Hilltop Lodge Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Beloit, Kansas.
- Location
- 815 N Independence Avenue, Beloit, Kansas 67420
- CMS Provider Number
- 175348
- Inspections on file
- 24
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Hilltop Lodge Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with cognitive impairments and a high risk for elopement managed to leave the facility by chiseling open a window. Despite assessments indicating the risk, the facility failed to update the care plan with necessary interventions. The resident was found at a nearby store after crossing a busy highway, expressing to police that he felt held captive. The facility's lack of action placed the resident in immediate jeopardy.
The facility did not employ a full-time certified dietary manager, which is necessary to ensure adequate nutrition for residents. Dietary Staff BB, who was managing dietary services, was not certified, although they had started the certification classes. This was confirmed by Administrative Staff A. The facility's policy required the director of food and nutrition services to be qualified according to job descriptions and regulatory guidelines, but this requirement was not met, placing residents at risk for inadequate nutrition.
A facility failed to provide proper catheter care for several residents, leading to unsanitary conditions and increased risk of UTIs. Observations revealed catheter bags on the floor and inadequate care planning. Staff did not follow infection control protocols, and care plans lacked necessary interventions for catheter management.
The facility failed to ensure the Consultant Pharmacist identified and reported medication irregularities, leading to potential risks of inappropriate medication use. Several residents were affected, including those with unapproved medication indications, lack of monitoring parameters, and absence of physician responses to pharmacist recommendations. These deficiencies highlight the facility's failure to adhere to its medication regimen review policy.
The facility failed to ensure appropriate indications and documentation for psychotropic medications for several residents, leading to the risk of unnecessary medication use. One resident was prescribed multiple antidepressants and an antipsychotic without a gradual dose reduction or physician documentation. Another resident received alprazolam as needed for anxiety without a required stop date, and a third resident's medications were not subjected to a gradual dose reduction despite recommendations. Additionally, a resident was prescribed quetiapine without appropriate documentation, placing them at risk for unnecessary side effects.
A resident with urinary retention and an indwelling catheter was observed in the dining room with his catheter bag uncovered, visible to other residents. Despite the facility's policy to maintain resident dignity, staff failed to cover the bag, as confirmed by an administrative nurse. This oversight risked the resident's dignity.
A resident's room was found to have crinkled duct tape between the floor carpet seams, posing a trip hazard. Maintenance staff acknowledged the need for flooring replacement but had not submitted a requisition. An administrative nurse was initially unaware of the issue but later agreed it could be hazardous. The facility's policy requires preventative maintenance to ensure safety, which was not followed.
Two residents in an LTC facility experienced neglect and potential abuse due to inadequate care and improper handling. One resident was left unattended in the bathroom for an hour, with a CNA being rude and unhelpful. Another resident suffered a large bruise from an improper transfer using a gait belt instead of a Hoyer lift. Both incidents were not thoroughly investigated or reported to the State Agency, highlighting a failure in the facility's procedures to prevent and address neglect and abuse.
The facility failed to report allegations of abuse and neglect for two residents to the State Agency. One resident, with multiple medical conditions, reported a CNA being rude and not assisting her, while another resident with severe cognitive impairment was found with a large bruise, suspected to be from improper transfer. The facility did not conduct thorough investigations or report these incidents, violating their policies and placing residents at risk.
The facility failed to investigate allegations of abuse and neglect for two residents, placing them at risk of ongoing mistreatment. One resident reported a CNA being rude and not assisting her, while another resident was found with a large bruise possibly from improper transfer techniques. The facility did not conduct thorough investigations or report the incidents to the State Agency, violating their policies on abuse and neglect.
The facility failed to develop comprehensive care plans for three residents with indwelling urinary catheters, leading to uncommunicated care needs and potential risks. One resident's catheter bag was observed dragging on the floor, another's was lying on the floor, and a third's catheter tubing was not properly anchored. The care plans lacked necessary interventions despite the residents' medical histories and physician orders.
A resident with a history of stroke and rheumatoid arthritis had a Stage 4 pressure ulcer and required a foot cradle to prevent further skin breakdown. Despite an APRN's recommendation, the care plan was not updated to include this intervention until nearly two months later, leading to a delay in care. Staff acknowledged the oversight, which placed the resident at risk for impaired care.
