Galena Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Galena, Kansas.
- Location
- 1220 E 8th Street, Galena, Kansas 66739
- CMS Provider Number
- 175233
- Inspections on file
- 17
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Galena Nursing & Rehab Center during CMS and state inspections, most recent first.
A cognitively impaired, hemiplegic resident who depended on staff for ADLs developed significant bruising on the right leg and later vaginal bleeding and genital injuries while her son, acting as her representative, remained almost constantly in the room with the door closed and frequently participated in intimate care. Night-shift staff reported bruising and later bright red vaginal bleeding to an RN, who attributed the findings to the wheelchair, therapy, or scratching/yeast infection, instructed CNAs to apply antifungal cream without assessing the genital area, and did not notify administration or the provider. The next day, CNAs again observed dried blood and genital wounds, and an RN initially documented no skin issues before a later two-nurse assessment revealed extensive bruising to the hip, thighs, abdomen, and labia, with lacerations and shearing injuries, while the resident showed anxiety and made distressing statements. Staff had previously reported feeling uncomfortable with the son’s constant presence and controlling behavior during peri care, but these concerns were not acted upon, and the delay in recognizing and reporting injuries of unknown origin and in restricting the son’s access led surveyors to find that the resident was not protected from abuse and was placed in immediate jeopardy.
A resident with a DPOA frequently present during care developed significant bruising on the right leg and later bright red vaginal bleeding and labial injuries, which were repeatedly observed and reported by CNAs to RNs/LPNs over the course of a shift. Nursing staff accepted the DPOA’s explanations, attributed findings to therapy, wheelchair use, itching, or yeast infection, did not promptly assess or document all injuries, and failed to recognize them as potential physical and sexual abuse or injuries of unknown origin requiring immediate reporting. Despite additional observations of dried blood, vaginal lacerations, extensive bruising resembling a handprint, abdominal bruising, petechiae, and the resident’s anxious statements, administrative staff, LE, and the SA were not notified within required timeframes, and the resident remained alone in the room with the alleged perpetrator for many hours before suspected abuse was finally reported.
A cognitively impaired, functionally dependent resident with hemiplegia developed significant bruising on the right leg and later vaginal bleeding and genital bruising while a family representative (treated as DPOA) remained almost constantly in the room with the door closed. CNAs repeatedly reported bruising and vaginal bleeding to RNs/LNs, but the initial nurse accepted the representative’s explanation, did not thoroughly assess or document the injuries, and ordered antifungal treatment for presumed yeast infection without investigation. Oncoming nurses delayed assessment despite reports of bleeding, and when assessments were finally completed, staff found extensive bruising to the hip, thighs, lower abdomen, and labia, with lacerations and active vaginal bleeding, while staff statements described the representative as nervous, intrusive during intimate care, and always present. The resident made concerning statements implying harm by a male, yet no immediate protective measures were implemented, and the resident was left alone with the representative for many hours before the situation was reported as potential abuse.
Surveyors found that staff failed to provide necessary ADL care for several residents, including not shaving a resident with Alzheimer's, leaving a resident with dementia in soiled clothing, missing showers and personal hygiene for a resident with cognitive decline, and not assisting a resident with feeding despite documented need. Staff interviews and observations confirmed that these lapses were not due to resident refusal but rather inconsistent care and staffing issues.
A resident with end-stage renal disease who required dialysis did not have dialysis care needs addressed in the admission baseline care plan. The care plan and electronic medical record lacked documentation and orders for dialysis care, and staff did not perform required pre- or post-dialysis assessments or communicate with the dialysis center. Staff interviews revealed a lack of awareness and education regarding dialysis care requirements, resulting in the omission of essential care instructions.
A resident with chorea and Alzheimer's disease, who was sometimes dependent on staff for wheelchair mobility, did not have staff instructions in the care plan regarding the use of foot pedals during assisted wheelchair propulsion. Staff were observed propelling the resident without foot pedals, despite facility policy requiring comprehensive care plans with measurable objectives.
