Meridian Rehabilitation And Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wichita, Kansas.
- Location
- 1555 N Meridian Street, Wichita, Kansas 67203
- CMS Provider Number
- 175274
- Inspections on file
- 28
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Meridian Rehabilitation And Health Care Center during CMS and state inspections, most recent first.
The facility failed to submit multiple completed abuse, neglect, exploitation, and misappropriation investigation reports to the State Agency within the required five working days after the incidents were reported. Several investigations were only provided much later during an on-site survey or by e-mail, and at least one investigation was neither submitted within the required timeframe nor available to surveyors. Administrative leadership acknowledged that some investigations were incomplete, contributing to delays, despite facility policy requiring the administrator to thoroughly investigate allegations, complete final reports, and submit them promptly to the appropriate agencies without withholding any reports.
A resident with a history of mental health disorders and exit-seeking behavior was neglected by facility staff, who failed to respond to his suicidal ideation after an elopement incident. Despite known risks, the resident's care plan was not effectively implemented, and there were delays in updating medication orders. The resident was found hanging in his room, highlighting the facility's failure to address his mental health crisis and ensure his safety.
A cognitively impaired resident with a history of elopement risk was left unsupervised in a courtyard, allowing them to climb a fence and leave the facility. The resident, diagnosed with dementia and other conditions, was found two miles away after traversing busy areas. Staff failed to adhere to the care plan and elopement policy, which required supervision and safety devices.
A resident with a history of mental health disorders and suicidal ideation was not provided appropriate care and monitoring by the facility. Despite expressing a desire to leave and making suicidal statements, the staff failed to respond adequately, leading to the resident's tragic death by hanging. The facility's neglect in addressing the resident's mental health needs placed him in immediate jeopardy.
The facility did not conduct annual performance evaluations for its CNAs, as revealed by a review of personnel files. Interviews with administrative staff showed confusion over who was responsible for these evaluations, and the facility lacked a policy to ensure their completion.
The facility failed to ensure CNAs completed the required 12-hour in-service education, as revealed by a review of personnel files for five CNAs employed for over a year. Interviews indicated staff awareness of the issue, with some CNAs lacking access to computer training and the facility lacking a policy for the training requirement.
The facility failed to provide effective behavioral health training for staff, as revealed by a review of CNA personnel files showing incomplete or unstarted training modules. Interviews with staff indicated that not all had access to computer training, and training often involved merely reading and signing off on documents. This deficiency placed all 96 residents at risk of not achieving their highest practicable well-being.
The facility failed to accommodate the bathing preferences of several residents, including those with cognitive impairments and physical disabilities. Residents reported not receiving baths according to their preferences, with care plans lacking specific directions for bathing schedules. Observations revealed inadequate personal hygiene care, and electronic medical records did not document offered or refused bathing opportunities. The facility's bathing schedule was based on room numbers rather than individual preferences, and there was no policy addressing residents' bathing preferences.
The facility failed to maintain a safe and clean environment for 28 residents who smoked, with cigarette butts littering designated smoking areas and a dirty service hallway. A resident expressed concerns about navigating the unclean hallway in a wheelchair, fearing infection due to existing wounds. Additionally, the facility delayed returning a resident's topcoat, which was missing for months, highlighting a lack of policy on personal property management.
The facility failed to accurately complete the MDS for several residents, leading to potential uncommunicated needs for care. Errors included incorrect documentation of medication administration and unreported falls, as confirmed by administrative staff.
The facility failed to update care plans for several residents, leading to deficiencies in addressing bathing preferences and fall prevention. A resident with hemiparesis did not have his bathing preferences documented, resulting in infrequent baths. Another resident with moderate cognitive impairment reported not receiving baths for months, and his care plan lacked directions for hygiene. Additionally, residents at risk for falls did not have appropriate interventions in their care plans. The facility lacked a policy on care plan revision, and staff interviews confirmed that care plans were not updated in a timely manner.
The facility failed to provide adequate personal hygiene care for several residents, including those with cognitive impairments and physical disabilities. Residents reported not receiving regular baths, and observations revealed unkempt appearances and inadequate grooming. Care plans lacked specific instructions for personal hygiene, and the facility did not have policies addressing residents' preferences and scheduling for bathing and grooming.
The facility failed to serve food at safe and appetizing temperatures, with residents reporting meals served late and at incorrect temperatures. Observations revealed meals were served from open carts without insulated covers, and sample trays showed cold foods exceeding recommended temperatures. Staff confirmed the lack of sufficient insulated covers and acknowledged the issue.
