Village Shalom Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Overland Park, Kansas.
- Location
- 5500 West 123rd St, Overland Park, Kansas 66209
- CMS Provider Number
- 175441
- Inspections on file
- 16
- Latest survey
- July 9, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Village Shalom Inc during CMS and state inspections, most recent first.
Surveyors observed multiple failures in food storage and handling, including staff not wearing hairnets or beard nets, opened frozen foods not being sealed, labeled, or dated, and improper glove use during food service. A CNA served food without performing hand hygiene and handled plates in a non-sanitary manner, all contrary to facility policy and increasing risk of food-borne illness.
The facility failed to keep oxygen tanks and hazardous chemicals secured in locked areas, leaving them accessible to cognitively impaired, independently mobile residents. A resident with severe cognitive impairment and ADL deficits was left unsupervised during meals in her room, with her call light out of reach, despite care plan requirements for supervision and call light accessibility. Staff interviews confirmed these lapses, and facility policies requiring secure storage and supervision were not followed.
Staff failed to consistently perform hand hygiene before blood glucose checks and IV administration, and did not sanitize a Hoyer lift between residents. Interviews confirmed that while staff were aware of infection control protocols, these were not always followed, resulting in lapses in hand hygiene and equipment sanitation.
A resident with severe cognitive impairment and behavioral challenges was repeatedly found undressed and exposed in his room, visible from the hallway and exterior windows. Staff acknowledged the resident's preference to be without clothing but did not consistently ensure privacy or cover the resident, and the care plan lacked specific interventions addressing these behaviors, resulting in a failure to maintain dignity and respect.
A resident transitioning from Medicare Part A to LTC was not provided with the required CMS SNF ABN and NOMNC forms, despite documentation of discussions about coverage ending and appeal rights. Social services staff confirmed that these forms had not been issued due to a recent staff changeover, in violation of facility policy.
Two residents with dementia received antipsychotic medications without documented physician rationale, risk versus benefit analysis, or evidence of unsuccessful nonpharmacological interventions. Staff and administration were unsure of appropriate indications for these medications, and the facility could not provide required documentation, resulting in the use of unnecessary psychotropic medications.
A resident with severe cognitive impairment and multiple ADL dependencies did not consistently receive required staff assistance and supervision during meals, as specified in her care plan and facility policy. Observations showed that meals and nutritional supplements were left at her bedside without staff present, and her call light was not within reach. Staff interviews confirmed that supervision and assistance were required but not always provided.
A resident with CHF and other comorbidities did not have daily weights recorded on multiple occasions as ordered by the physician, and there was no documentation that the physician was notified when weights were missed. Staff interviews confirmed the expectation to follow such orders, but records showed repeated omissions.
A deficiency was identified when staff did not ensure a low air-loss mattress was set to the correct weight for a resident with severe cognitive impairment and high risk for pressure ulcers. Despite care plans and assessments indicating the need for pressure-reducing interventions, the mattress was repeatedly observed set at 200 lbs, while the resident weighed 122 lbs. Staff interviews confirmed the expectation to check and adjust mattress settings each shift, but this was not done, resulting in noncompliance with the facility's wound management policy.
Two residents with dementia and Alzheimer's disease were prescribed antipsychotic medications for non-approved indications, and the facility did not address the Consultant Pharmacist's recommendations or ensure proper physician documentation for risk versus benefit. Additionally, a resident's as-needed Midodrine was not administered according to physician orders, and the physician was not notified as required. Staff interviews revealed uncertainty about appropriate antipsychotic use and proper documentation procedures.
A resident with multiple diagnoses, including dementia and hypotension, had a physician's order for Midodrine to be administered as needed for low blood pressure. Over a period of more than two months, there were numerous instances where the resident's blood pressure met the criteria for administration, but the medication was only given once and there was no documentation that the physician was notified when it was not administered as ordered. Staff interviews and facility policy confirmed the expectation to follow physician orders and document notifications, but the clinical record did not reflect this.
A resident with multiple medical conditions received Midodrine without staff following the physician-ordered blood pressure parameters, and there was no documentation that the physician was notified when orders were not followed. Nursing staff confirmed the expectation to check vitals and notify the physician as required, but the facility failed to ensure proper administration and documentation.