A resident with CHF experienced multiple significant weight gains that met the criteria for provider notification according to the care plan, but staff did not notify the provider as required. Nursing staff were aware of the notification protocol, and the resident was observed with edema and wearing compression socks. No supporting policy was provided.
A resident with chorea and Alzheimer's disease, who was generally independent but sometimes required staff assistance, was transported in a wheelchair without foot pedals in place. Staff propelled the resident while his feet were tucked under the seat and one foot was skimming the floor, contrary to facility expectations for safe transport. The facility lacked a policy on safe wheelchair transport.
The facility failed to maintain acceptable nutritional status for a resident by not providing required meal assistance, double portions, and nutritional shakes as outlined in the care plan, resulting in significant weight loss. Additionally, another resident with end-stage renal disease on dialysis did not have proper dietary assessment, care planning, or monitoring related to dialysis, and required weights and dietary orders were not consistently followed.
A resident with end-stage renal disease did not receive necessary dialysis assessments, care, or services. The care plan and medical record lacked documentation and orders for dialysis, and staff failed to perform required pre- and post-dialysis assessments, including vital signs, weights, and fistula checks. Staff interviews confirmed these omissions, and the facility did not coordinate with the dialysis center as required.
A resident with hypotension did not receive midodrine as ordered when their systolic blood pressure was below the specified threshold, and staff failed to notify the physician as required. Staff were also unaware of the medication order and proper monitoring procedures, and the resident was observed being assisted to lie down, contrary to care plan instructions.
Staff did not implement Enhanced Barrier Precautions (EBP), such as gowns and gloves, for several residents with Foley catheters, tube feedings, wounds, or ostomies. Observations showed a lack of EBP signage and PPE outside rooms, and interviews confirmed that staff were not using required protective equipment during care, despite facility policy mandating these precautions.
A resident with severe cognitive impairment and limited mobility was found to have a persistent six-inch gap between the mattress and head of the bed, due to the mattress being shorter than the bed frame. Facility staff confirmed the issue had existed for some time, and maintenance had not inspected the bed because it was provided by hospice. The facility did not ensure the bed and mattress were properly fitted or regularly inspected, as required by policy.
Failure to Protect Cognitively Impaired Resident From Suspected Sexual and Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from abuse and to respond appropriately to injuries of unknown origin, including bruising and vaginal bleeding. The resident had hemiplegia and severe cognitive impairment, required extensive assistance with ADLs, and depended on staff for care. Her care plan noted participation in activities but did not address the involvement of her son, identified as her representative and alleged perpetrator (AP), in her care, and listed another son as DPOA. Prior skin and weekly assessments documented no bruising or vaginal bleeding up to mid-March, and the last weekly skin assessment before the incident showed no bruises or open lesions. On the night in question, a CNA observed significant bruising on the resident’s right leg around late evening and reported it to the charge nurse (LN G). LN G assessed the bruising, determined it was probably from the wheelchair or therapy, and did not report it as an injury of unknown origin to administration. Later that night, around early morning, the same CNA observed bright red blood in the resident’s brief and vaginal area, along with what he thought might be clotted blood or a sore, and again reported this to LN G. LN G, relying on the AP’s report that the resident had been scratching and might have a yeast infection, instructed the CNA to apply antifungal powder or cream without personally assessing the vaginal area and without reporting the bleeding and possible injury to administration or the provider. During this time, the AP remained in the room with the resident, often with the door closed, and staff had previously reported feeling awkward and uncomfortable performing peri care while he was present. On the following