A resident with vascular dementia and other conditions did not receive consistent bathing assistance as required by their care plan. Despite being independent in most activities of daily living, the resident needed help with bathing, which was not provided for extended periods. Observations showed poor hygiene, and staff confirmed the resident did not refuse showers, contrary to the facility's policy.
Two residents in an LTC facility experienced deficiencies in care related to non-pressure skin injuries. One resident developed a worsening skin abrasion due to improper use of a Hoyer lift sling, while another resident's toe injury went unreported to a physician, despite evident pain and drainage. These incidents highlight failures in adhering to care plans and communication protocols, placing residents at risk for further complications.
The facility failed to provide adequate pressure ulcer care and prevention for two residents. One resident, with a complex medical history, did not receive a pressure-relieving cushion or nutritional support, leading to a painful sore. Another resident, dependent on staff for all activities, had a Stage 4 pressure ulcer, but the facility delayed implementing recommended nutritional and pressure relief interventions. These failures placed both residents at risk for ongoing pressure injuries and complications.
A facility failed to provide range of motion (ROM) services to a resident with a history of CVA, hemiplegia, and rheumatoid arthritis, as outlined in her care plan. The resident was dependent on staff for all ADLs and mobility, and her care plan required daily ROM exercises. Observations and staff interviews confirmed that these services were not provided, placing the resident at risk for impaired mobility and decreased function.
A facility failed to provide necessary nutritional assessments and interventions for two residents, leading to continued weight loss and inadequate meal provision. One resident, with a history of weight loss and severe cognitive impairment, did not receive proper diet orders or supplements, and the RD and physician were not notified. Another resident on a pureed diet did not receive the full meal components as per the menu, despite RD recommendations. The facility's policies on weight loss interventions were not followed, placing residents at risk for further decline.
A resident with a history of mental health issues and multiple diagnoses, including major depressive disorder and bipolar disorder, did not receive the necessary mental health services at the facility. Despite expressing a need for mental health support and having a care plan in place, the resident's clinical record lacked evidence of such services being offered. The facility's failure to adhere to its Behavioral Health Services policy placed the resident at risk for unmet mental health care needs.
A resident with type 2 diabetes mellitus was not adequately monitored for blood sugar levels, as the care plan lacked parameters for physician notification of abnormal readings. Despite a high postprandial blood sugar level of 456 ml/dL, there was no evidence of physician notification or assessment, highlighting a deficiency in the facility's monitoring and communication protocols.
The facility failed to provide sanitary catheter care for three residents, leading to increased infection risk. Observations showed catheter bags placed on the floor and improper hand hygiene by staff. A CNA did not change gloves or wash hands after care, violating the facility's infection prevention protocols.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to identify and implement necessary interventions to prevent an elopement for a resident who was cognitively impaired and at high risk for elopement. Despite assessments on two occasions indicating the resident's high risk for wandering or elopement, the facility did not update the resident's care plan to include interventions or alert staff to the elopement risk. On the day of the incident, the resident was last seen at 7:30 AM, and by 10:30 AM, the facility was informed by a community member that the resident was outside the facility. The resident had managed to open a window by chiseling wooden blocks with a butter knife and exited the facility, crossing a busy highway to reach a nearby store. The resident, who had a history of frontotemporal neurocognitive disorder, dementia, depression, and both homicidal and suicidal ideations, was found at a farm store 0.3 miles away from the facility. The resident had to navigate a busy highway and steep ditches to reach the store. Upon being found, the resident expressed to a police officer that he felt the facility was holding him captive. The resident was returned to the facility with the assistance of law enforcement but refused further assessment upon return. The facility's failure to implement interventions and provide adequate supervision placed the resident in immediate jeopardy. The resident's care plan lacked documentation of interventions aimed at preventing wandering or elopement until after the incident occurred. The facility's policy on elopement and wandering residents was not effectively followed, as the resident's risk was not adequately addressed in their care plan prior to the elopement incident.
Removal Plan
- R1 was placed on one-to-one with staff.
- The facility notified R1's primary care physician and responsible party of the situation.
- A new wandering assessment was completed for R1.
- The elopement book was reviewed and updated.
- R1's Care Plan was updated.
- An ad hoc meeting was held with the medical director.
- Maintenance secured the windows in R1's room.
