Great Plains Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Wichita, Kansas.
- Location
- 7101 E 21st Street North, Wichita, Kansas 67206
- CMS Provider Number
- 175168
- Inspections on file
- 26
- Latest survey
- March 19, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Great Plains Post Acute during CMS and state inspections, most recent first.
A LTC facility failed to ensure proper medication administration for two residents. One resident received Trazodone at the wrong time, causing increased exhaustion, while another resident was left with medication in her room without supervision, leading to an accumulation of pills. The facility's policy requires safe and timely administration with verification, which was not followed, resulting in deficiencies in care.
A resident with severe cognitive impairment and constipation required surgery to remove a fecal impaction due to the facility's inadequate system for identifying signs and symptoms of fecal impaction. The facility lacked clear protocols and training for bowel management, leading to inconsistent documentation and failure to administer necessary medications. This placed all residents at risk in immediate jeopardy.
A resident was left with a tourniquet on their arm for five days after a blood draw, leading to discoloration and requiring further medical assessment. The oversight was discovered when a nurse assessed the resident's arm, and it was confirmed that the lab vendor did not collect all ordered labs. The facility's policy on neglect was not upheld, as the resident was not adequately supervised.
A resident at a facility developed stage 3 pressure ulcers due to the facility's failure to implement care plan interventions. Despite being at risk, the resident was often left on their buttocks without repositioning or pressure-relieving devices. The facility did not promptly measure or document the ulcers, and an air mattress was delayed. Staff interviews revealed communication issues and a lack of coordination in the resident's care.
A resident with a history of falls and fractures fell from an unlocked wheelchair, resulting in a pelvic fracture. The facility failed to assess and document the fall, and the incident was not recorded in the nurse's notes. Staff interviews confirmed the fall was reported, but the resident was moved before an assessment was completed, violating the facility's fall management policy.
A resident with severe cognitive impairment experienced a 20.54% weight loss in one month due to the facility's failure to monitor and address the issue. Despite being on an NPO diet and receiving tube feedings, the resident's care plan was not effectively implemented, and a speech therapy evaluation was not documented. Staff interviews revealed inconsistencies in weight monitoring and communication, contributing to the deficiency.
A facility failed to ensure competent nursing care when a LN did not apply a pressure dressing to a resident's bleeding hematoma, leading to the resident being sent to the emergency room. Additionally, the facility did not assess or document a fall for another resident, who was later diagnosed with a pelvic fracture. The lack of appropriate response and documentation contributed to the deficiencies.
The facility did not conduct annual performance reviews for five direct care staff members, including CMAs and CNAs, who had been employed for over a year. This deficiency was confirmed by Administrative Staff A and highlighted the absence of a policy to ensure these evaluations, which are crucial for identifying staff weaknesses and improving performance to provide adequate resident care.
The facility did not provide quarterly statements for the trust accounts of 57 residents. Administrative Staff PP indicated that statements were either hand-delivered or mailed, but no documentation was available to confirm this. Additionally, the facility lacked a policy for managing trust funds, leading to the deficiency.
The facility's call system only activated a light above the door without an audible indicator or centralized console, requiring staff to walk the halls to identify activated call lights. Resident council minutes documented ongoing complaints about delayed responses, with wait times of up to three hours. Staff interviews confirmed the lack of visibility from the nurse station, and no effective policy was produced to address the issue.
The facility failed to provide annual mandatory training on abuse, neglect, and exploitation (ANE) for its nurse aides, as required by its policy. A review of employment files for five CMAs/CNAs employed for over a year showed they lacked the necessary continuing education on ANE. Administrative Staff A confirmed the deficiency, acknowledging the absence of assurance that the mandatory in-services had been provided.
The facility failed to ensure nurse aides received the required 12 hours of continuing education, including training on abuse prevention and dementia management. A review of five CMAs/CNAs employed for over a year showed they lacked this mandatory training. Administrative Staff A confirmed the absence of a system to ensure all staff received necessary in-services, as outlined in the facility's Abuse Prevention Program.
The facility failed to serve food at appropriate temperatures, with multiple residents reporting cold and unappetizing meals. Observations confirmed food items were below required temperatures, and improper thermometer cleaning practices were noted. Despite ongoing grievances and staff awareness, the facility did not adhere to its food preparation policy.
The facility failed to store, prepare, and serve food in a sanitary manner, risking food-borne illnesses. Observations revealed improperly sealed and unlabeled food items, dirty ice maker drains, and a lack of awareness among staff regarding food labeling requirements. These deficiencies violated the facility's food handling policy, potentially affecting resident safety.
