Avita Health And Rehab At Reeds Cove
Inspection history, citations, penalties and survey trends for this long-term care facility in Wichita, Kansas.
- Location
- 2114 N 127th Court East, Wichita, Kansas 67228
- CMS Provider Number
- 175532
- Inspections on file
- 26
- Latest survey
- April 24, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Avita Health And Rehab At Reeds Cove during CMS and state inspections, most recent first.
A resident with multiple risk factors developed facility-acquired Stage 3 pressure ulcers after staff failed to implement timely repositioning, monitor wounds adequately, and provide standard interventions such as a low air loss mattress. Wound assessments and documentation were inconsistent, and physician orders for wound care were not always followed. Nutritional support for wound healing was delayed, and the resident's wounds worsened, leading to hospitalization for suspected sepsis.
A significant medication error occurred when a CMA mistakenly administered medications intended for another resident to a cognitively impaired resident with a J-tube. Despite instructions not to give oral medications, the CMA gave clopidogrel, morphine ER, and acetaminophen to the resident, who had a complex medical history and was dependent on tube feeding. The error was discovered when the resident was found coughing with tablets in their mouth, leading to immediate medical intervention.
The facility failed to maintain sanitary conditions in its food service operations, with issues such as missing thermometers, unlabeled and improperly stored food items, and a refrigerator operating above the recommended temperature. These deficiencies were observed in two kitchen areas, placing residents at risk for food-borne illness.
The facility failed to secure a maintenance shop containing hazardous chemicals and did not maintain a functional alarm on an exit door, posing risks to residents. Additionally, the facility did not address a tripping hazard in a resident's room, despite the resident's history of falls and mobility issues. Staff acknowledged these hazards but did not take corrective actions, leading to deficiencies in maintaining a safe environment.
A facility failed to uphold resident dignity when a CNA referred to residents needing feeding assistance as 'feeders' in front of others. This practice was confirmed by the CNA and recognized as a dignity issue by other staff, violating the facility's Right to Dignity policy.
The facility failed to provide written bed-hold notices to four residents or their representatives during hospital transfers, as required by policy. This deficiency was identified through observations, interviews, and record reviews, revealing that verbal consent was obtained without completing necessary forms. The lack of documentation placed residents at risk of not returning to their former rooms.
A licensed nurse from a nursing agency failed to administer medications to 12 residents during a night shift, citing unavailability or unnecessary use, despite medications being available. The nurse also did not complete required assessments or document narcotic administration properly. Interviews revealed the nurse's unusual behavior and failure to notify the physician about held medications.
A resident with multiple medical conditions experienced a 48% medication error rate during administration. A CMA spilled medications, failed to replace them, and administered them without proper hygiene or gloves, violating infection control standards. The facility's policy requires safe and sanitary medication administration, which was not followed, leading to deficiencies.
A licensed nurse from an agency failed to maintain complete and accurate medical records for several residents during a shift, resulting in undocumented and unadministered medications and treatments. The nurse did not follow standard procedures, leading to discrepancies in medication counts and incomplete resident assessments. Facility staff reported the nurse's disregard for communication and documentation protocols.
A certified medication aide failed to maintain infection control standards during medication administration by using contaminated pills and neglecting hand hygiene. The aide also administered a nasal spray without gloves, causing the resident to cough. These actions were against the facility's policies, as confirmed by administrative staff.
A resident with intact cognition was not included in their care plan meetings, despite facility policy requiring their participation. The resident, who needed assistance with daily activities due to diabetes and osteoarthritis, reported never being invited to these meetings. Social service staff failed to document the resident's involvement, assuming it was implied, leading to a risk of inadequate care and uncommunicated needs.
The facility failed to verify and document advanced directives for a resident with chronic conditions, leading to a discrepancy between a DNR order and the resident's stated preference for full code. Additionally, the facility improperly allowed a guardian to consent to a DNR for another resident with schizophrenia and bipolar disorder, contrary to policy. These deficiencies risked uncommunicated end-of-life care needs.