day, a day-shift CNA providing peri care observed dried blood on the resident’s labia and vaginal area and notified another nurse (LN I), who noted dried blood and bruising on the right hip and leg and reported this to the charge nurse (LN H). Despite this, an earlier skilled evaluation by LN H that same day inaccurately documented no skin issues. Later that afternoon, a two-nurse assessment by LN H and LN I revealed a large bruise on the right hip and leg resembling the shape of a hand, extensive maroon/purple bruising and petechiae around and into the vagina, small lacerations and shearing injuries to the labia, and bruising on the lower abdomen and thighs. The resident displayed increased anxiety and repeatedly said “Oh God” during the assessment and was unable to explain how the injuries occurred. Multiple staff statements documented that the AP stayed in the room almost continuously with the door closed, remained present during intimate cares, acted nervous and fidgety, sometimes took over incontinent care, and left the building frantically after the injuries were discovered. The facility’s failure to recognize and report the initial bruising and vaginal bleeding as potential abuse, to promptly assess the resident, and to remove or restrict the AP allowed him to remain alone with the resident for many hours while her injuries progressed, resulting in a finding of immediate jeopardy. Additional documentation from the hospital and law enforcement supported concerns of sexual assault. The hospital record noted bleeding in the vaginal area with signs of injury, scattered bruises on the extremities, hips, and thighs, and documented that staff had concern for possible sexual assault. Hospital staff also recorded that the resident became agitated and yelled statements such as “Noooo why would a man do that” when her genitalia were cleaned, and that access to her hospital records was blocked from the patient portal due to reasonable belief that sharing them could result in harm to her life or physical safety. Witness statements from CNAs described the resident asking, “why she let that man do that” and saying “Son, why would you do this to me?” during care, though it was not documented that these statements were reported at the time. Law enforcement officers and the SANE examiner later described the resident’s wounds as among the worst they had seen and indicated that a warrant was required for the SANE exam because the AP, listed as legal representative, had left and could not be contacted. Throughout the period leading up to the discovery of the full extent of the injuries, staff had observed the AP’s constant presence, closed-door behavior, and controlling involvement in care, and some staff had reported discomfort and concerns to charge nurses, but these concerns were not acted upon prior to the incident. The facility’s abuse, neglect, and exploitation policy required prevention of all types of abuse and ensuring resident safety regarding visitors and representatives, but staff did not implement protective measures in response to the AP’s behavior or the resident’s injuries and statements. The failure to promptly recognize, assess, and report bruising and vaginal bleeding of unknown origin, combined with allowing the AP to remain alone with the resident with the door closed and to participate in intimate care despite staff discomfort and the resident’s cognitive impairment, led to the determination that the resident was not kept free from abuse and experienced preventable and intentional physical and sexual abuse and psychosocial trauma. The delay of approximately 16 hours from the initial report of bruising of unknown origin to notification of administrative staff, and the inaccurate documentation of no skin issues by LN H earlier on the day the injuries were identified, were key factors in the deficiency finding.
Removal Plan
- Re-education for abuse, neglect and exploitation (ANE) for all facility staff.
- Implemented a protection plan for Resident 1 (R1) requiring all cares be performed with two staff.
- Implemented a protection plan for R1 requiring the room door to remain open unless private cares were being provided.
- Implemented a protection plan for R1 requiring that if the alleged perpetrator (AP) entered the facility, law enforcement (LE) would be notified immediately.
- Implemented a protection plan for R1 requiring a staff member to go to R1's room and remain with her until law enforcement arrived if the alleged perpetrator entered the facility.
- Implemented a sign-in sheet for all visitors to the facility.
- Implemented a specific visitor log for R1.
