Willow Point Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Kansas.
- Location
- 6500 Greeley Avenue, Kansas City, Kansas 66104
- CMS Provider Number
- 175135
- Inspections on file
- 23
- Latest survey
- December 3, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Willow Point Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility failed to ensure the director of food and nutrition services was a certified dietary manager (CDM), placing residents at risk for unmet dietary and nutritional needs. Dietary BB had not yet taken the certification test, and the registered dietician was only available by phone and visited twice a month. The facility lacked a policy regarding the CDM.
A facility with 29 residents was found to have deficiencies in food storage practices. Observations revealed unlabeled and undated food items, including a pitcher of juice, Kool-Aid, and several glasses of juice and milk without covers. The dishwashing area had unwashed dishes from the previous night and a musty odor. Dietary staff acknowledged the oversight, noting that all food items should be labeled and dated, and the facility lacked a policy on food storage.
The facility failed to conduct required criminal background checks for a Licensed Nurse and a Housekeeping staff member upon hire, as per its policy. This oversight allowed the employees access to residents without verifying their history of abuse, neglect, exploitation, or mistreatment, placing residents at risk.
The facility failed to secure hazardous cleaning chemicals, leaving them accessible to seven cognitively impaired, independently mobile residents. An inspection revealed that the restorative room was left unlocked with multi-purpose cleaners stored in an unlocked cabinet. A CNA and an Administrative Nurse acknowledged that these chemicals should be secured to prevent resident access, as per the facility's policy.
The facility failed to conduct proper safety assessments and obtain informed consent for the use of bed rails for several residents, including those with cognitive impairments and mobility issues. This oversight led to potential safety risks, as the facility did not document the risks associated with low air-loss mattresses or communicate these risks to residents or their representatives.
A resident with severe cognitive impairment and physical limitations was pushed in a wheelchair without foot pedals on multiple occasions, leaving her vulnerable to accidents. Staff acknowledged the necessity of foot pedals, but the facility lacked a policy to ensure their use, resulting in unmet care needs.
A resident with severe cognitive impairment and a primary language other than English did not receive adequate support for communication and socialization. Despite having a care plan that included an interpreter and media in his native language, these were not consistently used. The resident was often left without communication aids, and staff did not engage with him during meals or in common areas, increasing his risk of isolation.
A resident with severe cognitive impairment and a history of Stage 3 pressure ulcers had their low air-loss mattress set incorrectly, contrary to physician's orders. The mattress was observed to be set at 500 lbs and later 550 lbs, instead of the prescribed <250 lbs. Staff confirmed the incorrect settings but could not explain the discrepancy, and the facility lacked a policy on pressure ulcer prevention.
A facility failed to maintain consistent communication with a dialysis center for a resident requiring dialysis, leading to a lack of post-hemodialysis assessments on multiple occasions. Despite having a care plan and guidelines in place, the facility did not ensure communication sheets were consistently sent and returned, placing the resident at risk of adverse outcomes.
The facility failed to follow physicians' ordered parameters for blood glucose monitoring for two residents, leading to the administration of insulin despite blood glucose levels being below the specified threshold. This placed the residents at risk for complications related to hypoglycemia and unnecessary medication. The facility lacked a policy for medication monitoring, contributing to this deficiency.
A facility failed to provide appropriate dementia care for a resident with schizoaffective disorder and dementia, leading to persistent and escalating behavioral issues. The care plan lacked specific triggers and interventions, and staff had inconsistent knowledge and training on managing the resident's behaviors.
A facility failed to ensure staff reported an allegation of physical abuse immediately to the Administrator. A CNA allegedly smacked a cognitively impaired resident on the hand, and the incident was not reported until three days later. The delay allowed the alleged perpetrator to continue working, placing the resident in immediate jeopardy. The resident's care plan and follow-up assessments were not adequately documented.
Lack of Certified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the director of food and nutrition services possessed the required qualifications of a certified dietary manager (CDM). This deficiency was identified during an observation, record review, and interview process. The facility had a census of 29 residents, with one main kitchen and dining area. During an interview, Dietary BB stated that she had not yet taken the test to obtain her dietary manager certification but was scheduled to take it in the future. Additionally, the registered dietician was only available for consultation by phone and visited the facility twice a month to review residents' diets. The facility did not provide a policy regarding the CDM, which contributed to the deficiency and placed residents at risk for unmet dietary and nutritional needs.
