Aspen Health And Wellness
Inspection history, citations, penalties and survey trends for this long-term care facility in Overland Park, Kansas.
- Location
- 6501 W 75th Street, Overland Park, Kansas 66204
- CMS Provider Number
- 175187
- Inspections on file
- 24
- Latest survey
- August 19, 2025
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Aspen Health And Wellness during CMS and state inspections, most recent first.
The facility did not provide enough nursing staff to meet resident needs, as shown by repeated resident complaints about missed showers and delayed call light responses. A resident was observed with poor hygiene and reported missing scheduled baths for several weeks due to low staffing, particularly on weekends. Administrative staff acknowledged ongoing issues with staff communicating insufficient staffing to residents, despite policies requiring adequate coverage.
Surveyors identified infection control deficiencies, including uncontained trash and laundry transport, urinary catheter bags left on the floor, and unsanitary storage of respiratory equipment such as BIPAP and nebulizer masks. Staff interviews confirmed these practices were not in line with facility policy, which requires proper containment and sanitary storage to prevent infection.
The facility did not maintain required tracking and trending of infections, including organism identification, for several months, and failed to document surveillance of antibiotic use for two residents treated for eye infections. Staff interviews confirmed missing records for key months, and the antibiotic surveillance binder lacked necessary documentation.
The facility did not resolve ongoing concerns raised by the Resident Council regarding food quality, adherence to bathing schedules, and timely response to call lights. Residents repeatedly reported that staff failed to provide scheduled showers and responded slowly to call lights, often citing insufficient staffing as the reason. Despite documentation of these issues and staff education efforts, the same concerns persisted over several months.
The facility did not provide direct, interactive activities based on resident preferences on weekends, particularly Sundays, instead offering only self-led activity packets. Resident Council and staff interviews confirmed that staff-led activities were inconsistent or absent on Sundays, with activity staff not scheduled and other staff too busy to facilitate groups. This practice did not align with the facility's policy to support residents' physical, mental, and psychosocial well-being.
A facility failed to secure an electrical room containing unlocked high-voltage panels and did not consistently implement fall prevention interventions for several residents with cognitive impairments and histories of falls. Observations showed call bells and fall mats were not within reach or properly placed, despite care plan requirements and facility policy.
Surveyors found that several residents did not receive proper catheter care, with one resident's catheter bag placed on the floor and another experiencing catheter leakage due to unavailable supplies. Documentation of catheter output was incomplete for a resident with an indwelling catheter, and two residents identified as candidates for toileting programs did not have such interventions implemented. Strong urine odors and evidence of incontinence were observed, and required care area assessments and policies were missing or incomplete.
A resident with severe cognitive impairment and on hospice care was not included, nor was her legal representative, in the development or planning of her person-centered care plan. The facility lacked documentation of care plan meetings or interdisciplinary team reviews for the past year, and the representative was unaware of any such meetings. Staff interviews confirmed the absence of required documentation and participation.
A resident with multiple chronic conditions was allowed to self-administer Voltaren gel as ordered by a physician, but no assessment was completed to determine her ability to do so safely. The care plan and medical record lacked documentation of a self-administration assessment, and staff confirmed that the required evaluation was not performed prior to the resident keeping and using the medication at her bedside.
Three dependent residents were found without access to their call lights, either due to the devices being placed out of reach or not present at all. Staff confirmed that call bells should always be accessible, and frequent rounding was occurring due to a malfunctioning call light system, but the facility lacked a specific policy for call light accommodations.
The facility did not provide required written bed-hold notifications to a resident and their representative prior to multiple hospital transfers, and failed to complete a discharge summary for another resident discharged to a different facility. Both residents had significant medical conditions and required staff assistance, but the necessary documentation and notifications as outlined in facility policy were not completed.
A resident with severe cognitive impairment and multiple diagnoses was discharged from hospice services, but the facility failed to identify this significant change and did not complete a required Significant Change MDS assessment. Staff were unaware of the resident's updated hospice status, hospice orders remained active in the record, and there was confusion regarding communication and documentation, resulting in unmet assessment requirements.