Failure to Recognize and Timely Report Suspected Physical and Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to recognize and immediately report signs of possible physical and sexual abuse, including injuries of unknown origin and vaginal bleeding, for one resident. On the night of 03/21, two CNAs observed significant bruising on the resident’s right leg while providing care with the resident’s durable power of attorney (DPOA) and primary caregiver present. They reported the bruising to the charge nurse, who assessed the bruises as small, linear, and appearing old, accepted the DPOA’s explanation that they were from therapy or wheelchair positioning, and did not initiate an investigation, document the findings, or report the injury to administrative staff or external authorities. Later that night, at approximately 04:20 AM, the same CNA observed bright red vaginal bleeding and a possible lesion or clotted blood on the labia, reported this to the same nurse, and was instructed to clean the resident and apply antifungal cream for a presumed yeast infection without the nurse assessing the area or documenting the change in condition. At 06:00 AM, the night nurse verbally passed on that there had been vaginal bleeding, suspected to be from itching or a yeast infection, to the oncoming nurses and recommended contacting the provider, but no one identified these findings as potential abuse or an injury of unknown origin requiring immediate reporting. Around 08:00 AM, another CNA providing peri care with the DPOA present noted dried blood and small cuts or lacerations around the vaginal area and promptly notified a nurse, who confirmed dried blood, bruising on the hip, and a labial laceration but attributed the findings to itching and did not suspect abuse. This nurse reported the findings only to the resident’s charge nurse and did not notify administrative staff, law enforcement, or the state survey agency. During this period, multiple CNAs reported feeling uncomfortable and unsettled by the DPOA’s constant presence during intimate care, his refusal to leave the room, his habit of closing the door, and his jittery and anxious behavior, and at least two CNAs documented that the resident made distressing statements such as asking why they let “that man” do that and “Son, why would you do this to me?”, but these concerns were either not documented as reported or, when reported, were not acted upon. In the early afternoon, around 02:22 PM, two nurses jointly assessed the resident and identified extensive injuries, including a large bruise on the right hip and leg resembling the shape of a hand, dark maroon/purple bruising on the labia and into the vagina, a small laceration at the posterior vaginal opening, a shearing-type injury on the labia, scattered petechiae, bruising on the lower abdomen, and ongoing vaginal bleeding. The resident displayed increased anxiety during this assessment, repeatedly saying “Oh God,” and was unable to state what had happened. Only at this point did the nurses recognize the situation as potential sexual abuse and notify an administrative nurse, who then notified the administrator. Law enforcement was contacted later that afternoon, and the state survey agency was notified by email that evening, nearly 20 hours after the initial identification of an injury of unknown origin and several hours after administrative staff became aware of suspected abuse. Throughout the delay in recognition and reporting, the resident remained in the room with the alleged perpetrator, who had been present during all cares over the previous 23 hours and left the building frantically after the injuries were more fully recognized. The facility’s own abuse policy required immediate reporting, but not later than two hours after an allegation involving abuse or resulting in serious bodily injury, which was not followed in this case.
Failure to Protect Resident From Suspected Sexual Abuse and Investigate Injuries of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to implement protective measures and conduct timely assessment and investigation after injuries of unknown origin and signs of potential sexual abuse were identified for a cognitively impaired resident. The resident had hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, severe cognitive impairment with a BIMS score of three, dependence on staff for nearly all ADLs, and no documented prior skin conditions. Her care plan did not address the alleged perpetrator’s (AP’s) involvement in care and listed another son as DPOA, while the AP was treated as the primary caregiver and remained in the room with the resident almost continuously, often with the door closed. Staff had previously felt awkward and uncomfortable performing care with the AP present and reported that he frequently remained in the room, watched cares closely, and sometimes took over intimate care, but these concerns were not acted upon. On the evening and night shift, CNAs observed significant bruising on the resident’s right leg and later vaginal bleeding, and reported these findings to the nurse. Around 10:30–11:00 PM, CNA staff reported significant bruising down the resident’s right leg to the nurse, who briefly assessed the bruises in the presence of the AP, accepted the AP’s explanation that the bruising might be from therapy or wheelchair positioning, and did not document the bruising in the EMR at that time. The resident was left alone in the room with the AP. Around 4:20 AM, CNA staff reported bright red blood in the resident’s brief and around the vaginal area to the same nurse, who did not assess the resident but instructed the CNA to apply antifungal cream or powder for a suspected yeast infection, again without further investigation or protective measures. The resident remained alone in the room with the AP with the door closed after care was completed. On the following day shift, multiple staff continued to identify concerning