The facility failed to provide adequate ventilation in the beauty shop, lacking an outside ventilation system as required. An administrative staff member indicated that certain treatments were not performed, so an exhaust fan was deemed unnecessary. The facility also could not provide a policy on beauty shop ventilation when requested.
A facility failed to notify a resident of the termination of Medicare Part A services by not providing the required Notice of Medicare Non-Coverage (NOMNC) or Advance Beneficiary Notice (ABN). The review found that the necessary CMS forms were not completed, and the facility lacked a policy for issuing these notices, as confirmed by administrative staff.
The facility failed to provide consistent activities for two residents in the Memory Care Unit, both with severely impaired cognition. Observations showed residents seated without engagement, and care plans lacked documented activity preferences. Staff interviews revealed reliance on CNAs and part-time staff, with a full-time activity position vacant for months. The facility lacked a policy on providing activities, leading to a deficiency in resident care.
A facility failed to document post-dialysis vital signs for a resident with end-stage renal disease, as required by their care plan. Despite the policy mandating the review and documentation of post-dialysis information, staff did not consistently record vital signs or check the dialysis site, as evidenced by missing documentation on 62 occasions. Interviews revealed that staff did not follow the facility's dialysis communication policy, compromising the resident's post-dialysis monitoring.
A resident with severely impaired cognition was served pork despite documented preferences against it, due to a new computer system error and lack of a facility policy on food preferences. The oversight was acknowledged by dietary staff and confirmed by administrative staff as unacceptable.
A resident with intact cognition and multiple care needs was not included in quarterly care plan development, despite expressing a desire to participate. The facility failed to document his attendance or invitation to care plan meetings, contrary to its policy requiring resident involvement.
The facility failed to ensure residents' rights to retain and use personal possessions, affecting a resident with a motorized wheelchair and another with a missing coat. The first resident, with multiple health issues, was not informed about her wheelchair's delivery and had to use a manual one, causing exhaustion. The second resident's coat was missing for months after dry cleaning, with staff initially unaware. The facility lacked a policy on personal property rights, contributing to these issues.
A resident with HIV did not receive prescribed medications due to the facility's failure to ensure availability, as documented in the MAR. The resident reported missed doses, and an administrative nurse confirmed that staff did not follow the policy for timely reordering or notify the physician when medications were unavailable.
Failure to Submit Completed Abuse/Neglect Investigations to State Agency Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to submit completed abuse/neglect/misappropriation investigation reports to the State Agency (SA) within the required five working days after alleged incidents were reported. The facility had a census of 96 residents, with seven residents reviewed for abuse, neglect, exploitation, and/or misappropriation of resident property. Review of the facility’s notifications to the SA showed multiple incident numbers reported on various dates; however, the corresponding completed investigations were either not submitted within the required timeframe or not submitted at all. For several incidents, the completed investigations were only provided much later during an on-site survey or via e-mail, and for at least one incident, the completed investigation was neither submitted within five working days nor provided to the surveyor during the visit. During an interview on 02/02/26 at 4:00 PM, Administrative Staff A acknowledged that some of the investigations were incomplete, which contributed to the delay in reporting and/or providing the completed investigation reports to the surveyor. Administrative Staff A stated awareness of the required timeframe for submitting completed investigations to the SA and confirmed that the facility’s expectation was for the administrator to complete and submit investigations to the appropriate agencies within that timeframe. The facility’s Abuse, Prevention and Prohibition Policy, dated 11/2025, documented that the administrator would ensure a thorough investigation of allegations, complete the final report, submit it to the required agencies, and maintain the report in a locked file in the administrator’s office, and that no reports would be screened or withheld from appropriate agencies.
Neglect of Resident with Suicidal Ideation
Penalty
Summary
The facility failed to prevent the neglect of a cognitively impaired resident, identified as R53, who had a history of mental health disorders, including dementia, bipolar disorder, and conduct disorder. R53 was known to have episodes of agitation and anxiety, and had a history of exit-seeking behavior. Despite these known risks, the facility staff did not adequately respond to R53's suicidal ideation statements following an elopement incident. After being returned to the facility, R53 expressed a desire to harm himself, including making statements about wanting a gun to shoot himself, but staff did not take immediate action to address these threats. R53's care plan included interventions for monitoring and managing his behaviors, but these were not effectively implemented. The resident was placed on one-hour checks and later on 15-minute checks, but these measures were not consistently maintained. Additionally, there were significant delays in updating R53's medication orders, which were intended to address his mood and behavior issues. The facility's records lacked documentation of progress notes during critical periods, and staff failed to maintain continuous observation of R53, despite his known risk factors and previous elopement. Ultimately, the facility's inaction and failure to respond appropriately to R53's mental health needs and suicidal ideation resulted in a tragic outcome. R53 was found hanging in his room, having used a television cable to harm himself. The facility's neglect in addressing R53's mental health crisis and ensuring his safety placed him in immediate jeopardy, leading to his death.