Medication carts containing treatment supplies and PRN creams were observed left unlocked and unattended, out of the nurse's view. Nursing staff acknowledged that carts should be locked when not directly supervised, in accordance with facility policy and regulatory requirements.
A resident with severe cognitive impairment and risk for malnutrition was ordered to receive a nutritional supplement 30 minutes after meals, but staff repeatedly provided the supplement with the meal instead. Observations showed the supplement was consumed during or before the meal without required staff supervision, contrary to the physician's order and facility policy.
Direct care staff, including CNAs and CMAs, did not complete the required 12 hours of annual in-service education as documented in their credentialing files. Essential training topics such as infection control, HIPAA, resident rights, and abuse prevention were not evidenced as completed. Administrative staff confirmed that the oversight occurred due to a lapse in tracking responsibilities.
Deficient Food Storage and Handling Practices Observed
Penalty
Summary
The facility failed to ensure proper food storage and handling practices in multiple areas, as observed during surveyor visits. Dietary staff were seen in the main kitchen without appropriate hairnets or beard nets, and opened packages of frozen potato products were found in the freezer without being placed in sealed bags, labeled, or dated. In the dining and serving areas, a dietary server wore gloves but did not change them after draining liquid from a bowl of fruit before continuing to serve food. Additionally, a dietary server in a kitchenette was observed serving food without her long hair secured in a hairnet. A Certified Nurse Aide (CNA) assisted with serving prepared plates to residents, handling plates with her thumb on the lip of the plate and failing to perform hand hygiene during the meal service. These actions were not in accordance with the facility's Food Storage- Food Safety & Infection Control policy, which requires all opened food items to be labeled, dated, and properly sealed, and for staff to wear hairnets in food preparation and serving areas. The observed deficiencies placed residents at risk of food-borne illnesses.
Failure to Secure Hazardous Materials and Provide Supervision During Meals
Penalty
Summary
The facility failed to secure pressurized supplemental oxygen tanks and hazardous cleaning chemicals in locked areas, leaving them accessible in unlocked closets within the dining area and adjacent storage spaces. Thirteen fully pressurized oxygen cylinders were observed stored in floor racks in an unlocked supply closet, and unsecured cleaning chemicals labeled as hazardous were found in a nearby storage closet. Staff interviews confirmed that these areas were expected to be locked at all times, but staff sometimes forgot to fully close the doors, resulting in the materials being accessible to residents, including those with cognitive impairments. Additionally, the facility did not provide consistent supervision to a resident with severe cognitive impairment, Alzheimer's disease, and significant ADL deficits during mealtimes. The resident's care plan required staff to supervise her during meals, encourage her to eat in the dining room, and ensure her call light was always within reach. However, multiple observations showed the resident eating alone in her room without staff present, with her call light out of reach under her bed, and her nutritional supplement left with her meal. Staff interviews confirmed that supervision and call light accessibility were required per the care plan, but these interventions were not consistently implemented. Facility policies required hazardous materials and oxygen to be secured and inaccessible to residents, and for residents to have access to a call system at all times. The facility's fall management and call light policies also emphasized the need for supervision and minimizing accident risks, but these were not followed, resulting in residents being exposed to preventable hazards and lacking necessary supervision.
Failure to Perform Hand Hygiene and Sanitize Shared Equipment
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols, specifically regarding hand hygiene and equipment sanitation. A licensed nurse did not perform hand hygiene before preparing a glucometer for a blood glucose check, nor before entering a resident's room or administering IV medication. The nurse also used the same alcohol wipe to clean the glucometer, the resident's finger, and the insulin pen hub, contrary to established procedures. Additionally, a certified nurse's aide did not sanitize a Hoyer lift after use with one resident before making it available for use with others. Staff interviews confirmed awareness of the required hand hygiene and equipment sanitation protocols, but also revealed inconsistent practices, particularly with the Hoyer lift, which was not always sanitized between residents. The facility's own policy, aligned with CDC guidelines, mandates hand hygiene before and after resident contact and after contact with medical equipment, as well as sanitizing shared equipment between uses. These lapses in protocol were observed directly by surveyors and acknowledged by staff during interviews.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
A resident with severe cognitive impairment, Parkinson's Disease, major depressive disorder, muscle weakness, and an overactive bladder was dependent on staff for all activities of daily living, including dressing, personal hygiene, and toileting. The resident exhibited behaviors such as wandering, rejection of care, and undressing, and was noted to have poor judgment, safety awareness, and memory recall. The care plan acknowledged behavioral challenges and refusal of care but did not include specific interventions related to the resident's preference or behaviors regarding undressing. Multiple nursing notes documented incidents where the resident was found naked in his room, either standing in the restroom or lying in bed without clothing or covers, and at times refused staff assistance to redress or provide care. Observations confirmed the resident was left uncovered and visible from the hallway and exterior windows for extended periods. Staff interviews indicated awareness of the resident's preference to be undressed but revealed inconsistent efforts to maintain the resident's dignity by ensuring privacy or covering him. The facility's dignity policy required maintaining each resident's dignity and respect, but the lack of individualized care plan interventions and insufficient measures to prevent exposure led to a failure to provide a dignified care environment.