- Maintenance checked all of the windows in the facility to ensure stoppers were in place.
- Education was provided to all staff on elopement and abuse, neglect, and exploitation.
Lack of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to employ a full-time certified dietary manager, which is a requirement for ensuring adequate nutrition for residents. At the time of the survey, the facility had a census of 59 residents, with a sample of 19 residents being reviewed. During observations and interviews, it was confirmed that Dietary Staff BB, who was responsible for managing the dietary services, was not a certified dietary manager. Although Dietary Staff BB had started the certified dietary manager classes, they had not yet obtained the certification. Administrative Staff A also verified that Dietary Staff BB did not possess the necessary certification. The facility's Director of Food Policy, revised on 07/02/21, required that the director of food and nutrition services be qualified according to the job description and regulatory guidelines. The absence of a certified dietary manager placed the residents at risk for inadequate nutrition.
Deficient Catheter Care Practices in LTC Facility
Penalty
Summary
The facility failed to provide sanitary indwelling urinary catheter care for several residents, placing them at risk for urinary tract infections and catheter-related injuries. Resident 55, who had multiple diagnoses including type two diabetes mellitus and dementia, was observed with a catheter drainage bag dragging on the floor under the wheelchair and resting on the floor mat next to the bed. The care plan for Resident 55 lacked interventions related to the indwelling catheter, and the resident had a history of UTIs treated with antibiotics. Resident 17, with a history of UTIs and other medical conditions, was observed with a catheter drainage bag lying on the floor, not attached to the bed. The care plan for Resident 17 also lacked directions for catheter care, despite the resident's history of UTIs. Staff confirmed that the catheter bag should not be on the floor and acknowledged the oversight in care planning. Resident 54 was observed with a catheter bag placed on the floor during care, and the staff member failed to change gloves or wash hands after providing catheter care. This was against the facility's infection prevention protocols. Additionally, Resident 20's care plan lacked information about the urinary catheter, and there was no anchor for the catheter tubing, which could lead to pulling or displacement. The facility's failure to ensure proper catheter care and documentation placed these residents at risk for complications.
Medication Review Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported medication irregularities for several residents, leading to potential risks of inappropriate medication use. For one resident, the CP did not report the use of multiple antidepressants prescribed for anxiety, which is not an approved indication. The resident's medical record lacked evidence of a physician's response to the CP's recommendations, placing the resident at risk for inappropriate use of psychotropic medications. Another resident's care plan lacked parameters for blood sugar monitoring, and the CP failed to identify and report this omission, risking complications related to insulin use. Additionally, the facility did not ensure that the CP identified and reported the lack of an end date for a PRN antianxiety medication for another resident. This oversight placed the resident at risk for inappropriate use of psychotropic medications. Furthermore, the CP recommended a gradual dose reduction for a resident's psychotropic medications, but the facility failed to ensure the physician reviewed and acknowledged these recommendations, leaving the resident at risk for unnecessary medication use. The facility also failed to ensure the CP identified and reported the lack of an appropriate indication for the use of an antipsychotic medication for another resident. The resident's medical record did not contain a documented physician rationale for the ongoing use of the medication, which could lead to unnecessary medication use and adverse side effects. These deficiencies highlight the facility's failure to adhere to its medication regimen review policy, which requires monthly reviews by a licensed pharmacist and communication of any irregularities within 72 hours.
Inadequate Documentation and Indication for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that several residents' psychotropic medications had appropriate indications and documentation, leading to the risk of unnecessary medication use. Resident 10 was prescribed multiple antidepressants and an antipsychotic without a gradual dose reduction or physician documentation indicating that such a reduction was clinically contraindicated. The pharmacy recommended reassessment of the indications for mirtazapine and hydralazine, as they were not FDA-approved for the conditions they were prescribed for, but there was no evidence of a physician response. Resident 55 was prescribed alprazolam as needed for anxiety without a required stop date, and the medication was administered multiple times over several months. The pharmacy noted the lack of an FDA-approved indication for alprazolam, but the physician only responded with the indication of anxiety, without addressing the need for a stop date. This oversight placed the resident at risk for unnecessary psychotropic medication use and related side effects. Resident 20's psychotropic medications, including Buspar, duloxetine, and zolpidem, were not subjected to a gradual dose reduction despite recommendations from the consultant pharmacist. The physician did not provide a risk versus benefit rationale for the continued use of these medications. Similarly, Resident 38 was prescribed quetiapine without appropriate documentation of the indication or non-pharmacological interventions attempted, placing the resident at risk for unnecessary side effects.
