Merriam Gardens Healthcare & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Merriam, Kansas.
- Location
- 9700 W 62nd Street, Merriam, Kansas 66203
- CMS Provider Number
- 175123
- Inspections on file
- 18
- Latest survey
- January 31, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Merriam Gardens Healthcare & Rehabilitation during CMS and state inspections, most recent first.
The facility did not complete yearly performance evaluations for three CNAs, risking inadequate care for residents. Despite the policy requiring annual evaluations, none were available for CNAs hired in 2022. Administrative staff confirmed the absence of these evaluations.
The facility failed to store food items according to professional standards, risking contamination and food-borne illness. Observations included an open bag of oats on the floor, undated condiments, and uncovered food in refrigerators and freezers. Dietary staff confirmed the need for proper labeling and storage, as outlined in the facility's Food Storage policy.
The facility failed to address recurring issues reported by the Resident Council, including cold meals, menu discrepancies, and unsanitary shower rooms. Despite ongoing concerns documented from September 2023 to September 2024, the facility did not take action to resolve these issues, leading to a deficiency that affected residents' psychosocial well-being.
The facility failed to maintain a safe and homelike environment, with medical equipment stored in resident areas and unclean bathrooms. The Resident Council reported concerns about cleanliness and equipment storage, which were not addressed. Equipment was moved due to construction, and non-emergency overhead paging was frequent, contrary to facility policy.
A facility failed to secure hazardous cleaning chemicals, leaving them accessible to cognitively impaired residents. Additionally, two residents did not receive care-planned fall interventions, placing them at risk for preventable accidents. One resident's bed was not in the low position, and a landing mat was missing, while another resident's call light was out of reach, and a wedge was not in place. Staff interviews confirmed these interventions should have been implemented according to care plans.
The facility failed to ensure controlled substances were properly accounted for between shifts, with missing signatures on Narcotic Shift Count Sheets for several dates. Staff interviews revealed that narcotic counts were not consistently conducted as required, despite the facility's policy emphasizing safeguards against loss or diversion.
The facility failed to provide the posted breakfast menu items when the kitchen ran out of bacon and sausage, leaving residents without promised protein options. Several residents expressed dissatisfaction, noting this was a recurring issue on weekends. The dietary staff did not offer alternatives, and the consultant was unaware of the shortage.
The facility failed to serve meals at appropriate temperatures, affecting several residents who reported receiving cold food. Observations confirmed that meals were often below safe and appetizing temperatures. Staff interviews revealed inconsistencies in meal delivery processes, with some meals requiring reheating. The facility's policy stated that meals should be served at appropriate temperatures, but this was not consistently followed.
The facility failed to implement proper infection control measures, including Enhanced Barrier Precautions (EBP) and sanitary practices. Several residents' rooms lacked EBP signage, and PPE was not used correctly. Oxygen equipment was improperly stored, and laundry services were not monitored for sanitation. These deficiencies placed residents at risk for infectious diseases.
The facility failed to maintain essential equipment, impacting residents' quality of life. The Resident Council reported a broken pipe in a shower room, which remained out of order for over a year, causing inconvenience. Additionally, a medication room sink was taped up and out of order for the same duration. Maintenance and administrative staff were uncertain about repair timelines, despite ongoing remodeling efforts.
The facility failed to accommodate the needs of two residents. One resident, with multiple health conditions, was not provided a lipped plate or cut-up meat, hindering his ability to eat. Another resident, with severe cognitive and physical impairments, had her call light out of reach, preventing her from communicating needs. These oversights violated the facility's policy and left the residents vulnerable to unmet care needs.
The facility failed to provide the correct SNF Advance Beneficiary Notice of Non-coverage (ABN) to two residents who remained for custodial care after their Medicare Part A episodes ended. Instead, an incorrect form was issued, contrary to the facility's policy. This error was due to miscommunication, as Social Services staff were instructed to use the wrong form until recently updated with the correct one.
