Winfield Senior Living Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Winfield, Kansas.
- Location
- 1320 Wheat Rd, Winfield, Kansas 67156
- CMS Provider Number
- 175327
- Inspections on file
- 17
- Latest survey
- March 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Winfield Senior Living Community during CMS and state inspections, most recent first.
The facility failed to conduct a thorough assessment to determine necessary resources for resident care during daily operations and emergencies. The assessment lacked specific staffing levels for each unit, including RNs, LPNs/LVNs, CMAs, and CNAs, and did not include contingency plans for non-emergency events. Input from residents and their representatives was also missing, affecting all 72 residents.
The facility failed to ensure sanitary storage and disposal of face masks and oxygen cannulas, and lacked a specific Legionella disease program. Observations showed improper storage of a resident's nasal cannula and a used face mask on a PPE cart. Staff interviews confirmed the need for proper storage and disposal practices, but there was a lack of awareness and documentation of the Legionella Water Management Program, putting residents at risk for infectious diseases.
The facility failed to ensure controlled substances were properly accounted for and reconciled between shifts, risking misappropriation and diversion. Missing signatures on narcotic count sheets for several shifts indicated non-compliance with the policy requiring on-coming and off-going nurses to count medications together. Staff interviews confirmed the expected practice, but discrepancies were not reported as required.
A facility failed to secure one of its medication carts, leaving it unattended and unlocked outside a resident's room. The cart contained medications and wound care supplies, and staff confirmed that carts should be locked when not in use. This oversight placed residents at risk for medication diversion and ineffective regimens.
The facility failed to offer the PCV20 vaccine or obtain informed declinations for four residents, despite their eligibility. The residents' records showed previous pneumococcal vaccinations but lacked documentation for PCV20. The Infection Preventionist admitted to overlooking this, contrary to the facility's policy requiring timely vaccine assessments and offerings.
A facility failed to provide written notification for a resident's transfer to an acute care facility for emergency evaluation due to low sodium levels. The resident, with a history of cerebral infarction and congestive heart failure, required substantial assistance with daily activities. Although verbal notification was given to the resident's representative, the facility did not provide the required written documentation, placing the resident at risk of delayed or uncommunicated care needs.
The facility failed to update care plans for two residents, leading to potential risks. One resident's care plan did not reflect the need for a Hoyer lift for transfers, while another's care plan inaccurately listed dialysis days and lacked fluid restriction monitoring. Staff interviews confirmed the discrepancies, and the facility could not provide a policy for care plan revisions.
A resident with cognitive impairment and hemiparesis experienced a coffee spill incident, but the facility failed to assess the resident's ability to handle hot liquids or update the care plan to reflect potential risks. Staff acknowledged the need for safety assessments and special utensils, but no such measures were documented or implemented.
A resident with a history of hemiparesis and cerebrovascular accident did not receive necessary ROM services to prevent worsening contractures in his left hand. Despite having intact cognition, the resident reported not receiving assistance due to lack of insurance coverage for therapy. Facility staff were unclear about restorative programs, and the facility's policy to prevent avoidable reduction in ROM was not followed, leaving the resident at risk for further decline.
A resident with a history of falls and high fall risk due to medical conditions did not receive the care-planned interventions to prevent falls. The facility failed to ensure the use of a gait belt and Dycem mat, leading to a witnessed fall and minor injury. Staff interviews confirmed the expectations, but these were not consistently followed, placing the resident at risk.
A resident with cognitive and mental health issues experienced significant weight loss, which the facility failed to address through proper nutritional interventions. Despite having a care plan that included monitoring and supplement recommendations, staff were unaware of the resident's weight loss and necessary interventions, leading to a risk of malnourishment-related complications.
A resident with diabetes and chronic kidney disease did not have a physician order for dialysis, and the facility failed to monitor her fluid restriction as per the physician's order. Staff interviews revealed confusion about the resident's dialysis schedule and fluid monitoring responsibilities, indicating a lack of adherence to the facility's ESRD care policy.