A facility failed to develop a person-centered baseline care plan for a newly admitted resident with acute pancreatitis, CKD, and DM2 within 48 hours, as required by policy. The resident's EHR lacked a complete Admission MDS and CAA, and the baseline care plan was missing essential information and signatures. The resident had not participated in a care plan meeting, leading to potential uncommunicated needs.
A facility failed to document a resident's oxygen and nebulized medication use in their care plan, despite physician orders and staff confirmation of these treatments. The resident had diagnoses of obstructive sleep apnea and COPD, requiring careful respiratory management. Staff interviews revealed inconsistencies in care plan documentation, with some staff unaware of the resident's specific respiratory care needs.
The facility failed to update the care plans for two residents after they experienced falls, leading to uncommunicated care needs. One resident, with bipolar disorder and dementia, reported falls that were not reflected in her care plan. Another resident, with a right hip fracture, had changes in her weight-bearing status that were not updated in her care plan. This failure violated the facility's Care Plan Revision Policy and risked the residents' well-being.
A CMA in a facility administered medications in an unsanitary manner by picking up spilled pills from the floor and medication cart and giving them to a resident. The CMA acknowledged the error, and administrative staff confirmed the violation of medication administration and infection control policies.
Two residents with severe cognitive impairment in a LTC facility did not receive adequate personal and oral care. One resident had facial whiskers despite needing assistance with ADLs, and another had poor oral hygiene with dried substances on her teeth and lips. Staff were unaware of grooming responsibilities, and the facility's policy on dignity was not followed, risking residents' psychosocial well-being.
A resident with a pressure ulcer and multiple medical conditions received inadequate infection control during wound care. The resident required substantial assistance and had a urinary catheter. During care, a nurse failed to change gloves between cleaning the resident's rectal area and continuing wound care, despite the resident being incontinent. This was against the facility's infection control policy, and the nurse admitted to forgetting to change gloves due to frequent use.
A resident with an indwelling urinary catheter was not provided proper care to prevent urinary tract infections. The resident's catheter collection bag was improperly placed on their lap and held above the bladder during a transfer, contrary to the facility's policy requiring the bag to be below the bladder. Staff were unaware of the correct protocol, posing a risk of urine backflow and infection.
The facility failed to manage respiratory care for two residents, leading to deficiencies. A resident did not have a physician's order for oxygen administration, and their oxygen cannula was contaminated and not replaced promptly. Another resident's nebulizer equipment was not properly cleaned or stored, and the equipment was not dated as required. These issues highlighted gaps in the facility's management of respiratory needs.
The facility failed to properly store medications for three residents, leading to a deficiency in medication management. Medications were found in residents' rooms without physician orders or self-administration assessments. Staff were unaware of the policy regarding medication storage, and the facility lacked a policy for medication storage in resident rooms.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development and worsening of facility-acquired pressure ulcers for a resident with multiple risk factors, including osteoarthritis, weakness, and incontinence. Despite being identified as at risk for pressure injuries, the resident was not placed on a turn and reposition schedule, and the electronic health record lacked documentation of such a program. The care plan directed staff to assist with repositioning as needed, but routine repositioning was not implemented until after the wounds had progressed. Additionally, the facility did not provide a low air loss mattress or other standard interventions until the pressure ulcers had worsened. Wound monitoring and documentation were inadequate following the initial development of skin issues. Weekly skin assessments failed to identify or document the presence of wounds until after the resident and their representative reported concerns. When wounds were identified, staff did not consistently measure or assess the wounds for infection, drainage, or peri-wound condition, and there was a lack of evidence that physician orders for wound care were carried out as documented in the medication and treatment administration records. Communication among staff regarding wound status and interventions was inconsistent, and there was a gap in wound assessments due to improper training of the responsible nurse. Nutritional interventions to support wound healing were not implemented promptly, and the resident's wounds progressed to Stage 3 pressure injuries with exposed adipose tissue and signs of infection. The wounds increased in size and severity before appropriate interventions, such as frequent repositioning and specialized mattresses, were put in place. The resident ultimately developed a fever and was transferred to the hospital with suspected sepsis secondary to wound infection.