A facility failed to provide written notification of transfers to a resident and their representatives, as well as to the LTCO, for multiple hospitalizations. The resident had severe cognitive impairment and was dependent on staff for all functional abilities. Staff interviews confirmed the lack of adherence to notification procedures, and the facility could not provide a relevant policy when requested.
A facility failed to provide a bed hold policy notice to a resident with severe cognitive impairment and other medical conditions during hospital transfers. The resident had multiple unplanned discharges to a hospital, and the facility did not issue the required bed hold notices, posing a risk to the resident's ability to return to the facility or their previous room.
A facility failed to complete the annual comprehensive MDS for a resident by not documenting analysis for triggered care areas. The resident, with severe cognitive impairment and multiple medical conditions, required extensive care and support. Despite this, the necessary documentation for areas such as communication, urinary incontinence, and pressure ulcers was missing, risking inaccurate status reflection and an incomplete care plan. Staff interviews indicated the MDS coordinator was responsible for these tasks, but the facility's policy was not adhered to.
A resident with cognitive and physical impairments did not receive the necessary assistance for dressing, as outlined in their care plan. Despite the facility's policy requiring staff to follow care-planned interventions, the resident was observed struggling to dress independently, and staff interviews confirmed a lack of consistent supervision and assistance.
A facility failed to follow a physician's order for weight monitoring and administration of a PRN diuretic for a resident with CHF, leading to a risk of fluid overload. Despite significant weight fluctuations, the PRN diuretic was not administered as ordered. The facility's process involved CNAs obtaining weights and nurses following up, but this was not effectively executed.
A resident with a history of hemiparesis following a stroke was not provided with a required palm splint, as observed on two occasions. The care plan indicated the need for a palm protector to prevent skin breakdown and maintain range of motion, but the EMR lacked instructions for its application. Staff interviews revealed an expectation to know device needs through care plans, yet the splint was not consistently used, risking decreased range of motion.
A facility failed to ensure a CP identified and reported when a resident's blood pressure medication was administered outside physician-ordered parameters. The resident, with respiratory and hepatic failure, received midodrine despite instructions to hold it if SBP exceeded 130 mm/Hg. The CP did not make recommendations to address this, and the facility lacked a policy for pharmacy recommendations.
A resident with respiratory and hepatic failure was prescribed midodrine with specific parameters to hold the medication if SBP exceeded 130 mm/Hg. However, the medication was administered outside these parameters multiple times over several months. Staff interviews revealed a lack of system alerts and responsibility adherence, leading to the risk of unnecessary medication administration and adverse side effects.
A facility failed to ensure a coordinated hospice care plan for a resident with multiple diagnoses, including dementia and diabetes mellitus, who was receiving hospice services for cerebral atherosclerosis. The care plan lacked details on hospice services, such as medication and equipment, placing the resident at risk for inappropriate end-of-life care. Staff interviews revealed confusion about hospice provisions, with some relying on the care plan or hospice binder for information. The facility's policy on coordinating hospice services was not adhered to, resulting in this deficiency.
A resident did not receive the PCV20 vaccine despite having a signed consent. The facility's records showed a previous Pneumovax administration but lacked documentation for the PCV20. The Infection Preventionist confirmed the absence of documentation, which was against the facility's policy to offer immunizations per CDC guidelines.
Failure to Complete Yearly CNA Performance Evaluations
Penalty
Summary
The facility failed to complete yearly performance evaluations for three out of five Certified Nurse Aides (CNAs) reviewed, which placed residents at risk for inadequate care. The facility had a census of 74 residents, and the sample included 18 residents. The CNAs in question were hired on specific dates in 2022, but upon request, no yearly performance evaluations were available for CNA N, CNA P, and CNA Q. Administrative Staff C confirmed the absence of these evaluations, and Administrative Nurse D acknowledged responsibility for completing the nursing staff's yearly performance reviews. The facility's Evaluation Process policy, dated December 1, 2019, mandates annual formal written evaluations of employee work performance, which were not adhered to in these cases.