Removal Plan
- An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting held by interdisciplinary team.
- The Administrator notified the Medical Director.
- The President of Clinical Operations re-educated the Administrator and Director of Nursing on community process for recognizing signs and symptoms of suicidal.
- The Corporate Director of Clinical Reimbursement educated the Administrator, Social Service staff, and Director of Nursing regarding the community process of the social service comprehensive assessment and trauma informed care assessment. Education included intended scheduled, psychosocial care planning.
- Current associates will be re-educated by the community by the Administrator or designee on community. Trauma Informed Care process with specific focus on identification of suicidal symptoms and suicidal ideation, required notifications and immediate actions.
- Social Service comprehensive assessments will be completed upon admission, annually and with significant change. Assessment will be documented in resident medical record.
- Residents identified with need for trauma preventative services will have a trauma informed assessment completed upon admission, annually and with identified significant change in condition. Assessments will be documented in resident medical record. Care plan will be updated as indicated.
- Routine angle rounds will be completed by assigned interdisciplinary team members routinely and will include staff members interviews to validate understanding of resident suicide awareness and notification requirements. Results of the angel rounds will be reported during routine morning stand up meetings. If discrepancies are identified immediate one on one educations will be completed with associate involved.
- During weekly risk review meetings, the interdisciplinary team will review the clinical record of newly admitted residents or residents identified change in condition to validate completion of required social service assessments and or trauma informed care evaluations when indicated. The review will be documented in the resident medical record.
- The Administrator or designee will routinely review sample selected residents to validate compliance of the following: completion of the social service comprehensive assessment as appropriate, completion of trauma informed care assessment as appropriate, psychosocial care plan present when indicated that include resident specific interventions based upon assessment findings; any noted suicidal ideation as indicated.
- Monthly review of completed weekly risk review and angle rounds results and trends will be completed by the Administrator or designee and reported to the QAPI committee and then re-evaluate to determine if further monitoring is indicated.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to a cognitively impaired resident, identified as a high risk for elopement. The resident, who had diagnoses including dementia, bipolar disorder, and conduct disorder, was admitted to the facility in December 2022. Despite being identified as an elopement risk on multiple occasions, the resident was left unsupervised in the courtyard, allowing them to climb a fence and leave the facility. The resident was found approximately two miles away, having traversed busy residential areas and crossed multiple crosswalks and river bridges. The resident's medical records indicated moderately impaired cognition and episodes of agitation and anxiety. The care plan instructed staff to monitor the resident closely and provide redirection if they became restless or agitated. However, on the day of the incident, staff allowed the resident to be outside unsupervised, which led to the elopement. The facility's investigation revealed that staff failed to follow the care plan and elopement policy, which required supervision and the use of safety devices like a Wander Guard bracelet. Interviews with staff indicated a lack of awareness and adherence to the facility's elopement policy. Some staff members were unsure of the resident's elopement history and the removal of the Wander Guard bracelet. The facility's policy required door alarms, personal safety devices, and staff supervision for residents at risk of elopement, but these measures were not effectively implemented, resulting in the resident's unsupervised departure.
Removal Plan
- The Community Interdisciplinary Team completed a review of the community with four additional residents identified as being at risk for elopement and placed in wander guard alarms.
- An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting held by interdisciplinary team.
- The Administrator notified the Medical Director.
- Current clinical associates were re-educated by the Director of Nursing or designee on the Community Elopement policy and Community Elopement Evaluation process. Education included identification of at-risk residents, and courtyard oversight requirements.
- Residents with a new risk for elopement or change in elopement risk will be reviewed by clinical interdisciplinary team during routine clinical huddle to verify elopement risk assessment accuracy, physician notification and preventative interventions in place as indicated. If discrepancies identified, immediate corrective action will be completed, and one on one education completed as indicated.
- Residents identified with a change in elopement risk or who have had an actual elopement attempt will be reviewed during routine risk meeting by clinical interdisciplinary team. Review will be documented in the resident electronic medical record.