A facility failed to provide necessary person-centered activities and interventions for a resident with dementia, leading to inadequate supervision and engagement. The resident, with a history of dementia and other health issues, required maximal assistance but was often left unsupervised. The care plan lacked specific directions for preferred activities, and the facility's activity program did not adequately address the resident's needs due to understaffing and limited engagement opportunities.
A facility failed to ensure a Consulting Pharmacist identified and made recommendations regarding a resident's Midodrine medication, used for low blood pressure. The resident, with a history of stroke, dementia, and orthostatic hypotension, received the medication despite high blood pressure readings, without proper monitoring parameters. Staff interviews revealed a lack of communication and policy on pharmacy reviews, placing the resident at risk for unnecessary medications and side effects.
A resident with a history of stroke, dementia, and orthostatic hypotension was administered Midodrine without proper blood pressure monitoring parameters in place. Despite high blood pressure readings, the medication was not held, contrary to the facility's policy and standard practice. This oversight placed the resident at risk for unnecessary medications and potential side effects.
A facility failed to document appropriate rationale for the use of psychotropic medications in two residents. One resident received Olanzapine without a documented attempt at gradual dose reduction or physician rationale, while another resident continued using PRN Ativan without a documented reason. These deficiencies risked unnecessary medication use and complications.
A resident with dementia and moderately impaired cognition consistently refused bathing, but the facility failed to revise the care plan to include notifying the family member of refusals. Despite the care plan requiring daily bathing offers and notification of refusals to the charge nurse, the facility did not adhere to these protocols, resulting in the resident not receiving a bath for 24 days.
A resident with dementia and prolapse bladder did not receive necessary bathing services for 24 days due to staff's failure to follow protocol. The resident preferred baths at night, but the facility moved her shower to the day shift, leading to refusals. Staff were unaware of the requirement to notify family when the resident refused bathing, and documentation was inconsistent.
Inadequate Facility-Wide Assessment for Staffing and Emergency Preparedness
Penalty
Summary
The facility failed to conduct a thorough facility-wide assessment to determine the necessary resources for competent resident care during both day-to-day operations and emergencies. The assessment, last updated on 08/08/24, did not specify staffing levels required for each unit, including the number of RNs, LPNs/LVNs, CMAs, and CNAs needed based on patient acuity and census. Additionally, the assessment lacked details on staffing requirements for each shift, including evenings and weekends. It also failed to include informed contingency plans for events that could impact resident care without activating the emergency plan. Furthermore, the assessment did not document input from residents and their representatives. Administrative Nurse D stated that the facility assessment was revised annually, with staffing requirements determined by the facility's acuity and each unit's needs. However, the facility's policy, revised in 10/2018, indicated that the assessment should identify specific nursing and staffing requirements, nursing services, treatment options, and emergency management. Despite these guidelines, the facility did not conduct a comprehensive and updated assessment, affecting all 72 residents residing in the facility.
Infection Control Deficiencies in PPE and Legionella Program
Penalty
Summary
The facility failed to maintain sanitary conditions for face masks and oxygen cannulas, and did not implement a Legionella disease program specific to the facility. Observations revealed that a resident's nasal cannula was improperly stored over a wheelchair and an oxygen canister, rather than in a sanitary manner. Additionally, a used face mask was found on a PPE cart outside a resident's room with COVID-19, indicating improper disposal or storage of personal protective equipment. Interviews with staff members, including a CNA, LN, and Administrative Nurse, confirmed that respiratory equipment not in use should be stored in a plastic bag with the resident's name, and used masks should be disposed of properly. However, there was a lack of awareness and documentation regarding the facility's Legionella Water Management Program, which is crucial for preventing waterborne contamination. These practices placed residents at risk for infectious diseases.
