Delmar Gardens Of Lenexa
Inspection history, citations, penalties and survey trends for this long-term care facility in Lenexa, Kansas.
- Location
- 9701 Monrovia Street, Lenexa, Kansas 66215
- CMS Provider Number
- 175122
- Inspections on file
- 16
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Delmar Gardens Of Lenexa during CMS and state inspections, most recent first.
Surveyors found that medication carts containing insulins and treatment supplies were left unlocked and unattended on two hallways, with carts observed open for several minutes while an LPN or a CMA was inside resident rooms or otherwise away from the carts. Staff acknowledged that carts are expected to be locked when not in use or out of direct eyesight, and facility policy requires carts to be kept in visible range or locked before entering a resident’s room.
A resident with Alzheimer’s disease, severely impaired cognition (BIMS 0), and total dependence for ADLs had a history of falls and a care plan requiring the call light to be kept within reach due to fall risk and poor safety awareness. During observation, the resident was in bed, awake and yelling out, while the call light was located behind the bed’s headboard and not accessible. Staff, including a CMA, an LN, and an administrative nurse, acknowledged that call lights should be within residents’ reach, and facility policy required staff to ensure call lights were reachable and answered promptly, but this was not done for this resident.
Surveyors found that when a resident’s Medicare Part A coverage ended and the resident remained in the facility, staff issued an outdated or incorrect ABN form instead of the required CMS-10055 notice. Record review confirmed the last covered day under Medicare Part A and showed that the wrong form (CMS-20052) was used. In interviews, administrative and social services staff acknowledged that the correct SNF ABN form was not provided, despite the facility having a policy referencing the proper CMS-10055 form.
Surveyors found that staff failed to protect resident PHI when two unattended medication carts were left in hallways with open computer screens displaying residents’ MAR and treatment orders. In each instance, the cart was left alone for several minutes with identifiable medical information visible, and the CMA and LN involved later acknowledged they should have closed the screens to maintain confidentiality, contrary to the facility’s stated residents’ rights policy.
A resident with dementia, Alzheimer's disease, and documented aggressive behaviors was involved in a resident-to-resident altercation in which she grabbed another resident and required redirection and removal from the area. Nursing documentation described the physical altercation and subsequent 1:1 interaction for calming, but staff did not recognize or treat the event as potential abuse. The incident was not reported to administration or the State Survey Agency, and no investigation, incident report, or witness statements were initiated, despite a facility abuse policy requiring immediate reporting and investigation of suspected abuse, including abuse by other residents.
A resident with dementia, Alzheimer’s disease, depression, and anxiety, who was care planned for disruptive and potentially aggressive behaviors, was documented as grabbing another resident’s arm and covering the resident’s mouth during an altercation that required redirection and removal from the area. Although the facility’s abuse policy required immediate reporting of suspected abuse, assessment, incident reporting, and interviews of involved parties, staff did not report the event to administration at the time, and the facility could not provide evidence that any formal investigation or required follow-up steps were completed.
A resident on hospice with DM, dysphagia, and a G-tube had physician orders and a care plan requiring continuous head-of-bed (HOB) elevation of at least 30 degrees during enteral feeding and Glucerna 1.5 at 50 ml/hr with a daily two-hour interruption. Surveyors observed the resident lying flat in bed while tube feeding was running, and at other times with the HOB at only 3–10 degrees, as well as periods when the feeding was off and disconnected outside the ordered schedule. Staff interviews showed an LPN was unsure of the required HOB elevation, CNAs gave conflicting and incorrect descriptions of the required HOB angle, and another LPN was unclear about when the feeding had been stopped and initially could not find the order for the scheduled gut rest. The G-tube care policy lacked HOB elevation guidance, despite a policy requiring staff to follow physician orders.
A resident had a PRN order for diphenhydramine 50 mg by mouth three times daily without any documented diagnosis or indication, despite having documented insomnia and anxiety, intact cognition, no skin issues, and independence with ADLs. The medication was not reflected in the care plan or in any progress, provider, dermatology, pharmacy, or psych notes. A consultant pharmacist later confirmed the absence of an indication and acknowledged missing it during a prior review, while a CMA, an LN, and an administrative nurse all stated that PRN and other medications are required to have a diagnosis or reason for use. The facility did not provide a policy governing PRN medication orders.
