Azria Health Wichita
Inspection history, citations, penalties and survey trends for this long-term care facility in Wichita, Kansas.
- Location
- 7057 West Village Circle, Wichita, Kansas 67205
- CMS Provider Number
- 175563
- Inspections on file
- 23
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Azria Health Wichita during CMS and state inspections, most recent first.
Surveyors found widespread failures in food labeling, sealing, and storage, along with poor sanitation and hand hygiene practices in the main kitchen and dining kitchenettes. Multiple opened, undated, and unsealed dry, refrigerated, and frozen food items were observed, as well as a nonfunctioning, rusted ice machine. Kitchenette areas contained trash, food debris, dirty and damaged cabinets, calcium buildup and rust on beverage and ice machines, and dirty refrigerators holding open, unlabeled food containers with utensils left inside. Dietary staff were seen handling food, utensils, and meal tickets with the same gloves, removing gloves without hand hygiene, and resuming food service tasks without washing hands. A resident’s hot meal tray sat out for an extended period and was later found to be below appropriate hot-holding temperatures before being discarded. Staff interviews confirmed dietary aides were responsible for cleaning these areas and that weekend cleaning coverage was lacking, despite facility policy requiring clean, properly labeled and dated food storage.
Surveyors identified multiple infection control failures involving two residents, including improper management of an indwelling urinary catheter and poor handling of oxygen tubing. One resident on EBP with a catheter had the drainage bag repeatedly placed on or dragging along the floor, at times positioned above bladder level, while CNAs provided peri-care, brief changes, dressing, and mechanical lift transfers without performing hand hygiene, changing gloves after soiled contact, or wearing gowns. Another resident’s oxygen tubing was repeatedly observed wrapped around a wheelchair handle instead of stored in a bag. Staff interviews showed CNAs lacked awareness of required glove changes, hand hygiene during care, and appropriate PPE and storage practices, despite nursing leadership stating expectations consistent with facility catheter care and hand hygiene policies.
A resident with anxiety, depressive disorder, and drug-induced dyskinesia, and with intact cognition per BIMS, was receiving multiple psychotropic medications, including an antidepressant, antianxiety, antipsychotic, and trazodone, without documented informed consent regarding risks and benefits. The care plan directed staff to educate the resident and family on psychotropic medication risks, benefits, and side effects, and assessments identified the medications as high risk with fall-related risk factors, yet the clinical record contained no consent documentation. Nursing staff reported being unaware of the psychotropic medication policy, and an administrative nurse stated that psychotropic evaluations and family notifications were usually done in-house, but in this case no psychotropic consent was obtained or documented because an outside provider managed the psychiatric medications.
Surveyors determined that the facility failed to provide required written notification of transfers for three residents who were sent to the hospital for issues including vomiting with pain, evaluation and treatment ordered by a provider, and hallucinations reported by family. In each case, documentation showed that the residents were transferred via EMS or at a family member’s request, but the EMR contained no evidence that written transfer notices were given to the residents or their representatives. Staff reported that they sent bed-hold information with the transfer packet and notified families by phone, but they were not aware of the requirement for written transfer notification, despite a facility policy stating that facility-initiated discharges require resident or representative notification and documentation.
A resident with intact cognition, depressive disorder, and an antidepressant order requiring monitoring for constipation went six consecutive days without a documented bowel movement, assessment, or treatment. Despite physician orders to follow the bowel routine protocol and PRN orders for prune juice, Milk of Magnesia, and Fleet enemas, staff did not initiate the constipation management steps outlined in the facility policy after three days without a BM. EMR review showed no constipation interventions or progress note assessments during this period, even though nurses reported they receive alerts after three days without a BM and are expected to assess, document, and follow the standing bowel protocol.
A resident with highly impaired hearing and a cognitive communication deficit did not receive adequate hearing-related care. Although standing orders and MAR entries showed intermittent Debrox use for cerumen impaction, there was no documentation of effectiveness assessments and no evidence of continued treatments in subsequent months. The resident reported difficulty hearing due to wax buildup and stated that hearing aids were not working and had not been cleaned recently. Staff interviews described expectations to verify hearing aid function, clean ears, and report problems to nursing leadership, and facility policy required assistance with hearing services and device maintenance, but the resident’s care plan lacked specific hearing interventions and the documented care did not align with these expectations.
A resident receiving IV ertapenem via a midline catheter had an undated dressing with dried blood visible under and through the soft cloth border and a loose bottom seal that remained unchanged over multiple days, with no documentation that staff assessed or addressed the soiled dressing. Physician orders and the care plan specified scheduled dressing changes but no PRN changes, and nursing documentation lacked evidence of dressing assessment despite twice-daily monitoring orders for IV-related complications. During IV medication administration, an LN performed hand hygiene and donned gloves but then repeatedly reached into pockets, handled the IV line, and touched her hair without changing gloves before connecting the IV tubing to the hub, while acknowledging the soiled, loose dressing and absence of a PRN order to change it, contrary to administrative expectations for daily IV site and dressing assessment and aseptic practice.
A resident with HTN and CHF, moderate cognitive impairment, and dependence for ADLs had physician orders for daily amlodipine and isosorbide mononitrate with specific BP and pulse hold parameters. MAR review over several months showed both antihypertensives were repeatedly administered when vital signs were outside the ordered parameters. The consultant pharmacist’s monthly medication regimen reviews did not identify or report these irregularities, despite facility expectations and written pharmacy service procedures that the consultant pharmacist oversee medication administration processes and report when medications are given contrary to physician‑ordered parameters.
A resident with HTN and CHF, moderate cognitive impairment, and dependence for ADLs had physician orders for daily isosorbide mononitrate and amlodipine with specific BP and pulse hold parameters. Over several months, MAR reviews showed both antihypertensives were repeatedly administered when BP and/or pulse readings were outside the ordered ranges, despite the care plan directing staff to follow medication orders and obtain and act on vital signs, and despite staff and consultant statements that medications should be held when parameters were not met. The facility’s policy required adherence to physician orders and notification of the DON and physician if orders could not be followed, but the documented medication administration did not align with these requirements.
Two residents receiving end-of-life and hospice-related care did not have hospice services fully integrated into their person-centered care plans. For one resident, the EMR contained only a hospice referral order without an admission order, and both residents’ care plans lacked the hospice provider’s contact information, a description of hospice services, and details on hospice-supplied medications, equipment, and supplies, as well as the frequency of hospice staff visits. A CNA reported relying on nurses to verbally identify hospice residents and visit days, while an LN stated that hospice plans of care were kept in separate hospice binders rather than incorporated into the EMR care plans. An administrative nurse confirmed that hospice information was not entered into the EMR until after the hospice episode ended, despite facility policy calling for an individualized, interdisciplinary plan based on comprehensive assessment and hospice appropriateness.
The facility failed to follow its policy for posting daily nurse staffing information by not including the actual hours worked by nursing staff on the publicly posted staffing sheets. On multiple observed occasions and in prior records, the sheets lacked required details about actual time worked for each category and type of nursing staff, despite the facility’s policy specifying that this information, along with census and staffing categories, must be recorded and posted. Administrative staff and a CMA responsible for staffing confirmed that the posted sheets did not contain the actual hours worked.
A resident's hydrocodone medication was misappropriated by an LPN, who removed a card of 45 tablets from the facility. The resident, dependent on staff for daily living and pain management due to paraplegia and lupus, was aware of the missing medication but reported receiving her pain relief as needed. The LPN confessed to taking the medication and attempted to replace it with fewer tablets, violating facility policy on medication management.
The facility failed to provide sanitary food preparation and storage, with issues such as unsealed and undated food items, expired orange juice, and improper hair restraint observed in the kitchen. The facility's food storage policy was not followed, and no policy for hair-restraint use was provided.
The facility failed to maintain and dispose of garbage and refuse properly, leading to medical waste littering the outside dumpster area and the dumpster lid being left open. Staff were unaware of their responsibilities regarding the cleanliness and closure of the dumpster area. The facility could not provide a policy on garbage and refuse handling and disposal.
The facility failed to ensure a safe environment for 11 confused and self-mobile residents by storing hazardous chemicals within reach and using a gait belt to secure a door in the open position, posing fire and safety hazards. Staff confirmed that these practices were against safety protocols.
The facility failed to ensure certified nursing staff had appropriate competencies, compromising resident safety and well-being. Issues included improper catheter care for a resident, delays in call light responses for two residents, and lack of Enhanced Barrier Precautions. These deficiencies placed residents at risk for infection and decreased quality of care.