Failure to Reconcile Controlled Substances Between Shifts
Penalty
Summary
The facility failed to ensure controlled substances were properly accounted for and reconciled between shifts, which placed residents at risk for misappropriation and/or diversion of these medications. During a review of the narcotic count sheets for December 2024, January, and February 2025, it was found that there were missing signatures for either the on-coming or off-going nurse for several shifts. Specifically, discrepancies were noted for the morning shifts on January 30, 31, February 1, 2, and 3, and for the evening shifts on January 26, 29, February 1, and 3. This indicates that the required procedure of counting controlled substances at the end of each shift was not consistently followed. Interviews with staff revealed that the facility's policy required both the on-coming and off-going nurses to count controlled substances together and ensure the count was correct before leaving the facility. Licensed Nurse G confirmed that this was the expected practice, and Administrative Nurse D reiterated that anyone handling medication carts should perform the count with the oncoming nurse each shift. The facility's Controlled Substances policy, revised in April 2019, mandates compliance with laws and regulations regarding the handling and documentation of controlled medications, including immediate reporting of any discrepancies to the director of nursing services. The failure to adhere to these procedures resulted in a deficiency that compromised the security and accountability of controlled substances within the facility.
Unsecured Medication Cart Poses Risk
Penalty
Summary
The facility failed to ensure the safe storage of medications on one of its four medication carts, which placed residents at risk for diversion and ineffective medication regimens. During an inspection on February 4, 2025, at 7:01 AM, a treatment cart was found unsecured outside a resident's room on the 100 Hall, with no staff present to monitor it. The cart contained medications and wound care supplies for the resident. At 7:05 AM, an administrative nurse confirmed the cart was left unlocked and secured it. On February 6, 2025, staff interviews revealed that medication carts were expected to be locked when not in use, as per the facility's policy revised in November 2020. However, the facility did not adhere to this policy, leading to the deficiency.
Failure to Offer PCV20 Vaccine to Eligible Residents
Penalty
Summary
The facility failed to offer or obtain informed declinations or a physician-documented contraindication for the Pneumococcal Conjugate Vaccine (PCV20) for four residents, identified as R1, R12, R27, and R28. This oversight was discovered through record reviews and interviews, revealing that these residents were not offered the PCV20 vaccine, nor was there documentation of a historical administration or a physician-documented contraindication. The clinical records of these residents showed previous administrations of other pneumococcal vaccines, such as PCV13 and PPSV23, but lacked any mention of the PCV20 vaccine being offered or declined. The facility's policy, last revised in August 2016, stated that all residents should be offered pneumococcal vaccines to prevent pneumonia and related infections. The policy required assessments of pneumococcal vaccination status within five working days of admission, with the vaccine series offered within thirty days unless contraindicated or previously administered. However, the facility's Infection Preventionist, responsible for tracking immunization status, admitted to overlooking the PCV20 immunization status for these residents, placing them at increased risk for complications related to pneumonia.
Failure to Provide Written Notification for Resident Transfer
Penalty
Summary
The facility failed to provide written notification of a facility-initiated transfer for a resident, identified as R44, who was sent to an acute care facility for emergency evaluation due to low sodium levels. The resident's medical history included cerebral infarction, hemiparesis/hemiplegia, and congestive heart failure, and he required substantial assistance with activities of daily living. Despite the verbal notification to the resident's representative about the hospital transport, the facility did not provide written notification detailing the reason and location of the transfer. The deficiency was identified during a review of R44's clinical records, which lacked evidence of the required written notification. The facility's administrative nurse confirmed that only verbal notifications were given, and the facility was unable to provide a policy related to transfer or notification requirements. This oversight placed the resident at risk of delayed care or uncommunicated care needs, as the necessary documentation was not available.
Care Plan Deficiencies for Transfer and Dialysis Needs
Penalty
Summary
The facility failed to update the care plan for Resident 12 to reflect her current transfer requirements. Despite a fall intervention update on 10/07/24 that instructed the use of a Hoyer lift for safe transfers, the care plan still listed a gait belt and walker for transfers. This oversight placed Resident 12 at risk for impaired care due to uncommunicated care needs. Staff interviews confirmed that the care plan should have been updated to reflect the current intervention, and the facility was unable to provide a policy related to care plan revisions. Additionally, the facility did not revise Resident 23's care plan to include updated dialysis days and monitoring of her fluid restriction. The care plan inaccurately listed dialysis days and lacked direction for nursing staff to monitor fluid restrictions, despite physician orders indicating dialysis on Monday, Wednesday, and Friday. Staff interviews revealed confusion about the dialysis schedule and fluid monitoring responsibilities, with some staff unaware of the correct dialysis days and who was responsible for monitoring fluid intake. These deficiencies in care plan updates for both residents placed them at risk for unmet care needs. Resident 12's care plan did not reflect her need for a Hoyer lift, and Resident 23's care plan did not accurately reflect her dialysis schedule or fluid restriction monitoring, leading to potential complications related to their respective conditions.