Surveyors observed that nurses crushed and administered multiple medications that should not have been crushed, resulting in a medication error rate of 19.23%. One resident with anemia and a G-tube received crushed ferrous sulfate and sennosides-docusate, while tamsulosin was withheld due to a discrepancy between the order and the medication card. Another resident with constipation and a psychotic disorder received crushed docusate sodium capsules and trazodone mixed in pudding. These practices conflicted with facility policy prohibiting crushing medications when contraindicated, contributing to the high observed error rate.
Staff failed to consistently implement Enhanced Barrier Precautions (EBP) and basic infection control practices, including not sanitizing a mechanical lift between residents, not using required gowns when providing high-contact care to a resident with an indwelling catheter, and allowing a urine drainage bag and tubing to rest on and drag along the floor. CNAs conducting an ice pass left the ice scoop in the cooler, kept the lid open, and moved between multiple residents without performing hand hygiene. For a resident on EBP, staff used appropriate PPE during incontinence care but later transferred the resident without gowns, despite acknowledging EBP requirements. Another resident with numerous open and scabbed wounds, active bleeding onto clothing and linens, and a widespread rash had no EBP signage or PPE setup, and the EMR lacked a detailed skin assessment, contrary to facility policy requiring covered skin lesions and hand hygiene.
The facility failed to properly label and discard insulin medications for several residents and expired stock medications. This included unlabeled and outdated insulin pens and vials, as well as expired Tussin DM. These deficiencies were confirmed through observations and interviews with the administrative nurse.
A resident was not treated with dignity during the noon meal as a CNA stood over him while assisting with eating and left the table multiple times to perform other tasks. Facility policy requires staff to sit next to residents and engage in conversation during meals.
The facility failed to provide written notice for hospital transfers for three residents, placing them at risk for uninformed care choices. The facility also lacked documentation and policies regarding these transfers.
The facility failed to provide three residents or their representatives with written information regarding the bed hold policy when they were transferred to the hospital. Administrative staff confirmed the absence of documentation and acknowledged that nursing staff were responsible for sending the bed hold policy with transfer papers but did not follow up on obtaining the signed notice.
The facility failed to ensure that three residents received a PASRR to identify potential care needs related to mental disorders or intellectual disabilities. The residents were admitted from the VA without the required assessments, placing them at risk for unidentified needs and inadequate care.
The facility failed to revise the care plan for a resident with PTSD, leading to uncommunicated care needs. Despite multiple diagnoses, including dementia and PTSD, the care plan did not address trauma triggers or coping strategies. Staff admitted to not assessing trauma triggers, and the facility's policy on Trauma Informed Care was not followed.
A resident with diabetes, osteoarthritis, and COPD did not receive the required restorative services to maintain mobility and ambulation. Despite a plan directing ambulation activities, the facility failed to document and follow through, placing the resident at risk for a decline in mobility and independence.
Unlocked and Unattended Medication Carts on Multiple Hallways
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medication carts containing drugs and biologicals were locked when unattended, as required by facility policy and professional standards. Surveyors observed three of six medication carts on the 500 and 600 hallways left unlocked and unattended for several minutes. On one occasion, an unlocked and unattended cart was observed on the 600 hallway for three minutes until a licensed nurse walked by, locked it, and left. On another occasion on the 600 hallway, a certified medication aide returned to an already unlocked cart, used the computer, then walked away into a resident’s room, leaving the cart unlocked and unattended for two minutes before returning to prepare medications. A further observation on the 500 hallway showed an unlocked and unattended medication cart for three minutes while a licensed nurse was in a resident’s room; during this time, a cart drawer was opened without the nurse noticing. Staff interviews confirmed that the medication carts stored residents’ insulins and treatment supplies and that staff understood the expectation that carts must be locked when not in use or out of direct eyesight. The administrative nurse also stated that all medication carts were expected to be locked when unattended. The facility’s Medication Administration policy dated January 2021 documented that staff were to keep the cart in visible range or lock all items prior to going into a resident’s room.