- Routine elopement drills scheduled per community policy on varying shifts to confirm staff competency.
- Findings of elopement drills are to be reported to the community Administrator and reviewed at the following morning meeting. If discrepancies are identified immediate correction will be completed and one on one education provided as indicated.
Failure to Address Suicidal Ideation in Resident with Mental Health Disorders
Penalty
Summary
The facility failed to provide appropriate treatment and services to a cognitively impaired resident, identified as R53, who had a history of mental health disorders, including dementia, bipolar disorder, and conduct disorder. R53 exhibited anger related to living in the facility, had a history of exit-seeking behavior, and expressed suicidal ideation. Despite these known risks, the facility staff did not adequately respond to R53's suicidal statements following an elopement incident. On one occasion, R53 eloped from the facility and was found two miles away, after which he was returned to the facility and placed on a WanderGuard bracelet and one-hour checks. R53 continued to express a desire to leave the facility and made statements indicating suicidal thoughts, such as asking for a gun to shoot himself. The staff's response to these statements was insufficient, as they failed to provide immediate and appropriate intervention. The facility's records showed gaps in documentation, and there was a delay in implementing new orders from the psychiatric provider. Despite being placed on one-on-one supervision at times, R53's behaviors and statements were not consistently addressed, leading to a lack of comprehensive care planning and monitoring. Ultimately, the facility's failure to respond to R53's suicidal ideation and manage his mental health needs resulted in a tragic outcome. R53 was found hanging in his room, having used a television cable to commit suicide. The facility's neglect in addressing R53's mental health needs and suicidal ideation placed him in immediate jeopardy, highlighting significant deficiencies in the care provided to him.
Removal Plan
- An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting held by interdisciplinary team.
- The Administrator notified the Medical Director.
- The President of Clinical Operations re-educated the Administrator and Director of Nursing on community process for recognizing signs and symptoms of suicidal.
- The Corporate Director of Clinical Reimbursement educated the Administrator, Social Service staff, and Director of Nursing regarding the community process of the social service comprehensive assessment and trauma informed care assessment. Education included intended scheduled, psychosocial care planning.
- Current associates will be re-educated by the community by the Administrator or designee on Trauma Informed Care process with specific focus on identification of suicidal symptoms and suicidal ideation, required notifications and immediate actions.
- Social Service comprehensive assessments will be completed upon admission, annually and with significant change. Assessment will be documented in resident medical record.
- Residents identified with need for trauma preventative services will have a trauma informed assessment completed upon admission, annually and with identified significant change in condition. Assessments will be documented in resident medical record. Care plan will be updated as indicated.
- Routine angle rounds will be completed by assigned interdisciplinary team members routinely and will include staff members interviews to validate understanding of resident suicide awareness and notification requirements. Results of the angel rounds will be reported during routine morning stand up meetings. If discrepancies are identified immediate one on one educations will be completed with associate involved.
- During weekly risk review meetings, the interdisciplinary team will review the clinical record of newly admitted residents or residents identified change in condition to validate completion of required social service assessments and or trauma informed care evaluations when indicated. The review will be documented in the resident medical record.
- The Administrator or designee will routinely review sample selected residents to validate compliance of the following: completion of the social service comprehensive assessment as appropriate, completion of trauma informed care assessment as appropriate, psychosocial care plan present when indicated that include resident specific interventions based upon assessment findings; any noted suicidal ideation as indicated.
- Monthly review of completed weekly risk review and angle rounds results and trends will be completed by the Administrator or designee and reported to the QAPI committee and then re-evaluate to determine if further monitoring is indicated.
- Residents identified with a change in elopement risk or who have had an actual elopement attempt will be reviewed during routine risk meeting by clinical interdisciplinary team. Review will be documented in the resident electronic medical record.
- Routine elopement drills scheduled per community policy on varying shifts to confirm staff competency.
- Findings of elopement drills are to be reported to the community Administrator and reviewed at the following morning meeting. If discrepancies are identified immediate correction will be completed and one on one education provided as indicated.
Failure to Conduct Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct annual performance evaluations for its certified nursing assistants (CNAs), which are essential to assess their strengths and weaknesses in providing resident care. The review of personnel files for five CNAs revealed that none had received an annual review, despite their varying hire dates ranging from 2019 to 2022. Interviews with administrative staff indicated a lack of clarity regarding responsibility for completing these evaluations, with one staff member believing it was the Director of Nursing's duty, while another thought it was the Administrator's responsibility. Additionally, the facility did not have a policy in place to ensure the completion of these evaluations, leading to the oversight.