Failure to Provide Required Medicare/Medicaid Beneficiary Notification Forms
Penalty
Summary
The facility failed to provide required Medicare/Medicaid beneficiary notification forms to a resident whose Medicare Part A coverage was ending and who was transitioning to long-term care. Specifically, the CMS form 10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) and the CMS form 10123 Notice of Medicare Non-Coverage (NOMNC) were not issued to the resident. Documentation in the electronic medical record indicated that staff discussed the end of Medicare coverage, the transition to LTC, and the right to appeal with the resident and their family, but the actual forms were not provided as required. A review of the facility's policy confirmed that residents should be informed in writing about services, charges, and their rights to appeal at least three days prior to a change in payor status or discharge. Social services staff acknowledged that due to a recent staff changeover, the required ABN and NOMNC forms had not been issued to residents as they should have been. This lapse was identified during the survey when the forms could not be produced upon request.
Failure to Document Appropriate Indication and Physician Rationale for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that two residents with dementia diagnoses received antipsychotic medications only with appropriate indications and documented physician rationale. For one resident with moderately impaired cognition and diagnoses including dementia and Alzheimer's disease, the medical record showed ongoing administration of olanzapine for psychosis without documentation of risk versus benefit or evidence of unsuccessful nonpharmacological interventions. The pharmacy consultant had identified and reported irregularities related to the non-approved indication for this antipsychotic use, but the facility was unable to provide the required physician documentation upon request. For another resident with severely impaired cognition and Alzheimer's disease, quetiapine was administered for severe dementia with agitation. The medical record lacked a physician-documented rationale for the continued use of this antipsychotic for dementia-related behaviors, and no documentation of risk versus benefit was available. The care plan referenced attempts at gradual dose reduction and nonpharmacological interventions, but there was no supporting physician documentation for the ongoing use of the medication. Interviews with nursing staff and administration revealed uncertainty regarding appropriate indications for antipsychotic medications and a lack of awareness about the need for physician documentation of risk versus benefit. The facility's policy required monitoring the need for psychotropic medications and evaluating their effectiveness, but these requirements were not met in the cases reviewed, resulting in the administration of unnecessary psychotropic medications without proper justification.
Failure to Provide Consistent Mealtime Assistance and Supervision
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease, severe cognitive impairment, and multiple ADL (activities of daily living) dependencies did not receive consistent assistance and supervision during mealtimes. The resident's care plan and assessments specified the need for staff to provide substantial to maximal assistance with eating, supervision during meals, and encouragement to eat in the dining room for proper monitoring. The care plan also instructed that the resident should not be left alone in her room while eating and required staff to provide feeding assistance and cues. Observations revealed that on multiple occasions, the resident was served meals in her room without staff present to assist or supervise her. On two separate mornings, the resident was found in bed with her meal and nutritional supplement left at her bedside, with no evidence of staff assistance. The call light was not within her reach, and staff were not present as she consumed her meal. Only on one occasion was staff observed staying in the room to assist the resident during her meal. Interviews with nursing and aide staff confirmed that facility policy and the resident's care plan required staff to supervise and assist the resident during meals, especially due to her cognitive and communication deficits. Staff acknowledged that the resident should not be left alone to eat in her room and that the call light should be accessible. The facility's policy on activities of daily living also required staff to provide necessary assistance to maintain residents' abilities.