Failure to Keep Resident Call Light Within Reach
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was kept within reach as required by the resident’s care plan and facility policy. The resident had diagnoses including Alzheimer’s disease, hypertension, depression, and anxiety, with a BIMS score of zero indicating severely impaired cognition, and was dependent on staff for all ADLs. The Falls CAA documented a prior minor-injury fall and that fall precautions were in place with close monitoring. The care plan included an intervention, initiated in December 2022, to keep the resident’s call light within reach and answer it promptly, along with multiple fall-related interventions following falls in August 2025 and September 2025, and documentation in May 2026 that the resident was at risk for falls due to poor safety awareness and impulsiveness. On the survey date, the resident was observed lying in bed on her back with eyes open, covered with blankets, and yelling out, while the call light was found behind the headboard of the bed and not within reach. A CMA stated that residents should always have their call lights within reach and moved the resident’s pancake light onto her abdomen. Subsequent interviews with a licensed nurse and an administrative nurse confirmed that residents’ call lights should be placed where they are reachable by the resident. The facility’s Call Light Answering policy required staff to answer call lights within 15 minutes, respond to emergency lights immediately, and check to ensure the call light was within the resident’s reach, which was not followed in this instance.
Failure to Use Correct ABN Form When Medicare Part A Coverage Ended
Penalty
Summary
The facility failed to provide the correct Medicare Advance Beneficiary Notice of Non-Coverage (ABN) to a resident whose Medicare Part A skilled coverage ended while the resident remained in the facility. The facility census was 162 residents, with three residents reviewed for beneficiary notifications, and documentation showed that one resident’s Medicare Part A last covered day was 10/31/25. Instead of using the required ABN Form CMS-10055, the facility issued Form CMS-20052 (11/2017). During interviews, an administrative staff member and a social services staff member both confirmed that the correct ABN Form CMS-10055 was not provided to this resident. The facility had an undated policy titled “Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) Form CMS-10055 (2024),” but it was not followed in this case. This deficiency was identified through record review and staff interviews, which established that the resident did not receive the appropriate standardized notice of Medicare non-coverage at the time their Part A coverage ended, despite the facility having a policy referencing the correct ABN form.
Failure to Protect Resident PHI on Unattended Medication Carts
Penalty
Summary
Surveyors identified a failure to maintain the privacy and confidentiality of residents’ personal and medical records when unattended medication carts were left with open computer screens displaying protected health information (PHI). On 03/16/26 at 8:53 AM, a medication cart in the 600 hallway was observed unattended for four minutes with the electronic medication administration record for Resident 10 visible on the screen. Later that morning at 11:37 AM, another medication cart in the 500 hallway was observed unattended for over three minutes with treatment orders for Resident 96 displayed on the computer screen. The certified medication aide responsible for the first cart acknowledged he should have closed the computer screen so that Resident 10’s information could not be seen, and the licensed nurse responsible for the second cart similarly acknowledged she should have closed the screen to maintain confidentiality of residents’ medical information. On 03/17/26 at 1:38 PM, an administrative nurse stated the expectation that all resident information on computers should be protected by closing the computer screen when the cart is unattended. The facility’s undated Residents’ Rights policy documented that residents have the right to privacy and confidentiality for their personal and clinical records, and that confidentiality of personal and clinical records is a resident right.
Failure to Report and Investigate Resident-to-Resident Altercation as Potential Abuse
Penalty
Summary
Facility staff failed to identify and report a resident-to-resident altercation as potential abuse in accordance with facility policy and regulatory requirements. One resident involved, R62, had diagnoses including dementia with behaviors, Alzheimer's disease, major depressive disorder, and anxiety, with a Quarterly MDS indicating severely impaired cognitive function and dependence on staff for most ADLs. Her care plan documented a history of disruptive and combative behaviors, including potential physical aggression toward other residents and staff, and directed staff to use non-pharmacological interventions and assess for unmet needs when behaviors occurred. Nurse's notes dated 09/04/25 at 2:26 PM documented that R62 was involved in a resident-to-resident altercation in which she was observed grabbing another resident's arm and covering the other resident's mouth. The note indicated that R62 required redirection and physical removal of her hands, after which she was removed from the area and provided 1:1 interaction with a nurse to calm her, with staff to continue monitoring for safety due to poor safety awareness. Despite this documentation of physical contact and an altercation between residents, the facility did not initiate an investigation into the incident. The facility was unable to provide evidence that the incident was reported to the Administrator or to the State Survey Agency as required by its Abuse, Neglect, and Exploitation policy. That policy requires all individuals to immediately report allegations or suspicions of abuse, including abuse by other residents, to the Administrator or supervisor, and requires the Administrator or designee to assess the resident, complete an incident report, gather witness statements, and report to the State agency and law enforcement as indicated. Interviews with administrative nursing staff revealed that the nurse who documented the incident was new, and the training nurse did not consider the event to be abuse and therefore did not report it to administration, resulting in no timely reporting or investigation of the altercation as potential abuse.