Significant Medication Error Involving Cognitively Impaired Resident
Penalty
Summary
The facility failed to prevent a significant medication error involving a cognitively impaired resident, identified as R1, who was incorrectly administered medications intended for another resident, R2. On the morning of 10/11/24, a Certified Medication Aide (CMA) mistakenly gave R2's medications, which included clopidogrel, morphine extended release, and acetaminophen, to R1. This error occurred despite the Licensed Nurse (LN) G having previously instructed the CMA that R1 had a jejunostomy tube and could not receive medications orally. The CMA had documented not to give medications to R1, but still proceeded to administer the wrong medications. R1 had a complex medical history, including hereditary ataxia, multiple system atrophy, quadriplegia, basal ganglia dysfunction, dysphagia, and aphagia, and was dependent on a jejunostomy tube for nutrition and medication administration. The resident was also noted to have short-term and long-term memory problems and was dependent on nursing staff for activities of daily living. The error was discovered when LN G heard R1 coughing and found four tablets in R1's mouth, which were removed to prevent further risk of aspiration, given R1's history of aspiration pneumonia. The incident was reported to the administrative staff and the healthcare provider, who ordered a chest x-ray and prescribed an antibiotic as a precautionary measure. The x-ray showed increased airspace disease in the right lung base, which could indicate atelectasis, infection, or aspiration. The CMA involved in the error was asked to leave the facility and placed on a do-not-return list. The facility's failure to prevent this medication error placed R1 in immediate jeopardy, as the resident was NPO and had a J-tube for medication administration.
Removal Plan
- The facility asked the CMA R to complete a witness statement, was escorted out of the facility, and placed the CMA on the Do Not Return (DNR) list.
- Licensed Nurses (LN) and Certified Medications Aides (CMA) were provided education related to medications administration.
- Licensed Nurses (LN) and Certified Medications Aides (CMA) completed a medication administration checkoff, observed by the Unit Managers.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in its food service operations, as observed in two kitchen areas. In the [NAME] House kitchen, several issues were noted, including the absence of thermometers in the refrigerator and freezer, a large bag of macaroni salad without a preparation or expiration date, and open containers of breadsticks and sausage patties in the freezer. Additionally, a bag containing an unknown frozen liquid lacked labeling. In the corridor between [NAME] House and the dry storage area, a large bin of pasta, egg noodles, and tortilla chips were found without open or expiration dates. In the Saghbene Kitchen, the refrigerator was observed to have a temperature of 46 degrees Fahrenheit, above the recommended 41 degrees. The freezer contained a plastic bag with an unknown meat product and open boxes of hamburger patties and breakfast biscuits, all lacking proper labeling. A discolored loaf of luncheon meat in the refrigerator also lacked labeling. These deficiencies were acknowledged by the facility's staff, including the Administrative Nurse and Dietary Staff, who were made aware of the concerns.