Failure to Follow Physician's Order for Daily Weights in Resident with CHF
Penalty
Summary
The facility failed to follow a physician's order for daily weights for a resident with multiple diagnoses, including congestive heart failure (CHF), diabetes mellitus, peripheral vascular disease, kidney disease, and edema. The resident's care plan required daily weights before breakfast, with instructions to notify the physician if there was a weight gain of more than two pounds in one day or five pounds in one week. Despite these orders, review of the resident's electronic medical record, medication administration record, and treatment administration record revealed that staff did not measure and record the resident's weight on nine specific dates over a 69-day period. There was also no documentation that the physician was notified when the daily weights were not obtained. Interviews with staff confirmed that all staff were responsible for assisting with daily weights if ordered, and that the nurse was responsible for ensuring weights were obtained, recorded, and that the physician was notified as needed. The facility's policy required all medications and treatments to be administered as ordered by a healthcare professional. However, the lack of documentation and failure to follow the physician's order for daily weights constituted a deficiency in providing appropriate treatment and care according to orders, resident preferences, and goals.
Failure to Set Pressure-Reducing Mattress to Resident's Weight
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident's low air-loss mattress, intended to reduce the risk of pressure ulcers, was set within the resident's current weight range as required. The resident, who had diagnoses including Alzheimer's disease, insomnia, anxiety, and speech/language deficits, was severely cognitively impaired and dependent on staff for most activities of daily living. The resident was identified as being at risk for skin breakdown and pressure ulcers, with care plans and assessments indicating the use of pressure-reducing devices and a repositioning program. Despite these interventions, observations over several days revealed that the mattress was consistently set to 200 lbs, while the resident's documented weight was 122 lbs. The care plan lacked specific instructions regarding the correct mattress settings. Interviews with nursing staff and administrative personnel confirmed that the mattress should have been set according to the resident's current weight and that staff were expected to check the settings each shift. The facility's wound management policy required assessment of pressure ulcer risk and implementation of preventative interventions, but the failure to set the mattress appropriately represented a lapse in following these protocols. This inaction placed the resident at risk for complications related to skin breakdown and pressure ulcers.
Failure to Address Pharmacist Recommendations and Inadequate Documentation for Antipsychotic Use
Penalty
Summary
The facility failed to address recommendations made by the Consultant Pharmacist (CP) regarding the medication regimen of two residents with dementia and Alzheimer's disease. For one resident, the CP identified irregularities related to the administration of Midodrine, a medication prescribed for hypotension. Although the resident's blood pressure readings were within the physician-ordered parameters for administration on multiple occasions, the clinical record did not document that the physician was notified when the medication was not administered as ordered. The CP had reported these irregularities in the Monthly Medication Reviews, but there was no evidence that the facility acted on these recommendations or communicated with the physician as required. Additionally, both residents were prescribed antipsychotic medications for non-approved indications, specifically for dementia and Alzheimer's disease. The CP identified and reported these irregularities, noting the lack of appropriate physician documentation for the risk versus benefit analysis and the rationale for continued use of antipsychotics for these diagnoses. The facility was unable to provide documentation supporting the use of these medications for the residents, despite repeated recommendations from the CP. The care plans for both residents indicated monitoring for side effects and collaboration with the physician, but there was no evidence that the required documentation or physician engagement occurred. Interviews with nursing staff and administrative personnel revealed a lack of understanding regarding appropriate indications for antipsychotic medication use. Staff were unsure about the correct process for addressing CP recommendations and for ensuring physician orders were followed and documented. The facility's policies required the CP to review medication regimens monthly and communicate potential or actual problems to the physician and Director of Nursing, but these procedures were not effectively implemented, resulting in the identified deficiencies.
Failure to Administer Hypotension Medication as Ordered and Notify Physician
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician's order for a resident's hypotension medication was properly administered. The resident, who had diagnoses including dementia, tachycardia, hypotension, hemiplegia, and Alzheimer's disease, had a physician's order for Midodrine to be given as needed for low blood pressure, with specific parameters for administration. Review of the electronic medical record showed that, over a 67-day period, there were 50 documented opportunities where the resident's blood pressure met the criteria for administration of Midodrine, but there was no documentation that the physician was notified when the medication was not administered as ordered. The medication was only administered on one occasion during this period, despite multiple qualifying blood pressure readings. Further review of the resident's care plan and psychotropic drug use assessment indicated that the resident was at risk for adverse side effects from medications, and staff were expected to monitor for side effects and notify the physician as needed. Interviews with nursing staff confirmed that the expectation was to follow physician orders and document any notifications to the physician if orders were not followed. However, the clinical record lacked evidence of such notifications, and the facility's policy required all medications to be administered as ordered by a healthcare professional.