Failure to Investigate Resident-to-Resident Altercation as Potential Abuse
Penalty
Summary
The deficiency involves the facility’s failure to identify a resident-to-resident altercation as potential abuse and to initiate an investigation as required by its abuse, neglect, and exploitation policy. One resident, who had diagnoses of dementia with behaviors, Alzheimer’s disease, major depressive disorder, and anxiety, was care planned for disruptive and potentially physically aggressive behaviors toward other residents and staff. Her care plan directed staff to use non-pharmacological interventions, assess for unmet needs, and review behaviors regularly. Despite this, nursing documentation on one occasion recorded that she was involved in a resident-to-resident altercation in which she grabbed another resident’s arm and covered the other resident’s mouth, requiring redirection and physical removal of her hands. The nurse’s note from that incident stated that the resident was removed from the area and provided one-on-one interaction to calm her, and that staff would continue to monitor for safety due to poor safety awareness. However, the facility was unable to provide evidence that a thorough investigation of this altercation was conducted. There was no documentation of an incident report, no documented assessment of injuries, and no collected witness statements related to the event, despite the description of physical contact between residents. Administrative staff later reported that the documenting nurse was new and had been trained by another nurse, and that the incident was not reported to administration at the time because the training nurse did not feel it was abuse. The facility’s written Abuse, Neglect, and Exploitation policy required that all individuals report allegations or suspicions of abuse, including abuse by other residents, immediately to the Administrator or supervisor. The policy further required the Administrator or designee to assess the resident, document injuries, complete an incident report, notify the physician and family, interview involved parties and witnesses, and report to the State agency and law enforcement within specified time frames when there is reasonable suspicion of a crime. In this case, despite a documented resident-to-resident altercation involving physical contact, these required reporting and investigative steps were not initiated or carried out, resulting in the failure to recognize and treat the event as a potential abuse incident in accordance with facility policy and regulatory expectations.
Failure to Maintain Ordered Head-of-Bed Elevation and Tube Feeding Regimen
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident receiving enteral nutrition via a gastrostomy tube (G-tube) had the head of bed (HOB) elevated as ordered and that tube feedings were administered according to physician orders. The resident had diagnoses including diabetes mellitus and dysphagia, a severely impaired BIMS score, required total assistance with ADLs, and was on hospice with a low BMI. The care plan and physician orders directed that the HOB be elevated 30 degrees continuously during enteral feeding and that Glucerna 1.5 be administered at 50 ml/hr with a scheduled daily two-hour “gut rest” period when the feeding was to be stopped. Surveyors observed multiple instances where these orders were not followed. On one day, the resident was found in bed lying flat while the enteral feeding pump was running at 50 ml/hr; the feeding bag label lacked the type of formula. On the following day, the resident was observed with the HOB at 30 degrees but the feeding pump was off and not connected, and later the same morning the resident remained with the HOB at 3 degrees and the tube feeding still off and disconnected. After medications were given, an LPN turned the pump on and connected the G-tube, then positioned the resident on the left side with the HOB at 30 degrees; later that morning, the resident was observed on the right side with the HOB at 10 degrees while the feeding was running at 50 ml/hr. Staff interviews further demonstrated lack of adherence to and understanding of the orders. One LPN did not notice the resident’s bed was flat while the feeding was running until prompted, and she was unsure how high the HOB should be elevated. CNAs gave inconsistent responses about who had provided care and what HOB elevation was required, with one CNA incorrectly stating the HOB should be elevated to 180 degrees. Another LPN reported that the tube feeding had not been turned back on until mid-morning and was unsure when it had been shut off, and initially could not locate the order for the scheduled two-hour morning interruption of feeding, despite the dietitian’s documented recommendation and the presence of the order in the EMR. The facility’s gastrostomy tube care policy did not address HOB elevation for enteral feedings, while the physician order-following policy required licensed staff to follow physician orders.