Failure to Assess Resident's Ability to Handle Hot Liquids
Penalty
Summary
The facility failed to evaluate a resident's risks and abilities related to handling hot liquids, which placed the resident at risk for preventable accidents and injuries. The resident, who had a medical history of hemiparesis, cognitive impairment, and required assistance with activities of daily living, experienced a coffee spill incident. Despite the incident, there was no documentation in the resident's care plan or electronic medical records indicating that a risk assessment was conducted to determine the resident's ability to safely manage hot liquids or if special utensils were needed. Observations and interviews revealed that the resident sometimes struggled to hold cups and had difficulty completing activities of daily living, requiring substantial staff assistance. Staff members acknowledged that residents at risk for spilling drinks should be provided with cups with lids and assessed for safety. However, there was no evidence that such assessments were conducted for the resident following the coffee spill incident, and the care plan did not reflect potential risks related to handling hot liquids.
Failure to Provide ROM Services for Resident with Contractures
Penalty
Summary
The facility failed to provide necessary services and treatment to prevent the worsening of contractures in a resident's left hand. The resident, who had a history of hemiparesis, hemiplegia, cerebrovascular accident, and muscle weakness, was observed sitting in a wheelchair with his left hand hanging downward and fingers slightly closed. Despite having intact cognition, as indicated by a BIMS score of 15, the resident reported not receiving assistance with range of motion (ROM) exercises for his left hand due to a lack of insurance coverage for therapy. Interviews with facility staff revealed a lack of clarity and implementation of restorative programs for residents. A CNA was unsure if any staff provided ROM exercises for the resident, and a licensed nurse was unaware of any restorative programs in place. The administrative nurse indicated that residents would only be placed on a restorative program if recommended by therapy, which would occur after a decline in ROM. The facility's policy stated that residents should not experience an avoidable reduction in ROM and should receive treatment to prevent further decline, but this was not adhered to, leaving the resident at risk for further decline and discomfort.
Failure to Follow Fall Interventions for Resident
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as R16, by not adhering to her care-planned fall interventions. R16, who had a history of falls and was at high risk due to her medical conditions including cerebral infarction, dementia, muscle weakness, and orthostatic hypotension, required assistance with activities of daily living and was dependent on staff for mobility. Her care plan specified the use of a gait belt and touch assistance during transfers and the presence of a Dycem mat in her chair to prevent slipping. However, on multiple occasions, it was observed that the Dycem mat was not in place when R16 was seated in her recliner, and staff failed to use a gait belt or provide touch assistance during a witnessed fall incident. The deficiency was further highlighted by a fall investigation report which identified that staff did not utilize the required safety measures, leading to a minor injury fall where R16 suffered a skin tear. Interviews with staff confirmed the expectations for using a gait belt and ensuring the Dycem mat was in place, yet these interventions were not consistently followed. The facility's fall guidelines required interventions to reduce fall risks, but the failure to implement these measures placed R16 at risk for preventable falls and injuries.
Failure to Address Resident's Weight Loss
Penalty
Summary
The facility failed to identify and implement nutritional interventions for a resident, referred to as R26, who experienced continued weight loss. R26's medical history included cognitive communication deficit, dementia, major depressive disorder, and anxiety. Despite having an intact cognition score, R26 was not on a physician-prescribed weight loss program. The resident's care plan included various interventions such as encouraging adequate intake, monitoring for chewing or swallowing difficulties, and offering snacks and supplements. However, these interventions were not effectively implemented, as evidenced by a significant weight loss of 26.4 pounds over several months. The facility's staff, including a CNA and a licensed nurse, were unaware of R26's weight loss and the necessary interventions to address it. The facility's policy required the multidisciplinary team to monitor and intervene in cases of undesirable weight loss, but this was not adequately done for R26. The registered dietitian reviewed R26's records and recommended supplements, but there was a lack of communication and follow-through among the staff. This deficiency placed R26 at risk for malnourishment-related complications, as the facility did not effectively address the ongoing weight loss.