Facility Fails to Secure Hazardous Areas and Address Fall Risks
Penalty
Summary
The facility failed to ensure a secure environment free from accident hazards, as evidenced by the unsecured maintenance shop door and the non-functional alarm on an exit door. The maintenance shop, located in the main hallway leading to resident units, contained hazardous chemicals labeled as harmful or fatal if ingested. Observations revealed that the maintenance shop door was often left open, and the chemicals were stored on an open shelf, accessible to residents. Maintenance Staff O admitted to setting the door to close slowly for convenience, and the Environmental Supervisor N confirmed the concern. Additionally, the exit door leading outside had a non-functional alarm system, posing a risk to residents who might wander outside unsupervised. The report also highlights the facility's failure to maintain a safe environment for Resident 9, who had a history of falls and a recent hip fracture. Despite being aware that Resident 9 engaged in 'furniture surfing' for mobility, the facility did not address the tripping hazard posed by an electric cord in the resident's room. The cord extended across the floor between the recliner and the dresser, creating a potential fall risk. Staff members, including a CNA and a Licensed Nurse, acknowledged the hazard but did not take action to mitigate it. Resident 9's medical history included dementia, a right hip fracture, and muscle weakness, requiring assistance with activities of daily living. The resident had experienced a fall resulting in a hip fracture, which was initially undiagnosed. Despite interventions in place to prevent further falls, the facility's inaction regarding the electric cord contributed to an unsafe environment. The facility's policies on chemical storage and fall prevention were not adhered to, leading to these deficiencies.
Violation of Resident Dignity Due to Labeling
Penalty
Summary
The facility failed to protect the privacy and dignity of residents who were dependent on staff assistance for eating. This deficiency was identified when a Certified Nurse Aide (CNA) was observed referring to these residents as 'feeders' in the presence of other residents. The CNA confirmed the use of this label, acknowledging that it violated the dignity of the residents. Further interviews with a Licensed Nurse and two Administrative Nurses corroborated that referring to residents by labels instead of their names is a dignity issue. The facility's Right to Dignity policy, dated December 7, 2023, explicitly states that residents should be cared for in a manner that maintains and enhances their dignity and respect, and that staff should never use terms or labels to refer to residents.
Failure to Provide Written Bed-Hold Notices
Penalty
Summary
The facility failed to provide written bed-hold notices to four residents, R22, R3, R8, and R32, or their representatives, at the time of their transfers to the hospital. This deficiency was identified through observations, interviews, and record reviews. The facility's policy, dated 09/01/23, mandates that written information regarding the bed-hold policy, including duration and cost, must be provided to the resident or their representative and included in the transfer packet. However, this procedure was not followed, placing the residents at risk of not being allowed to return to their former rooms. For Resident R8, the Electronic Health Record (EHR) documented a hospitalization from [DATE] to 08/09/24, but there was no evidence of a written bed-hold notice being provided. Administrative Staff CC confirmed that she only obtained verbal consent for the bed-hold and did not complete any form. Similarly, for Resident R32, the EHR documented a hospitalization from [DATE] to 02/17/24, but the documentation lacked evidence of verbal or written contact with the resident or their representative regarding the bed-hold. Resident R3's EHR revealed a hospitalization on 05/15/24, but the progress notes lacked documentation for a bed-hold. Administrative staff and social services personnel acknowledged the absence of a bed-hold form in the EHR or progress notes. For Resident R22, the EHR documented a hospitalization on 03/28/24, but again, there was no documentation of a bed-hold notice. The facility's failure to provide written bed-hold notices for these residents could lead to uncommunicated needs, potentially impacting their physical, mental, and psychosocial well-being.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that 12 out of 20 residents received their prescribed medications during a specific shift. This occurred when a licensed nurse from a nursing agency, who was employed to work the night shift, did not administer medications as ordered by the physician. The investigation revealed that the nurse exhibited unusual behavior and failed to administer medications for various reasons, including documenting that medications were unavailable or not needed, despite them being available in the medication cart. Several residents, including those with intact cognition and those with moderate to severe cognitive impairments, were affected by this deficiency. The nurse failed to administer critical medications such as antibiotics, inhalers, cholesterol medications, and pain relief medications. Additionally, the nurse did not complete necessary assessments for conditions like anxiety, depression, and respiratory issues, and failed to document the administration of narcotics properly. Interviews with staff and residents indicated that the nurse did not follow proper procedures, often claiming that medications were unnecessary or unavailable. The nurse also failed to notify the physician about holding medications and did not complete vital sign assessments. Despite the nurse's actions, the physician assistant determined that no significant harm was done to the residents due to the omission of medications.