Failure to Maintain Resident Dignity by Not Covering Urinary Catheter Bag
Penalty
Summary
The facility staff failed to treat Resident 54 with dignity by not covering his urinary catheter bag with a privacy bag, leaving the urine visible to other residents and guests. This incident was observed when Resident 54, who had a diagnosis of urinary retention and an indwelling urinary catheter, was seen ambulating from his room to the dining room with the catheter bag hanging on the side of his walker without a privacy cover. The resident, who had intact cognition as indicated by a BIMS score of 15, sat at the dining room table with the urine collection bag uncovered, visible to 12 other residents. The facility's policy on promoting and maintaining resident dignity, revised in November 2017, requires staff to protect and promote resident rights and treat each resident with respect and dignity. Despite this policy, the staff did not adhere to the expected practice of ensuring the urinary catheter bag was covered, as confirmed by an interview with Administrative Nurse D. This oversight placed Resident 54 at risk for impaired dignity, as the facility failed to maintain the resident's privacy and dignity in accordance with their own policy.
Unsafe Environment Due to Crinkled Duct Tape
Penalty
Summary
The facility failed to provide a safe environment for a resident when staff placed crinkled duct tape between the floor carpet seams in the resident's room. This was observed on two occasions, with the duct tape running from the bed to the south wall and crinkled up approximately one foot in the middle. Maintenance staff verified the issue and acknowledged that the flooring needed replacement, but had not yet submitted a requisition to the administrator. An administrative nurse was initially unaware of the issue but later agreed that the duct tape could pose a trip hazard. The facility's Resident Environmental Quality Policy, revised in November 2017, requires preventative maintenance schedules to be followed to maintain a safe environment, which was not adhered to in this instance.
Neglect and Abuse of Residents Due to Inadequate Care and Improper Handling
Penalty
Summary
The facility failed to protect two residents, R11 and R18, from neglect and abuse, as evidenced by incidents involving inadequate care and improper handling. R11, who had multiple medical conditions including cerebral infarction, COPD, and dementia, was left unattended in the bathroom for approximately one hour despite using the call light for assistance. During this time, a CNA was reported to have been rude, throwing a shirt at R11 without providing the necessary help. This incident was not thoroughly investigated, and the grievance was not reported to the State Agency, indicating a failure in addressing the neglect and potential abuse. R18, who had severe cognitive impairment and required extensive assistance for daily activities, suffered a large bruise on her chest, likely from an improper transfer using a gait belt instead of the required Hoyer lift. The facility's records lacked documentation of an investigation into the origin of the bruising or the improper use of the gait belt. Observations revealed additional bruising on R18's body, and staff were unsure of how these injuries occurred. The facility did not report this incident to the State Agency, nor did it document any staff education on proper transfer techniques, highlighting a neglect in ensuring R18's safety and care. Both incidents demonstrate a failure to adhere to the facility's policies on preventing abuse and neglect, as well as a lack of proper investigation and reporting procedures. The facility's inaction placed both residents at risk for further neglect and abuse, as the necessary care and services were not provided, and the incidents were not adequately addressed or reported.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and mistreatment to the State Agency (SA) for two residents, R11 and R18, as required. R11, who had multiple medical conditions including cerebral infarction, COPD, and dementia, reported an incident where a Certified Nurse Aide (CNA) was rude and threw a shirt at her without providing assistance. Despite the grievance being documented, the facility did not conduct a thorough investigation or report the incident to the SA, leaving the resident at risk for ongoing mistreatment. R18, who had severe cognitive impairment and required extensive assistance for daily activities, was found with a large bruise on her chest, suspected to be caused by improper use of a gait belt during a transfer. The facility's records lacked documentation of an investigation into the origin of the bruising or the use of a gait belt on a resident who required a Hoyer lift. Despite the visible injuries, the facility did not report the incident to the SA, failing to identify it as a potential case of abuse or neglect. The facility's policies on abuse, neglect, and exploitation were not followed, as they did not implement proper procedures for investigating and reporting these incidents. The lack of investigation and reporting placed the residents at risk for further abuse and mistreatment, as the facility did not take the necessary steps to ensure their safety and dignity.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to fully investigate allegations of abuse, neglect, and injuries of unknown origin for two residents, R11 and R18, placing them at risk of ongoing mistreatment. R11, who had a history of multiple medical conditions including cerebral infarction, COPD, and dementia, reported an incident where a CNA was rude and threw a shirt at her without providing assistance. Despite the grievance being reported, the facility did not conduct a thorough investigation, as confirmed by Administrative Nurse D, who did not interview R11 or gather statements from staff present during the incident. R18, who had severe cognitive impairment and required extensive assistance for daily activities, was found with a large bruise on her chest, possibly from improper use of a gait belt during transfers. The facility's records lacked documentation of an investigation into the bruise's origin, and there was no evidence of staff education on proper transfer techniques. Observations revealed additional bruises on R18's body, yet the facility did not report these findings to the State Agency or complete a comprehensive investigation. The facility's policies on abuse, neglect, and exploitation were not followed, as they failed to investigate the allegations thoroughly and report them as required. This lack of action and documentation placed both residents at risk for further abuse and neglect, as the facility did not take adequate steps to ensure their safety and dignity.