Food Storage Deficiency in Facility Kitchen
Penalty
Summary
The facility, with a census of 74 residents and one main kitchen, failed to store food items in accordance with professional standards for food service safety. During an initial tour of the kitchen, surveyors observed a large open bag of oats stored on the floor of the dry storage area. Additionally, the refrigerator contained open and undated condiments, and another refrigerator had an undated and uncovered silver pan with two heads of lettuce in an unsealed bag on top of wilted lettuce. The side-by-side freezer also contained an undated and uncovered silver pan of a dessert. Dietary Staff BB confirmed that all items should be labeled, dated, and stored off the floor, and that all food in the freezers and refrigerator must be covered, sealed, labeled, and dated. The facility's undated Food Storage policy stated that food should be stored on shelves in a clean, dry area free from contaminants, at appropriate temperatures, and using appropriate methods to ensure food safety. The facility's failure to adhere to these standards placed residents at risk for contamination and food-borne illness.
Facility Fails to Address Resident Council Concerns
Penalty
Summary
The facility failed to address and resolve recurring issues reported by the Resident Council, which placed residents at risk for decreased psychosocial well-being. The Resident Council Minutes from September 2023 through September 2024 documented ongoing concerns about food choices, menu discrepancies, food temperatures, and the availability of meals. Additionally, there were repeated issues with the maintenance and cleanliness of shower rooms, specifically the [NAME] hall's right shower room, which had been out of service for over a year. Despite these concerns being raised consistently in the council meetings, the minutes lacked documentation of actions taken or outcomes achieved to resolve these issues. Observations and interviews conducted in October 2024 further highlighted the facility's inaction. The Resident Council reported that meals were still being served cold, the kitchen frequently ran out of food items and condiments, and the [NAME] Hall shower room remained out of service, leading to missed or delayed showers. An inspection of the left shower room revealed unsanitary conditions, including soiled towels, feces in the toilet, and a rust-like substance on the walls. Dietary Staff BB and Administrative Nurse D were unaware of the ongoing issues, and Maintenance Staff V indicated that the facility was still seeking bids to repair the shower room, with no timeline for resolution. The facility's Resident Council policy required the use of a resident response form to track concerns and resolutions, with the relevant department responsible for addressing issues. However, the facility did not act upon the council's concerns in a timely manner, failing to accommodate the residents' recommendations. This lack of action and resolution of the recurring issues reported by the Resident Council resulted in a deficiency that compromised the residents' quality of life and psychosocial well-being.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations and resident council reports. During a walkthrough, surveyors noted various pieces of medical equipment, such as wedge cushions, a bathroom commode, walkers, an IV pole, a shower bed, wheelchairs, and a Broda chair, stored in resident areas and hallways, including near an emergency exit. Additionally, the facility's bathrooms were found to be unclean, with soiled towels on the floor and a rust-colored substance on the shower tiles. The Resident Council expressed ongoing concerns about the cleanliness of the bathrooms and the inappropriate storage of medical equipment in common areas, which they had reported to staff multiple times. Further investigation revealed that the facility's 500-hallway was under construction, leading to the relocation of equipment into other hallways. Housekeeping staff indicated that direct care staff were responsible for cleaning the showers after resident care, while cleaning staff typically cleaned the shower rooms daily or as needed. Despite this, inspections found the shower rooms to be inadequately maintained, with feces in the toilet and a rust-like substance on the walls. The facility's policy on maintaining a safe and homelike environment, which includes limiting overhead paging to emergencies, was not adhered to, as numerous non-emergency pages were made throughout the facility.