A resident with multiple chronic conditions was permitted by physician order to self-administer Voltaren gel, but the care plan was not updated to reflect this, nor was an assessment for self-administration completed. Staff interviews confirmed the omission, and the facility lacked a policy for care plan revision.
Two residents dependent on staff for ADLs, including bathing, did not receive consistent bathing opportunities as required by their care plans. Documentation showed infrequent bathing, missing records of refusals or alternative offers, and observations revealed hygiene concerns. Staff interviews confirmed that required bathing and documentation practices were not consistently followed.
A resident with multiple medical conditions, including edema and fluid overload, did not have weights obtained as ordered by the physician, and there was no evidence that the physician was notified of this lapse. The resident's care plan and facility policy required adherence to such orders, but records showed the scheduled weights were missed over a period of time.
A resident with multiple risk factors for pressure ulcers, including malnutrition and immobility, was observed in bed without the physician-ordered heel protectors on several occasions. Despite clear care plan instructions and staff awareness of the order, the required pressure-reducing boots were not applied, leaving the resident's heels directly on the mattress.
A resident with multiple medical conditions, including COPD and obstructive sleep apnea, had their BiPAP mask, nebulizer mask, and oxygen cannula repeatedly left on surfaces such as the bedside table and floor instead of being stored in dated plastic bags as required by facility protocol. Staff interviews confirmed knowledge of the correct procedure, but the equipment was not stored properly, contrary to infection control policies.
A consulting pharmacist did not identify or report that a resident received midodrine outside of physician-ordered blood pressure parameters on multiple occasions. Despite clear orders to withhold the medication if systolic blood pressure exceeded a certain level, the medication was administered eight times when this threshold was surpassed, and the pharmacist's monthly reviews did not address these incidents.
Staff failed to administer medications within physician-ordered parameters for two residents, including giving an anti-hypotensive medication when blood pressure was above the specified limit and not monitoring blood pressure or pulse before giving an antihypertensive. These actions occurred despite care plans and facility policies requiring adherence to medication orders and monitoring for adverse effects.
Two residents receiving hospice services experienced a breakdown in communication and collaboration between the facility and hospice providers. One resident's hospice discharge was not properly communicated or documented, leaving an active hospice order in place and staff unaware of her status. For another resident, hospice CNA and nurse visits were not consistently documented in the hospice binder, and the hospice provider was unaware of the missing records until notified by the facility. These lapses resulted in unclear care coordination and incomplete documentation, contrary to facility policy.
A resident experienced a significant weight loss of 25.6% due to the facility's failure to implement effective interventions. Despite initial measures, the resident continued to lose weight, and staff did not adequately monitor nutritional intake or adjust care plans. The resident's weights fluctuated, and the accuracy of these weights was questioned, yet no further interventions were recommended by the interdisciplinary team or Consultant GG.
A resident with a history of inappropriate sexual behavior exposed himself to another cognitively impaired resident in a public area of the facility. Despite known behavioral issues, the primary intervention was redirection, which failed to prevent the incident. Staff intervened after hearing the impaired resident scream, highlighting a deficiency in protecting residents from abuse.
Failure to Provide Sufficient Nursing Staff for Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple documented concerns regarding inadequate care and delayed call light responses. Payroll-Based Journal (PBJ) staffing data indicated the facility triggered for One Star Staffing across several fiscal quarters. Resident Council minutes over several months documented ongoing complaints about missed showers, untimely call light responses, and staff communicating to residents that there were not enough staff to complete care tasks. Observations included a resident with unkempt hair and dirty, untrimmed fingernails, who reported missing scheduled baths for three consecutive weeks due to insufficient Sunday staffing. Electronic medical records confirmed the missed baths. Administrative staff acknowledged ongoing issues with staff telling residents that there was not enough staff to complete care, despite education on required staffing levels. The facility's policy required sufficient and competent staff to ensure completion of care and services according to resident care plans and the facility assessment. However, the documented observations, resident interviews, and council minutes indicated that these requirements were not consistently met, resulting in unmet resident care needs.