The facility failed to document the bathing preferences of three residents and the tube feeding needs of another, despite clear expectations and policies. This oversight involved residents with varying cognitive abilities and care needs, leading to potential negative impacts on their well-being.
The facility failed to provide necessary bathing services to six residents dependent on staff for ADL care due to a lack of hot water. Despite the facility's policy requiring support for residents unable to perform ADLs independently, the residents did not receive regular baths or showers. Staff interviews confirmed the absence of hot water and alternative bathing solutions, leading to inadequate personal hygiene care.
A resident with a history of edema, pain, and anxiety did not receive the ordered Replens vaginal gel for dryness due to repeated delays in delivery. Despite being ordered, the gel was not administered, leading to the resident experiencing vaginal itching and being diagnosed with candidiasis. Staff interviews revealed the gel was not found in the treatment cart, and the pharmacy had not delivered it until later. The facility could not provide a policy on medication order and delivery.
A facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage Form (CMS-10055) to a resident, as confirmed by administrative staff. This form is necessary when terminating services expected to be non-covered by Medicare, as per the facility's policy.
The facility failed to maintain the dignity and privacy of two residents by not addressing their grooming needs and privacy during care. One resident was observed with unwanted facial hair and reported staff entering without knocking, while another had long facial hair and fingernails, expressing shame and lack of assistance. Additionally, staff did not close blinds during care, exposing a resident to public view. Interviews confirmed these practices, and grievances were filed regarding nail care.
A facility failed to honor a resident's bathing preferences, offering her preferred shower only once in 25 days due to hot water issues. The resident, who had intact cognition and was partially dependent on staff, reported feeling unclean with the alternative methods provided. Despite reporting grievances, there was no follow-up or resolution, and the care plan lacked documentation of her preferences.
A resident receiving tube feedings for dysphagia and malnutrition did not have tube placement or gastric residuals checked prior to a bolus feeding, and staff failed to maintain the head of bed at the required elevation for 60 minutes after feeding. These actions were not consistent with facility policy and could negatively impact the resident's physical well-being.
A resident with end stage renal disease requiring regular dialysis did not have consistent pre- and post-dialysis assessments or communication forms completed as required by physician orders and facility policy. Staff interviews and record review confirmed that documentation was missing for numerous dialysis sessions, and the resident reported that vital signs, weights, and access site checks were not always performed before and after dialysis.
A resident in an LTC facility experienced misappropriation of medications when two Percocet tablets were unaccounted for. The discrepancy was discovered during a shift change by a CMA and an LN, who attempted to correct the count but remained short. Despite an investigation, the facility could not substantiate theft or identify the responsible party, highlighting a lapse in medication accountability and resident protection policies.
A resident at risk for falls due to severe cognitive impairment and physical limitations did not receive the necessary fall prevention interventions as outlined in their care plan. Observations revealed that the resident's bed was not in the lowest position, the call light was out of reach, and no fall mats were present, contrary to the facility's Fall Prevention Program. An incident occurred where the resident fell during a bed bath, underscoring the failure to implement these safety measures.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure the proper administration of medication for two residents, leading to deficiencies in professional standards of care. For one resident, the Certified Medication Aide administered Trazodone, a medication with a black box warning, at the incorrect time. The resident was supposed to receive the medication at bedtime, but it was given at noon, causing increased exhaustion. The error was discovered when the resident reported feeling tired, prompting a review of the medication administration process. The facility's policy requires medications to be administered safely and timely, with verification of the right resident, medication, dosage, time, and method, which was not adhered to in this case. Another resident experienced a failure in medication administration when staff left medication in the resident's room without observing its consumption. This resident, who had severely impaired cognition, was found with 15 medication cups containing gabapentin and tramadol, and an additional 19 tramadol pills in a drawer. The facility's policy mandates that staff ensure residents take their medication while being observed, which was not followed, leading to the accumulation of medication in the resident's room. Interviews with staff revealed that the facility expected medications to be administered correctly and residents to be observed taking their medications. However, these expectations were not met, resulting in medication errors and potential risks to the residents' health. The facility's failure to adhere to its medication administration policy contributed to these deficiencies, as staff did not verify medication administration or ensure residents consumed their medications as required.