Medication Administration Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 48% error rate during a medication administration pass for a resident. The resident, who had medical diagnoses including diabetes mellitus, hypertension, and heart failure, was observed during a medication pass where 25 medication opportunities resulted in 12 errors. This significant error rate placed the resident at risk for adverse reactions from the medications. During the medication administration, a Certified Medication Aide (CMA) spilled a medication cup containing the resident's oral medications, with some pills landing on the floor and others on the medication cart. Despite this, the CMA proceeded to administer the medications to the resident without replacing them. Additionally, the CMA administered a nasal spray without wearing gloves and failed to perform hand hygiene before and after administering medications, which violated infection control standards. The facility's Medication Administration Policy requires that all medications be administered safely and sanitarily as ordered by a physician. However, the CMA's actions did not adhere to these standards, as confirmed by both the CMA and administrative nurses. The failure to administer medications in a sanitary manner and maintain a medication error rate below 5% were identified as deficiencies that could negatively impact the residents' overall physical and psychosocial well-being.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for seven residents during a shift from 06:00 PM on 07/21/24 to 06:00 AM on 07/22/24. A licensed nurse from a nursing agency, referred to as LN I, was responsible for medication administration and documentation during this period. However, multiple medications and treatments were not documented or administered as required. For instance, vital signs were not recorded for a resident with intact cognition, and orders for medications and treatments such as ASV, melatonin, and skin tear care were not documented or completed. Several residents with varying levels of cognitive impairment were affected by the nurse's failure to document and administer medications. One resident with moderate cognitive impairment reported uncertainty about receiving medications, while another with severe cognitive impairment did not receive ordered treatments for skin care. Additionally, a resident with intact cognition did not receive insulin or have their fluid restriction documented, and there was no follow-up on the reasons for these omissions. The nurse also failed to document the administration of narcotics and other medications, leading to discrepancies in the medication count. Interviews with facility staff revealed that the nurse disregarded standard procedures and failed to communicate effectively with other staff members. A certified medication aide noted discrepancies in the narcotic count, and a licensed nurse reported that the nurse dismissed her attempts to provide a resident report. The administrative nurse confirmed the lack of documentation and attempts to contact the nurse were unsuccessful. The facility's policy on medication administration emphasizes the importance of administering medications as ordered, but this was not adhered to during the shift in question.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection control program during medication administration, as observed with a certified medication aide (CMA) who did not adhere to sanitary practices. During the administration of morning medications to a resident, the CMA spilled the medication cup, causing several pills to fall on the floor and the medication cart. Instead of discarding the contaminated medications, the CMA placed them back into the cup and proceeded to administer them to the resident. Additionally, the CMA administered a nasal spray without wearing gloves, which caused the resident to cough, and failed to perform hand hygiene before and after administering medications. The facility's policies on medication administration and infection control were not followed, as confirmed by administrative nurses. The CMA acknowledged the errors, including the failure to use gloves and perform hand hygiene. The facility's policies clearly state that medications should be administered in a safe and sanitary manner, and hand hygiene should be performed before and after contact with a resident. These deficiencies were confirmed by administrative staff, who expected adherence to infection control standards.
Resident Excluded from Care Plan Meetings
Penalty
Summary
The facility failed to include a resident in the development and continued planning of their care plan, which was supposed to occur quarterly. The resident, who had intact cognition and a good memory, was not invited to any care plan meetings despite being documented as such in the care plan. The resident's medical conditions included diabetes mellitus and osteoarthritis, and they required varying levels of assistance with activities of daily living. Despite the facility's policy requiring residents to be invited to care plan meetings, the resident reported never being invited, and there was no documentation to confirm their attendance. The facility's policy stated that care plan conferences should be scheduled at least every 90 days and include the resident, family, or healthcare representative, along with the interdisciplinary team. However, the social service staff failed to document the resident's involvement in these meetings, assuming it was implied. The lack of documentation and failure to invite the resident to participate in their care planning placed them at risk for inadequate care and services, with potential negative psychosocial effects related to safety and uncommunicated needs.