The facility failed to ensure medications were securely stored, leading to a potential risk for accidental ingestion by confused and mobile residents. Specifically, two residents' rooms were found with unsecured medications, despite the lack of self-administration assessments or physician's orders. Staff confirmed that medications should not be stored in resident rooms without appropriate assessments and orders, highlighting a deficiency in the facility's adherence to its medication storage policy.
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature. Test trays from two satellite kitchens revealed that some foods were served below the required temperature and were unpalatable. The facility could not provide a policy related to food palatability and service temperatures.
The facility failed to provide a sanitary environment, proper PPE use, and appropriate catheter care, leading to potential cross-contamination and infection risks for residents with catheters, wounds, and PEG tubes. Staff were unaware of Enhanced Barrier Precautions requirements, and necessary PPE supplies were not readily available.
The facility failed to maintain the dignity of three residents: one was spoken to in a demeaning manner, another had an uncovered urinary catheter bag, and a third was exposed during incontinence care with open window blinds. These actions violated the facility's dignity policy.
A resident with multiple health issues, including rheumatoid arthritis and mobility problems, struggled to reach and use the call light due to its improper placement. Despite staff protocols to ensure call lights are within reach, the resident's needs were not accommodated, and no policy was provided to address reasonable accommodations.
The facility failed to track and resolve a grievance filed by a resident regarding a nurse's behavior. The resident, who was cognitively intact, reported that a nurse refused to clean a resident lying in their waste. Despite reporting this grievance, the facility did not follow up, document the grievance, or provide a written decision or summary of findings, contrary to their grievance policy.
The facility failed to develop comprehensive, individualized care plans for two residents, one requiring grab bars for bed mobility and another needing oxygen. The care plans lacked necessary documentation and guidance, placing the residents at risk for uncommunicated care needs and potential health complications.
The facility failed to decrease the risk of UTIs for two residents by not adhering to proper hand hygiene and Enhanced Barrier Precautions during catheter care. Observations revealed improper storage of catheter bags, failure to perform hand hygiene, and reuse of washcloths and wipes, which are against the facility's policies. Additionally, one resident did not have a securement device for the catheter tubing, despite the facility having the necessary supplies in stock.
The facility failed to properly clean and store nebulizer equipment for two residents and did not label oxygen tubing for another resident, leading to potential respiratory complications and infection risks. The facility's policies for respiratory equipment maintenance were not followed, as confirmed by staff interviews and observations.
The facility failed to assess a resident for safety and risk of entrapment from bed rail use and did not obtain informed documented consent prior to the installation of the siderails. The resident had diagnoses of generalized muscle weakness, reduced mobility, incomplete paraplegia, and muscle wasting with atrophy. Despite using grab bars for bed mobility, no prior safety assessment or informed consent was documented.
Improper Food Storage, Sanitation, and Hand Hygiene in Dietary Services
Penalty
Summary
The deficiency involves failure to properly label, seal, and store food items and to maintain clean food service areas in the main kitchen and satellite kitchenettes. During an initial tour of the main kitchen, surveyors observed multiple opened, undated, and unsealed dry goods in the dry storage area, including cream of wheat, macaroni noodles, rainbow sprinkles, and hamburger buns. In the walk-in refrigerator and kitchen serving area refrigerator, there were opened, undated, and unsealed items such as shredded cheese, fish, sliced cheese, an onion, lettuce, and chicken base. The kitchen freezer contained several opened, undated, and unsealed bags and boxes of frozen foods, including chicken strips, potato wedges, beef patties, chicken nuggets, and corn dogs, with some corn dogs showing frost buildup. The ice machine in the kitchen was not working and had visible rust at the hinges. In the dining kitchenette areas, surveyors observed trash present, clean towels stored directly on the floor of a cabinet, and multiple food and beverage items that were open, unlabeled, undated, or stored in dirty refrigerators. These included an open water bottle, an open bottle of soda, and undated food containers such as a green dessert and rice casserole, some with utensils left inside the food. The juice machines and ice/water dispensers in different dining areas had visible calcium buildup, juice splatter on surrounding surfaces, rust on drip racks, and black particles floating in ice. Cabinets, drawers, and areas under sinks and around trash compartments contained food crumbs, coffee grounds, dried spills, discoloration from leaks, peeling laminate with exposed wood, and black debris of unknown substance. On subsequent days, these areas remained visibly soiled and largely unchanged from prior observations, with additional trash noted. Surveyors also observed improper hand hygiene and glove use by dietary staff during food plating and service. A dietary aide in a kitchenette plated food while wearing the same pair of gloves to handle utensils, meal tickets, and bread, then removed gloves without performing hand hygiene, donned new gloves, and continued handling food and clean plates without washing hands. Another dietary staff member handled covered food containers, set them up on the steam table, removed gloves without hand hygiene, made a phone call, then resumed uncovering food and placing serving utensils without washing hands or wearing gloves, and later donned clean gloves and began serving food without prior hand hygiene. Additionally, a resident’s meal tray with oatmeal, eggs, bacon, and toast remained on a service table for an extended period, and when temperatures were checked, all items were below appropriate hot-holding temperatures before the tray was discarded. Staff interviews confirmed that dietary aides were responsible for cleaning kitchenettes and dining service stations and that there was no one assigned to clean on weekends, contributing to the observed unclean conditions, despite a facility policy requiring clean food storage areas and proper labeling and dating of stored foods.
Inadequate Infection Control for Catheter Care, Hand Hygiene, and Oxygen Tubing
Penalty
Summary
The deficiency involves failures in infection prevention and control practices related to hand hygiene, use of PPE under Enhanced Barrier Precautions (EBP), management of indwelling urinary catheters, and handling of respiratory equipment. One resident with an indwelling urinary catheter was on EBP, as indicated by a sign on the door and a PPE bin that contained no gowns. Surveyors observed the resident in bed with the catheter drainage bag attached to the bed, and later in the dining room with the catheter bag hanging outside the dignity bag and touching the floor. When the resident was assisted back to her room, the catheter bag continued to drag on the floor as the wheelchair was pushed. During morning care, a CNA placed the catheter bag on the floor while draining urine from the tubing into the bag, then temporarily hung the bag above the level of the bladder on the footboard before another CNA repositioned it below bladder level. Throughout peri-care, brief change, dressing, and use of a mechanical lift, the CNAs did not perform hand hygiene, did not change gloves after contact with soiled areas, and did not wear gowns despite the resident being on EBP and having an indwelling catheter. Another resident using oxygen had her oxygen tubing wrapped around the handle of her wheelchair while she was in bed with oxygen in use, and this condition persisted on subsequent observation. A CNA reported that when assisting residents with oxygen, she typically wound the tubing and laid it on a surface and was unaware of any bag or sanitary container for storing the tubing. Staff interviews revealed gaps in knowledge and practice expectations: one CNA stated she did not know gloves had to be changed and hand hygiene performed during care after touching something dirty, and she was unsure about gown use for a resident with a catheter. The licensed nurse and administrative nurse both stated their expectations that catheter bags remain below bladder level, never touch the floor, that staff perform hand hygiene and change gloves after contact with contaminated areas, and that oxygen tubing be kept in a bag when not in use, consistent with facility policies on catheter care and hand hygiene.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to inform a cognitively intact resident or her representative about the risks and benefits of multiple psychotropic medications, including an antianxiety, antidepressant, and antipsychotic. The resident’s EMR documented diagnoses of anxiety, depressive disorder, and drug-induced dyskinesia, and her MDS showed a BIMS score of 15, indicating intact cognition. The MDS and Psychotropic Drug Use CAA documented that she received high-risk psychotropic medications, including two antidepressants and an antianxiety medication, with identified risk factors such as falls and injuries related to falls. Her care plan documented use of an antidepressant for depression, an antianxiety medication for anxiety with a directive to educate the resident and family on risks, benefits, and side effects, and an antipsychotic medication. Physician’s orders showed active prescriptions for Lexapro 10 mg daily for depression, haloperidol 1 mg daily for dyskinesia, trazodone 75 mg at bedtime for dyskinesias, and Klonopin 0.5 mg twice daily for anxiety. However, the clinical record lacked evidence of informed consent for any of these medications. During interviews, a licensed nurse stated she was unaware of the policy when a resident received psychotropic medication. An administrative nurse reported that she or another nurse completed psychotropic evaluations and notified families when new psychotropic medications were prescribed, and that a PA typically documented psychiatric medication management, but the PA did not see this resident because she used an outside provider. The administrative nurse further stated that the facility did not obtain a psychotropic consent for this resident because the off-site provider would obtain it, and no psychotropic consent documentation was present in the facility record despite a policy addressing antipsychotic medication use.