Inadequate Bowel Management Leads to Resident Surgery
Penalty
Summary
The facility failed to have an adequate system in place to identify the known signs and symptoms of fecal impaction for a resident, who required surgery to remove a large stool ball from his upper rectum under anesthesia. The resident, identified as R77, had a diagnosis of constipation and severely impaired cognition, requiring total assistance with all activities of daily living. Despite being always incontinent of bowel, the facility's records lacked any orders for monitoring or medications for the resident's bowels. The facility's documentation revealed inconsistencies in recording the resident's bowel movements, with some shifts missing documentation entirely. The resident had several documented bowel movements that were charted as normal and formed, but there were days with no bowel movements documented. On one occasion, the resident became lethargic and exhibited signs of distress, including a fever and increased pulse, leading to his transfer to the hospital. A CT scan at the hospital revealed a massive stool burden, and the resident required surgery to remove the fecal impaction. Interviews with facility staff highlighted a lack of clear protocols and training regarding bowel management. Staff members reported confusion over what constituted a normal bowel movement and admitted to incorrectly charting small bowel movements. The facility lacked a policy for monitoring and documentation of bowel movements, relying instead on standing orders for as-needed bowel medications. This deficiency placed all residents at risk in immediate jeopardy, as the facility failed to recognize and address the signs and symptoms of fecal impaction in a timely manner.
Removal Plan
- Identify residents who have suffered or are likely to suffer a serious adverse outcome as a result of the alleged noncompliance.
- Clinical managers will interview interviewable residents for last BM, signs and symptoms of constipation, and fecal impaction.
- CNAs will document BMs before the end of their shifts.
- Nurses will assess non-interviewable residents for signs and symptoms of constipation or fecal impaction.
- If any residents are identified with constipation and fecal impaction, MD will be notified, and orders will be followed as needed.
- DON/designee will educate clinical staff on proper BM documentation, urinary output, signs and symptoms of constipation and fecal impaction.
- DON/designee will educate CNAs to document BMs on POC before they leave their shift.
- DON/designee will educate nurses to review POC documentation before end of the shift that CNA has completed BM documentation.
- DON/designee will educate nurses to review alerts on PCC before the end of the shift.
- DON/designee will educate Nurses to assess residents with no BMs, signs and symptoms of impaction, or abdominal pain; notify MD; and follow physician's orders.
- DON/designee will educate clinical staff.
- Unit manager will review POC documentation on clinical meeting to ensure compliance with BM documentation, urinary output and necessary follow up.
- DON will perform random audit on POC documentation, progress notes, MD notification, and medication administration for residents identified with no BM or signs and symptoms of constipation or fecal impaction.
- If additional discrepancies are identified, they will be corrected immediately according to physician's orders.
Failure to Remove Tourniquet Leads to Resident Neglect
Penalty
Summary
The facility failed to provide adequate supervision for a resident, identified as R157, when a tourniquet was left on his arm following a blood draw. The tourniquet was applied on a Friday and was not discovered until the following Monday, remaining on the resident's arm for a total of five days. This oversight was identified during a review of the resident's Electronic Health Record (EHR), which documented a history of transient ischemic attack, sepsis, and lactic acidosis. The EHR also noted an order for lab tests related to hyponatremia, hyperkalemia, and transaminitis. The delay in discovering the tourniquet resulted in a deep blue ring and reddish discoloration on the resident's arm, prompting further medical assessment and intervention. Interviews with facility staff revealed that the lab vendor failed to collect all the ordered labs and left the tourniquet on the resident's arm. Licensed Nurse J assessed the resident's condition and notified the provider, who ordered a doppler study to evaluate the resident's arm. Administrative Staff A confirmed the expectation that the tourniquet should have been discovered much sooner. The facility's policy on abuse, neglect, and exploitation emphasizes the residents' right to be free from neglect, which was not upheld in this instance, as the resident was not provided with the necessary supervision to prevent this oversight.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to implement care plan interventions to prevent the development of facility-acquired, stage 3 pressure ulcers for a resident identified as R14. R14 was readmitted to the facility with diagnoses including metabolic encephalopathy and dementia, and was at risk for pressure ulcers. Despite this, the facility did not apply necessary interventions such as frequent repositioning, use of pressure-relieving devices, and regular skin assessments. Observations revealed that R14 was often left positioned on his buttocks without repositioning or the use of positioning devices, contributing to the development of pressure ulcers. The facility's records indicated that R14 had no pressure ulcers upon readmission, but later developed open areas on the buttocks that were not promptly measured or documented. The care plan included instructions for skin care and the use of pressure-relieving devices, but these were not consistently followed. The facility also failed to ensure that an air mattress was provided in a timely manner, which was only applied after the pressure ulcers had developed. Interviews with staff revealed a lack of communication and coordination in the care of R14. The wound nurse was unable to contact the resident's guardian for consent, delaying wound assessments. Additionally, there was confusion regarding the use of a camera for wound documentation. The facility's failure to implement and monitor appropriate interventions led to the preventable development of stage 3 pressure ulcers on R14's buttocks.