Infection Control Deficiencies in Trash Handling, Catheter Bag Placement, and Respiratory Equipment Storage
Penalty
Summary
Surveyors observed multiple infection control deficiencies during their walkthrough of the facility. A certified nurse's aide was seen transporting uncontained trash and laundry down the hallway, rather than using the designated barrels with lids. In several resident rooms, urinary catheter collection bags were found lying directly on the floor, filled with urine, instead of being properly secured off the floor. Additionally, respiratory equipment such as BIPAP masks, nebulizer masks, and nasal cannulas were not stored in a sanitary manner, with items left on bedside tables, on top of machines, or wrapped around oxygen canister handles. Interviews with nursing staff confirmed that facility policy requires trash and laundry to be transported in containers with lids, respiratory equipment to be stored in dated bags when not in use, and catheter bags to be kept off the floor, potentially in a wash basin if necessary. The facility's own policies on indwelling urinary catheter care and infection control emphasize daily care and proper hygiene practices to reduce infection risk. Despite these policies, the observed practices did not align with facility protocols, resulting in deficiencies related to infection prevention and control.
Failure to Implement Antibiotic Stewardship and Infection Surveillance
Penalty
Summary
The facility failed to develop and implement the core elements of an antibiotic stewardship program as part of its infection prevention and control program. Specifically, the facility did not provide evidence of tracking and trending organism identifications for several months, including December 2024, January 2025, and February 2025, as required by their infection control log. When requested, the facility was unable to produce documentation of trending for these months. Additionally, the antibiotic surveillance binder lacked tracking and trending of eye infections for two residents who were prescribed antibiotic ophthalmic solutions for bacterial conjunctivitis and conjunctivitis/blepharitis. Interviews with facility staff revealed that tracking and trending were reportedly done in real-time, but the administrative nurse could not account for months prior to March 2025, citing changes in infection preventionists. Documentation for March, April, and May was reportedly maintained by the administrator, but earlier months were not available. The facility's infection surveillance policy indicated that infection surveillance is a core activity intended to identify infections and monitor adherence to infection prevention practices, but the lack of documentation and trending for the specified months demonstrated a failure to implement these practices.
Failure to Address Resident Council Concerns on Care and Staffing
Penalty
Summary
The facility failed to resolve recurring issues reported by the Resident Council, specifically regarding food choices, menu options, food temperatures, and the cleanliness and maintenance of shower rooms. Over a period of several months, Resident Council minutes documented repeated concerns about staff not adhering to resident bathing schedules, with reports that staff would enter rooms, turn off call lights, and leave without providing care. Residents also reported that showers were not completed on assigned days, with staff citing being too busy or insufficient staffing as reasons for missed care. Additionally, there were ongoing complaints about delayed call light responses and untimely completion of resident care tasks. Despite these concerns being consistently raised in Resident Council meetings and documented in meeting minutes, the issues persisted over time. Staff responses included statements that staff had been educated on following shower schedules and responding to call lights, but residents continued to report the same problems. The facility's policy required communication and response to council concerns, but the repeated nature of the complaints indicated that the facility did not effectively address or resolve the issues, leading to ongoing dissatisfaction among residents.
Failure to Provide Staff-Led Activities on Weekends
Penalty
Summary
The facility failed to provide direct, interactive activities based on resident preferences for residents on weekends, specifically on Sundays. Review of activity calendars for several months showed that on most Sundays, only self-led activity packets were offered, rather than staff-led group activities. Resident Council members reported that weekend activities were inconsistent with the schedule, and on Sundays, staff-led activities were often not provided. Instead, residents were typically given puzzles or packets to complete individually. The council also noted that activities staff did not work on Sundays and that other staff were often too busy to facilitate group activities due to short staffing. Interviews with activities staff and a CNA confirmed that while staff sometimes came in on Saturdays to lead activities, Sundays were limited to distributing activity packets containing puzzles, games, coloring pages, and drawings. The facility's Activities Programming policy, revised in May 2025, stated that activities should meet residents' needs and interests to support their physical, mental, and psychosocial well-being. The lack of staff-led activities on Sundays was inconsistent with this policy and contributed to the deficiency.