Failure to Provide Written Transfer Notifications for Hospitalized Residents
Penalty
Summary
Surveyors found that the facility failed to provide required written notification of transfers for three residents who were sent to the hospital. One resident experienced vomiting of a reddish-brown substance and reported right shoulder pain; the nurse obtained provider orders to send the resident to the ER via EMS, but the electronic medical record contained no evidence that written notification of the transfer was provided to the resident or representative. A second resident was sent to the ER for evaluation and treatment based on a verbal provider order documented in the progress notes, yet the electronic medical record similarly lacked documentation that written notification of the transfer was given to the resident or representative. A third resident was documented as hallucinating and talking to people who were not present, and the resident’s daughter requested that the resident be taken to the hospital; the resident was transferred, but the electronic medical record again lacked evidence of written notification of the transfer to the resident or representative. During interviews, social services staff stated that a bed-hold notice was sent with residents upon transfer and that families were notified by phone, but acknowledged they were not aware that written notification of transfers to the hospital was required. Administrative staff also stated they had not heard of the written notification requirement for hospital transfers and inquired about the applicable regulation. The facility’s transfer or discharge policy indicated that facility-initiated discharges require resident or representative notification, orientation, and documentation.
Failure to Monitor and Treat Constipation per Bowel Protocol
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to monitor and respond to a resident’s lack of bowel movements in accordance with physician orders, the care plan, and the facility’s constipation management policy. The resident had diagnoses including anxiety, depressive disorder, and drug-induced dyskinesia, and MDS assessments showed intact cognition and that the resident was always continent of bowel without constipation. The care plan documented that the resident was on an antidepressant and directed staff to monitor for side effects, including constipation. Physician orders included following the facility’s bowel routine protocol and PRN orders for prune juice, Milk of Magnesia, and Fleet enemas for constipation. Review of the EMR task records showed that between 02/02/26 and 02/08/26, the resident went six consecutive days without a documented bowel movement or any constipation treatment or assessment. There were no progress notes documenting any assessment or intervention for constipation during this period, despite the facility’s constipation management policy directing that if no bowel movement occurred in three days, Milk of Magnesia should be given, followed by escalating interventions and provider notification if there were no results. Staff interviews confirmed that nurses were expected to monitor bowel movements, receive alerts when a resident went three days without a bowel movement, assess the resident, document the assessment, and follow the standing bowel protocol, which did not occur for this resident during the identified timeframe.
Failure to Provide Hearing Treatments and Maintain Hearing Devices
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary hearing treatments and maintain hearing devices for a resident with documented highly impaired hearing. The resident’s EHR showed a diagnosis of cognitive communication deficit and a need for assistance with personal care, while a recent MDS documented intact cognition, independence with footwear, and the need for varying levels of assistance with ADLs. The same MDS documented that the resident had highly impaired hearing. The resident’s care plan, including a revision dated 04/06/22 instructing staff to anticipate and meet the resident’s needs, lacked any interventions specifically addressing the resident’s impaired hearing as of 12/03/25. An audiology report dated 12/22/25 documented impacted cerumen, and the facility’s standing orders included Debrox ear drops and ear flushing for cerumen impaction. The resident’s EHR contained a standing order dated 12/23/25 for Debrox ear drops for wax buildup, and the December MAR showed Debrox was administered on multiple dates in December. However, there was no documentation in the progress notes that staff assessed the effectiveness of these Debrox treatments. The MARs for January and February lacked evidence of any Debrox treatments. During observation, the resident moved closer and tilted and turned his head when asked questions and reported difficulty hearing due to wax buildup. The resident also reported having hearing aids that did not work and that staff only cleaned them occasionally and not recently. A CNA stated she would check hearing aids and notify the nurse if they did not work, and an LN stated she would verify hearing aid function and notify the DON if there were issues, also stating the resident’s ears were cleaned regularly. An administrative nurse stated she expected daily verification that hearing aids were operational and that staff should notify leadership for repair or replacement and report hearing concerns to the provider. The facility’s policy on care of hearing-impaired residents required staff to assist with locating resources, scheduling appointments, arranging transportation, and assisting with care and maintenance of hearing devices, which was not reflected in the documented care and follow-through for this resident.
Failure to Maintain Clean, Intact Midline IV Dressing and Use Proper Aseptic Technique
Penalty
Summary
The deficiency involves the facility’s failure to provide IV care and services consistent with standards of practice for a resident with a midline IV catheter. The resident had diagnoses including UTI and hypertension and physician orders for daily IV ertapenem, heparin flushes, and twice-daily monitoring for signs and symptoms of infection, pain, redness, infiltration, bruising, embolism, phlebitis, fluid overload, and electrolyte imbalance. The care plan and physician orders directed that the midline dressing be changed on a set weekly schedule, but did not include any PRN order for dressing changes when soiled. Documentation in the MAR/TAR and progress notes showed staff recorded the ordered clinical monitoring but lacked evidence that staff assessed or documented the midline dressing’s cleanliness or integrity. During observation, the resident was noted in bed with a single-lumen midline IV in the right upper arm, and the dressing was undated with a large amount of dried blood collected under the dressing and seeping through the soft cloth border. The bottom seal of the dressing was loose, while the top was reinforced, and this condition remained unchanged on subsequent observation. There was no documentation that staff had assessed or addressed the soiled and loose dressing from the time it was first observed through later surveyor observations. When a nurse prepared to administer the resident’s IV antibiotic, she performed initial hand hygiene and donned gloves and a gown, but then placed her gloved hand into her pocket to retrieve supplies, wiped the IV hub with an alcohol wipe, allowed the hub to rest back on the resident’s arm, and continued to handle the IV line, touch her hair, and remove items from her pocket multiple times without changing gloves. She then connected the IV tubing to the hub while still wearing the same contaminated gloves. The nurse acknowledged the dressing was soiled and loose and that there was no date on it, and stated she believed a PRN order was needed to change a soiled dressing. Another nurse later confirmed the dressing was scheduled only for weekly changes, verified the presence of dried blood and the need for a change, and confirmed there was no PRN order. Administrative nursing staff stated their expectations that IV sites and dressings be assessed daily, that midline dressings be changed multiple times weekly and as needed, and that nurses document site and dressing condition during medication administration, but the facility’s written policy addressed only peripheral IV catheter and site selection and did not address care and monitoring of the site and dressing.
Consultant Pharmacist Failed to Identify and Report Antihypertensives Given Outside Hold Parameters
Penalty
Summary
The deficiency involves the facility’s failure to ensure the consultant pharmacist identified and reported repeated administration of antihypertensive medications outside of physician‑ordered hold parameters for one resident. The resident had diagnoses of hypertension and congestive heart failure, a BIMS score of 12 indicating moderately impaired cognition, dependence on staff for ADLs, and was receiving an anticoagulant and a diuretic. Her care plan directed staff to administer medications as ordered, obtain vital signs at least daily per physician orders and as needed, and notify the physician of abnormal readings. Physician orders for isosorbide mononitrate 30 mg daily and amlodipine 10 mg daily for hypertension included explicit parameters to hold the medications if pulse was less than 50 BPM or greater than 120 BPM, or if BP was less than 120/40 or greater than 200/90 mm/Hg. Review of the resident’s MARs showed that both antihypertensive medications were administered multiple times when vital signs were outside the ordered parameters over several consecutive months. In November, amlodipine and isosorbide mononitrate were each given outside parameters on 6 of 30 opportunities. In December, each medication was given outside parameters on 12 of 30 opportunities. In January, each was given outside parameters on 15 of 30 opportunities. In February, each was given outside parameters on 5 of 24 opportunities. Despite this pattern, the consultant pharmacist’s Medication Regimen Reviews from January 2025 to the present did not identify or report that these medications were being administered contrary to the physician‑ordered hold parameters. Interviews confirmed that facility staff and administration expected medications to be held when BP or pulse readings were outside the ordered parameters and expected the consultant pharmacist to report when medications were given outside those parameters. A consultant stated she interpreted the physician parameters as directions to hold the medications when readings were below or above the ordered numbers and would expect the consultant pharmacist to identify and report when medications were not held appropriately. A CMA and a licensed nurse described processes for checking BP and pulse and holding medications or notifying a nurse when readings were low. The administrative nurse stated she expected anyone administering medications to hold them when readings were outside parameters and expected the consultant pharmacist to report such occurrences. The facility’s Pharmacy Services Overview documented that the consultant pharmacist oversees development of procedures related to medication administration and staff roles and responsibilities, but the consultant pharmacist’s reviews did not address the repeated administration of antihypertensives outside the ordered parameters for this resident.