Failure to Assess and Document Resident Fall
Penalty
Summary
The facility failed to ensure proper assessment and documentation following a fall incident involving a resident, identified as R409. The resident, who had a history of falls and fractures, was admitted with a diagnosis of unspecified fracture of the left femur and required substantial assistance with daily activities. Despite being on fall precautions, the resident fell from an unlocked wheelchair, resulting in a right-side fracture of the pelvis. The incident was not documented in the nurse's notes, and there was no record of a fall assessment or adherence to the facility's fall protocol. Interviews with staff revealed that the fall was reported to the charge nurse, but the resident was moved before an assessment was completed. The facility's policy on fall management, which requires identification of interventions to prevent falls and minimize complications, was not followed. The lack of documentation and assessment after the fall was confirmed by the facility's investigation, which noted the absence of a fall assessment and documentation in the resident's records until after the resident was transferred to a hospital.
Failure to Monitor and Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to adequately monitor and address the significant weight loss of a cognitively impaired resident, identified as R14, who experienced a 20.54% weight loss in one month. R14 had a history of anorexia, metabolic encephalopathy, and dementia, and required total staff assistance with activities of daily living. Despite these needs, the facility did not develop or implement effective care plan interventions to address the resident's weight loss, which was documented as severe. The resident's care plan included instructions for staff to monitor weights, observe for chewing or swallowing problems, and provide a diet per physician orders. However, the facility did not ensure these interventions were followed. The resident was placed on an NPO diet and received tube feedings, but there was a lack of documentation and follow-up on the speech therapy evaluation, which was crucial for assessing the resident's ability to safely consume food orally. Additionally, the facility's policy required weights to be monitored and documented, but there were inconsistencies in the recording and communication of the resident's weight changes. Interviews with staff revealed that the speech evaluation was completed but not documented in the electronic health record, and the resident's weight loss was not addressed in a timely manner. The facility's failure to adhere to its policies and procedures for weight monitoring and care planning contributed to the resident's significant weight loss, which was not adequately addressed by the interdisciplinary team. This deficiency had the potential to negatively impact the resident's physical well-being.
Failure to Ensure Competent Nursing Care and Fall Assessment
Penalty
Summary
The facility failed to ensure competent nursing staff when a Licensed Nurse (LN) did not apply a pressure dressing to a resident's ruptured and heavily bleeding hematoma on the right lower leg. The resident, who had a history of hemiplegia and hemiparesis following a stroke, was observed with acute swelling and pain in the leg, which was initially treated with a pressure dressing. However, when the bleeding became extreme, the LN failed to apply pressure or a pressure dressing, instead obtaining an order to send the resident to the emergency room. The facility subsequently removed the LN from the schedule and terminated her employment. Another deficiency involved the facility's failure to assess and document a fall for a resident who had a history of fractures and was at risk for falls. The resident, who required substantial assistance with activities of daily living and used a wheelchair, was sent to the hospital for changes in mental status and pain, where a pelvic fracture was diagnosed. The facility's investigation revealed that the resident had fallen while attempting to stand from an unlocked wheelchair, but the incident was not documented, and the facility's fall protocol was not followed. Interviews with staff indicated a lack of appropriate response to the resident's fall, with the charge nurse failing to assess the resident or document the incident. The facility's policy on fall management required staff to identify interventions to prevent falls and minimize complications, but this was not adhered to in the case of the resident's fall. The facility's failure to assess and document the fall and the resident's status afterward contributed to the deficiency.
Failure to Conduct Annual Performance Reviews for Direct Care Staff
Penalty
Summary
The facility failed to conduct annual performance reviews for five direct care staff members, including certified medication aides and certified nurse aides, who had been employed for one year or more. This deficiency was identified through observation, interviews, and record reviews, which revealed that none of the five staff members had received the required annual performance evaluations. These evaluations are essential to identify weaknesses and develop action plans to improve staff performance, ensuring that residents receive adequate care. Administrative Staff A confirmed the absence of these evaluations and acknowledged that the facility lacked a policy to address the completion of required performance reviews.