Failure to Secure Hazards and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards and did not provide adequate supervision and implementation of fall prevention interventions for multiple residents. Observations revealed that a room labeled 'Staff Only' containing five unlocked electrical panels with high voltage warnings was left unsecured and accessible from the central hallway. Staff confirmed that the room should have been locked at all times to prevent resident access to potential hazards, but it was found propped open during inspection. Several residents with cognitive impairments and histories of falls did not have their fall prevention interventions properly implemented. One resident, who was dependent on staff for mobility and had a history of falls, was repeatedly observed with her call bell and bedside table out of reach, despite care plans requiring these items to be accessible. The facility's call light system had been nonfunctional for an extended period, and the alternative call bell provided was not consistently within the resident's reach. Another resident, who used a walker and had mild cognitive impairment, was observed multiple times with his call light stuffed under his mattress and out of reach, contrary to care plan instructions. A third resident with severe cognitive impairment and a history of falls was found with his fall mat folded at the end of the bed rather than in place as required by his care plan. Staff interviews confirmed that all nursing staff were responsible for ensuring fall interventions were in place, but there was inconsistency in access to care plans and communication of interventions. Facility policies required a safe environment and adherence to fall prevention interventions, but these were not consistently followed, placing residents at risk for preventable accidents and injuries.
Deficient Catheter Care, Incontinence Management, and Documentation
Penalty
Summary
Multiple deficiencies were identified regarding the care of residents with urinary incontinence, indwelling catheters, and the prevention of urinary tract infections. One resident with an indwelling catheter was observed with the catheter drainage bag placed directly on the floor, contrary to facility policy and staff expectations that the bag should be kept below the bladder and never on the floor. The same resident's Care Area Assessment (CAA) for urinary incontinence and catheter care lacked required analysis, and the facility was unable to provide this documentation when requested. Another resident with a suprapubic catheter experienced leakage and reported to staff that the appropriate size Foley catheter was not available for replacement, despite physician orders and care plan directives specifying the use of a 22 French Foley catheter. Nursing notes confirmed the need to order the correct catheter size, and the resident used towels to manage the leakage. Staff interviews revealed conflicting information about the availability of the required catheter supplies. Additional deficiencies included the lack of documentation of catheter output for a resident with an indwelling catheter, with multiple missed entries across several months, despite physician orders to record output every shift. Two residents who were incontinent and identified as possible candidates for bowel and bladder retraining did not have toileting programs implemented, and their care plans lacked interventions to address or prevent incontinence episodes. Observations noted strong urine odors and evidence of incontinence in their rooms. The facility also failed to provide or follow policies related to toileting programs and catheter/UTI prevention for these residents.
Failure to Include Resident or Representative in Care Plan Development
Penalty
Summary
The facility failed to include a resident or her legal representative in the development and planning of her person-centered care plan. The resident, who had diagnoses of dementia, dysphagia, and aphasia, was documented as having severely impaired cognition and was receiving hospice services. Review of the electronic medical record (EMR) showed no documentation of care plan meetings or attendance by the resident or her representative over the past 12 months. Although letters were sent to the representative, there was no evidence of actual care plan meetings or interdisciplinary team (IDT) care plan reviews being completed and documented as required. Interviews with the resident's legal representative confirmed he was not aware of any care conferences or care plan meetings held for the resident. Social Services staff acknowledged the lack of documentation and stated that the IDT-Care Plan Review assessment would be completed after the care plan meeting, but could not explain the absence of prior documentation. The facility's policy required care plan meetings to be scheduled with the resident and family when possible, and for explanations to be documented if participation was not practicable, but no such documentation was found in the resident's record.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including embolism of the deep veins, malignant neoplasm of the breast, diabetes mellitus, and diabetic neuropathy, was permitted to self-administer Voltaren gel without a documented assessment of her ability to do so safely. The resident had a physician's order allowing unsupervised self-administration of the medication and kept the Voltaren gel at her bedside, applying it as needed. Despite this, her electronic medical record did not contain an assessment for self-administration of medications, and her care plan lacked direction regarding self-administration of Voltaren. Interviews with the resident and facility staff confirmed that no assessment had been completed prior to the resident self-administering the medication. The facility's policy required clinicians to assess and document a patient's ability to self-administer medications, provide education, and record pertinent observations, but these steps were not followed in this case. This failure was identified during a survey, and staff acknowledged the oversight when questioned.