Failure to Secure Hazardous Chemicals and Implement Fall Interventions
Penalty
Summary
The facility failed to secure potentially hazardous cleaning chemicals, leaving them accessible to ten cognitively impaired, independently mobile residents. During an inspection, a bottle of Sani-wipes was found unsecured on a table in the television area, and an unlocked cabinet containing Virex II disinfecting solution was discovered in an unlocked shower room. Both products had warnings indicating they were hazardous to humans and should be kept out of reach of children. Staff interviews confirmed that cleaning products should be locked up when not in use, as per the facility's Accidents and Supervision policy. The facility also failed to implement care-planned fall interventions for two residents, R9 and R73, placing them at risk for preventable accidents and injuries. R9, who has severe cognitive impairment and requires total staff assistance, was found without a landing mat next to his bed, which was in a high position, contrary to his care plan instructions. Staff interviews revealed that fall interventions should be reviewed and implemented as per the care plan, but this was not done for R9. Similarly, R73, who has moderately impaired cognition and is at risk for falls, was found with her call light out of reach and her wedge not in place, as required by her care plan. Despite multiple falls and documented interventions, staff failed to ensure these measures were in place. Interviews with staff confirmed that interventions should be implemented as per the care plan, but this was not consistently done for R73, as outlined in the facility's policy.
Failure to Reconcile Controlled Substances
Penalty
Summary
The facility failed to ensure controlled substances were properly accounted for and reconciled between shifts, which placed residents at risk for misappropriation and/or diversion of these medications. During a review of the Narcotic Shift Count Sheets for July, August, and September 2024, it was found that there were missing signatures for either the on-coming or off-going nurse for several dates on both the 500 and 600 halls. This issue was observed for both morning and evening shifts, indicating a pattern of non-compliance with the facility's procedures for controlled substance accountability. Interviews with staff revealed that the expectation was for each nurse or Certified Medication Aide to count the narcotics with the on-coming and off-going nurse daily, and that staff should not leave the facility until the narcotic count was correct. However, this procedure was not consistently followed, as evidenced by the missing signatures. The facility's Controlled Substance Administration and Accountability policy, dated January 1, 2020, emphasized the importance of safeguards to prevent loss, diversion, or accidental exposure, yet these safeguards were not effectively implemented, leading to the deficiency.
Failure to Provide Posted Menu Items
Penalty
Summary
The facility failed to ensure that dietary staff provided the posted menu items to residents during a breakfast meal on 09/30/24. Specifically, the kitchen ran out of bacon and sausage, which were listed as options on the menu. This incident was observed during breakfast at 08:30 AM, where several residents, including R6, R25, R75, R24, and R182, expressed dissatisfaction that the menu promised either bacon or sausage, but these items were not available. Instead, residents were served toast, scrambled eggs, and jelly, without any alternative protein options being offered. Resident R24 noted that this was a recurring issue on weekends, where the kitchen frequently ran out of food, and no alternatives were provided. The Week At A Glance - Week1 Menu for Monday Day 2 documented that breakfast should include assorted juice, a choice of hot or cold cereal, an egg of choice, two strips of bacon or sausage, toast, margarine and syrup, and milk or beverage. On 10/02/24, Consultant HH reported being unaware of the shortage and had not received any concerns from staff or residents about food shortages. However, Dietary BB acknowledged that some residents did not receive bacon or sausage on 09/30/24 due to the kitchen running out of these items. This failure to provide the posted menu items placed residents at risk of not having their nutritional needs and preferences met.
