Lawrence Memorial Hospital Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Lawrence, Kansas.
- Location
- 325 Maine Street, Lawrence, Kansas 66044
- CMS Provider Number
- 175151
- Inspections on file
- 13
- Latest survey
- December 3, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lawrence Memorial Hospital Snf during CMS and state inspections, most recent first.
The facility failed to post required information, including names, addresses, and phone numbers of pertinent State agencies and advocacy groups. Observations revealed that postings lacked complete contact details, and the administrative nurse indicated that risk management cleared the information for the entire hospital. Residents received some contact numbers in their admission packet, but the facility did not provide a policy on required postings, risking miscommunication of resident rights.
The facility did not establish a system for residents to file grievances anonymously, as required to protect their rights. An inspection revealed no method for anonymous submissions, and interviews showed a lack of awareness among residents and staff about the process. The facility's policy on grievances was not effectively implemented, risking residents' psychosocial well-being.
The facility failed to implement an admissions agreement that protected residents' rights to personal property. The agreement stated that valuables not placed in the facility's safe were the resident's responsibility, absolving the facility of liability for loss or damage. Administrative Nurse D explained the process for logging and reporting missing belongings but did not address the liability waiver. The facility did not provide a policy on admission agreements when requested.
The facility's assessment was incomplete, missing key sections such as staff competencies, physical environment, and cultural considerations. The document provided was undated and lacked details on resources and agreements for services during normal and emergency operations, placing residents at risk for inadequate care.
A facility failed to provide timely written notification to a resident or their representative regarding a transfer to the hospital, and also did not notify the State LTCO. The resident, with impaired mobility and cognition, was transferred due to increased respiratory issues and atrial fibrillation. Staff interviews revealed a lack of awareness and action regarding the notification process, and the facility did not provide a policy on transfer notifications.
A facility failed to establish a bed hold policy and provide written notification to a resident or their representative during a hospital transfer. The resident, with impaired mobility and cognition, was transferred due to increased respiratory issues. Staff confirmed the absence of a bed hold policy and lack of notification, risking the resident's return to the facility.
A resident consented to receive a pneumococcal vaccination, but the LTC facility failed to administer it before discharge. Staff interviews revealed that the vaccination process involved notifying the pharmacy through the EMR, but the vaccination was not given. A conversation with the resident's representative about previous vaccination records was not documented.
The facility did not post the most recent survey results or the last three years of reports in an accessible location for residents and their families. Instead, outdated results from 2020 were found in a binder in a different unit. Staff directed residents to access results online, and no policy was provided for posting survey results, impairing resident rights.
Deficiency in Posting Required State Agency Information
Penalty
Summary
The facility failed to post the required information, including a list of names, addresses (mailing and e-mail), and telephone numbers of all pertinent State agencies and advocacy groups. This deficiency was identified during a survey where it was observed that an empty resident room had a posting directing residents to call the facility's patient advocate, but it did not include the necessary contact information for State agencies. Additionally, a bulletin board in the hallway displayed thank you cards from residents and families, but the important phone numbers listed did not include addresses for the State Agency departments and the State Long-Term Care Ombudsman. During the survey, it was noted that the facility's administrative nurse stated that risk management had cleared the information for the entire hospital, which was the same information available in the skilled nursing unit. The administrative nurse also mentioned that residents received the phone numbers for the Long-Term Care Ombudsman and State Agency in their admission packet and that most residents have internet access and know how to use a phone. However, the facility did not provide a policy on the required postings, and the lack of complete information placed all residents at risk for miscommunication of their rights and impaired resident rights.
Failure to Implement Anonymous Grievance System
Penalty
Summary
The facility failed to implement a system that allows residents and their representatives to file grievances anonymously, which is a requirement to honor residents' rights to voice grievances without fear of discrimination or reprisal. During an inspection, it was observed that there was no submission box or method for filing anonymous grievances. A Resident Rights poster was located near the nurse's station, but it did not include directions on how to file grievances anonymously. Interviews with residents and staff revealed a lack of awareness and clarity on how to file grievances anonymously. One resident stated they were not informed about the grievance filing process, and a licensed nurse mentioned that grievances could probably be filed anonymously through a phone number or website, though this was not clearly communicated. The facility's policy on Customer Complaints and Grievances, approved in May 2022, states that patients and their representatives have the right to express concerns without fear of reprisal and that staff should respond confidentially and professionally. However, the policy did not translate into practice, as evidenced by the lack of a clear system for anonymous grievance submission. The administrative nurse indicated that grievances are typically reported directly to a patient advocate, who then forwards the information to relevant department leaders. Despite the policy's intentions, the absence of a practical, anonymous grievance filing system placed residents at risk for decreased psychosocial well-being.