Failure to Ensure Call Lights Within Reach for Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents who were unable to self-transfer or had cognitive impairments. Observations revealed that one resident, who was unable to self-transfer, was found lying in bed with the call light placed on an over-the-bed table that was pushed away and out of reach. Another resident, who was cognitively impaired and unable to transfer herself, was observed asleep with her call bell on a bedside table that was not accessible, and her urinary catheter drainage bag was on the floor. A third resident, also unable to transfer himself, was found in bed with no call bell present. Staff interviews confirmed that call bells were expected to be within reach of all residents, and that staff were conducting frequent rounds due to a malfunctioning call light system. Despite these expectations, the facility did not provide a policy specific to call light accommodations, and multiple instances were documented where residents did not have access to their call lights, leaving them unable to call for assistance.
Failure to Provide Required Bed-Hold Notifications and Discharge Documentation
Penalty
Summary
The facility failed to provide required written notifications and documentation related to bed-hold policies and discharge procedures for two residents. For one resident with multiple diagnoses including hypertension, cirrhosis, liver carcinoma, and congestive heart failure, the facility did not provide a written notification of transfer or a bed-hold policy to the resident or their representative prior to several hospital transfers. The resident had severely impaired cognition and required staff assistance for daily activities, with documentation indicating an intention to remain in the facility for long-term care. Despite the facility's policy requiring a second written notice of bed-hold rights before each transfer or within 24 hours in emergencies, this was not completed as required. Additionally, another resident with osteoarthritis, Alzheimer's disease, and hypertension was admitted for a respite stay and subsequently discharged to another facility. The facility did not complete an admission MDS, Care Area Assessment, or a discharge summary that included a recapitulation of the stay. The discharge was described as sudden, and while the resident's spouse received medications and belongings, the required discharge summary and documentation were not completed as per facility policy. Staff interviews confirmed misunderstandings regarding the need for repeated bed-hold notifications and acknowledged the omission of the discharge summary due to the unexpected nature of the discharge. The facility's own policies specify the need for timely and comprehensive written notifications and summaries, which were not followed in these cases.
Failure to Complete Significant Change MDS After Hospice Discharge
Penalty
Summary
The facility failed to identify a significant change in condition and complete a comprehensive Significant Change Minimum Data Set (MDS) assessment for a resident following discharge from hospice services. The resident had diagnoses of dementia, dysphagia, and aphasia, with documentation of severely impaired cognition. Despite the resident's discharge from hospice, the facility's records continued to reflect active hospice orders, and there was no timely completion of a Significant Change MDS as required. Staff interviews revealed confusion regarding the resident's hospice status, with some staff unaware of the discharge and others unable to locate relevant hospice communication materials. The resident's care plan and medical record indicated ongoing hospice involvement, even after discharge, and there was a lack of clear communication and documentation regarding the change in the resident's status. Administrative and social services staff were not fully informed or coordinated about the resident's discharge from hospice, and the facility was unable to provide a policy related to MDS procedures. This resulted in a failure to reassess the resident's needs and update care plans accordingly after a significant change in condition.
Failure to Revise Care Plan for Self-Administration of Medication
Penalty
Summary
The facility failed to revise the care plan for a resident to include staff direction regarding self-administration of a physician-ordered medication, Voltaren gel. The resident had multiple diagnoses, including embolism of the deep veins, malignant neoplasm of the breast, diabetes mellitus, and diabetic neuropathy, and required supervision to partial/moderate assistance for activities of daily living. The resident's care plan, last revised on 04/04/25, directed staff to administer medication as ordered for neuropathy but did not address the resident's ability to self-administer Voltaren gel, despite a physician's order allowing unsupervised self-administration and storage of the medication at the bedside. The electronic medical record lacked an assessment for self-administration of medications, and interviews with the resident and staff confirmed that no such assessment had been completed. The resident reported independently applying the Voltaren gel as needed since it was ordered, without recall of any assessment for self-administration. Both a licensed nurse and an administrative nurse stated that an assessment and care plan revision should have been completed to reflect the resident's ability to self-administer the medication. The facility also lacked a policy for care plan revision.