Failure to Provide Quarterly Trust Account Statements
Penalty
Summary
The facility failed to provide quarterly statements for the personal trust accounts of 57 residents. The facility had a total census of 102 residents, with 57 having active trust accounts managed by the facility. Upon review, no quarterly statements were available for these accounts. During an interview, Administrative Staff PP stated that the facility printed and hand-delivered statements to residents with high cognitive functioning or mailed them to representatives of residents with low cognitive functioning. However, the facility could not provide documentation to confirm that these statements were distributed. Additionally, the facility did not have a policy related to the management of trust funds, contributing to the deficiency in providing quarterly statements for the residents' personal funds entrusted to the facility.
Inadequate Call System in Resident Areas
Penalty
Summary
The facility failed to provide an adequate call system for residents to communicate with staff from their bedside, toilet, and bathing facilities. Observations revealed that the call lights in resident rooms and bathing areas only activated a light above the door in the hallway, with no audible indicator or connection to a centralized console. This system required staff to physically walk the halls to identify activated call lights, as there were no pagers or screens to indicate which light was on. Interviews with staff confirmed that the only way to know if a call light was activated was to visually check the hallways, which was not possible from the nurse station due to limited visibility. Resident council minutes from November 2024 to February 2025 documented ongoing complaints about delayed call light responses, with reported wait times ranging from one to three hours. Despite these complaints, no effective response or policy was produced by the facility to address the issue. Interviews with administrative staff revealed a lack of awareness of the resident council's complaints and a misunderstanding of the visibility limitations from the nurse station. The facility's failure to provide a direct communication system for residents potentially delayed response times and posed a risk of serious injury.
Failure to Provide Mandatory ANE Training
Penalty
Summary
The facility, with a census of 102 residents, failed to ensure the continuing competence of its nurse aides by not providing annual mandatory training on abuse, neglect, and exploitation (ANE). A review of employment files for five certified medication aides/certified nurse aides (CMA/CNA) employed at the facility for over a year revealed that none had received the required continuing education or training on ANE. The staff members identified were CNA VV, CNA WW, CMA XX, CMA YY, and CNA ZZ. On February 10, 2025, Administrative Staff A confirmed these findings and acknowledged the lack of assurance that the mandatory in-services for ANE had been provided to the noted staff. The facility's policy, dated April 2021, mandates staff orientation and training programs that include topics such as abuse prevention, identification, and reporting of abuse, stress management, and handling verbally or physically aggressive residents. However, the facility did not adhere to this policy, resulting in the deficiency.
Deficiency in Nurse Aide Training and Competence
Penalty
Summary
The facility failed to ensure the continuing competence of nurse aides, as evidenced by a lack of required continuing education and training. A review of employment files for five certified medication aides/certified nurse aides (CMA/CNA) employed at the facility for over a year revealed that none of them had completed the mandatory 12 hours of continuing education. This education should have included training on abuse, neglect, and exploitation (ANE), as well as dementia management and addressing areas of weakness identified in performance reviews. The absence of this training was confirmed by Administrative Staff A, who acknowledged the facility's responsibility to provide such education to ensure adequate care for residents. The facility's policy on the Abuse Prevention Program, dated April 2021, mandates staff orientation and training programs that cover topics such as abuse prevention, identification, and reporting of abuse, as well as stress management and handling aggressive behavior. However, the facility did not have a system in place to ensure that all staff received these mandatory in-services. This lack of training and oversight could potentially impact the quality of care provided to residents, particularly those with special needs as determined by the facility staff.
Failure to Serve Food at Appropriate Temperatures
Penalty
Summary
The facility failed to provide residents with food that was palatable, attractive, and served at the appropriate temperature. Multiple residents reported that the food was often cold and unappetizing. Observations revealed that food items, such as pureed corn, were served at temperatures below the required 135 degrees Fahrenheit. The dietary staff used improper methods to clean the thermometer between temperature checks, using the same cloth towel repeatedly, which could compromise food safety. The facility's grievance forms and resident council meeting notes documented ongoing complaints about cold food, indicating a pattern of dissatisfaction among residents. Interviews with staff, including a registered dietician and administrative personnel, confirmed that the food temperatures were unacceptable and that there were expectations for proper food handling and serving practices. Despite these expectations, the facility's policy on food preparation and service was not adhered to, as evidenced by the repeated grievances and observations of improper food temperature management. The lack of a comprehensive response to grievances and the absence of an effective action plan to address the issue contributed to the deficiency.