Deficient Dialysis Care and Monitoring
Penalty
Summary
The facility failed to ensure that a resident, identified as R23, had a physician order for hemodialysis that included an indication. Additionally, the facility did not adhere to the physician's order for fluid restriction for R23. These deficiencies were identified through observation, record review, and interviews, indicating a lack of proper documentation and monitoring of the resident's dialysis care. R23's medical history included diagnoses of diabetes mellitus and chronic kidney disease, requiring dialysis services. The resident's care plan outlined specific instructions for monitoring renal failure, lab work, weight, protein and potassium intake, and signs of infection. However, the clinical record lacked a physician order for dialysis and documentation of fluid restriction monitoring, which are critical components of managing a resident with end-stage renal disease. Interviews with facility staff revealed a lack of clarity and responsibility regarding the monitoring of R23's fluid intake and dialysis schedule. Certified Nurse Aide M was unsure of R23's dialysis days, while Licensed Nurse G acknowledged the absence of a physician order for dialysis and uncertainty about who monitored the fluid restriction. Administrative Nurse D expected an order for dialysis and stated that dietary staff monitored fluid intake, but there was no documentation of this monitoring. The facility's policy on ESRD/hemodialysis care was not effectively implemented, leading to potential risks for the resident.
Failure to Provide Person-Centered Dementia Care
Penalty
Summary
The facility failed to provide necessary person-centered activities and interventions for a resident diagnosed with dementia, which included the need for close supervision to prevent wandering and falls. The resident, identified as R13, had a history of dementia, heart failure, hypertension, and osteoporosis, and required maximal assistance with activities of daily living. Despite these needs, the care plan lacked specific directions for person-centered activities that R13 preferred or attended, and the resident was often left unsupervised in the memory care unit. Observations revealed that R13 spent significant time in a wheelchair in the main television area or dining table, often without direct supervision. The resident's care plan directed staff to engage R13 in activities of interest and monitor for exit-seeking behavior, but these interventions were not effectively implemented. The facility's activity program, which was supposed to be based on comprehensive resident-centered assessments, did not adequately address R13's needs, as evidenced by the resident's limited participation in activities and the lack of staff available to provide consistent engagement. Interviews with staff indicated that the memory care unit was often understaffed, with only one staff member present to manage multiple residents, limiting the ability to provide individualized activities. The part-time activity staff and occasional additional aide support were insufficient to meet the needs of residents like R13, who required more consistent and personalized attention. This deficiency in providing appropriate dementia care placed R13 at risk of ineffective treatment and decreased quality of care.
Failure to Monitor and Recommend on Midodrine Medication
Penalty
Summary
The facility failed to ensure that the Consulting Pharmacist (CP) identified and made recommendations regarding a resident's Midodrine medication, which is used to treat low blood pressure. The resident, who had a history of cerebral infarction, dementia, muscle weakness, and orthostatic hypotension, was at risk for unnecessary medications and potential side effects due to the lack of proper monitoring and recommendations. The resident's care plan indicated a risk for cardio/circulatory complications, and the medication orders did not include blood pressure monitoring parameters. The resident's Medication Administration Record (MAR) showed that Midodrine was administered multiple times despite the resident having high blood pressure readings, which were above the usual parameters for holding the medication. Licensed Nurse G stated that Midodrine should be held if the resident's blood pressure was higher than the ordered amount, and the order should have included parameters. However, the facility's pharmacy reviews did not include any notes or recommendations related to the resident's Midodrine medication. Interviews with facility staff revealed that the pharmacy reviews all residents' medications and sends reports back to the facility, but the Administrative Nurse D was not informed that the resident's medication was being given with high blood pressure. Additionally, the facility was unable to provide a policy related to monthly pharmacy reviews when requested. This oversight placed the resident at risk for unnecessary medications and potential side effects due to the lack of proper monitoring and recommendations from the CP.