Failure to Follow Hold Parameters for Antihypertensive Medications
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered parameters for administering antihypertensive medications to one resident. The resident had diagnoses of hypertension and congestive heart failure, a BIMS score of 12 indicating moderately impaired cognition, dependence on staff for ADLs, and was receiving an anticoagulant and a diuretic. The care plan directed staff to administer medications as ordered, obtain vital signs at least daily per physician orders and as needed, and notify the physician of any abnormal readings. Physician orders for isosorbide mononitrate 30 mg daily and amlodipine 10 mg daily included explicit parameters to hold the medications if pulse was less than 50 BPM or greater than 120 BPM, or if BP was less than 120/40 or greater than 200/90 mm/Hg. Review of the resident’s MARs showed that both antihypertensive medications were administered multiple times when BP and/or pulse readings were outside the ordered parameters over several months. In November, each medication was given outside parameters on 6 of 30 opportunities; in December, on 12 of 30 opportunities; in January, on 15 of 30 opportunities; and in February, on 5 of 24 opportunities. Staff interviews revealed that the consultant pharmacist interpreted the parameters as directions to hold the medications when readings were outside the ordered ranges, a CMA reported she would retake low readings and notify the nurse and hold the medication if still low, and an LN and administrative nurse both stated that medications should be held when BP or pulse readings were outside the ordered parameters. The facility’s medication and treatment orders policy required that physician orders be followed and that the DON/designee and physician be notified if orders could not be followed, but the documented MARs showed repeated administration of the antihypertensives contrary to those parameters.
Failure to Integrate Hospice Services Into Resident Care Plans
Penalty
Summary
Surveyors identified a deficiency in the facility’s coordination and documentation of hospice services for two residents receiving end-of-life care. For one resident, the EMR contained a physician’s order for a hospice referral dated 01/06/26 but lacked an order to admit the resident to hospice services. The resident’s care plan, dated 01/07/26, included general directions to adjust ADLs, encourage participation, consult with physicians and Social Services for hospice care, and work cooperatively with the hospice team to meet the resident’s needs and provide maximum comfort. However, the care plan did not specify the hospice provider’s contact information, the services hospice would provide, the supplies, equipment, and medications hospice would furnish, or the frequency of hospice staff visits. During observation on 02/23/26, the resident was seen in a high-back wheelchair in his room with a soft-touch call light nearby and a fall mat folded and leaning against the wall. For the second resident, the EMR showed a physician’s order dated 10/15/25, and the care plan revised on 02/02/26 indicated the resident was on end-of-life support, with directions to participate in activities as tolerated, assist with ADLs such as ambulation and mobility, and keep the resident as comfortable as possible. This care plan also lacked specific directions regarding the hospice provider’s services, including what supplies, equipment, and medications hospice would provide and how often hospice staff would visit. A CNA reported that nurses typically informed aides which residents were on hospice and which days the hospice aide would provide showers, but could not identify what supplies and equipment hospice provided. An LN stated that each hospice resident had a separate hospice book containing the hospice plan of care, including medications, supplies, equipment, and visit schedules, and did not believe this information needed to be in the resident’s person-centered plan. The Administrative Nurse confirmed that she expected this information to be in the resident’s plan of care, acknowledged that hospice orders for one resident were likely only in the hospice binder, and stated that hospice information was not entered into the EMR until after the resident died or the hospice episode ended, despite facility policy requiring an interdisciplinary, individualized plan based on comprehensive assessment and hospice appropriateness.
Failure to Post Required Actual Nursing Hours on Daily Staffing Sheets
Penalty
Summary
The facility failed to ensure that posted daily nurse staffing sheets included accurate and identifiable information, specifically the actual hours worked by nursing staff. On two separate observations in February, surveyors noted that the posted staffing sheets did not list the actual hours worked. Additionally, review of historical daily staffing sheets from two prior dates showed the same omission of actual hours worked. The posted sheets were required to reflect detailed staffing information, including the actual time worked during each shift for each category and type of nursing staff. Administrative staff reported that a certified medication aide functioning as the staffing coordinator provided staffing numbers to the receptionist, who then printed and posted the daily staffing sheets in the lobby. The staffing coordinator confirmed that the actual hours worked were not included on the posted sheets, and administrative staff later verified that the posted daily staffing sheets did not contain the required actual hours worked for resident care medical staff. The facility’s own policy, dated July 2016, required that the posted form include the facility name, date, resident census, 24-hour shift schedule, shift, type and category of nursing staff, the actual time worked during the shift for each category and type of nursing staff, and the total number of licensed and non-licensed nursing staff for the posted shift, which was not followed.
Misappropriation of Resident's Pain Medication
Penalty
Summary
The facility failed to protect a resident from the misappropriation of medications, specifically hydrocodone, which is used for pain management. On a specified date, a Licensed Nurse removed a card containing 45 tablets of hydrocodone from the facility, which was intended for a resident diagnosed with paraplegia, lupus, and chronic back pain. The resident was dependent on staff for all activities of daily living and required opioid medication for pain relief. The resident was aware of the missing medication but reported receiving her pain medications as needed. The investigation revealed that a Licensed Nurse had worked on the unit during the time the medication went missing and later confessed to taking the card of hydrocodone. The nurse attempted to replace the missing medication with a new card containing fewer tablets. The facility's policy required immediate reporting of missing medications to initiate an investigation, which was not followed promptly. The incident placed the resident at risk for missed medication and uncontrolled pain.
Sanitary Food Preparation and Storage Deficiencies
Penalty
Summary
The facility failed to provide sanitary food preparation and storage of food, which could potentially lead to the spread of foodborne illness among residents. During an initial tour of the kitchen, several issues were observed, including a staff member with long hair not properly restrained, expired food items, and multiple instances of unsealed and undated food in both the refrigerator and freezer. Specifically, expired orange juice, unsealed hotdog buns, and various undated and unsealed food items such as potatoes, onions, mayonnaise, raw chicken, and assorted vegetables were found in different storage areas of the kitchen. Additionally, the facility's food storage policy was not adhered to, as it mandates that all foods should be labeled with the name and expiration date, and raw poultry should not be left uncovered or unsealed. The facility also failed to provide a policy for hair-restraint use in the kitchen areas when requested. These deficiencies were confirmed by Dietary Staff H, who acknowledged that all items in the refrigerators and freezers should be sealed and dated, and that all staff should have hair restraint devices on when in the kitchen areas.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain and dispose of garbage and refuse properly in a sanitary condition, which could prevent the harborage and feeding of pests. During an initial tour of the kitchen facilities, it was observed that the outside dumpster area was littered with medical waste, including soiled bandages and disposed gloves, and the dumpster lid was open. Dietary Staff H was unaware that kitchen staff were responsible for the cleanliness of the area around the dumpster or that the dumpster lid should remain closed. Administrative Nurse B stated that all staff taking trash to the dumpster should ensure the area is free of debris and the lid is closed. Housekeeping Supervisor J was also unaware of these requirements. The facility could not provide a policy related to garbage and refuse handling and disposal when requested. This deficiency had the potential to attract pests and posed an infection control concern.
Failure to Maintain a Safe Environment and Prevent Accident Hazards
Penalty
Summary
The facility failed to ensure the environment was free of accident hazards for 11 confused and self-mobile residents. Observations revealed that hazardous chemicals, such as an unidentified spray bottle, Fabuloso cleaning agent, and air-freshener, were stored in residents' rooms and bathrooms within reach. These chemicals had manufacturer labels indicating they should be kept out of reach of children. Additionally, a gait belt was used to secure a resident's door in the open position, which restricted door movement and posed a fire and safety hazard. Staff members, including a Licensed Nurse (LN) and Certified Nurse Aides (CNAs), confirmed that chemicals should not be stored in resident rooms and that door movement should not be restricted with any device due to safety concerns. The facility did not provide a policy related to the prevention of accident hazards when requested. The observations and interviews with staff indicated a failure to maintain a safe environment by keeping hazardous chemicals out of reach and improperly securing doors. This deficiency was identified through multiple observations over several days, highlighting a systemic issue in the facility's safety protocols and supervision of residents.