Deficient Food Storage and Handling Practices
Penalty
Summary
The facility failed to store, prepare, and serve food in a sanitary manner, which could potentially lead to food-borne illnesses among residents. During an observation of the kitchen and food storage areas, several issues were noted, including a large bag of panko crumbs with a ripped hole that was not properly sealed, several opened and unsealed bags of pasta, and a bag of honey granola without a date label. Additionally, two standing freezers contained several unidentifiable frozen items without dates or labels, and turkey burgers were found without expiration dates or labels. A bag of cut-up potatoes and some kind of pink meat were also found without labels or dates. In the walk-in cooler, two heads of lettuce and a bag of cheese were opened without dates, and a bag of toasted bread was found without a date or label. Further observations revealed that the drain for the ice maker was lying directly on the floor, which was visibly dirty, and the nourishment room's refrigerator contained a gallon of open milk with no date. Interviews with dietary staff and a licensed nurse revealed a lack of awareness regarding the requirement for labeling and dating food items. The facility's policy on food receiving and storage, dated 2001, documented that food should be received and stored in a manner that complies with safe food handling practices, including labeling and dating dry foods removed from original packaging and all foods stored in the refrigerator/freezer. The facility's failure to adhere to these practices had the potential to negatively affect the residents by increasing the risk of food-borne illness.
Failure to Document Resident Preferences and Care Needs
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for four residents, leading to potential negative impacts on their well-being. Resident 88, who had moderately impaired cognition, required substantial assistance with activities of daily living and expressed a preference for the type and timing of bathing. However, the care plan did not document these preferences, which was confirmed by interviews with nursing staff who acknowledged the expectation to include such details in care plans. Similarly, Resident 75, with intact cognition, also had preferences for bathing that were not documented in the care plan. Despite the resident's ability to communicate these preferences, the care plan lacked any indication of the preferred times, days, or type of bathing. Interviews with nursing staff reiterated the expectation that care plans should reflect residents' preferences, yet this was not adhered to in practice. Resident 82, who was cognitively intact, had specific preferences for bathing frequency and type, which were not included in the care plan. The facility lacked a policy to address the development of care plans related to bathing preferences. Additionally, Resident 14, who had severe cognitive impairment and required tube feeding, did not have the care plan updated to reflect this significant change in care needs. The delay in updating the care plan for tube feeding interventions was acknowledged by administrative staff, highlighting a failure to ensure timely updates to care plans following significant changes in residents' conditions.
Failure to Provide Adequate Bathing Services Due to Lack of Hot Water
Penalty
Summary
The facility failed to provide necessary bathing services to six residents who were dependent on staff for activities of daily living (ADL) care. The residents, identified as R27, R80, R79, R76, R88, and R82, did not receive regular baths or showers due to the unavailability of hot water in the facility. This deficiency was observed through a review of the residents' Electronic Health Records (EHRs), which documented infrequent bathing over a specified period. Interviews with staff confirmed the lack of hot water and the absence of alternative bathing solutions, such as bath wipes. Resident R88, who had diagnoses of edema, pain, and anxiety, and was documented as having moderately impaired cognition, required substantial assistance with ADLs, including bathing. The resident's care plan indicated a need for staff assistance with showering. However, the EHR revealed that R88 received showers only five times out of ten opportunities, with significant gaps between bathing sessions. Staff interviews further highlighted the ongoing issue of water availability, which hindered the provision of adequate personal hygiene care. The facility's policy on ADLs, dated March 2018, stated that residents unable to perform ADLs independently should receive necessary support to maintain good personal hygiene. Despite this policy, the facility did not ensure that residents received the required services, as evidenced by the lack of hot water and the unavailability of alternative bathing methods. Interviews with administrative staff revealed expectations for staff to accommodate the lack of hot water, but these measures were not effectively implemented, resulting in the deficiency.
Failure to Administer Ordered Medication
Penalty
Summary
The facility failed to provide necessary care for a resident, identified as R88, by not obtaining and administering the ordered Replens external comfort vaginal gel for vaginal dryness. R88's medical history included diagnoses of edema, pain, and anxiety, with a BIMS score indicating moderately impaired cognition. The resident required substantial assistance with activities of daily living and was occasionally incontinent of the bladder. An order for the vaginal gel was placed on 12/09/24, but subsequent progress notes indicated repeated delays and failures in obtaining the medication, with the gel being on order or pending delivery multiple times. Despite the order being placed, the gel was not delivered or administered, leading to R88 experiencing vaginal itching and eventually being diagnosed with candidiasis during a hospital visit. Interviews with facility staff revealed that the gel was not found in the treatment cart, and the pharmacy had not delivered it until a later date. The facility was unable to provide a policy regarding the medication order and delivery process when requested, highlighting a deficiency in ensuring the resident received the necessary care as per the medical orders.