Deficiencies in Food Storage Practices
Penalty
Summary
The facility, with a census of 29 residents, was found to have deficiencies in food storage practices during a survey. Observations in the main kitchen revealed several issues that did not comply with professional standards for food service safety. Specifically, a dry, brown-tinged towel was found in front of the coffee maker, and dishes from the previous night were left unwashed in the dishwashing area, which also had a musty odor. In the drink refrigerator, a pitcher of juice or drink was not labeled or dated, and a pitcher of Kool-Aid also lacked a label or date. Additionally, a tray with 12 clear plastic drinking glasses filled with juice and three glasses filled with milk were found without covers, labels, or dates. The condiment refrigerator contained a salad with a date of 10/18/24, but two covered fruit cups and two bowls of applesauce and peaches lacked labels or dates. Dietary staff member BB acknowledged the oversight, stating that she had not yet checked the refrigerators and freezers for unlabeled or undated items that morning. She confirmed that all food items should be dated and labeled when opened or transferred to a new container or sealed bag. Furthermore, she stated that juice and milk glasses should be covered with plastic wrap and dated when stored in the refrigerator. The facility did not provide a policy on food storage, which contributed to the failure to ensure that food items were stored according to professional standards, placing residents at risk of foodborne illness and cross-contamination.
Failure to Conduct Background Checks on New Employees
Penalty
Summary
The facility failed to implement its policy prohibiting the hiring of employees found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. This failure was identified during a review of staffing for license verification, in-service training, and background checks. Specifically, the facility did not conduct criminal background checks for two employees, a Licensed Nurse (LN) and a Housekeeping staff member, upon their hire dates. The absence of these checks meant that the facility did not verify whether these employees had any history of abuse, neglect, exploitation, or mistreatment, which is a requirement according to the facility's policy revised in September 2023. The deficiency was discovered when the facility was unable to provide evidence of completed background checks for the two employees. Administrative Staff A acknowledged the oversight and was unsure why the background checks were missing from the employees' files. This oversight allowed the employees to have access to residents without the necessary verification of their backgrounds, placing the residents at risk for potential abuse, neglect, misappropriation, or mistreatment.
Failure to Secure Hazardous Chemicals
Penalty
Summary
The facility failed to secure potentially hazardous cleaning chemicals in a safe, locked area, placing seven cognitively impaired, independently mobile residents at risk for preventable accidents and injuries. During an inspection of the 100-hall, it was observed that the restorative room was left unlocked and unsupervised, with several types of multi-purpose cleaners stored in an unlocked cabinet under the sink. These bottles were labeled with warnings indicating they were hazardous to humans, could cause eye irritation, and were harmful if swallowed. A Certified Nurse's Aide acknowledged that the chemicals should be secured or the door should be closed to prevent resident access. An Administrative Nurse confirmed that potentially hazardous cleaning products should be locked up and inaccessible to residents. The facility's Accidents and Fall Management policy, revised in December 2017, requires staff to ensure a safe care environment by addressing potential room hazards, but this was not adhered to in this instance.
Failure to Conduct Proper Bed Rail Assessments and Obtain Informed Consent
Penalty
Summary
The facility failed to ensure the proper assessment and management of bed rails for several residents, leading to potential safety risks. Resident 24, who had severe cognitive impairment and required substantial assistance with daily activities, was observed with bed rails despite an assessment indicating they should not be used. The facility did not provide a safety assessment that considered the risks associated with the resident's low air-loss mattress, nor did they obtain informed consent or communicate the risks and benefits to the resident or their representative. Similarly, Resident 5, who had moderate cognitive impairment and required significant assistance, was found to have bed rails without a proper safety assessment. The facility did not document the risks associated with the use of bed rails in conjunction with a low air-loss mattress, nor did they ensure that the resident or their representative was informed about the potential risks and benefits. This lack of documentation and communication placed the resident at risk for uninformed decisions and impaired safety. Residents 17 and 12 also experienced similar deficiencies. Resident 17, who had memory impairments and required assistance for mobility, had a bed cane without a documented safety assessment or informed consent. Resident 12, who was on hospice care and had intact cognition, used a bed cane without a proper safety assessment or documentation of the risks associated with their low air-loss mattress. In both cases, the facility failed to ensure that the residents or their representatives were advised of the risks and benefits of using bed rails, leading to potential safety hazards.