Deficiency in CNA In-Service Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an in-service training program to ensure that Certified Nurse Assistants (CNAs) completed the required 12-hour in-service education. This deficiency was identified through a review of personnel files and in-service training records for five CNAs who had been employed at the facility for at least one year. Each of these CNAs, identified as UU, VV, S, PP, and T, lacked the necessary 12 hours of in-service education, with CNA T having received only 0.5 hours. This lack of training placed residents at risk of decreased quality of care. Interviews with facility staff revealed awareness of the deficiency. Administrative Nurse D acknowledged the issue, stating it was a work in progress, and the Director of Nurses had begun monitoring the training. Licensed Nurse L reported that while some staff had access to computer training, not all had login credentials, and training was sometimes conducted through meetings or paper sign-offs. Administrative staff A confirmed that the computer training system was not being used as intended. Additionally, the facility lacked a policy outlining the 12-hour in-service training requirement.
Inadequate Behavioral Health Training for Staff
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all staff, specifically in the area of behavioral health care and services. This deficiency was identified through a review of personnel files and course completion histories of five Certified Nursing Assistants (CNAs). The review revealed that several CNAs had not started or completed required training modules on Alzheimer's Disease and Related Disorders: Behaviors and Behavioral Health, with due dates ranging from 2022 to 2024. The lack of training was acknowledged by the administrative nurse and other staff members, who reported that the training was a work in progress and that not all staff had access to the computer training system. Interviews with staff further highlighted the inadequacy of the training program. A Licensed Nurse reported that while some computer training was available, not all staff had login access, and training often consisted of reading and signing off on a piece of paper rather than receiving actual instruction on handling residents with behavioral issues. Administrative staff also admitted that the computer training was not being utilized as intended, and there was no policy in place regarding the requirements for behavioral training. This lack of an effective training program placed all 96 residents at risk of not reaching their highest practicable well-being.
Failure to Accommodate Resident Bathing Preferences
Penalty
Summary
The facility failed to honor and facilitate resident self-determination by not accommodating the bathing preferences of several residents. Resident 92, who had cognitive intactness and required substantial assistance due to hemiparesis, reported that he was only allowed a bath once a week, despite his preference for at least two baths per week. The facility's shower schedule was based on room numbers rather than individual preferences, and the care plan lacked specific directions regarding his bathing schedule and preferences. The resident's electronic medical record showed he received a bath only three times in the previous 30 days, and there was no documentation of offered bathing opportunities or refusals. Resident 74, with severe cognitive impairment and dependent on staff for daily living activities, also experienced a lack of accommodation for bathing preferences. The care plan directed staff to assist with showering twice weekly, but it did not address specific preferences or schedules. Observations revealed the resident had long, unkempt fingernails and a stale urine odor, indicating inadequate personal hygiene care. The electronic medical record showed the resident received a bath only twice in the previous 30 days, with no documentation of offered or refused bathing opportunities. Resident 73, with moderate cognitive impairment and dependent on staff for personal hygiene, reported not having a bath for months and expressed a preference for a weekly bed bath. The care plan did not specify the type of assistance or bathing schedule, and the resident's electronic medical record lacked documentation of offered or refused bathing opportunities. The resident also reported issues with grooming, as his hair and beard were not trimmed, and his fingernails were unclean. The facility's master schedule for bathing was based on room numbers, not individual preferences, and there was no policy addressing residents' bathing preferences and scheduling.
Deficiencies in Smoking Area Maintenance and Personal Property Management
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for 28 residents who smoked in three designated smoking areas and the service hallway leading to the southeast smoking area. Observations revealed that the smoking areas were not maintained, with cigarette butts littering the ground and broken cigarette disposal towers. The service hallway had missing floor tiles, chipped chair rails, and a buildup of grime, which residents had to navigate to access the smoking area. These conditions were confirmed by both activity and administrative staff, who acknowledged the need for cleaning and repairs. A resident, who was alert and oriented, expressed concerns about the cleanliness and maintenance of the smoking area. She reported having to use her hands to propel her wheelchair through the dirty hallway, fearing infection due to her existing wounds and diabetes. Despite staff supervision during smoke breaks, the smoking areas remained unclean, posing a risk to residents' safety and comfort. Additionally, the facility failed to ensure a resident received his personal property back in a timely manner. The resident's topcoat, which required dry cleaning and button replacement, was missing for a couple of months. Despite the resident's repeated requests to administrative and social service staff, the coat was only returned after the survey, without the buttons replaced. The facility lacked a policy on personal property, contributing to the delay in returning the resident's belongings.