Failure to Verify and Authorize Advanced Directives
Penalty
Summary
The facility failed to verify and document the advanced directives for Resident 8, who had a history of chronic obstructive pulmonary disease, diabetes mellitus type 2, and chronic respiratory failure with hypoxia. Despite the resident's intact cognition and a stated preference to be a full code, the facility's records contained an un-rescinded DNR order signed by the resident. The facility's staff, including a Certified Medication Aide and a Certified Nurse Aide, were unable to locate the resident's advance directive wishes in the care plan book or on the lanyards meant to document code status. This discrepancy between the DNR order and the full code order was not addressed, leading to potential uncommunicated needs regarding end-of-life care. The facility also failed to obtain proper authorization for a DNR order for Resident 3, who had diagnoses of schizophrenia and bipolar disorder. Although the resident had a BIMS score indicating moderately impaired cognition, the facility allowed the resident's guardian to consent to a DNR order, which was not permissible according to the facility's policy. The care plan did not document the presence of a guardian, and the uploaded guardianship document lacked direction for advanced directives. Administrative Nurse D was unaware that a guardian could not sign a DNR, leading to a failure in obtaining proper authorization. Both cases highlight the facility's failure to adhere to its policy for advanced directives, which required assessment and documentation of each resident's directives in the EHR. The lack of verification and proper authorization for advanced directives had the potential to lead to uncommunicated needs specifically related to end-of-life care for the residents involved.
Failure to Develop Baseline Care Plan for New Resident
Penalty
Summary
The facility failed to develop a person-centered baseline care plan for Resident 153 within 48 hours of admission, as required by their care planning policy. Resident 153, who was admitted with acute pancreatitis, chronic kidney disease, and diabetes mellitus type 2, did not have a completed Admission Minimum Data Set (MDS) or Care Area Assessment (CAA) in their Electronic Health Record (EHR). The baseline care plan was incomplete and lacked essential information such as the resident's initial goals, communication risks, dietary preferences, therapy services, and other critical care instructions. Additionally, the care plan was neither signed nor dated by the interdisciplinary team (IDT) or the resident's representative. Interviews and observations revealed that Resident 153 had not participated in a care plan meeting with the staff, nor had any staff inquired about her needs or wishes regarding her care since her arrival. The facility's policy mandates that a summary of the baseline care plan be provided to residents and their representatives within 48 hours of admission, but this was not adhered to in the case of Resident 153. The lack of a complete and signed baseline care plan had the potential to lead to uncommunicated needs for the resident.
Failure to Document Respiratory Care in Resident's Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as R30, regarding the use of oxygen and nebulized medication. R30's electronic health record included diagnoses of obstructive sleep apnea and chronic obstructive pulmonary disease, conditions that necessitate careful management of respiratory support. Despite physician orders for nebulized medication and supplemental oxygen, the care plan lacked documentation related to these treatments. Interviews with staff revealed inconsistencies in care plan documentation, with some staff unaware of the specific respiratory care needs of R30. The deficiency was identified through interviews, observations, and record reviews. Certified Nurse Aide LL confirmed that R30 used oxygen, and the tubing and nebulizers were changed weekly. However, the care plan did not reflect these practices. Licensed Nurse K and Administrative Nurse D acknowledged that the care plan should accurately reflect the care administered, but it did not include the necessary information for R30's oxygen and nebulized medication use. This oversight had the potential to lead to uncommunicated needs, negatively impacting R30's physical well-being.