Failure to Develop Comprehensive Care Plans for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents with indwelling urinary catheters, placing them at risk for impaired care due to uncommunicated care needs. Resident 55, who had multiple diagnoses including type two diabetes mellitus, heart failure, and dementia, was observed with a catheter drainage bag and tubing dragging on the floor, which was confirmed by a licensed nurse as inappropriate. The care plan for Resident 55 lacked interventions related to the indwelling catheter and psychotropic medication use, despite the resident's history of urinary tract infections and the administration of alprazolam for anxiety. Resident 17, with a history of urinary tract infections and other medical conditions such as chronic obstructive pulmonary disease and type two diabetes mellitus, was observed with a catheter drainage bag lying on the floor. The care plan for Resident 17 did not include directions for the indwelling catheter, even though the resident had been treated for multiple UTIs. A licensed nurse confirmed that the catheter bag should not be on the floor and that the resident's indwelling urinary catheter should have been care planned. Resident 20, diagnosed with cerebral palsy and neuromuscular dysfunction of the bladder, had a care plan that lacked interventions for the suprapubic catheter. Observations revealed that the catheter tubing was not properly anchored to prevent pulling or displacement. Administrative staff verified that the care plan should have included instructions for anchoring the catheter tubing. The facility's policy required comprehensive person-centered care plans, but these were not adequately developed for the residents involved.
Failure to Update Care Plan for Pressure Ulcer Interventions
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R19, to include necessary interventions for pressure ulcers. R19 had a history of cerebrovascular accident, hemiplegia, hemiparesis, dysphagia, and rheumatoid arthritis, and was dependent on staff for all activities of daily living. The resident had a Stage 4 pressure ulcer and required specific interventions such as a foot cradle to prevent further skin breakdown. Despite recommendations from an APRN on 11/27/23 to use a foot cradle, this intervention was not documented in the care plan until 01/24/24, leading to a delay in implementing the necessary care. Observations and interviews revealed that the facility's staff did not update the care plan in a timely manner, as required by the facility's policy. The care plan lacked documentation for the foot cradle, which was crucial for the resident's care. Administrative Nurse E acknowledged missing the recommendation for the foot cradle, and Administrative Nurse D confirmed that the care plan should have been updated immediately. This oversight placed the resident at risk for impaired care due to uncommunicated care needs.
Inconsistent Bathing for Resident with Dementia
Penalty
Summary
The facility failed to provide consistent bathing for Resident 38, who had a diagnosis of vascular dementia, PTSD, diabetes mellitus, and depressive disorder. The resident was independent with all activities of daily living except for bathing, for which he required partial to moderate assistance. The care plan for Resident 38, initiated in June 2021, directed staff to offer a choice of a whirlpool or shower based on his preference on chosen bath days and to notify the nurse if he refused. However, the facility's records showed that Resident 38 did not receive a bath or shower for extended periods in January and February 2024, with no documentation of refusal in the electronic medical record. Observations on February 28, 2024, revealed that Resident 38 wore a stocking cap and a red sweatshirt with multiple food stains, indicating a lack of proper hygiene. Interviews with staff confirmed that Resident 38 should have received his showers as requested and that there were no recorded refusals. The facility's policy on bathing residents, dated 2017, emphasized assisting residents with bathing to maintain hygiene and prevent skin issues. The failure to provide consistent bathing placed Resident 38 at risk for complications related to poor hygiene.