Inaccurate MDS Documentation for Multiple Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for several residents, leading to potential uncommunicated needs for care and services. Resident 28's MDS inaccurately documented the administration of hypoglycemic medication, which was not supported by the electronic medical record or physician's orders. This discrepancy was confirmed by Administrative Nurse E, who acknowledged the error in the MDS assessment. Resident 47's MDS inaccurately recorded the use of hypnotic medication, which was not administered during the assessment period. The resident's care plan and physician's orders did not support the use of hypnotic medication, and this error was also confirmed by Administrative Nurse E. Similarly, Resident 41's MDS failed to capture a documented fall, despite progress notes indicating a fall that resulted in hospitalization. The lack of accurate documentation on the MDS was acknowledged by the administrative staff. Residents 54 and 82 also had inaccuracies in their MDS assessments related to falls. Resident 54 experienced multiple falls that were not documented in the MDS, despite being noted in progress notes and care plans. Resident 82's MDS failed to document a fall with injury, and the Care Area Assessment (CAA) lacked necessary documentation. These inaccuracies were confirmed by Administrative Nurse E, who noted the absence of a facility policy for MDS completion, relying instead on the Resident Assessment Instrument (RAI) manual.
Deficiencies in Care Plan Revisions for Bathing Preferences and Fall Prevention
Penalty
Summary
The facility failed to review and revise care plans for several residents, leading to deficiencies in addressing their bathing preferences and fall prevention needs. Resident 92, who had cognitive intactness and required assistance with bathing due to hemiparesis, reported dissatisfaction with the bathing schedule and frequency, which was not reflected in his care plan. Despite being scheduled for showers twice a week, the electronic medical record showed he only received three baths in the previous month, and there was no documentation of offered or refused bathing opportunities. Social services confirmed multiple grievances from residents about not receiving baths, and staff interviews revealed that residents' preferences should be documented and respected, which was not the case for Resident 92. Resident 73, with moderate cognitive impairment and dependent on staff for activities of daily living, also had a care plan that failed to address his bathing preferences and schedule. He reported not receiving a bath for months and expressed a preference for a weekly bed bath, which was not accommodated. His care plan lacked directions for hygiene and grooming, and the facility's documentation did not reflect offered or refused bathing opportunities. Staff interviews confirmed that residents should receive a minimum of two baths a week, and their preferences should be documented in the care plan, which was not done for Resident 73. Residents 74 and 81 also had care plans that did not reflect their bathing preferences, with Resident 74 receiving only two baths in the previous month and Resident 81's care plan lacking specific days and times for preferred baths. Additionally, Residents 54 and 41, who were at risk for falls, had care plans that did not include necessary interventions to prevent falls. Resident 54 had multiple falls due to tripping on blankets, and Resident 41 had a fall that resulted in hospitalization, yet their care plans were not updated with appropriate interventions. The facility lacked a policy on care plan revision, and staff interviews revealed that care plans were not always revised or updated in a timely manner, contributing to these deficiencies.
Deficiencies in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for several residents, including those with cognitive impairments and physical disabilities. Resident 92, who had a history of spastic hemiplegia and hemiparesis, reported not receiving a bath for over a week, despite his preference for at least two baths per week. The care plan for Resident 92 lacked specific directions regarding his bathing schedule and preferences, and the facility's documentation did not reflect that bathing opportunities were offered or refused. Resident 74, diagnosed with Alzheimer's disease and receiving hospice care, was found with long, jagged fingernails and a stale urine odor, indicating a lack of personal hygiene care. The facility's records showed that Resident 74 received only two baths in the previous 30 days, and there was no documentation of nail care or refusals of offered care. Similarly, Resident 73, who had multiple health issues including diabetes and a chronic ulcer, reported not receiving a bath for months and had long, unkempt hair and nails. The care plan for Resident 73 also lacked specific instructions for personal hygiene care. Resident 81, with end-stage renal disease and diabetes, received inadequate bathing services, with records showing only a few baths over several months. The care plan did not specify the resident's preferences for bathing. Additionally, Resident 82, who had dementia and required assistance with daily living activities, was observed with long facial hair, indicating a lack of grooming care. The facility lacked policies addressing residents' bathing preferences, scheduling, and personal hygiene care, contributing to the deficiencies observed.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to serve food that is palatable and at a safe and appetizing temperature for its residents. During an entrance tour, it was observed that meal trays were being served from open metal carts without insulated covers or closed insulated food service carts. Residents expressed concerns about the food being served at incorrect temperatures, with some reporting that meals were served late and that hot foods were cold while cold foods were warm. Social Service Staff confirmed that residents had complained about food temperatures during Resident Council meetings, and it was noted that the facility had been serving meals in residents' rooms due to COVID-19, using open carts without sufficient insulated covers. Further investigation revealed that the facility lacked enough insulated covers or closed meal carts to maintain appropriate food temperatures for all residents eating in their rooms. A sample tray tested showed cold food items, such as potato salad and egg salad, were served at temperatures exceeding the recommended 42 degrees Fahrenheit, while hot items were served on the same plate, further compromising the cold food temperatures. Dietary Staff confirmed these temperatures were unacceptable, and Administrative Staff acknowledged that cold foods should not be served on heated plates. The facility's policy on cooking and cooling did not address maintaining food temperature through the point of service.