Failure to Follow Physician-Ordered Parameters for Midodrine Administration
Penalty
Summary
A deficiency occurred when staff failed to follow physician-ordered parameters for administering Midodrine, a medication used to treat hypotension, to a resident with multiple diagnoses including dementia, tachycardia, hypotension, hemiplegia, and Alzheimer's disease. The physician's order specified that Midodrine should only be administered if the resident's systolic blood pressure was less than 130 mmHg or diastolic blood pressure was less than 60 mmHg, not to exceed three times daily. Review of the resident's electronic medical record and vital signs from March 1 to May 6 showed 50 instances where blood pressure readings met the criteria for administration, but there was no documentation that the physician was notified as required. Additionally, the medication was administered on a date within this period, but the clinical record lacked evidence of proper notification or documentation. Interviews with nursing staff confirmed that the nurse or certified medication aide was responsible for obtaining vital signs before administering medications requiring such checks, and that the nurse should ensure medications are given as ordered. Staff also stated that the physician should be notified if orders are not followed, with documentation in the interdisciplinary notes. The facility's policy required all medications to be administered as ordered by a healthcare professional. The failure to adhere to these protocols resulted in a significant medication error for the resident.
Failure to Secure Medication Carts When Unattended
Penalty
Summary
Surveyors observed that medication carts containing residents' treatment supplies and as-needed (PRN) creams were left unlocked and unattended, specifically noting an instance where a treatment cart was out of the nurse's view on hall 600. A licensed nurse confirmed that the cart should have been locked and secured when staff walked away. Additionally, an administrative nurse stated that the facility's expectation was for medication carts to be locked if not within the nurse's view. The facility's own Medication Labeling and Storage policy required all drugs and biologicals to be stored securely and in accordance with state and federal regulations, but this policy was not followed during the observed incidents.
Failure to Follow Physician's Order for Timed Supplement Administration
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order regarding the administration of a nutritional supplement for a resident with Alzheimer's disease, severe cognitive impairment, and multiple care needs. The physician's order specified that the resident was to receive one carton of Ensure by mouth 30 minutes after each meal to address protein-calorie malnutrition. However, observations on multiple occasions revealed that the Ensure supplement was provided with the resident's meal rather than 30 minutes after, as ordered. The resident was dependent on staff for most activities of daily living, including eating, and was at risk for malnutrition and weight loss. Documentation in the resident's care plan and assessments indicated the need for supervision and assistance during meals, as well as specific nutritional interventions. Despite these documented needs and orders, staff were observed leaving the supplement with the meal, and the resident consumed the Ensure during or before the meal without staff present to supervise or assist as required. Interviews with nursing and dietary staff confirmed that the expectation was to provide the supplement 30 minutes after meals, in accordance with the physician's order, to encourage meal consumption before supplement intake. The facility's policy also indicated that dietary supplementation should follow the guidance of the medical and dietician team. The failure to adhere to the specified timing of the supplement administration constituted a failure to follow the physician's order and the facility's own policy.
Failure to Provide Required Annual In-Service Training for Direct Care Staff
Penalty
Summary
The facility failed to ensure that direct care staff, including Certified Nurse Aides (CNAs) and Certified Medication Aides (CMAs), received the required 12 hours of annual in-service education and demonstrated competency as mandated by facility policy. Record review revealed that the credentialing files for four staff members lacked evidence of completion of the required yearly training. The missing in-service education included essential topics such as infection control, HIPAA, resident rights, abuse prevention, compliance, emergency preparedness, and behavioral health, among others. During interviews, administrative staff confirmed that the responsibility for tracking and ensuring completion of nurse aide in-services had previously been assigned to the facility scheduler. However, it was discovered that CNAs and CMAs had not completed the necessary annual education hours. The director of nursing (DON) was subsequently identified as the new responsible party for ensuring compliance with training requirements. The facility census at the time was 65 residents.
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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