Failure to Provide Consistent Bathing and ADL Assistance
Penalty
Summary
The facility failed to provide consistent bathing opportunities and assistance with activities of daily living (ADLs) for two residents who were dependent on staff for personal care. One resident, with diagnoses including anxiety, diabetes mellitus, muscle weakness, depression, and moderately impaired cognition, was documented as dependent on staff for bathing and toileting. Review of her electronic medical record over a 120-day period showed infrequent bathing, with only a few showers and sponge baths documented, and multiple days marked as 'Not Applicable' without evidence that she was unavailable for care. There was also a lack of documentation regarding refusals or alternative bathing offers. Observations found her call bell and bedside table out of reach, and her soft call light was missing. Another resident, with end-stage renal disease, diabetes, absence of a left leg, and mild cognitive impairment, was also dependent on staff for all ADLs, including bathing. Her care plan indicated a preference for twice-weekly baths, but records showed missed scheduled baths on several occasions without documentation of refusals or reasons for the missed care. The resident reported not receiving her preferred Sunday baths for several weeks and expressed dissatisfaction with her hygiene, noting greasy hair and dirty fingernails. Staff interviews confirmed that bathing was to be offered at least twice weekly, with refusals to be documented, but the records did not reflect this practice. The facility's ADL policy required that residents receive assistance with ADLs based on individualized care plans and that their abilities should not diminish unless unavoidable due to clinical condition. Despite this, both residents did not receive consistent bathing opportunities as required, and documentation was lacking regarding care provided, refusals, or alternative offers. These failures were identified through observation, record review, and staff and resident interviews.
Failure to Follow Physician's Order for Weight Monitoring
Penalty
Summary
A deficiency occurred when facility staff failed to follow a physician's order for scheduled weight monitoring for a resident with diagnoses including cognitive communication deficit, hypotension, edema, muscle weakness, and unsteady gait. The resident's care plan required nursing staff to administer medications as ordered and observe for adverse effects, with specific physician orders for diuretic medications and to obtain weights every Monday and Thursday to monitor for fluid overload. Review of the resident's electronic medical record, medication administration record, and treatment administration record over a specified period showed that weights were not obtained as ordered, and there was no evidence that the physician was notified of the missed weight monitoring. Observations confirmed the resident's ongoing medical needs, and interviews with administrative nursing staff indicated an expectation that physician orders, including weight monitoring, should be followed and that the physician should be notified if orders are not carried out. The facility's policy required accurate implementation of all orders, but documentation and practice did not reflect compliance with the weight monitoring order for this resident.
Failure to Apply Ordered Pressure-Reducing Devices for High-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to implement physician-ordered pressure-reducing interventions for a resident identified as high risk for pressure ulcer development. The resident had multiple diagnoses, including malnutrition, adult failure to thrive, cerebral infarction, and was receiving hospice care. The care plan and physician's orders specified that heel protectors were to be applied bilaterally when the resident was in bed, as a preventive measure. Despite these orders and a Braden Scale score indicating high risk, observations on multiple occasions revealed that the resident was in bed without heel protectors, with her heels resting directly on the mattress. The resident's boots, intended for pressure relief, were found in her chair instead of on her heels. Interviews with nursing staff confirmed that both nurses and CNAs had access to the care plan or Kardex, which included the intervention to apply heel protectors. Staff acknowledged that it was the CNA's responsibility to apply the boots and the nurse's responsibility to ensure compliance. The facility's policy required interventions for residents with a Braden score of 12 or less, but the required preventive measure was not consistently implemented, as evidenced by direct observation and staff statements.