Failure to Provide Required Beneficiary Notice
Penalty
Summary
The facility failed to provide the correct and complete Beneficiary Protection Notification Forms to a resident, identified as R56, as required by regulations. During a review on February 10, 2025, it was found that the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage Form (CMS-10055) was missing for R56. This form is necessary when a facility proposes to stop providing extended care items or services because it anticipates that Medicare will not continue to cover them. On February 11, 2025, Administrative Staff A confirmed that the form should have been issued to the resident. The facility's policy, dated September 2024, mandates that residents receive this notice before the termination of services expected to be non-covered by Medicare. The absence of this form for R56 indicates a failure to comply with the policy and regulatory requirements.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to protect the dignity of two residents, R80 and R27, by not addressing their personal grooming needs and privacy. R80 was observed with over one inch of unwanted facial hair, which he expressed a preference to be clean-shaven, and reported that staff frequently entered his room without knocking or announcing themselves. Similarly, R27 was observed with two inches of facial hair and long fingernails, which she found shameful and reported that staff did not assist her with grooming. These observations were made during interviews and visits, where both residents expressed dissatisfaction with the lack of assistance from the staff. Additionally, the facility staff failed to maintain privacy during care activities. During an incontinence care session for R80, CNAs SS and TT did not close the window blinds, exposing the resident to a public sidewalk and parking lot. Interviews with staff confirmed that blinds should be closed during such activities. Administrative Staff A acknowledged that nail care should be offered twice a month and facial hair removal should occur during bathing, but grievances had been filed by residents regarding the lack of nail care. The facility did not provide a policy related to protecting residents' dignity when requested.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not providing choices related to bathing preferences. Resident 82, who had intact cognition and was partially dependent on staff for bathing, expressed a preference for showers four times a week. However, the facility did not document these preferences in the care plan and failed to offer the resident her preferred type of bath consistently. During a period when the facility experienced issues with the hot water boiler, the resident was only offered her preferred shower once in 25 days, and alternative bathing methods were not consistently provided. The resident reported feeling unclean and dissatisfied with the alternative bathing methods offered, such as bed baths with wipes, which were not provided consistently due to the lack of hot water. Despite the resident's grievances being reported to the administrator, there was no follow-up or resolution. The facility's policy on bed baths did not include directions for accommodating resident preferences, contributing to the deficiency in providing resident-centered care.
Failure to Follow Enteral Feeding Protocols
Penalty
Summary
A resident with a history of anorexia, metabolic encephalopathy, dementia, dysphagia, and moderate malnutrition was reviewed for tube feeding management. The resident was on a physician-ordered NPO diet and received Glucerna 1.5 Cal via tube feeding every four hours, with instructions to monitor tube feeding tolerance, residuals, and weights. During an observation, a licensed nurse administered a bolus tube feeding without checking for tube placement or gastric residuals prior to the feeding, despite facility policy and expectations to do so. The nurse acknowledged that there was no specific order to check placement but admitted that it should have been done regardless. Additionally, after the bolus feeding was administered, staff failed to maintain the resident's head of bed at a minimum of 30 degrees elevation for at least 60 minutes, as required by facility policy to prevent aspiration. The head of bed was elevated less than 30 degrees for only four minutes before the resident was transferred out of bed. Administrative nursing staff confirmed the lapse in maintaining head elevation and were uncertain about the required duration for elevation post-feeding. These actions were inconsistent with the facility's enteral feeding safety precautions and had the potential to negatively affect the resident's physical well-being.
Failure to Ensure Consistent Dialysis Communication and Assessment
Penalty
Summary
The facility failed to ensure proper coordination of care and communication between the dialysis center and the facility for a resident diagnosed with end stage renal disease (ESRD) who required regular dialysis. The resident's care plan and physician orders required staff to complete pre- and post-dialysis assessments, monitor vital signs, weights, and the dialysis access site, and document this information using a dialysis communication form for each dialysis session. However, a review of the resident's electronic health record revealed that pre-dialysis communication forms were not completed for 33 documented dialysis days over a five-month period. The resident also reported that staff did not always assess his vital signs, weight, and access site before and after dialysis as required. Interviews with facility staff confirmed that the expected documentation and assessments were not consistently performed or recorded in the electronic health record. The facility's own policy required ongoing communication and coordination with the dialysis center, including the use of a dialysis communication form to ensure safe and effective care. The lack of completed documentation and communication forms indicated a failure to follow established protocols for residents receiving dialysis, resulting in inadequate communication between the facility and the dialysis center for this resident.