Failure to Provide Wheelchair Foot Pedals for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R4, had foot pedals on her wheelchair while being pushed by staff, which left her vulnerable to accidents and injuries. R4's medical history included diagnoses of depressive disorder, hypertension, hemiparesis/hemiplegia following a stroke, major depressive disorder, vascular dementia, and anxiety. The resident had a severely impaired cognition with a BIMS score of seven and required supervision or assistance from staff once seated in her wheelchair. Her care plan indicated the need for staff assistance with activities of daily living and specified the use of a wheelchair for transportation. Observations revealed that on two separate occasions, R4 was pushed in her wheelchair without foot pedals, causing her feet to repeatedly bounce on the floor. Staff members, including CNAs and a licensed nurse, acknowledged that residents should have foot pedals when being pushed. However, the facility did not provide a policy on the accommodation of needs, resulting in the failure to provide foot pedals for R4's wheelchair. This oversight constituted a deficiency in meeting the resident's care needs.
Failure to Support Resident Communication and Socialization
Penalty
Summary
The facility failed to ensure that a resident, identified as R18, received supportive care and services to promote and maintain his quality of life. R18, who had a primary language other than English, was not provided with adequate strategies to communicate his wants, needs, or feelings, nor was he encouraged to socialize. Despite having a care plan that included the use of an interpreter and the provision of TV and radio in his native language, these strategies were not consistently implemented. Observations showed that R18 was often left without communication aids, such as a TV or radio in his language, and staff did not engage with him during meals or in common areas. R18's medical history included cerebral infarction, hypertension, diabetes mellitus, depression, cognitive-communication deficit, hemiplegia, vascular dementia, expressive language disorder, and protein-calorie malnutrition. His cognitive abilities were severely impaired, as indicated by a BIMS score of six. Despite having a communication book and access to an interpreter, staff relied on gestures and pointing for communication. The facility did not provide a policy related to maintaining communication and other activities of daily living, which contributed to the resident's risk of decreased quality of life and isolation.
Improper Mattress Settings for Resident with Pressure Ulcer Risk
Penalty
Summary
The facility failed to ensure that a resident's low air-loss mattress was set to the appropriate weight settings as per the physician's order and the resident's current weight. The resident, who had a history of severe cognitive impairment, bilateral upper and lower extremity impairments, and a history of Stage 3 pressure ulcers, was at risk for pressure injuries and skin breakdown. The resident's care plan required the mattress to be set to less than 250 lbs, but observations revealed that the mattress was set to 500 lbs and later to 550 lbs, which was not in accordance with the physician's order. Licensed Nurse G confirmed the incorrect settings but was unaware of the reason for the discrepancy. Administrative Nurse D stated that the mattress settings should be checked each time staff enter the room, suggesting that the control panel might have been accidentally adjusted. The facility was unable to provide a policy related to the prevention of pressure ulcers when requested, indicating a lack of proper documentation and adherence to care protocols.
Inadequate Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure consistent communication between the facility and a resident's dialysis center, which placed the resident at risk of potential adverse outcomes and physical complications related to dialysis. The resident, who had diagnoses including diabetes mellitus, congestive heart failure, obesity, hypertension, and required dialysis, was documented to have intact cognition and was independent in certain activities of daily living. The resident's care plan included monitoring the dialysis shunt daily and changing dressings as ordered. However, the facility's records lacked evidence of post-hemodialysis assessments for several dates, indicating a lapse in communication and documentation. Licensed Nurse G and Administrative Nurse D confirmed that it was the nurse's responsibility to ensure communication sheets were sent to and returned from the dialysis center. The facility's Dialysis Management Guideline policy required maintaining communication and coordinating care with the dialysis center, including assessing the dialysis access site routinely. Despite these guidelines, the facility did not consistently receive or follow up on communication sheets from the dialysis center, leading to the deficiency in care coordination for the resident receiving dialysis.