Deficiencies in Skin Care and Communication in LTC Facility
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards for two residents with non-pressure related skin injuries. Resident 18, who had severely impaired cognition and required extensive assistance, developed a skin abrasion on her back due to staff leaving a Hoyer lift sling underneath her. This abrasion worsened over time, and despite physician orders for treatment, the area became irritated due to moisture and the resident's fragile skin. Observations revealed a large wet spot on the resident's clothing, and multiple bruises were noted on her body, indicating further issues with skin care and handling. Resident 17, who had intact cognition and required assistance with activities of daily living, reported pain in the right first toe extending to the ankle. The resident had a bandage on the toe, which was not documented in the clinical record, and staff were unaware of the issue. Upon assessment, the toe was found to have dried blood, redness, and drainage, indicating a need for medical attention. However, the facility failed to notify the physician about the condition, which was a requirement under their policy for changes in a resident's condition. The deficiencies in care for both residents highlight a lack of adherence to care plans and facility policies, resulting in inadequate treatment and monitoring of skin conditions. The failure to remove the Hoyer sling and the lack of communication regarding Resident 17's toe injury placed both residents at risk for further complications, including infection and impaired healing.
Inadequate Pressure Ulcer Care and Prevention for Two Residents
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, R11 and R19, who were either at risk for or had existing pressure injuries. R11, with a complex medical history including cerebral infarction, COPD, and rheumatoid arthritis, was identified as at risk for skin integrity issues due to decreased mobility. Despite having a care plan that included education on skin breakdown prevention and the use of specific cushions and mattresses, R11 did not receive a pressure-relieving cushion for her recliner. Additionally, R11's clinical record lacked evidence of nutritional supplements or dietician involvement, which are crucial for wound healing. Observations revealed that R11 had a painful sore on her buttock, and staff failed to provide necessary bandages, further exacerbating the situation. R19, who had a history of cerebrovascular accident, hemiplegia, and rheumatoid arthritis, was dependent on staff for all activities of daily living and had a Stage 4 pressure ulcer. The care plan for R19 included pressure relief interventions and nutritional support, but these were not implemented in a timely manner. The facility failed to follow through with the registered dietician's recommendation for Prostat and the APRN's recommendation for a foot cradle. Observations showed that R19's medication administration record lacked documentation for these interventions, and there was a delay in entering the order for Prostat into the facility system. The facility's policy on pressure ulcer prevention and management emphasized a systematic approach, including prompt assessment and treatment, and evidence-based interventions. However, the facility did not adhere to these guidelines, resulting in inadequate care for R11 and R19. The lack of timely and appropriate interventions placed both residents at risk for ongoing pressure injuries and related complications.
Failure to Provide ROM Services as Care Planned
Penalty
Summary
The facility failed to provide range of motion (ROM) services to Resident 19 as outlined in her care plan, which placed her at risk for impaired mobility and decreased function. Resident 19 had a history of cerebrovascular accident (CVA), hemiplegia, hemiparesis, dysphagia, and rheumatoid arthritis, and was dependent on staff for all activities of daily living (ADLs) and mobility. Her care plan required staff to provide gentle ROM exercises with morning and evening care daily. However, there was no documentation that these services were provided. Observations revealed that Resident 19 was often in positions that could lead to contractures, such as lying with clenched hands without padding or protection and sitting in a Broda chair while chewing on her thumbnail. Interviews with staff, including a Restorative Aide and a Certified Nurse Aide, confirmed that ROM services were not provided to Resident 19. The facility's policy on the prevention of decline in ROM required interventions to be documented and consistently implemented, which was not adhered to in this case.