Misappropriation of Medications in LTC Facility
Penalty
Summary
The facility failed to protect a resident from the misappropriation of medications when two tablets of Percocet, a narcotic pain medication, were unaccounted for and never found. The resident, who had diagnoses of generalized muscle weakness and primary generalized osteoarthritis, was receiving scheduled opioid medications for chronic pain. The incident occurred when a Certified Medication Aide (CMA) and a Licensed Nurse (LN) discovered a discrepancy in the narcotic count during their shift change. They attempted to correct the count by administering an additional pill, but the count was still short by two tablets the following morning. The facility's investigation revealed that the medication cart on the East wing was short two Percocet tablets at shift change. The CMA and LN involved were suspended pending investigation, and drug tests for opiates returned negative results. Despite efforts to trace the missing tablets, the facility was unable to substantiate theft or pinpoint a single person responsible for the discrepancy. The facility's Controlled Substance Administration and Accountability policy required that all controlled substances be recorded on a designated usage form, and discrepancies were to be reported immediately. The facility's policies on abuse, neglect, and exploitation directed them to protect residents from misappropriation of property. However, the failure to account for the missing Percocet tablets indicated a lapse in these protections. The incident was treated as a potential misappropriation and a medication error, but the facility could not determine the exact cause or responsible party for the missing medication.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent falls for a resident identified as R2, who was at risk for falls due to multiple medical conditions including hemiplegia, hemiparesis, and severe cognitive impairment. Despite being dependent on staff for activities of daily living, R2's care plan included specific interventions such as ensuring the call light was within reach, placing the bed in a low position, and using a perimeter mattress with fall mats. However, these interventions were not consistently implemented, as observed during a survey when R2's bed was not in the lowest position, the call light was out of reach, and no fall mats were present. An incident occurred where R2 fell from the bed while receiving a bed bath, highlighting the failure to adhere to the care plan's directives. Staff interviews revealed that while they were aware of the fall risk interventions through the care plan and Kardex, these measures were not always put into practice. The facility's Fall Prevention Program outlined the need for environmental interventions to reduce fall risks, but these were not effectively executed, leading to the deficiency noted in the report.
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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.
The facility failed to coordinate hospice services within the care plans for two residents receiving hospice. Both residents had severe cognitive impairment and extensive ADL needs, and their MDS assessments documented hospice care. Their care plans included general directions about ADL assistance, pain monitoring, and consulting with hospice or the physician, but omitted key hospice-specific details such as hospice contact information, visit schedules, services to be provided, and what supplies, equipment, and medications hospice would furnish. Clinical record review and interviews with an administrative nurse confirmed that there was no documented coordination between hospice and facility care plans, contrary to the facility’s hospice policy requiring an interdisciplinary plan integrating hospice and facility services.
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 Coordinate Hospice Services in Resident Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain a coordinated hospice plan of care that integrated hospice services with facility services for two residents receiving hospice. For one resident with Alzheimer’s disease, CAD, and atrial fibrillation, the Significant Change MDS documented severely impaired cognition and extensive assistance needs for bed mobility and transfers, and indicated the resident was receiving hospice services. The resident’s care plan noted a terminal prognosis due to Alzheimer’s, directed staff to adjust ADL care, consult the physician for hospice care in the facility, and monitor and treat pain, but it did not include instructions on hospice services such as hospice staff visit schedules, supplies, medical equipment, or medications covered by hospice. The clinical record showed the resident had been admitted to hospice care months earlier, yet there was no documented evidence of coordination of care between hospice and the facility. For the second resident, diagnosed with PVD, DM, HTN, and atherosclerotic heart disease, the Significant Change MDS showed severe cognitive impairment with a BIMS score of two and dependence on staff for most ADLs, and documented that the resident received hospice services. The resident’s care plan recorded admission to hospice and directed staff to adjust ADL provision, encourage participation as desired, assess coping, respect wishes, and consult with the physician and hospice for continuing hospice care, as well as monitor for pain and notify the physician and hospice for breakthrough pain. However, the care plan lacked a hospice contact number, information on what supplies, equipment, and medications hospice would provide, and details on when hospice staff would be in the building and what care they would deliver. Observations and staff interviews confirmed these omissions. One resident was observed in bed receiving eye drops from a CMA, and during record review, the Administrative Nurse acknowledged that the facility care plan lacked specific information coordinating with the hospice care plan. For the second resident, the Administrative Nurse verified that the care plan did not contain information regarding hospice visits, phone numbers, or medical supplies provided by hospice, and stated that such information should be on the resident’s care plan. These findings were inconsistent with the facility’s Hospice Services policy, which required an interdisciplinary care plan integrating facility and hospice services, including coordination of services and supplies provided by the hospice provider.
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