Failure to Revise Care Plans After Resident Falls
Penalty
Summary
The facility failed to accurately revise the care plans for two residents, R22 and R9, after they experienced falls, which placed them at risk for uncommunicated care needs. Resident R22, who had diagnoses of bipolar disorder and dementia, reported falling out of bed and later out of her wheelchair, but her care plan was not updated to reflect these incidents. Despite having a history of falls and being on medications that increased her fall risk, the care plan did not include new interventions to prevent further falls after these incidents were reported by the resident and her family. Resident R9, who had a history of dementia and a right hip fracture, also experienced a fall that resulted in a major injury. Although her care plan should have included guidance on her weight-bearing status following her hospital discharge, it lacked any instructions regarding hip fracture precautions. Despite therapy communication forms indicating changes in her weight-bearing status, these updates were not reflected in her care plan, leaving staff without crucial information to provide appropriate care. The facility's failure to update the care plans for R22 and R9 after their falls and changes in their medical conditions was a violation of their Care Plan Revision Policy. This policy requires that care plans be revised by a licensed nurse in collaboration with the interdisciplinary team and communicated to all staff. The lack of updates in the care plans for these residents had the potential to negatively affect their physical and psychosocial well-being.
Unsanitary Medication Administration
Penalty
Summary
The facility failed to meet professional standards of care when a Certified Medication Aide (CMA) administered medications in an unsanitary manner. During the morning medication administration, the CMA accidentally spilled a medication cup containing oral pills for a resident, with some pills landing on the floor and others on the medication cart. Instead of discarding the contaminated medications, the CMA picked them up and placed them back into the medication cup, then proceeded to administer them to the resident along with an Oxycodone tablet. The incident was confirmed by the CMA shortly after, acknowledging that she should have replaced the dropped medications with new ones. Administrative staff, including two nurses, also confirmed that the medications should not have been administered after falling on the floor and cart, as it violated the facility's medication administration and infection control policies. These policies require that all medications be administered in a safe and sanitary manner, ensuring a safe and comfortable environment for residents.
Deficient Personal and Oral Care for Residents
Penalty
Summary
The facility failed to provide adequate personal care for Resident 19, who was dependent on staff for activities of daily living (ADLs) due to severe cognitive impairment and physical limitations. Despite requiring maximal assistance with personal hygiene, the care plan lacked documentation for facial hair removal, and observations over several days revealed that the resident had noticeable facial whiskers. A family member expressed concern about the resident's appearance, and staff interviews indicated a lack of awareness and adherence to the facility's policy on grooming, which emphasized maintaining residents' dignity. Similarly, Resident 40, who also had severe cognitive impairment and required total assistance with ADLs, did not receive proper personal hygiene and oral care. Observations showed the resident had facial whiskers and poor oral hygiene, with dried substances on her teeth and lips. Despite having oral care supplies available, there was a lack of documentation and consistent care provided. Staff interviews revealed confusion about responsibilities for facial hair removal and oral care, with some staff unaware of the resident's personal care items. The facility's policy on dignity and grooming was not followed, as both residents did not receive the necessary care to maintain their dignity and well-being. The lack of proper grooming and oral care placed the residents at risk for decreased psychosocial well-being, as noted in the report. The facility's failure to ensure these dependent residents received appropriate care highlights deficiencies in staff training and adherence to care policies.
Infection Control Lapse During Wound Care
Penalty
Summary
The facility failed to adhere to effective infection control practices during wound care for a resident with a pressure ulcer. The resident, who was admitted with a pressure ulcer on the coccyx, had multiple medical conditions including muscle weakness, diabetes mellitus type two, chronic kidney disease, and disseminated intravascular coagulation. The resident required substantial assistance for daily care and had a urinary catheter due to neurogenic bladder. The care plan included the use of a pressure-reducing mattress and wheelchair cushion, assistance with repositioning, and specific wound care orders. However, during an observation, a licensed nurse failed to change gloves between cleaning the resident's rectal area and continuing wound care, despite the resident being incontinent of bowel movement. The incident was observed when the licensed nurse, after removing the resident's brief and exposing the wound, cleansed the rectal area with wet wipes, removed gloves, used hand sanitizer, and replaced gloves. However, after the resident continued to have a bowel movement, the nurse wiped the bowel movement and continued wound care without changing gloves. This action was contrary to the facility's wound management policy, which required maintaining general infection control practices during wound care. The nurse later admitted to forgetting to change gloves due to frequent glove use, and the administrative nurse confirmed that failing to change gloves appropriately presented an infection control problem.