PRN Diphenhydramine Order Lacked Indication for Use
Penalty
Summary
Surveyors identified a deficiency related to unnecessary medications when a resident had a PRN diphenhydramine order without an associated diagnosis or documented reason for use. The resident’s EMR showed diagnoses of insomnia and anxiety, an Annual MDS with a BIMS score of 15 indicating intact cognition, no skin issues, and independence with ADLs. The Psychotropic Drug Use CAA noted the resident was prescribed psychotropic medications for anxiety and would be closely monitored. However, the care plan dated 03/16/26 did not include diphenhydramine, and a physician order dated 11/12/25 directed administration of diphenhydramine 50 mg by mouth three times a day as needed, without specifying an indication. Review of the EMR from 11/12/25 through 03/17/26 showed no documentation of this PRN diphenhydramine order in progress notes, provider notes, dermatology notes, pharmacy notes, or psychiatric notes. During observations, the resident was seen independently ambulating, participating in activities, and reporting that she did not know all of her medications but would ask the nurse if she needed something, stating she had many options to choose from. The consultant pharmacist confirmed on 03/17/26 that the PRN diphenhydramine order lacked a reason or diagnosis and acknowledged missing this issue during the last medication review. A CMA, a licensed nurse, and an administrative nurse each stated that all medications, including PRNs, were required to have a diagnosis or reason for administration, and the administrative nurse acknowledged that the diphenhydramine order should have included a reason since its initiation on 11/12/25. The facility did not provide a policy on PRN medication orders.
Crushing of Contraindicated Medications Leads to Elevated Medication Error Rate
Penalty
Summary
Surveyors identified a failure to maintain a medication error rate below 5 percent when five errors were found among 26 observed medication administrations, resulting in a 19.23 percent error rate. For one resident with anemia and a G-tube, physician orders directed daily administration of ferrous sulfate 325 mg and sennosides-docusate 8.6-50 mg via G-tube, and tamsulosin 0.4 mg via G-tube for malignant neoplasm of the bladder. During a morning medication pass, a licensed nurse noted a discrepancy between the tamsulosin order and the medication card, which was labeled for bedtime administration, and therefore withheld the tamsulosin pending clarification. The same nurse then crushed and administered the ferrous sulfate and sennosides-docusate via the G-tube, despite later confirmation from facility nursing leadership and the consultant pharmacist that these medications should not have been crushed. For another resident with an order for docusate sodium 100 mg capsules (two capsules once daily for constipation) and trazodone 50 mg twice daily for a psychotic disorder, a licensed nurse crushed the trazodone tablet and both docusate capsules and administered them mixed in pudding. Facility nursing leadership later reported that these medications also should not have been crushed. The facility’s medication administration policy stated that medications should not be crushed when contraindicated on a caution label or in the Prescribers’ Digital Reference, but the observed practice of crushing ferrous sulfate, sennosides-docusate, docusate sodium, and trazodone was inconsistent with this policy and contributed to the elevated medication error rate identified during the survey.
Failure to Implement Enhanced Barrier Precautions and Basic Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow Enhanced Barrier Precautions (EBP) and basic infection prevention practices for multiple residents. Surveyors observed that staff did not consistently use required PPE, including gowns and gloves, when providing high-contact care to residents on EBP or with open wounds and indwelling devices. For one resident with an indwelling catheter, CNAs used a sit-to-stand mechanical lift that had not been sanitized between residents, did not wear gowns as required for EBP, and allowed the resident’s urine drainage bag and tubing to rest on and drag along the floor during transfers. One CNA removed gloves and exited the room without performing hand hygiene. Staff acknowledged they should have worn gowns and sanitized the lift but stated they were in a hurry. Surveyors also observed improper hand hygiene and handling of ice during an ice pass. A CNA left the ice scoop in the cooler and the lid open while going in and out of resident rooms, and another CNA repeatedly retrieved resident cups from rooms, filled them from the cooler, and returned them without performing hand hygiene between residents. Both CNAs later confirmed that the scoop should be kept in a holder, the cooler lid should remain closed when not in use, and that hand hygiene should be performed between residents. A licensed nurse confirmed that facility expectations were for the ice coolers to remain closed, the scoop to be stored in a holder, and staff to wash their hands between residents. Additional deficiencies were identified related to EBP implementation and wound management. One resident with EBP signage on the door had PPE available, and a CNA initially used gown and gloves with appropriate hand hygiene during incontinence care, but when two CNAs later returned to transfer the resident with a mechanical lift, they did not wear gowns despite acknowledging the resident was on EBP. Another resident with multiple open and scabbed wounds, bleeding onto clothing and linens, and a widespread rash had no EBP signage or PPE setup at the door, and the electronic medical record lacked a detailed skin assessment despite the presence of at least 13 documented wounds. Facility policy required all skin lesions to be covered with dry dressings and mandated hand hygiene, but staff confirmed that EBP had not been implemented for this resident and that open, bleeding wounds had been present for a couple of months.
