalty
Summary
The facility failed to prevent the neglect of a cognitively impaired resident. On the morning of 11/27/23, a Certified Medication Aide (CMA) found the resident on the floor with her legs extended in the doorway of her closet. Despite observing the resident in this condition, the CMA administered medications and left the room without reporting the incident to any other staff members. The resident remained on the floor for four hours until a Certified Nurse Aide (CNA) heard noises coming from the room and discovered the resident still on the floor. The resident was then assessed by a Licensed Nurse (LN) and found to have a left hip fracture, which required surgical repair. The resident had a history of vascular dementia, diabetes mellitus, hypertension, seizures, anxiety, depressive disorder, narcolepsy, bilateral hearing loss, and mixed receptive-expressive language disorder. She was severely cognitively impaired, requiring extensive assistance with bed mobility, transfers, and toileting, and had a history of falls. The resident's care plans included specific instructions for fall prevention and assistance with activities of daily living (ADLs). The facility's investigation revealed that the CMA did not think anything of the resident being on the floor because she had known the resident to do her own thing while still needing help. However, the facility's abuse prevention policy clearly stated that residents have the right to be free from neglect. The failure to report the resident's fall and provide immediate assistance resulted in the resident remaining on the floor for an extended period, leading to a serious injury that required emergency medical intervention.
Removal Plan
- The facility educated all staff on the topics of Falls, Abuse, Neglect and Exploitation, and Timely Reporting.
- R1 was assessed by Administrative Nurse D and no adverse effects noted.
- R1's care plan related for falls reviewed by the Interdisciplinary Team and fall interventions were appropriate.
- Staff education provided for all clinical staff and completed prior to the onsite survey.
Medication Error Due to Documentation Failure
Penalty
Summary
The facility failed to prevent a medication error when a Licensed Nurse (LN) did not document the administration of a pain medication in a resident's Electronic Health Records (EHR). On the specified date, LN I administered a five-milligram tablet of oxycodone as an as-needed (PRN) pain medication at 06:00 AM. However, this administration was not recorded in the Medication Administration Record (MAR). Two hours later, at 08:00 AM, another nurse, LN H, administered the resident's scheduled dose of oxycodone, which was supposed to be given one hour before the resident left for dialysis. This resulted in the resident receiving two doses of oxycodone within a two-hour period, contrary to the physician's order that required a six-hour interval between doses. The resident involved had a history of pneumonia and pain, with moderately impaired cognition as indicated by a Brief Interview of Mental Status score of eight. The resident's Pain Care Plan documented a pain rating of four out of ten. The facility's Medication Administration Policy required verification of the right resident, medication, dosage, time, and method of administration, and documentation in the MAR after each medication was given. Despite these guidelines, the failure to document the PRN dose led to the medication error. The incident was confirmed through interviews with the involved nurses and a review of the controlled substance log and progress notes.
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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