findings without immediate protective action. At approximately 6:00 AM, the night nurse told two oncoming nurses that the resident had vaginal bleeding suspected to be from itching or yeast infection, but no assessment was done at that time. Around 8:00 AM, a CNA providing peri care with the AP present observed dried blood all over the vaginal area and reported it to a nurse, who assessed the resident at about 8:30 AM, noted dried blood, bruising on the labia and vaginal opening, and bruising on the hip, but attributed the injuries to itching and did not suspect abuse; the resident was again left in the room with the AP. Later that afternoon, a two-nurse assessment revealed extensive bruising on the right hip and leg, bruising and lacerations to the labia and vaginal area, bruising on the lower abdomen, and active vaginal bleeding, with the bruising on the hip described as resembling the shape of a hand. During this assessment the AP left the room, which staff noted was unusual. Witness statements documented that throughout this period the AP remained in the room during cares, the door was mostly closed, staff felt unsettled and had previously reported discomfort with the AP’s presence, and the resident made statements such as “why I let that man do that?” and “Son, why would you do this to me?” during or after care. Despite these observations and escalating physical findings, the resident remained alone in the room with the AP for approximately 16 hours after the initial report of bruising and subsequent vaginal bleeding before the situation was reported to administrative staff as potential abuse. The EMR lacked timely documentation of the initial bruising and early vaginal bleeding, and a late entry note regarding the bruising was not entered until several days later, after surveyor interviews had begun. The facility’s abuse, neglect, and exploitation policy stated that the facility would ensure the health and safety of each resident regarding visitors such as family members or resident representatives, but staff did not remove or restrict the AP, did not initiate immediate protective measures when injuries of unknown origin and signs of possible sexual abuse were first identified, and did not promptly report or investigate the concerns. The deficiency was cited at a level of past noncompliance with actual harm, based on the existence of physical sexual abuse injuries that progressed while the resident was left alone with the AP and the likelihood of severe psychosocial trauma related to sexual abuse.
Failure to Provide Necessary ADL Care and Assistance
Penalty
Summary
Surveyors identified multiple failures by facility staff to provide necessary assistance with activities of daily living (ADLs) for several residents. One resident with Alzheimer's disease and chorea, who required substantial to maximum assistance for bathing and hygiene, was observed unshaven at breakfast. Staff interviews revealed that shaving was typically performed on shower days, but due to staffing shortages and the bath aide being reassigned to other duties, residents were not consistently receiving showers or being shaven as scheduled. Documentation showed missed or infrequent bathing opportunities, and staff confirmed the resident had not refused care. Another resident with severe cognitive impairment and dependent on staff for dressing was repeatedly observed in soiled clothing throughout the day, including at meals and while resting in bed. Despite multiple staff members interacting with the resident, her soiled clothing was not changed. Staff interviews confirmed the resident was fully dependent for dressing and that her clothing should have been changed if dirty, but this was not done. A third resident with a history of cerebral infarction and cognitive decline required substantial assistance with bathing and personal hygiene. This resident was observed unshaven with greasy, dirty hair, and records indicated missed or unattempted showers. Staff confirmed the resident had not refused care and that personal hygiene was not consistently provided. Additionally, another resident with moderate cognitive impairment and a history of stroke, who required substantial to maximum assistance with eating, was observed at meals without receiving needed feeding assistance until staff intervened later. Staff acknowledged the resident's increased need for help with eating, but assistance was not provided in a timely manner.
Failure to Address Dialysis Care Needs on Admission Baseline Care Plan
Penalty
Summary
The facility failed to address the immediate care needs of a resident with end-stage renal disease who was dependent on dialysis. Upon admission, the resident's baseline care plan did not include any documentation or instructions regarding dialysis care and services, despite the resident's medical record indicating a diagnosis of end-stage renal disease and a regular dialysis schedule. The electronic medical record also lacked orders related to dialysis care, and staff interviews confirmed that no pre- or post-dialysis assessments, vital signs, weights, or site assessments were performed by facility nurses. The resident reported that staff did not obtain vital signs, pre-dialysis weight, or assess the dialysis site prior to his departure for dialysis treatments. Further interviews with facility staff revealed a lack of awareness and education regarding the resident's dialysis care requirements. A certified nurse aide was only aware of a fluid restriction and not of other dialysis-related needs. A licensed nurse acknowledged that the facility missed necessary orders and assessments for dialysis care upon admission, and the administrative nurse confirmed that the baseline care plan should have included dialysis instructions. The facility's policy required baseline care plans to include instructions needed for effective and person-centered care, but this was not followed for the resident in question.