Inadequate Ventilation in Beauty Shop
Penalty
Summary
The facility, with a reported census of 96 residents, failed to provide adequate ventilation in the beauty shop. During an observation on August 5, 2024, it was noted that the beauty shop lacked ventilation to the outside through a window, mechanical vent, or a combination of both, which is required to promote good air circulation. An interview with Administrative Staff A revealed that the beautician did not perform certain treatments like perms or bleaching in the beauty shop, leading to the belief that an exhaust fan was not necessary. Additionally, the facility was unable to provide a policy regarding beauty shop ventilation when requested on the same day.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to notify a resident, identified as R22, of the termination of Medicare Part A services as required by regulations. The deficiency was identified during a review of discharged Medicare A residents, where it was found that R22, who was discharged from Part A services, did not receive the necessary Notice of Medicare Non-Coverage (NOMNC) or Advance Beneficiary Notice (ABN). These forms are crucial as they inform residents about the end of Medicare-covered services and any potential financial responsibilities they may incur. The review revealed that the facility did not complete the required CMS forms, specifically the CMS-10055 and CMS-10123, which are used to document the provision of these notices. During an interview, Administrative Staff B confirmed the absence of the required forms for R22 and acknowledged the facility's procedure to issue a NOMNC and/or ABN three days before discharge. However, the facility was unable to provide a policy regarding Beneficiary Notice when requested, further highlighting the deficiency in their process. The lack of documentation and adherence to the notification procedure resulted in the failure to inform R22 of the Medicare Part A service termination and the remaining benefit days, as required by regulations.
Inconsistent Activity Provision in Memory Care Unit
Penalty
Summary
The facility failed to provide consistent activities for residents in the Memory Care Unit, specifically affecting two residents, R41 and R82. R41, with severely impaired cognition, was observed multiple times seated in the lounge with the television on, without engaging in any activities. The care plan for R41 lacked any documented activity preferences, and there were no activity notes in the progress records from April to July 2024. Family members and staff confirmed the absence of activities, and the facility relied on CNAs to provide activities, which were not consistently delivered. Similarly, R82, also with severely impaired cognition, was observed seated in her wheelchair facing a wall, with no activities provided. Although R82's care plan included activity preferences such as music and painting, there was little evidence of these activities being offered. The progress notes indicated minimal engagement, with only a nail spa activity documented in May 2024. Staff interviews revealed a lack of understanding and implementation of scheduled activities, with reliance on part-time staff and CNAs who did not consistently provide the activities listed on the calendar. The facility's activity department was understaffed, with a full-time position vacant for about three months, leading to inadequate activity provision. The facility lacked a policy on providing activities, contributing to the deficiency. This failure to provide consistent activities placed residents at risk for complications related to decreased psychosocial wellbeing.