Failure to Properly Label and Discard Insulin and Expired Medications
Penalty
Summary
The facility failed to properly label and discard insulin medications for several residents, as well as expired stock medications. Specifically, Resident 53's Lantus flex pen lacked an open date and discard date, while Resident 15's Lantus flex pen and Resident 346's Levemir flex pen were outdated but not discarded. Additionally, Resident 1's Lantus vial was outdated and not discarded. Expired stock medications, such as a bottle of Tussin DM, were also found in the medication cart. These deficiencies were confirmed through observations and interviews with the facility's administrative nurse, who verified that the nurses were responsible for dating insulin when opened and discarding outdated insulin and expired stock medications. The facility's policies on insulin administration and drug storage were not followed, leading to the risk of residents receiving ineffective medications.
Failure to Maintain Resident Dignity During Assisted Dining
Penalty
Summary
The facility failed to treat Resident 115 with dignity during the noon meal in one of the dining rooms. Certified Nurse Aide M was observed standing over Resident 115 while assisting him to eat, leaving the table multiple times to perform other tasks, and then returning to continue feeding the resident. This behavior was contrary to the facility's expectations, as confirmed by the Certified Dietary Manager and Administrative Nurse, who stated that staff should sit next to the resident and engage in conversation while assisting with eating. The facility's Resident Rights Policy emphasized the importance of treating residents with dignity and respect, which was not upheld in this instance.
Failure to Provide Written Notice for Hospital Transfers
Penalty
Summary
The facility failed to provide written notice for facility-initiated transfers to the hospital for three residents, placing them at risk for uninformed care choices. Resident 68, who had a diagnosis of benign prostatic hyperplasia and an indwelling catheter, was transferred to the hospital without written notice being provided to the resident or their representative. Both Administrative Staff B and Administrative Nurse D confirmed the lack of documentation for the written notice. The facility also failed to provide a policy regarding facility-initiated transfers to the hospital upon request. Similarly, Resident 347, who had a diagnosis of lung disorders and required oxygen therapy, was transferred to the hospital without written notice being provided to the resident or their representative. Observations and interviews with Administrative Staff B and Administrative Nurse D confirmed the absence of documentation for the written notice. The facility again failed to provide a policy for facility-initiated transfers to the hospital upon request. Resident 75, who had diagnoses including diabetes mellitus, heart failure, and hypertension, was also transferred to the hospital without written notice being provided to the resident or their representative. Interviews with Licensed Nurse G and Administrative Nurse D confirmed that the facility did not notify the resident's representative in writing regarding the transfer. The facility's Bed Hold policy indicated that written notice should be provided, but this was not followed in these cases.