Failure to Include Foot Pedal Use in Resident's Care Plan
Penalty
Summary
The facility failed to complete a comprehensive care plan for one resident, specifically omitting staff instructions regarding the use of foot pedals when propelling the resident in his wheelchair. The resident had diagnoses of chorea and Alzheimer's disease, with a BIMS score indicating moderately impaired cognition. Documentation showed the resident was generally independent with his wheelchair and walker, but at times required staff assistance for mobility. The care plan noted the resident's jerking movements and independence with a walker but did not address the use of foot pedals during staff-assisted wheelchair propulsion. Observations revealed that staff propelled the resident in his wheelchair without foot pedals, with the resident's feet crossed and tucked under the seat, and the toe of his left foot skimming the floor. Staff interviews confirmed that while the resident usually propelled himself, he sometimes needed staff assistance, at which point foot pedals were expected to be used. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timeframes, but the care plan lacked specific instructions for staff regarding foot pedal use during assisted wheelchair mobility.
Failure to Notify Provider of Significant Weight Gains in Resident with CHF
Penalty
Summary
A deficiency occurred when the facility failed to monitor and report significant weight fluctuations for a resident with a diagnosis of congestive heart failure (CHF). The resident's care plan required daily weights and provider notification for weight gains of three pounds overnight or five pounds in three days, as well as for increased shortness of breath or swelling. Despite this, the electronic medical record showed multiple instances where the resident experienced weight gains meeting or exceeding these thresholds, but there was no documentation that the provider was notified as required by the care plan. Observations confirmed the resident had edema in both legs and was wearing compression socks. Interviews with nursing staff revealed awareness of the notification requirement, and administrative staff stated the expectation that orders be followed. However, no policy was provided to support the process, and the required notifications to the provider were not made on several occasions when the resident's weight increased significantly.
Failure to Use Wheelchair Foot Pedals During Staff-Assisted Transport
Penalty
Summary
Staff failed to ensure a safe environment free from accident hazards for a resident diagnosed with chorea and Alzheimer's disease. The resident, who had moderately impaired cognition and was generally independent with mobility, was observed being propelled in a wheelchair by staff without foot pedals in place. During this incident, the resident's feet were crossed and tucked under the seat, with one foot skimming the floor, increasing the risk of injury. The staff member stated that foot pedals were not used because the resident usually propelled himself, but at times, staff assistance was required for mobility. Further interviews confirmed that staff were expected to use foot pedals when propelling the resident in the wheelchair. The facility did not provide a policy regarding the safe transport of residents in wheelchairs. The lack of foot pedals during staff-assisted wheelchair propulsion constituted a failure to maintain a safe environment and prevent avoidable accidents for the resident.
Failure to Maintain Nutritional Status and Properly Assess Dialysis-Related Needs
Penalty
Summary
The facility failed to provide adequate care and services to maintain acceptable nutritional status for two residents. For one resident with a history of stroke, diabetes, and cognitive impairment, the care plan required substantial to maximal assistance with eating, a soft diet with double portions, and nutritional shakes. Despite these interventions, the resident experienced significant weight loss over a two-month period. Observations revealed that staff did not consistently provide the required assistance during meals, and the resident was often left unattended with food and nutritional shakes, resulting in incomplete consumption. Additionally, the kitchen was not informed of the double portion requirement, so the resident did not receive the prescribed diet enhancements. Documentation in the electronic medical record for this resident did not reflect the observed weight loss, and there was a lack of communication and follow-through regarding dietary interventions. Staff interviews confirmed that the resident's need for assistance with eating had increased, but this was not consistently addressed during meal times. The facility also lacked a restorative aide, and nurse aides were expected to provide the necessary support, which was not reliably done. For another resident with end-stage renal disease on dialysis, the facility failed to properly assess and document nutritional needs related to dialysis. The baseline care plan did not include any information about dialysis care, dietary restrictions, or fluid management, despite hospital discharge instructions specifying a diabetic, heart-healthy diet. Orders for daily and weekly weights were not consistently followed, and the registered dietitian's assessment did not address the resident's dialysis status. Staff interviews confirmed that essential dialysis-related care and monitoring were missed, and the care plan was incomplete regarding the resident's specialized needs.