Deficiencies in Staff Competencies and Call Light Response Times
Penalty
Summary
The facility failed to ensure that certified nursing staff had the appropriate competencies and skill sets to provide nursing-related services, which compromised resident safety and well-being. For Resident 50, the staff did not follow proper catheter care procedures, including hand hygiene and the use of Enhanced Barrier Precautions. CNA C was observed not washing her hands before and after glove use and was unaware of the guidelines for proper catheter care and Enhanced Barrier Precautions. This placed Resident 50 at risk for infection and decreased quality of care. Resident 165 experienced delays in call light responses, with logs showing multiple instances where the call light remained unanswered for 15 to 30 minutes. This delay in response time was confirmed by both the resident and staff interviews. The facility failed to provide a policy regarding call lights, and the administrative nurse indicated that audits and investigations would be conducted if call light responses exceeded 10 minutes. However, the lack of timely response placed the resident at risk for decreased quality of care. Resident 25 also faced issues with catheter care. Staff failed to perform hand hygiene and did not use Enhanced Barrier Precautions during catheter care. Additionally, the resident did not have a securement device for the catheter, despite it being available in the facility's supply room. Both CNA D and LN M did not follow proper procedures for hand hygiene and catheter care, which was confirmed through interviews. This failure placed the resident at risk for infection and decreased quality of care. Similar issues were observed with Resident 11 and Resident 3, who also experienced delays in call light responses, further indicating a systemic issue with staff competencies and response times.
Failure to Secure Medications in Resident Rooms
Penalty
Summary
The facility failed to ensure that medications were securely stored, leading to a potential risk for accidental ingestion by confused and mobile residents. Specifically, Resident 25's room was found to have a bottle of generic antacid tablets on the bathroom counter, despite the resident not having a self-administration assessment or a physician's order for self-administration. The facility's policy prohibited medications in resident rooms unless these conditions were met, and staff confirmed the lack of necessary assessments and orders for Resident 25. Similarly, Resident 1's room was observed multiple times with various medications, including refresh eye drops, Ciclopirox drops, and Restasis drops, on the over-the-bed table. Like Resident 25, Resident 1 did not have a self-administration assessment or a physician's order for self-administration. Staff interviews confirmed that medications should not be stored in resident rooms without the appropriate assessments and orders, and the facility's policy lacked specific instructions related to self-administration of medications. The facility's failure to secure medications in the rooms of Residents 25 and 1 created a potential risk for accidental ingestion by confused and mobile residents. The observations and staff confirmations highlighted a deficiency in the facility's adherence to its medication storage policy, which required medications to be stored in a safe, secure, and orderly manner. The lack of self-administration assessments and physician's orders for these residents further underscored the facility's failure to provide a safe environment for its residents.
Failure to Provide Palatable and Safe Food
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature. During a survey, test trays were requested from two satellite kitchens. The noon meal tray from the west kitchen had all foods measured above the appropriate temperature of 135 degrees Fahrenheit, but the tater-tots tasted stale and freezer burnt. The meal tray from the east kitchen had tater-tots and popcorn shrimp measured below the required 135 degrees Fahrenheit, and both items were cool and unpalatable. Dietary staff confirmed that all hot foods should be served at a minimum of 135 degrees Fahrenheit. The facility was unable to provide a policy related to food palatability and food service temperatures when requested. This deficiency had the potential to lead to residents not eating appropriate portion sizes and causing foodborne illnesses due to improper serving temperature.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to provide a sanitary and safe environment to prevent cross-contamination and infection related to the appropriate use of personal protective equipment (PPE) and the safe and sanitary handling of glucometers. Licensed Nurse P did not perform hand hygiene before applying gloves, used a community glucometer without sanitizing it between residents, and failed to sanitize the medication cart and glucometer container. This led to potential cross-contamination and infection risks for multiple residents, including those with catheters, wounds, and percutaneous enteral gastrostomy tubes (PEG). Additionally, the facility did not have Enhanced Barrier Precautions (EBP) in place for residents requiring them, and staff were not aware of the need for EBP until after the surveyor's observation. The facility also failed to provide appropriate catheter care and hand hygiene for residents with urinary catheters. Certified Nurse Aide (CNA) C did not wash her hands before applying gloves and did not use a gown while providing catheter care. CNA C placed soiled wipes on top of clean wipes and did not wash her hands after removing gloves. Similarly, Licensed Nurse (LN) AA did not perform hand hygiene when changing gloves and used improper infection control techniques while providing catheter care. These actions increased the risk of urinary tract infections and other complications for residents with catheters. Furthermore, the facility did not implement Enhanced Barrier Precautions for residents with catheters, wounds, and PEG tubes until after the surveyor's observation. Staff were not aware of the need for EBP, and PPE supplies such as gowns and signage were not readily available. This lack of implementation and awareness among staff further contributed to the risk of cross-contamination and infection for residents requiring enhanced precautions during care activities.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of Resident 20 when a nurse spoke to her in a demeaning manner, stating 'That's not my job' when the resident was lying in her waste. Despite the resident reporting this grievance during a Resident Council Meeting, the facility did not document the complaint in the Grievance Log or follow up with the resident regarding an action plan to address the concern. The facility's dignity policy mandates that all residents be treated with respect and that their privacy be maintained during personal care, which was not upheld in this instance. Resident 50, who had a diagnosis of urinary retention and required an indwelling catheter, was observed without a privacy bag for the catheter collection bag on multiple occasions. This oversight was noted by both a Certified Nurse Aide and a Licensed Nurse, who confirmed that all residents with catheter bags should have a privacy bag to protect their dignity. The facility's policy explicitly states that urinary catheter bags should be covered to maintain resident dignity, which was not adhered to in this case. Resident 25, who had diagnoses including generalized muscle weakness and incomplete paraplegia, was subjected to incontinence and catheter care with the window blinds open, exposing her lower abdomen and genitals to a courtyard visible from the main entrance of the building. Both the Certified Nurse Aide and Licensed Nurse involved in the care confirmed that the window blinds should have been closed to protect the resident's privacy. The facility's dignity policy requires that residents' privacy be protected during personal care, which was not followed, leading to the resident feeling a negative psychosocial impact on her dignity.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light remained within reach, which is a deficiency in accommodating the resident's needs. The resident, who had diagnoses including diabetes mellitus type 2, generalized weakness, aphasia following a stroke, and rheumatoid arthritis, required substantial assistance for all activities of daily living except eating. Despite having intact cognition, the resident had difficulty grasping and pressing the call light due to deformities in his fingers and mobility issues with his left shoulder and arm. On multiple occasions, the resident was observed struggling to reach and use the call light, which was tied to the left upper grab bar on the bed, making it difficult for him to access it without repositioning himself in an unnatural and potentially harmful manner. Interviews with staff, including CNAs and a licensed nurse, confirmed that call lights should be placed within easy reach of residents, especially those with mobility problems. The staff acknowledged that they should notify the nurse on duty if a resident had difficulty using the call light so that appropriate adjustments could be made. Despite these protocols, the resident's need for an easier way to alert staff for assistance was not addressed, and the facility failed to provide a policy related to reasonable accommodations of individual needs when requested. This oversight resulted in the resident not receiving the appropriate call light equipment to accommodate his individual needs.
Failure to Track and Resolve Resident Grievance
Penalty
Summary
The facility failed to track grievances through to their conclusions and provide prompt efforts to resolve a grievance filed by a resident regarding the behavior of staff. Resident 20, who had a history of cognitive communication deficit, cerebral vascular accident, traumatic brain injury, repeated falls, and fractures, reported a grievance about a nurse's behavior. The resident, who was cognitively intact with a BIMS score of 13, expressed concerns about a nurse's refusal to clean a resident lying in their waste, stating, 'That is not my job.' Despite reporting this grievance in a Resident Council Meeting, the facility did not follow up with the resident or document the grievance in the Grievance Log. The Social Service Worker responsible for tracking grievances was unaware of Resident 20's complaint, and the Grievance Log lacked documentation of the concern. Administrative staff confirmed that the grievance was reported but not followed up on, and the facility did not provide a written grievance decision or a summary of the findings to the resident. The facility's policy on grievances, which requires prompt investigation and resolution, was not adhered to in this case. The facility's failure to track and resolve the grievance, provide written decisions, and offer a summary of the findings or corrective actions taken, highlights a significant deficiency in handling resident grievances. This lapse in procedure left Resident 20's concerns unaddressed and undocumented, contrary to the facility's stated grievance policy.