Improper Handling of Urinary Catheter Collection Bag
Penalty
Summary
The facility failed to provide proper care to prevent urinary tract infections for a resident with an indwelling urinary catheter. The resident, who had a history of hydronephrosis, diabetes mellitus type two, and neuromuscular dysfunction of the bladder, required substantial assistance for daily care. The care plan specified that the urinary catheter collection bag should be positioned below the level of the bladder to prevent urine backflow. However, during an observation, it was noted that the catheter collection bag was placed on the resident's lap and later held above the resident's bladder during a transfer, contrary to the facility's policy. Staff members involved in the incident were not aware of the requirement to keep the urinary collection bag below the bladder. A Certified Nursing Assistant (CNA) reported being unaware of this protocol, and a Licensed Nurse confirmed that all CNAs should be trained in the proper placement of the catheter. The facility's policy, dated December 2023, clearly stated that the catheter and drainage bag should be kept lower than the bladder to allow drainage by gravity. The failure to adhere to this policy posed a risk of urine backflow and potential urinary tract infection for the resident.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to properly manage respiratory care for two residents, leading to deficiencies in their care. For Resident 1, the facility did not obtain a physician's order for the administration of oxygen, despite the resident's diagnoses of chronic obstructive pulmonary disease, obstructive sleep apnea, and chronic respiratory failure with hypoxia. The care plan and physician's orders lacked documentation related to oxygen use, and the Medication Administration Record and Treatment Administration Record did not include information on oxygen administration. Additionally, the resident's oxygen cannula was contaminated and not replaced promptly, and the staff failed to date the new cannula as required by the facility's policy. For Resident 30, the facility did not properly clean and store the nebulizer equipment. The resident, who had diagnoses of obstructive sleep apnea and chronic obstructive pulmonary disease, had a nebulizer mask that was not dated, and the equipment was not stored according to the facility's policy. The nebulizer was observed on the resident's bedside table and in the resident's lap without proper cleaning or storage. Staff interviews revealed that the nebulizer and oxygen tubing were supposed to be changed and dated weekly, but this was not consistently done. These deficiencies in respiratory care practices had the potential to negatively impact the residents' physical and psychosocial well-being. The facility's failure to adhere to its own policies regarding the administration of oxygen and the maintenance of nebulizer equipment contributed to these issues. The lack of proper documentation and adherence to protocols for respiratory care highlighted significant gaps in the facility's management of residents' respiratory needs.
Improper Medication Storage for Residents
Penalty
Summary
The facility failed to properly store medications for three residents, leading to a deficiency in medication management. Resident 153 had miconazole powder stored on her bedside table without a physician's order or a completed self-administration assessment. The facility's records lacked documentation allowing medications to be left at the bedside, and staff were unaware of the policy regarding medication storage in resident rooms. This oversight had the potential to negatively impact the resident's well-being. Resident 8 had multiple over-the-counter medications, including Voltaren Gel, Flonase, and a petroleum-based salve, stored on her over-the-bed table without specific physician orders or a self-administration assessment. The resident was unable to specify the dosage or frequency of use for these medications. The facility's records did not document permission for these medications to be left at the bedside, and staff were not informed about the policy for medication storage in resident rooms. Resident 22 had Fluticasone Propionate Suspension and Saline Nasal Spray stored in plain view on her overbed table without a physician's order or a self-administration assessment. The facility's records lacked documentation allowing these medications to be left at the bedside. Staff were unaware of the policy regarding medication storage in resident rooms, and there was concern that removing the medications could lead to behavioral issues. The facility did not have a policy for medication storage in resident rooms, contributing to the deficiency.
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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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