Failure to Store Respiratory Equipment in a Sanitary Manner
Penalty
Summary
The facility failed to ensure that a resident's respiratory care equipment, including a BiPAP mask, nebulizer mask, and oxygen nasal cannula, was stored in a sanitary manner when not in use. Observations over several days revealed that the BiPAP mask was placed directly on the bedside table, the nebulizer mask was left on top of the BiPAP machine or bedside table, and the oxygen cannula was found lying on the floor beside the bed. These items were not stored according to facility protocol, which requires respiratory equipment to be placed in a dated plastic bag when not in use. The resident involved had multiple complex medical conditions, including hypertension, obstructive sleep apnea, pulmonary edema, vascular dementia, neurogenic bladder, hemiparesis following a stroke, contracture of the right hand, and muscle weakness. The resident was dependent on staff for all activities of daily living except eating and required the use of supplemental oxygen and a non-invasive ventilator. The care plan documented the need for BiPAP use as ordered and monitoring for respiratory insufficiency, but lacked specific staff instructions for the care and storage of the BiPAP mask, nebulizer mask, and oxygen nasal tubing. Interviews with facility staff, including a licensed nurse, a CNA, and an administrative nurse, confirmed that all respiratory equipment not in use should be stored in a dated plastic bag per facility protocol. Staff acknowledged responsibility for ensuring proper storage but failed to do so in this case. The facility's infection surveillance policy emphasized the importance of monitoring adherence to infection prevention and control practices, but these were not followed for the resident's respiratory equipment.
Consulting Pharmacist Failed to Identify Medication Administration Outside Physician Parameters
Penalty
Summary
The facility failed to ensure that the consulting pharmacist identified and reported instances where a resident received midodrine outside of the physician-ordered parameters. The resident had multiple diagnoses, including cognitive communication deficit, hypotension, edema, muscle weakness, and required assistance with personal care. Physician orders specified that midodrine should not be administered if the resident's systolic blood pressure (SBP) exceeded 140 mmHg. However, review of the Medication Administration Record and Treatment Administration Record over a 45-day period showed that midodrine was administered eight times when the resident's SBP was above the ordered threshold. Further review of the Monthly Medication Reviews from September 2024 to May 2025 revealed no evidence that the consulting pharmacist identified or reported these deviations from the physician's order. Interviews with facility staff confirmed the expectation that the pharmacist should have recognized and reported the medication administration outside of the prescribed parameters. Additionally, the facility was unable to provide a policy outlining the pharmacy's responsibility for monthly medication reviews.
Failure to Administer Medications Within Physician-Ordered Parameters
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders and within prescribed parameters for multiple residents. One resident with a history of hypotension, cognitive impairment, and other medical conditions received midodrine, an anti-hypotensive medication, outside of the physician-ordered blood pressure parameters on eight documented occasions. The medication was administered even when the resident's systolic blood pressure exceeded the maximum threshold specified in the order. Documentation also showed that the care plan required staff to observe for adverse effects and report to the physician as needed, but there was no evidence that the deviations from the order were reported. Another resident with severe cognitive impairment, hypertension, diabetes, and a history of stroke was prescribed metoprolol, an antihypertensive medication, with specific instructions to hold the medication and notify the physician if the systolic blood pressure was below 90 or the pulse was below 60. However, review of the medication administration records revealed that staff failed to monitor and document the resident's blood pressure and pulse prior to administering metoprolol on all opportunities in one month and on multiple occasions in the following month. There was no documentation that the physician was notified about the lack of required monitoring prior to medication administration. Interviews with nursing staff and administrative personnel confirmed that the expectation was to follow physician orders, including monitoring vital signs as required by medication parameters. The facility's policies also required accurate implementation of medication orders and adherence to the resident's plan of care. Despite these policies, staff did not consistently monitor or document vital signs as required, nor did they report deviations from physician orders, resulting in the administration of medications outside of prescribed parameters.