Failure to Protect Residents' Personal Property Rights
Penalty
Summary
The facility failed to establish and implement an admissions agreement that protected residents' rights to personal property. The facility's Consent to Treatment Authorizations/Agreements/Insurance assignments included a section on Personal Belongings, which stated that the facility maintained a safe for storing patient valuables and recommended that residents place any valuables in the safe during their stay. However, it also stated that all personal belongings not placed in the safe were solely the resident's responsibility, and the facility would not be liable for any resulting loss or damage. This practice posed a risk of loss of personal property, including items of monetary and sentimental value, and compromised residents' dignity and personal rights. During the survey, Administrative Nurse D explained that the Health Information Management department reviewed admission agreements and that an admission log was completed with the resident's belongings upon admission, which the resident signed. If belongings went missing and were not on the log, the resident reported it to the nurse, who then reported it electronically. Risk management would work with the resident to resolve the issue of missing belongings. However, Administrative Nurse D declined to address the admission agreement waiving facility liability for resident belongings and stated she would need to check with risk management. The facility did not provide a policy related to admission agreements upon request.
Inadequate Facility Assessment Lacks Critical Components
Penalty
Summary
The facility failed to develop a comprehensive facility assessment that accurately reflected the required sections, including services provided, staff required, staff competencies, and religious practices. The assessment provided was an undated, half-page document titled 'Transitional Care Unit Facility Assessment,' which lacked essential details such as staff competencies necessary to provide the level and types of care needed for the resident population, the physical environment, equipment, services, and other physical plant considerations. Additionally, it did not address any ethnic, cultural, or religious factors that may affect the care provided by the facility, including activities and food and nutrition services. The facility's assessment also failed to include information on resources, equipment, services provided, contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment during both normal operations and emergencies. Furthermore, it did not cover health information technology resources, such as systems for electronically managing patient records and sharing information with other organizations. The facility's failure to provide a policy related to facility assessment upon request further highlighted the deficiency, placing residents at risk for unidentified care needs and inadequate care and services.
Failure to Notify Resident and Ombudsman of Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident, identified as R3, or his representative regarding a facility-initiated transfer to the hospital. R3 was admitted to the facility with diagnoses including impaired mobility, cognition, and atrial fibrillation. On the day of the transfer, R3 experienced increased respiratory rate and fatigue, leading to a decision by Consultant GG to admit R3 to a higher level of care. Despite these events, the facility did not document or provide evidence of sending a written notification of the transfer to R3 or his representative. Additionally, the facility did not notify the State Long Term Care Ombudsman (LTCO) of the transfer, as required. Interviews with facility staff, including Administrative Nurse D, Licensed Nurse G, and Social Services X, revealed a lack of awareness and action regarding the notification process for transfers. The facility also failed to provide a policy on transfer notifications, indicating a systemic issue in communication and compliance with regulatory requirements.
Failure to Establish and Notify Bed Hold Policy
Penalty
Summary
The facility failed to establish a bed hold policy and provide written notification of this policy to a resident or their representative during a transfer to a hospital. The resident, who was admitted to the facility and later discharged to the hospital, had diagnoses including impaired mobility, cognition, and atrial fibrillation. The resident's medical records indicated a significant decline in mobility and daily function, and the care plan included measures to address these issues. However, upon transfer to the hospital due to increased respiratory rate and fatigue, there was no evidence of written notification regarding the bed hold policy being sent to the resident or their representative. Interviews with facility staff revealed that there was no existing bed hold policy, and no written notifications were provided during the resident's transfer. Administrative Nurse D and Licensed Nurse G confirmed that notifications were not sent, and Social Services X stated that the facility did not have a bed hold policy. The absence of a bed hold policy and the lack of written notification posed a risk to the resident's ability to return to the facility and their previous room.
Failure to Administer Pneumococcal Vaccination
Penalty
Summary
The facility failed to administer a pneumococcal vaccination to Resident 107, who had consented to receive it on September 26, 2024. Despite the resident's consent, a review of the Medication Administration Record (MAR) during his stay revealed that the vaccination was not administered before his discharge on October 11, 2024. This oversight was identified through observations, record reviews, and interviews conducted during the survey. Interviews with facility staff, including Administrative Nurse D and Licensed Nurse G, indicated that the process for administering vaccinations involved asking residents about their immunization history and preferences during the admission process. If a resident expressed interest in receiving a vaccination, this information was entered into the electronic medical record (EMR), which then notified the pharmacy. However, in the case of Resident 107, there was a breakdown in this process, as the vaccination was not administered before discharge. Consultant HH mentioned a conversation with the resident's representative about obtaining vaccination records from a previous facility, but this was not documented, and the vaccination was not given before discharge.
Failure to Post Survey Results in Accessible Location
Penalty
Summary
The facility failed to comply with regulations requiring the posting of survey results in a location that is easily accessible to residents, family members, or legal representatives. During a tour of the skilled nursing facility, it was observed that the most recent survey results, as well as the last three years of survey reports, were not posted in a prominent and accessible area. Instead, a binder containing outdated survey results from 2020 was found in the dining room area of a different unit, not the skilled nursing facility unit. This oversight was confirmed by Administrative Nurse D, who admitted to not updating the binder because the results were available online. Interviews with residents and staff further highlighted the deficiency. A resident expressed unawareness of how to locate the survey results within the facility. Licensed Nurse G mentioned that the survey results were probably available on the state's website, while Administrative Nurse D directed residents to access the results online. The facility did not provide a policy regarding the posting of survey results, which contributed to the failure to make these documents readily accessible, thereby impairing resident rights.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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