Deficient Care Plans for Bed Mobility and Oxygen Use
Penalty
Summary
The facility failed to develop a comprehensive, individualized person-centered care plan for two residents, leading to uncommunicated care needs. Resident 25, who had diagnoses including generalized muscle weakness, reduced mobility, and incomplete paraplegia, required the use of grab bars for bed mobility. Despite this need, the care plan, physician's orders, and electronic health records lacked documentation related to grab bar use. Interviews with staff confirmed that interventions performed by staff should be included in the care plan, but this was not done for Resident 25, placing the resident at risk for uncommunicated care needs. Resident 27, who had diagnoses of heart failure and chronic respiratory failure, required oxygen as part of her care. The care plan for Resident 27 did not address the use of oxygen or provide guidance on maintaining oxygen equipment to prevent infection. Observations revealed that the oxygen equipment, including tubing, cannula, and humidifier bottle, was not labeled with dates indicating when they were placed into service. Staff interviews confirmed that the care plan should provide guidance on the care and treatment of oxygen equipment, but this was not done for Resident 27, leading to potential risks of cross-contamination and infection. The facility's policy on comprehensive person-centered care plans stated that the care plan should describe the services to be furnished, including any specialized services. However, the facility failed to adhere to this policy for both residents, resulting in deficiencies in their care plans. This lack of documentation and guidance placed the residents at risk for uncommunicated care needs and potential health complications.
Failure to Adhere to Hand Hygiene and Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to provide necessary services to decrease the risk of urinary tract infections (UTIs) for two residents, R1 and R25, by not adhering to proper hand hygiene and Enhanced Barrier Precautions (EBP) during catheter care. For R1, observations revealed that the catheter bag was improperly stored on the floor and the catheter tubing contained dark amber urine with sediment. Licensed Nurse (LN) AA did not perform hand hygiene when changing gloves and used improper infection control techniques during catheter care, which was confirmed by the nurse during an interview. The facility's policy required aseptic techniques and proper hand hygiene, which were not followed in this case, increasing the risk of UTIs for R1. For R25, the facility also failed to adhere to proper hand hygiene and EBP during catheter care. Observations showed that LN M and Certified Nursing Aide (CNA) D did not perform hand hygiene when changing gloves and reused washcloths for multiple swipes, which is against the facility's policy. Additionally, R25 did not have a securement device for the catheter tubing, despite having a documented history of adverse reactions to adhesive devices. The facility's supply room had leg securement straps in stock, but they were not used for R25, as confirmed by staff interviews. This failure to follow proper procedures and provide necessary equipment increased the risk of UTIs for R25. Interviews with staff, including Administrative Nurse B, confirmed that the facility's policies for catheter care and EBP were not followed. The staff admitted to not using proper hand hygiene and reusing wipes and washcloths, which are infection control concerns. The facility's failure to adhere to its own policies and procedures for catheter care and EBP led to an increased risk of UTIs for both R1 and R25.
Deficiencies in Respiratory Care Practices
Penalty
Summary
The facility failed to properly clean and store nebulizer equipment for two residents, R28 and R11, and did not place a date label on the oxygen tubing for R27. For R28, the nebulizer was observed with an unknown clear liquid in the chamber, and the care plan lacked guidance related to the care of the nebulizer equipment. The facility's policy required nebulizer equipment to be rinsed, dried, and stored in a plastic bag, but this was not followed. Similarly, R11's nebulizer was found intact on a windowsill, and the care plan also lacked instructions for the care of the nebulizer equipment. The facility's policy for nebulizer care was not adhered to, as confirmed by staff interviews and observations. For R27, the facility failed to label the oxygen tubing, cannula, and humidifier bottle with the date of placement, which is necessary to ensure routine changes and prevent infection. The resident's room had an undated container of distilled water on the bedside commode, which should have been stored elsewhere to prevent cross-contamination. Staff interviews confirmed that oxygen equipment should be labeled and changed weekly, but this protocol was not followed. The facility lacked a policy to address the maintenance of oxygen equipment to prevent the spread of infection. These deficiencies in respiratory care practices placed the residents at risk of respiratory complications and potential infection. The facility's failure to adhere to its own policies and professional standards of care for respiratory equipment maintenance was evident in the observations and staff interviews documented in the report.
Failure to Assess Bed Rail Safety and Obtain Informed Consent
Penalty
Summary
The facility failed to assess Resident 25 for safety and risk of entrapment from bed rail use and did not obtain informed documented consent from the resident or resident representative prior to the installation of the siderails. Resident 25 had diagnoses of generalized muscle weakness, reduced mobility, incomplete paraplegia, and muscle wasting with atrophy. Despite having intact cognition and being dependent on staff for most cares, the resident's records, including the Minimum Data Set (MDS) and Care Area Assessments (CAA), lacked documentation related to grab bar use. Additionally, the physician's orders and Electronic Health Records (EHR) did not include a safety assessment for bed rail use. The resident revealed using grab bars for bed mobility and repositioning, but no prior safety assessment or informed consent was documented before the installation of the siderails. Interviews with staff confirmed the absence of a safety assessment and informed consent in the resident's records. A safety assessment and informed consent were only documented on 04/15/24, after the deficiency was identified. The facility's Bed Safety and Bed Rails policy required resident assessment for potential risks and informed consent about the benefits and hazards associated with bed rail use, which was not followed in this case. This failure placed Resident 25 at risk for uninformed decisions and potential injury due to bed rail use.
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Surveyors identified unsanitary food storage and preparation conditions, including food debris in a reach-in freezer, an unknown spilled liquid in a reach-in refrigerator, missing two-inch air gap on an ice machine drain, dirty carts used for clean dishes, and a steamtable shelf with built-up food debris. A dietary staff member acknowledged these areas needed cleaning, and it was determined the facility lacked a cleaning schedule or policy for kitchen cleanliness.
The facility failed to complete and analyze Care Area Assessments (CAAs) for multiple residents after Admission, Annual, and Significant Change MDS assessments triggered areas such as cognition, mood/behavior, functional status, urinary incontinence/indwelling catheter, nutrition, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, and visual function. Instead of documenting individualized analysis of underlying causes and contributing factors, an LPN reported she had stopped writing CAA notes and relied mainly on check-off worksheets and the fact that triggers appeared in the MDS CAA section. No facility policy on CAAs was provided to surveyors, and the CAAs consistently lacked required analytical documentation for residents with diverse and significant clinical needs.
A resident with dementia, severe cognitive impairment, and an indwelling urinary catheter was repeatedly observed sitting in common areas with his catheter drainage bag resting on his lower leg, visibly filled with dark amber urine and lacking a privacy cover, despite a care plan directing staff to cover the drainage bag. CNAs reported that the bag often slid down from the resident’s thigh, that they did not use catheter dignity bags on their hall, and that they simply moved the bag back up when it slid down. An administrative nurse stated she had not considered the use of dignity bags on the memory care unit, even though the facility’s resident rights policy affirms each resident’s right to a dignified existence, privacy, and confidentiality.
Two residents with documented cognitive ability to participate in care planning were not invited to any care plan meetings, and their EMRs lacked evidence of care plan conferences, invitations, or Interdisciplinary Care Conference assessments. Administrative staff stated that invitations should be mailed or hand-delivered and uploaded to the EMR, and that an Interdisciplinary Care Conference note should be completed, but none of this documentation existed for these residents, contrary to facility policy and federal requirements for resident and/or representative participation in care planning.
A resident with C-diff and CHF, newly admitted and with a baseline care plan that did not address call light use, was repeatedly found without access to a call light. Surveyors observed the resident yelling for help with her room door closed and later noted the call light on the floor under the bed and again on the floor while the resident sat in a recliner and stated she wanted to return to bed but could not do so independently. Staff reported using a binder clip to attach the call light to the resident’s clothing because the cord lacked a clip, acknowledged the resident sometimes threw the call light to the floor, and stated that call lights should be kept within residents’ reach. An administrative nurse confirmed the expectation that call lights be accessible at all times and was unsure about the use of a binder clip, and no facility policy on call lights was provided.
Surveyors found that a resident’s bathroom and handwashing area were not maintained in a safe, sanitary, and comfortable condition, including a loose baseboard with black substance behind it, a cracked toilet seat, and an empty, improperly mounted hand soap dispenser. Maintenance staff confirmed these conditions, noted that the soap dispenser was nonfunctional, and reported that although a QR code system existed for reporting maintenance issues, these problems had not been reported. Maintenance staff also stated there were no facility policies for maintenance repair in resident rooms and no policy provided for ensuring a safe, homelike environment.