Failure to Follow Blood Glucose Monitoring Parameters
Penalty
Summary
The facility failed to adhere to physicians' ordered parameters for blood glucose monitoring for two residents, R10 and R15, which resulted in the administration of insulin despite blood glucose levels being below the specified threshold. For R10, the Electronic Medical Record (EMR) indicated a history of diabetes mellitus, among other conditions, and prescribed insulin with specific instructions to hold the medication if blood glucose levels were below 110 ml/dl. However, the Treatment Administration Record (TAR) showed multiple instances where insulin was administered despite blood glucose readings below this threshold, such as 82 ml/dl and 84 ml/dl. Similarly, R15's EMR documented a diagnosis of diabetes mellitus and prescribed insulin with instructions to hold the medication for blood glucose levels below 110 ml/dl. The TAR recorded several instances where insulin was administered despite blood glucose levels being below the ordered parameters, such as 94 ml/dl and 104 ml/dl. Interviews with nursing staff confirmed that it was their responsibility to verify blood glucose levels and administer or hold insulin accordingly, yet the facility did not provide a policy for unnecessary medication or medication monitoring. The failure to follow the ordered parameters for blood glucose monitoring placed both residents at risk for complications related to hypoglycemia and unnecessary medication. The facility's lack of a policy for medication monitoring contributed to this deficiency, as evidenced by the repeated administration of insulin outside the prescribed parameters for both residents.
Failure to Provide Appropriate Dementia Care and Services
Penalty
Summary
The facility failed to provide appropriate dementia care and services for a resident diagnosed with schizoaffective disorder and dementia with behavioral disturbances. The resident exhibited moderate cognitive impairment, hallucinations, delusions, and various behavioral symptoms, including wandering, verbal outbursts, and inappropriate physical contact with staff and other residents. Despite these behaviors, the facility did not adequately assess, identify, record, respond to, or reassess the resident's specific behaviors and triggers to support his individualized care needs. The resident's care plan included several interventions to manage his behaviors, such as discussing inappropriate behavior, cuing appropriate requests, ensuring staff attention before starting care, and encouraging verbal expression instead of physical contact. However, the care plan lacked evidence of specific triggers related to the resident's behaviors. Multiple incidents were documented where the resident grabbed or touched staff and other residents inappropriately, and staff attempted various redirection strategies, including providing snacks and one-on-one supervision. Despite these efforts, the resident's behaviors persisted and escalated over time. Interviews with staff revealed inconsistent knowledge and training regarding the resident's triggers and appropriate behavioral interventions. Some staff members were aware of certain triggers, such as the resident's desire for coffee or snacks, while others were not. Additionally, not all staff had received behavioral health or dementia training. The facility's policy on behavior management and psychotropic medications required individualized care plans with specific triggers and interventions, but this was not adequately implemented for the resident. The facility's failure to properly assess and manage the resident's behaviors affected his ability to maintain his highest practicable level of physical, mental, and psychosocial well-being.
Failure to Report Alleged Abuse Immediately
Penalty
Summary
The facility failed to ensure staff identified and reported an allegation of physical abuse immediately to the Administrator as required. On 02/09/24, a Certified Nurse Aide (CNA) allegedly smacked a severely cognitively impaired resident on the hand after the resident hit the CNA during peri-care. Another CNA witnessed the incident but did not report it immediately to the Administrator, instead mentioning it to another CNA and later writing a Report of Concern three days after the incident. The delay in reporting allowed the alleged perpetrator to continue working in the facility, placing the resident in immediate jeopardy. The resident involved had significant cognitive impairments, including short and long-term memory problems, and communicated primarily through gestures and noises due to being non-verbal and deaf. The resident's care plan directed staff to communicate clearly and observe the resident's facial expressions and gestures. Despite these directives, the incident occurred, and the resident's electronic medical record lacked documentation of follow-up assessments to monitor the resident's ongoing psychosocial wellbeing after the alleged abuse. The facility's investigation revealed that the CNA who witnessed the abuse did not report it immediately, and the alleged perpetrator was not interviewed during the investigation. Witness statements from other staff indicated that they were unaware of the incident until the Report of Concern was submitted. The facility's policy on abuse, neglect, and exploitation required immediate reporting of such incidents to the Administrator, which was not followed in this case, leading to a citation for past noncompliance at the scope and severity of J.
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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