Failure to Provide Adequate Nutritional Care
Penalty
Summary
The facility failed to provide necessary nutritional assessments and interventions for Resident 59, who had a history of weight loss prior to admission and continued to lose weight after being admitted. Despite being dependent on staff for all activities of daily living and having severely impaired cognition, the resident's care plan lacked documentation of diet orders and interventions to prevent weight loss. The facility did not notify the Registered Dietician (RD) or the physician about the resident's weight loss, and no nutritional assessments were completed. Observations revealed that the resident did not finish meals, and staff confirmed that no nutritional supplements were provided. Resident 19, who was on a pureed diet due to conditions such as cerebrovascular accident, hemiplegia, and dysphagia, did not receive the full nutritional benefit of the meals served. The care plan directed staff to monitor nutritional status and provide supplements as ordered, but during a meal observation, the resident did not receive all the components of the meal as listed on the menu. The RD had recommended specific supplements, but the resident received a different shake than requested, and the pureed stuffing was missing from the meal. The facility's policies on interventions for unintended weight loss and the responsibilities of the food and nutrition services department were not followed. The failure to implement immediate interventions and involve the RD and physician placed the residents at risk for further weight loss and decline. The facility's lack of adherence to its policies and procedures contributed to the deficiencies observed in the nutritional care of the residents.
Failure to Provide Mental Health Services
Penalty
Summary
The facility failed to provide appropriate mental health treatment and services to a resident, identified as R11, who had a history of mental health issues and expressed a need for mental health support. R11's electronic medical record indicated multiple diagnoses, including major depressive disorder and bipolar disorder, and the resident was on medications such as antidepressants and antianxiety drugs. Despite these conditions and the care plan's directives to monitor and report any mental health concerns, there was no evidence in R11's clinical record that mental health services were offered or provided at the facility. R11 reported feeling down and expressed a desire for mental health assistance, which she had not received since transitioning from another facility where she had been receiving such services. The resident, who was also the resident council president, mentioned that she stopped attending meals in the dining room due to another resident's behavior, which further isolated her. Social Service X confirmed that R11 had requested continued mental health services and that the previous provider had contacted the facility to ensure a smooth transition, but services had not yet commenced. Administrative Nurse D acknowledged that R11's participation in meals and activities had decreased and that she was more irritable with staff. The facility's Behavioral Health Services policy emphasized the importance of providing necessary behavioral health care to maintain residents' mental and psychosocial well-being. However, the facility did not adhere to this policy, resulting in R11 not receiving the mental health services she requested and needed, placing her at risk for unmet mental health care needs.
Failure to Monitor Blood Sugar Levels in Diabetic Resident
Penalty
Summary
The facility failed to ensure adequate monitoring of a resident's blood sugar levels, which is crucial for managing diabetes mellitus. The resident, who had a history of type 2 diabetes mellitus among other health conditions, was receiving insulin as part of their treatment. However, the care plan did not include parameters for notifying a physician in case of abnormal blood sugar levels. This oversight was evident when the resident's postprandial blood sugar level was recorded at 456 ml/dL, significantly higher than the normal range, without any documented physician notification or assessment. Additionally, the facility's medication regimen review process, which is supposed to identify and resolve medication-related problems, did not address the lack of blood sugar monitoring parameters. The administrative nurse was unable to confirm whether the physician had been notified about the high blood sugar reading, indicating a lapse in communication and protocol adherence. This deficiency placed the resident at risk of receiving unnecessary medications and potential complications related to their diabetes management.
Inadequate Infection Control in Catheter Care
Penalty
Summary
The facility failed to provide sanitary indwelling urinary catheter care according to standard infection prevention practices for three residents, identified as R17, R55, and R54. Observations revealed that R17's catheter drainage bag was improperly placed on the floor and not attached to the bed, despite the resident's history of urinary tract infections (UTIs). Similarly, R55's catheter drainage bag was observed resting on the floor mat next to the bed, and R54's catheter bag was placed on the floor during care. These actions were contrary to the facility's infection prevention protocols, which require catheter bags to be hung below the bladder level and never placed on the floor. Additionally, the facility's staff failed to adhere to proper hand hygiene and glove-changing protocols during catheter care. Certified Nurse Aide (CNA) N was observed placing a catheter bag on the floor, failing to change gloves or wash hands after providing care, and using the same gloves to assist a resident with clothing. CNA N also handled the catheter bag with ungloved hands and did not perform hand hygiene before entering another resident's room. These actions were inconsistent with the facility's Hand Hygiene Policy and Catheter Care Policy, which emphasize the importance of hand hygiene and changing gloves between clean and dirty tasks to prevent the spread of infection.
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Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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