Failure to Provide Bed Hold Policy to Residents During Hospital Transfers
Penalty
Summary
The facility failed to provide three residents or their representatives with written information regarding the facility's bed hold policy when they were transferred to the hospital. Resident 68, who had a diagnosis of benign prostatic hyperplasia and required substantial assistance with toileting and personal hygiene, was admitted to the hospital. The facility lacked documentation that Resident 68 or his representative was provided with the bed hold policy at the time of transfer. Administrative staff confirmed the absence of this documentation and acknowledged that nursing staff were responsible for sending the bed hold policy with transfer papers but did not follow up on obtaining the signed notice. Resident 347, who had a diagnosis of lung disorders and required various levels of assistance for daily activities, was also admitted to the hospital. Similar to Resident 68, there was no evidence in Resident 347's clinical record that the bed hold policy was provided to the resident or their representative. Administrative staff verified the lack of documentation and confirmed that the bed hold policy was supposed to be sent with transfer papers but was not followed up on. Resident 75, who had multiple diagnoses including diabetes mellitus and heart failure, was admitted to the hospital. The clinical record for Resident 75 also lacked evidence that the bed hold policy was provided to the resident or their representative. Staff interviews revealed that while the bed hold policy was sent with the resident, there was no written notice provided to the resident's representative. The facility's bed hold policy stated that residents should be informed and given a written copy of the policy upon admission and if transferred to a hospital or during therapeutic leave, but this was not adhered to in these cases.
Failure to Complete PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure that three residents, identified as R87, R68, and R110, received a Preadmission Screening and Resident Review (PASRR) to identify potential care needs related to mental disorders or intellectual disabilities. This deficiency was identified through observation, interview, and record review. R87, who had diagnoses including bipolar disorder, did not have a PASRR completed before admission from the Veteran's Administration (VA). Similarly, R68, who required substantial assistance with activities of daily living and had diagnoses including congestive heart failure, also lacked a PASRR assessment. Both residents' clinical records lacked evidence of the required screening, and the facility did not provide a policy on PASRR completion upon request. Administrative staff confirmed that the VA did not perform PASRR assessments for these residents before admission. R110, who had diagnoses of posttraumatic stress disorder and anxiety disorder, also did not have a PASRR assessment completed as required. The resident's care plan indicated a history of behavioral symptoms and manipulative behavior. Despite this, the facility was unable to provide a PASRR screening for R110 upon request. Administrative staff verified that the VA did not assess for PASRR upon admission. The lack of PASRR assessments for these residents placed them at risk for unidentified needs and inadequate care.
Failure to Address PTSD in Resident Care Plan
Penalty
Summary
The facility failed to revise the care plan for a resident (R50) with PTSD, which placed the resident at risk for impaired care due to uncommunicated care needs. R50's electronic medical record documented multiple diagnoses, including dementia, anxiety, cerebral infarction, aphasia, PTSD, major depressive disorder, and Wernicke's encephalopathy. Despite these diagnoses, the care plan did not address trauma triggers or coping strategies for R50. The resident's quarterly MDS indicated moderate cognitive impairment and episodes of care refusal. The Behavioral Symptoms CAA noted multiple episodes of care refusal, and the care plan directed staff to inform R50 before initiating care and to encourage discussions about her past. However, the care plan did not include specific interventions for PTSD. Observations and interviews revealed that the facility's social services and nursing staff had not assessed or gathered information related to R50's trauma triggers. Social Service X admitted to not assessing R50's trauma triggers or speaking to the family about them. Administrative Nurse D confirmed that PTSD assessments were only conducted when symptoms like depression, flashbacks, or anxiety were observed. The facility's policy on Trauma Informed Care and Behavioral Health Management emphasized early identification of past traumatic events and the development of interventions to manage behaviors, but this was not followed for R50. Consequently, the facility failed to identify and implement necessary interventions for R50's PTSD, leading to uncommunicated care needs.
Failure to Provide Appropriate Restorative Services
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and services to maintain and prevent a decline in mobility and ambulation. The resident, who had diagnoses of diabetes mellitus, osteoarthritis, and chronic obstructive pulmonary disease, required partial to moderate assistance with activities of daily living and supervision to walk 50 to 150 feet. Despite having a restorative therapy plan that directed the resident to walk two to three times a week, the facility did not document any ambulation activities from the time the plan was developed until the resident refused to walk on one occasion. This lack of documentation and follow-through placed the resident at risk for a decline in mobility and impaired independence. Observations and interviews revealed that the resident was often found sitting in a recliner with feet elevated and did not receive the restorative services as directed. The facility's policy required that each resident be assisted to attain and maintain their highest functional level of independence, with restorative services documented in the electronic medical record. However, the facility did not adhere to this policy, as the resident did not receive the necessary restorative services, and the documentation was incomplete. This failure was verified by both the physical therapist and the administrative nurse, confirming that the resident had not received the directed restorative services since the plan was developed.
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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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