Failure to Ensure Communication and Collaboration with Hospice Providers
Penalty
Summary
The facility failed to ensure effective communication and collaboration with hospice providers for two residents receiving hospice services. For one resident with diagnoses including dementia, dysphagia, and aphasia, there was a lack of clarity regarding her hospice status. Although her medical record and care plan indicated she was to receive hospice services, her legal representative and social services staff confirmed she had been discharged from hospice, yet an active hospice order remained in her record. Nursing and administrative staff were unaware of the discharge, and there was confusion about the location and use of the hospice communication book, with no clear documentation or notification process in place. For another resident with multiple diagnoses such as malnutrition, epilepsy, and cognitive deficits, the facility's hospice communication binder did not contain up-to-date documentation of visits by hospice CNAs or nurses, with the last entry being from a social worker. Staff interviews revealed that hospice aides and nurses were expected to document their visits in the binder, but this was not consistently done. The hospice provider was only made aware of the missing documentation after being contacted by the facility, and there was a lack of evidence showing regular collaboration or communication between the hospice team and facility staff regarding the resident's care. The facility's own policy required ongoing interdisciplinary assessment and individualized care planning for residents receiving hospice or palliative care, including thorough documentation and communication with hospice providers. However, the observed practices did not align with these requirements, resulting in a breakdown of communication and collaboration for both residents, as evidenced by missing documentation, unclear discharge processes, and staff uncertainty about hospice involvement.
Failure to Prevent Significant Weight Loss in Resident
Penalty
Summary
The facility failed to implement effective interventions to prevent further weight loss for a resident who experienced significant weight loss. The resident, who had diagnoses including generalized muscle weakness, mild intellectual abilities, and anxiety, was admitted to the facility and later transferred to the hospital. Despite initial interventions in September 2024, the resident continued to experience significant weight loss, amounting to 25.6% over several months. The facility's records indicated that the resident required assistance with eating and had a risk for alteration in nutrition, but the interventions in place were insufficient to address the ongoing weight loss. The facility's documentation revealed that the resident was on a regular diet with supplemental shakes and liquid protein, yet there was a lack of evidence that staff monitored the intake percentages of these supplements. The resident's weights fluctuated significantly, and there were multiple instances where the accuracy of the weights was questioned. Despite the resident reportedly eating 76 to 100% of meals, the weight loss persisted, and the facility did not implement additional interventions beyond the initial measures. The facility's interdisciplinary team and Consultant GG were involved in monitoring the resident's condition, but no further recommendations were made to address the weight loss effectively. Interviews with facility staff indicated that there was a lack of consistent documentation and monitoring of the resident's nutritional intake. Staff members were aware of the resident's weight loss but did not recall specific interventions or supplements provided. The facility's policies directed ongoing evaluation and adjustment of care plans in response to significant weight changes, but these were not adequately followed. The failure to implement further interventions and accurately monitor the resident's nutritional intake contributed to the continued significant weight loss, highlighting deficiencies in the facility's care practices.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to prevent an incident of resident-to-resident sexual abuse involving a resident with a history of inappropriate sexual behavior. The resident, identified as R1, had a documented history of obsessive-compulsive behavior, dementia, and cognitive communication deficits. Despite these known issues, R1 was able to expose his genitals to another resident, R2, who was cognitively impaired and unable to consent. This incident occurred in a public area of the facility, where R1 was observed standing close to R2 with his pants partially down. R1's medical records and care plan indicated a history of sexually inappropriate behavior, including previous incidents at another facility. The care plan directed staff to evaluate behavior patterns and remove causes for such behavior, yet R1 continued to exhibit inappropriate actions, including exposing himself to staff and attempting to enter other residents' rooms. Despite these behaviors, the primary intervention in place was to redirect R1, which proved insufficient in preventing the incident with R2. The incident was witnessed by staff who responded after hearing R2 scream. R2, who was non-verbal and dependent on staff for all needs, was unable to protect herself from R1's actions. Staff intervened by removing R2 from the situation and placing R1 under one-to-one supervision. The facility's failure to implement effective interventions for R1's known behaviors resulted in a situation where R2 was exposed to sexual abuse, highlighting a significant deficiency in protecting residents from abuse.
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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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