Failure to Document Post-Dialysis Vital Signs
Penalty
Summary
The facility failed to ensure that staff obtained vital signs or checked the dialysis site after Resident 81 returned from dialysis. Resident 81, who has a diagnosis of diabetes mellitus and end-stage renal disease, requires dialysis three times a week. The care plan for Resident 81 specifies that staff should monitor and document any new orders, communication, or information received after dialysis, and report any signs of infection or bleeding at the access site. However, a review of the dialysis book forms from August 7, 2023, to July 30, 2024, revealed that the facility lacked documentation of post-dialysis vital signs and nurses' signatures on 62 occasions. Interviews with staff indicated a lack of adherence to the facility's policy on dialysis communication. Licensed Nurse K mentioned documenting vitals in the Electronic Medical Record but not on the dialysis form, while Administrative Nurse D noted that staff do not remove the dialysis book from the resident's wheelchair upon return. The facility's policy requires the nurse in charge to review the communication form and obtain necessary post-dialysis information, which was not consistently done. This failure to document and monitor post-dialysis vital signs compromised the ability to ensure Resident 81's stability and detect any adverse reactions to the dialysis procedure.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a food preference for a resident, identified as R41, who was served pork despite having a documented preference against it. R41 had a severely impaired cognition as indicated by a BIMS score of 00 and required assistance with meal setup. The resident's care plan and physician's order both specified no pork or shellfish, yet these preferences were not consistently honored. On one occasion, R41 was served a salami sandwich, and on another, a bowl of ham and bean soup, both of which contained pork. These incidents were brought to the attention of staff by R41's family member. The dietary staff acknowledged the oversight, attributing it to a new computer system that failed to print extra comments on meal tickets, which staff relied on during meal preparation. Despite the meal ticket clearly stating "NO PORK," the dietary staff missed this instruction. The facility lacked a policy on food preferences, contributing to the oversight. Administrative staff confirmed the issue and deemed it unacceptable, highlighting a deficiency in the facility's ability to provide adequate care and services by not adhering to documented food preferences.
Failure to Include Resident in Care Plan Development
Penalty
Summary
The facility failed to include Resident 61 in the development and planning of his care plan quarterly, despite his intact cognition and expressed desire to participate. The resident's electronic medical record documented diagnoses including acute kidney failure, HIV, and muscle weakness, and indicated a BIMS score of 15, showing intact cognition. The resident had various care needs, including assistance with ADLs, occasional bladder incontinence, and moisture-associated skin damage. Despite these needs and the resident's interest in being involved in care discussions, the facility did not document his participation or invitation to care plan meetings beyond an initial conference. Interviews with facility staff revealed that the resident reported never being given the opportunity to participate in his care plan, which he felt was important. Social services staff and administrative nurses confirmed that the facility lacked documentation of the resident's attendance or invitation to care plan meetings. The facility's policy stated that residents should be given notice and options for participation in care plan meetings, but this was not adhered to in the case of Resident 61, leading to a deficiency in ensuring resident involvement in care planning.
Failure to Ensure Residents' Rights to Personal Possessions
Penalty
Summary
The facility failed to uphold the resident's right to retain and use personal possessions, specifically concerning a motorized wheelchair for one resident and a missing coat for another. Resident 63, who has multiple diagnoses including diabetes, COPD, and anxiety disorder, was not informed about the delivery of her motorized wheelchair to the facility. Despite being cognitively intact and expressing the importance of her personal belongings, she was left to use a manual wheelchair, which caused her exhaustion when navigating to the designated smoking area. The facility did not conduct an assessment to determine her ability to safely operate the motorized wheelchair, and staff were unaware of its presence in the facility. Another resident, Resident 54, who has dementia and muscle weakness but is cognitively intact, reported his topcoat missing after it was sent for dry cleaning. Despite his repeated requests and discussions with staff, the coat was not returned for several months. The facility's records lacked any documentation regarding the missing coat, and staff were initially unaware of the issue. Eventually, the coat was located and returned, but the delay in its return was not addressed in a timely manner. The facility lacked a policy on resident rights related to retaining and using personal property, which contributed to these deficiencies. The absence of such a policy and the staff's lack of awareness and communication regarding the residents' personal possessions led to the failure to ensure the residents' rights were respected.
Failure to Ensure Medication Availability for Resident
Penalty
Summary
The facility failed to ensure that a resident's medication was available for administration without missed doses, which placed the resident at risk of unnecessary complications. The resident, who had a diagnosis of Human Immunodeficiency Virus (HIV), required specific medications, Abacavir Sulfate-Lamivudine and Efavirenz, to be administered daily at bedtime as ordered by the physician. However, the Medication Administration Record (MAR) indicated that these medications were not administered as prescribed, and the progress notes lacked documentation explaining why the medications were on hold. The deficiency was further highlighted when the resident reported not always receiving medications as ordered. An administrative nurse confirmed that the staff failed to notify the physician for further guidance when the medications were unavailable. The facility's policy required timely reordering of medications when only a three-day supply remained, but this was not adhered to, resulting in the resident being out of medication. The staff also failed to utilize the emergency drug kit or notify the director of nursing and the practitioner when the medication was not available.
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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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