Multiple residents were affected by inaccurate MDS assessments, including a resident with dementia and an indwelling catheter who was miscoded as always incontinent of urine and independent in ADLs despite staff and EMR documentation showing long-term catheter use and total dependence for dressing and wheelchair positioning. Another resident with a history of stroke was incorrectly coded as having a restraint, even though bed grab bars were used as enablers to assist with repositioning and did not limit voluntary movement. A resident with diabetes and unsteadiness experienced two documented falls that were not captured on the MDS, and another resident with diabetes, depression, CAD, and CKD was actively receiving hospice services per EMR, social services, and staff interviews, yet hospice was not coded on the MDS. The consultant MDS nurse confirmed these were significant coding errors not in accordance with the RAI User’s Manual.
A resident with C. diff and CHF was admitted, and while a baseline care plan documenting contact precautions was created, the resident later reported not knowing what a baseline care plan was. The resident was also found yelling for help with her call light on the floor under the bed. Nursing staff stated that baseline care plans are started on the day of admission and reviewed with residents, but also indicated that residents and families are not given written copies. An administrative nurse claimed a 48-hour interdisciplinary care conference had been completed, yet no corresponding documentation existed in the EMR, and explanations about who was responsible and why it was missing were inconsistent. No facility policy for baseline care plans was provided.
A resident with dementia and severe cognitive impairment was inaccurately assessed and care planned as needing only setup or independent assistance with dressing, despite actually requiring total staff assistance. The EMR lacked clear ADL documentation, and the ADL CAA did not trigger, leading to inaccurate MDS entries and a care plan that did not match the resident’s functional status. Surveyors observed the resident sitting in a wheelchair wearing dirty, food-stained pants and being taken to the dining room without a clothing change, with the soiled pants not changed until later when two CNAs provided total assistance. Staff, including CNAs, an LN, and an administrative nurse, acknowledged that the resident needed total help with dressing and should always be in clean clothing, revealing a failure to provide appropriate ADL support and maintain clean attire.
A resident with dementia and severe cognitive impairment was transported multiple times in a wheelchair without staff ensuring that his feet remained safely on the foot pedals. Although assessments inaccurately documented that he was independent with walking using a walker and/or wheelchair, his care plan did not instruct staff on proper use of wheelchair foot pedals. During observed transports by CNAs, the resident’s shoed feet repeatedly fell off the pedals and skimmed the floor between them. Staff acknowledged that his feet did not stay on the pedals and that the pedals were not effectively adjusted, and nursing leadership confirmed expectations that feet should remain on the pedals during transport. No wheelchair safety policy was provided.
Unsanitary Kitchen Conditions and Lack of Cleaning Policy
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions when surveyors observed multiple cleanliness and equipment issues in the kitchen. During an initial kitchen tour on 04/27/26 at 08:57 AM, the three-door reach-in freezer was found with food debris on the bottom shelf, and the three-door reach-in refrigerator had an unknown spilled liquid on the bottom shelf. The drain to the ice machine did not have the required two-inch air gap. Two black two-tiered plastic carts used to store clean dishes had food debris on the bottom tier, and the bottom shelf of the steamtable, which was used to store plate covers, had a buildup of food debris. On 04/28/26 at 01:57 PM, a dietary staff member confirmed these areas required cleaning, and it was identified that the facility did not have a cleaning schedule or a policy regarding kitchen cleanliness. No specific residents, medical histories, or clinical conditions were mentioned in the report in relation to this deficiency.
Failure to Complete and Analyze Care Area Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive Care Area Assessments (CAAs) with analysis of underlying causes, contributing factors, and risk factors for multiple residents following MDS assessments. Record review showed that numerous residents had Admission, Annual, or Significant Change MDS assessments that triggered CAAs in areas such as mood/behavior, cognitive loss/dementia, functional abilities, communication, urinary incontinence/indwelling catheter, nutritional status, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, visual function, and psychosocial well-being. For each of these triggered areas, the corresponding CAAs lacked analysis of the findings. This pattern was identified for residents with a wide range of clinical issues, including dementia, incontinence, falls, pressure ulcers, nutritional concerns, psychotropic medication use, pain, and functional decline. During an interview, a licensed nurse reported that she had stopped writing CAA notes the previous year after being told to do so by someone she could not identify. She stated that she did not write anything on the triggered CAAs and that, at times, she would document risk concerns only on a main check-off worksheet, relying on the fact that the triggers were already reflected in the MDS CAA section. The facility did not provide a policy regarding CAAs when requested. These findings demonstrate that the facility did not ensure that comprehensive assessments were fully completed as required when residents were first admitted and periodically thereafter.
Failure to Maintain Dignity and Privacy for Resident with Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to a dignified existence by not maintaining privacy for his urinary catheter drainage bag as directed in his care plan. The resident had diagnoses including bladder calculus and dementia, with a BIMS score of one indicating severe cognitive impairment, and was dependent on staff for toileting hygiene with an indwelling urinary catheter and constant urinary incontinence. His care plan, revised 03/23/26, instructed staff to cover his drainage bag with a privacy cover. However, during observations on 04/27/26, the resident was seen sitting in his wheelchair at his room doorway and later in the dining room with his catheter drainage bag resting on his lower left leg, supported by his shoe, containing dark amber urine and visible to visitors and other residents, without a privacy cover. Staff interviews confirmed that the catheter drainage bag frequently slid from the resident’s left thigh down to his lower leg and that staff did not consistently reposition it or use dignity/privacy bags. One CNA stated he had never placed a dignity bag on the resident’s drainage bag, and another CNA reported that staff on their hall did not utilize catheter dignity bags, instead just moving the bag back up when it slid down. An administrative nurse acknowledged she had not considered staff use of dignity bags for urinary catheters on the memory care unit. The facility’s Resident Rights policy, approved 12/2024, stated that each resident has the right to a dignified existence including privacy and confidentiality, which was not followed in this case.
Failure to Involve Cognitively Able Residents in Care Plan Meetings
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were given the opportunity to participate in the development and implementation of their person-centered plans of care. For one resident with a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognition, the electronic medical record showed an admission MDS and a Significant Change MDS, but there was no documentation of any care plan meeting in the prior four months. This resident reported not being invited to any care plan meeting. For a second resident with a BIMS score of 14, indicating intact cognition, the electronic medical record contained an admission MDS and a Quarterly MDS, but there was no documentation of a care plan meeting in the prior two months. This resident also reported not being invited to any care plan meeting. Administrative staff reported that residents and/or family members were supposed to be mailed or hand-delivered invitations to attend care planning meetings and that a copy of the invitation should be uploaded into the EMR. They further stated that an Interdisciplinary Care Conference assessment should be completed in the EMR during the care plan meeting. However, the administrative nurse confirmed that there was no documentation of invitations, Interdisciplinary Care Conference assessments, or completed care plan meetings for the two residents. The facility’s care planning policy stated that social services should attend care plan meetings and that the team presents information to the resident and/or representative about progress toward care plan goals, and referenced federal law requiring resident and/or representative participation in care plan meetings to the extent possible, but this process was not carried out or documented for the two residents identified.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach and to reasonably accommodate the resident’s needs and preferences. The resident had documented diagnoses of C-diff and CHF, and her baseline care plan dated 04/23/26 directed staff to evaluate for changes in level of consciousness but did not include any direction regarding call light use or accessibility. On 04/28/26 at 08:06 AM, surveyors observed the resident’s room door closed while she yelled loudly for help several times. When a licensed nurse entered the room, the resident was lying on her left side in bed, stated she wanted to get up, and reported she could not find her call light. The call light was observed on the floor under her bed. Later that morning, a CNA attached the call light to the resident’s shirt using a black and silver binder clip because the call light cord did not have its own clip. On 04/29/26 at 12:15 PM, the resident was seated in a recliner with the call light again lying on the floor out of her reach; she reported she wanted to go to bed and could not get herself back into bed. Staff interviews revealed that the CNA used the binder clip to keep the call light attached to the resident, and the licensed nurse stated staff should make sure the call light is clipped to the resident’s clothes and reported that the resident would throw her call light on the floor. An administrative nurse stated she expected staff to ensure all residents always have their call lights in reach and was unsure about using a binder clip to hold a call light in place. The facility did not provide a policy regarding call lights.