Failure to Ensure Safe Administration of Midodrine
Penalty
Summary
The facility failed to ensure safe medication administration for Resident 16's Midodrine medication, which is used to treat low blood pressure. The resident had a history of cerebral infarction, dementia, muscle weakness, and orthostatic hypotension, and was at high risk for falls due to her prescribed medications. Despite these conditions, the facility did not include blood pressure monitoring parameters in the physician's orders for Midodrine, which was administered even when the resident's blood pressure readings were above typical holding parameters for the medication. Licensed Nurse G and Administrative Nurse D acknowledged that Midodrine should be held if the resident's blood pressure was higher than the ordered amount to avoid the risk of hypertension. However, the facility's Medication and Treatment Orders policy, which requires medications to be administered based on the practitioner's order and intended use, was not followed. This oversight placed the resident at risk for unnecessary medications and potential side effects, as the staff did not verify the medication with the physician or hold the medication when blood pressure readings were high.
Failure to Document Rationale for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure an appropriate indication or a documented physician rationale for the use of antipsychotic medication in Resident 26. The resident, who had diagnoses including cognitive communication deficit, dementia, major depressive disorder, and anxiety, was receiving Olanzapine for violent behaviors. However, there was no documented attempt at a gradual dose reduction (GDR) or a physician's rationale for not attempting GDR, which is a requirement unless clinically contraindicated. This oversight placed the resident at risk for unnecessary psychotropic medication use and potential related complications. Additionally, the facility did not ensure that Resident 1 had a documented physician rationale for the continued use of as-needed (PRN) Ativan beyond 14 days. The resident, diagnosed with major depressive disorder and bipolar disorder, was receiving multiple psychotropic medications, including Ativan for anxiety. The consultant pharmacist recommended a rationale for the continued use of PRN Ativan, but the physician's response lacked a reason or rationale, which is necessary to justify the extended use of such medications. This deficiency also placed the resident at risk for unnecessary medication administration and potential complications. The facility's Medication and Treatment Orders policy requires that medication orders be consistent with safe and effective order writing principles and that they be reviewed monthly by a consultant pharmacist. Despite this policy, the facility failed to ensure compliance, as evidenced by the lack of appropriate documentation and rationale for the use of psychotropic medications in the cases of Residents 26 and 1. These deficiencies highlight a failure in the facility's medication management practices, potentially compromising resident safety.
Failure to Revise Care Plan for Resident's Personal Hygiene
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R1, to include necessary interventions related to personal hygiene. R1 had diagnoses of dementia without behavioral disturbance and prolapse bladder, with a Brief Interview for Mental Status (BIMS) score indicating moderately impaired cognition. Despite being independent with Activities of Daily Living (ADLs), R1 consistently refused bathing, as noted in the Quarterly Minimum Data Set. The care plan required staff to ask R1 daily if she wanted a bath and to notify the charge nurse if she refused, but it did not include notifying R1's family member of the refusals. Observations and interviews revealed that R1 did not receive a bath for 24 days, and the facility did not contact R1's family member despite repeated refusals. Staff interviews indicated a lack of awareness and adherence to the protocol of notifying the family member and documenting refusals. The facility's policy required ongoing assessments and revisions of care plans as residents' conditions changed, but this was not followed in R1's case, leading to the deficiency.
Failure to Provide Necessary Bathing Services
Penalty
Summary
The facility failed to ensure that Resident 1 received necessary bathing services to maintain good grooming and personal hygiene. Resident 1, who had diagnoses of dementia without behavioral disturbance and prolapse bladder, was noted to have moderately impaired cognition with a BIMS score of 8. Despite being independent with ADLs, the care plan required staff to offer a bath daily and notify the charge nurse if the resident refused. However, the facility's records indicated that Resident 1 did not receive a bath for 24 days, and there was no evidence of family notification when the resident refused bathing. Interviews with staff revealed that Resident 1 preferred baths at night, but the facility had moved her shower to the day shift due to staffing arrangements. This change contributed to the resident's refusal to bathe. Staff members, including a CNA and a licensed nurse, were unaware of the protocol to contact the resident's family when bathing was refused. The facility's policy required documentation of bathing assistance, which was not consistently followed, leading to the deficiency in providing necessary bathing services.
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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