Failure to Provide Required Dialysis Assessment and Care
Penalty
Summary
The facility failed to provide necessary dialysis assessment, care, and services for a resident diagnosed with end-stage renal disease who was dependent on dialysis. The resident's baseline care plan did not include documentation of dialysis services or instructions for dialysis care. The electronic medical record lacked orders related to dialysis care, and there was no evidence of completed dialysis communication forms before or after treatments. Progress notes inconsistently documented the resident's dialysis schedule and did not consistently record whether the resident attended dialysis, returned from dialysis, or received assessments related to dialysis. On several occasions, there was no documentation of pre- or post-dialysis assessments, vital signs, weights, or fistula assessments. Interviews with staff revealed that the facility missed entering dialysis orders and did not perform required pre- and post-dialysis assessments. The resident reported that nurses did not obtain vital signs, pre-dialysis weight, or assess the dialysis site before he left for dialysis, and sometimes he left before breakfast. Staff confirmed that the resident's representative transported him to dialysis, which contributed to the missed assessments. The facility's hemodialysis policy required coordination and collaboration with the dialysis center to meet the resident's needs, but this was not followed in practice.
Failure to Monitor and Administer Midodrine per Physician Orders
Penalty
Summary
Staff failed to ensure proper blood pressure monitoring and administration of midodrine for a resident diagnosed with hypotension. The resident's care plan and physician's order required staff to check blood pressure before administering midodrine, only give the medication if the systolic blood pressure (SBP) was less than 100 mm/Hg, and ensure the resident was sitting upright during administration. The care plan also instructed staff not to give the medication while the resident was lying down or within four hours of bedtime. Record review showed that on two occasions, the resident's SBP was below 100 mm/Hg, but midodrine was not administered and the physician was not notified as required. Additionally, staff interviews revealed a lack of awareness of the medication order and the need to notify the provider for out-of-range blood pressures. Observations also indicated that the resident was assisted to lie down after eating, which could conflict with the care plan instructions regarding medication administration.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices and Wounds
Penalty
Summary
Facility staff failed to implement Enhanced Barrier Precautions (EBP), including the use of gowns and gloves, for residents with conditions requiring such measures. Specifically, one resident with a Foley catheter, another receiving tube feedings and wound care, and a third with an ostomy did not have EBP signage or personal protective equipment (PPE) available or in use. Observations revealed that no EBP signage or PPE was present outside any of the residents' rooms, and staff did not use gowns or gloves when providing care to these residents. Interviews with the affected residents confirmed that staff did not use appropriate protective equipment during care activities. Staff interviews indicated a lack of consistent EBP implementation, with some staff acknowledging that EBP should be used for residents with indwelling devices or wounds, but admitting that these precautions had not been followed. The facility's policy required EBP for residents with wounds or indwelling medical devices, and mandated that gowns and gloves be made available near or outside the resident's room. Despite this, staff reported that EBP had not been practiced, and attributed the lapse to staff oversight and recent changes in nursing leadership.
Failure to Inspect and Maintain Safe Bed Equipment
Penalty
Summary
A deficiency was identified when the facility failed to regularly inspect a resident's bed frame and mattress as part of its maintenance program, specifically to identify areas of possible entrapment. The resident involved had a diagnosis of dementia with severe cognitive impairment, as indicated by low BIMS scores, and was dependent on staff for bed mobility. Observations revealed a persistent gap of approximately six inches between the top of the mattress and the head of the bed. Staff interviews confirmed that the mattress had been shorter than the bed frame for an extended period, and maintenance staff had not checked the bed because it was supplied by hospice and not considered a facility bed. The resident's care plan noted that hospice would provide the bed and mattress, but there was no evidence that the facility ensured the equipment was safe or properly fitted. The facility's policy required reasonable accommodations to individualize the resident's environment, including the bedroom, but this was not followed in this case. The lack of inspection and failure to address the mismatch between the mattress and bed frame placed the resident at risk for injury.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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