Failure to Maintain Safe and Sanitary Resident Bathroom Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, functional, sanitary, and comfortable environment in Resident 87’s bathroom and handwashing area. During an environmental tour with Maintenance Staff UU, surveyors observed an approximately four-foot section of loose baseboard to the left of and behind the toilet, with a black substance present on the wall and floor behind the loose baseboard. They also noted an approximately three-inch crack in the toilet seat and an empty hand soap dispenser hanging above the handwashing sink, mounted with exposed lag bolt fasteners. Maintenance Staff UU confirmed these conditions, acknowledged that the soap dispenser did not work, and stated that the toilet seat should be replaced, the bathroom baseboard removed, the black substance tested for mold, and the sheetrock removed and replaced. Further interview with Maintenance Staff UU revealed that the facility had implemented a QR code system for staff and visitors to report maintenance items, but the issues in this resident’s bathroom had not been reported through that system. He also reported that there had been a leak behind the handwashing sink that had flowed into the bathroom area, leading to the sink’s replacement, but he had received no report of the specific deficiencies observed in the bathroom. Additionally, Maintenance Staff UU stated that the facility did not have policies for maintenance repair in residents’ rooms, and the facility did not provide a policy for ensuring a safe, homelike environment.
Inaccurate MDS Coding for ADLs, Restraints, Falls, and Hospice Services
Penalty
Summary
The deficiency involves the facility’s failure to complete accurate Minimum Data Set (MDS) assessments in accordance with the Resident Assessment Instrument (RAI) User’s Manual, resulting in multiple residents’ clinical status not being correctly reflected. For one resident with dementia and severe cognitive impairment, the Significant Change and subsequent Quarterly MDS assessments coded him as always incontinent of bladder and independent with eating and upper body dressing, with use of a walker and wheelchair. However, the electronic medical record showed ongoing indwelling catheter care each shift and no documentation of walker use, wheelchair mobility, or dressing requirements during the review period. Staff interviews revealed that this resident had an indwelling catheter for more than a year, had not walked for several years, and was dependent on staff for all ADLs, including dressing and wheelchair positioning, contradicting the MDS coding. Observations showed the resident slumped in a wheelchair, wearing a hospital gown over clothing, with a visible catheter bag on his lower leg and feet frequently skimming the floor despite foot pedals being present, further indicating dependence and catheter use not accurately captured on the MDS. Another deficiency involved a resident with a history of stroke, hemiplegia, and hemiparesis whose Significant Change MDS coded the use of “other restraint.” During observation, the resident was seen in bed with bilateral grab bars at the head of the bed and her right arm positioned on a pillow. The resident reported using the grab bars to help move and reposition herself in bed. CNAs and administrative nursing staff confirmed that the facility did not use restraints and that the grab bars were used as enablers to assist residents with repositioning and to increase independence. Administrative staff acknowledged that the MDS coding for restraints was inaccurate because the grab bars did not limit the resident’s voluntary movement or access to her body. A further inaccuracy was identified for a resident with diabetes, atrial fibrillation, unsteadiness of feet, and a toe fracture. Both a Significant Change and a Quarterly MDS documented intact cognition, partial/moderate assistance with transfers, no ambulation, and no falls. However, progress notes in the EMR documented two unwitnessed falls during the look-back period, including one where the resident was found on the floor next to the bed with a forehead skin tear and another where the resident was found sitting on a fall mat on the floor with a scratch on the ankle. These documented falls were not reflected on the MDS. In addition, another resident with diabetes, depression, CAD, and chronic kidney disease had a Significant Change MDS that coded no hospice services, while the EMR contained a hospice certification and physician orders initiating hospice services, and social service notes and staff interviews confirmed that hospice services, including bathing by a hospice aide, were being provided during the look-back period. The consultant MDS nurse confirmed that these assessments were inaccurate and not completed in accordance with the RAI User’s Manual, constituting significant errors in coding for urinary status, ADL dependence, restraints, falls, and hospice services. The consultant MDS nurse stated that the resident with the indwelling catheter should have been coded as not rated for urinary continence due to catheter placement rather than as always incontinent, and that his ADL status should not have been coded as independent given his dependence on staff for dressing and wheelchair positioning. For the resident with grab bars, the nurse confirmed that the grab bars were used as enablers and not as restraints, making the restraint coding inaccurate. For the resident with documented falls, the MDS failed to capture falls that occurred within the look-back period, and for the resident receiving hospice services, the MDS did not reflect hospice care that was active during the look-back period. These miscodings met the RAI Manual’s definition of significant error, in which the resident’s overall clinical status is not accurately represented on the assessment and the error has not been corrected by a more recent assessment.
Failure to Provide and Communicate Baseline Care Plan to New Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide a summary of the baseline care plan to a newly admitted resident and to ensure that the baseline care plan process was completed and documented as required. The resident’s EMR documented diagnoses of C. difficile and CHF. The Entry MDS was completed on the admission date, and the admission MDS was noted as in progress with no information available. A baseline care plan dated the day after admission documented contact precautions, including staff use of gowns and masks when changing contaminated linens and proper handling and bagging of soiled linens. However, during an interview several days after admission, the resident reported she did not know what a baseline care plan was, indicating that the plan had not been explained or summarized to her. Further observations and interviews showed additional failures in implementing and communicating the baseline care plan. On one occasion, the resident was heard yelling for help with her room door closed; when a nurse entered, the resident stated she wanted to get up but could not find her call light, which was observed on the floor under the bed. A nurse reported that the baseline care plan was started on the day of admission and that nurses would review it with the resident, but also stated that the charge nurse would not provide a written copy of the baseline care plan to the resident or family. An administrative nurse reported she would review the baseline care plan with the resident and/or family and claimed to have completed a 48-hour interdisciplinary care conference, but there was no opened or completed conference note in the EMR. She gave inconsistent explanations regarding who was responsible and why the conference note was missing. The facility did not provide a policy for baseline care plans.
Failure to Provide Accurate ADL Assessment and Timely Clothing Changes
Penalty
Summary
The facility failed to provide appropriate assistance with activities of daily living (ADLs), specifically dressing and clothing changes, for a resident with severe cognitive impairment. The resident had a diagnosis of dementia and repeated Brief Interview for Mental Status (BIMS) scores of one, indicating severe cognitive impairment. Despite this, both a Significant Change MDS and a Quarterly MDS inaccurately documented that the resident required only setup assistance with lower body dressing. The ADL Care Area Assessment did not trigger, and the resident’s care plan, revised on 03/23/26, inaccurately instructed staff that the resident was independent with dressing. The electronic medical record lacked staff documentation of the resident’s ADL needs, resulting in care instructions that did not reflect the resident’s actual functional status. On the day of observation, the resident was seen sitting in a wheelchair wearing black pants with food crumbs on them in the morning, and later was transported by a CNA to the dining room still wearing the same dirty pants. The pants were not changed until early afternoon, at which time two CNAs provided total assistance to change the dirty pants, and the resident was unable to participate in dressing or undressing. During interviews, the CNAs, a licensed nurse, and an administrative nurse all stated that residents should always be dressed in clean clothing and confirmed that this resident required total staff assistance with dressing. These observations and interviews showed that the resident’s actual need for total assistance with dressing and clothing changes was not accurately reflected in the MDS, care plan, or ADL documentation, and that the facility did not ensure the resident was kept in clean clothing as expected by facility policy for ADL care.
Failure to Maintain Safe Wheelchair Foot Positioning During Resident Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision during wheelchair transport for a resident with dementia. The resident’s EMR documented a diagnosis of dementia and a BIMS score of one on both a Significant Change MDS and a Quarterly MDS, indicating severe cognitive impairment. These MDS assessments inaccurately documented that the resident was independent with walking using a walker and/or wheelchair, and the ADL CAA did not trigger. The resident’s care plan, revised 03/23/26, identified cognitive impairment due to dementia but did not include instructions for staff on the use of wheelchair foot pedals while propelling the resident. On multiple observed occasions, staff propelled the resident in a wheelchair without maintaining his feet safely on the foot pedals. During transport from his room to the dining room, the resident’s left shoed foot fell from the foot pedal and skimmed the floor between the pedals, and later, during transport from the dining room to the shower room, both shoed feet skimmed the floor between the pedals. CNAs reported that the resident’s feet never stayed on the foot pedals and described the pedals as useless because he could not keep his feet on them. A licensed nurse confirmed the resident’s feet did not always remain on the foot pedals when staff propelled him and stated the pedals should be adjusted to better fit his needs. An administrative nurse stated it was the expectation that staff ensure the resident’s feet remained on the foot pedals during transport and that pedals should be lowered if needed. The facility did not provide a policy regarding wheelchair safety.
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