Deficiency in Serving Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at a palatable, safe, and appetizing temperature, affecting several residents. Observations and interviews revealed that residents frequently received meals that were cold, both in the dining room and in their rooms. For instance, one resident reported that his breakfast was often cold, with temperature checks confirming that his eggs were at 90 degrees Fahrenheit and oatmeal at 107 degrees Fahrenheit. Another resident in the dining room reported similar issues, with eggs at 97 degrees Fahrenheit and oatmeal at 101 degrees Fahrenheit. The Resident Council also expressed ongoing concerns about cold food being served. Staff interviews indicated a lack of clarity and consistency in meal delivery processes. A CNA mentioned that meals sometimes needed reheating, while a Licensed Nurse acknowledged frequent complaints about food temperatures. Dietary staff stated that meals should not sit for more than 15 minutes before being served, yet acknowledged that communication between nursing staff and the kitchen was necessary if meals were cold. The facility's Dining Experience policy emphasized that meals should be nourishing, attractive, and palatable, maintaining appropriate temperatures, but this was not consistently achieved.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, specifically Enhanced Barrier Precautions (EBP), for residents identified as at risk for multidrug-resistant organisms. During an inspection, it was observed that several residents' rooms lacked appropriate EBP signage, which is crucial for alerting staff and visitors to the necessary precautions. For instance, residents requiring care for PEG tubes, Foley catheters, and hemodialysis did not have the required EBP signage. Additionally, there were instances where personal protective equipment (PPE) was not used correctly, such as a licensed nurse not wearing a protective gown during wound care. The facility also failed to maintain sanitary infection control practices related to oxygen equipment and laundry services. Oxygen tubing and nasal cannulas were found improperly stored, often resting on beds or wheelchairs without sanitary bags. Soiled clothing was observed placed directly on the floor, and there was no monitoring of laundry temperatures to ensure proper sanitation. Furthermore, the shower room was found in an unsanitary condition, with soiled towels on the floor and feces in the toilet. These deficiencies in infection control practices placed residents at risk for infectious diseases.
Failure to Maintain Functional Equipment
Penalty
Summary
The facility failed to maintain essential equipment in a safe and functional status, impacting the quality of life for its residents. The Resident Council Minutes from September 2023 indicated concerns about a broken pipe in the right-side shower room of the [NAME] Hall, which was confirmed by a plumber. Despite this, the issue persisted, as noted in the October 2023 minutes, and the shower room remained out of order as of September 2024. During a walkthrough on September 30, 2024, an out-of-order sign was observed on the shower room, and the Resident Council reported on October 1, 2024, that the shower room had been closed for over a year, causing inconvenience to residents who had to be wheeled across the building for bathing. Additionally, an inspection of the East Hallway medication room on October 1, 2024, revealed a sink that had been taped up and out of order for over a year. Maintenance Staff V was unaware of the sink issue and stated that the facility was seeking bids to fix the shower room pipe. Administrative Nurse D and Administrative Staff A were also uncertain about the timeline for repairs, with the latter mentioning ongoing remodeling efforts. The facility's Preventative Maintenance Program policy, revised in October 2019, mandates a safe, comfortable, functional, and sanitary environment, which was not upheld in this instance.
Failure to Accommodate Resident Needs
Penalty
Summary
The facility failed to accommodate the needs of Resident 47 by not providing a lipped plate and not cutting his meat into bite-size portions, as required by his care plan and physician's orders. Resident 47, who has diagnoses including congestive heart failure, hypertension, hemiparesis following a stroke, aphasia, and anemia, was observed struggling to eat his breakfast due to the absence of these accommodations. Despite the facility's policy requiring nursing staff to check meal tickets for special equipment needs, the oversight occurred, leaving Resident 47 unable to eat his meal properly. Additionally, the facility did not ensure that Resident 50's call light was within reach, which is crucial for her to communicate her needs due to her severely impaired cognition and physical limitations. Resident 50, who has a history of hypertension, cerebral infarction, and congestive heart failure, was found with her call light under her bed, out of reach. This was contrary to the facility's policy and the statements from staff members who acknowledged that call lights should always be accessible to residents. Both deficiencies highlight a failure in the facility's processes to ensure that residents' individual needs and preferences are met, as outlined in their care plans and the facility's Accommodation of Needs policy. These oversights left Residents 47 and 50 vulnerable to unmet care needs, as they were unable to independently manage their meals and communicate their needs effectively.
Failure to Provide Correct Medicare Coverage Notices
Penalty
Summary
The facility failed to provide the correct Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage (ABN), form CMS-10055, to two residents, identified as R3 and R132, who remained in the facility for custodial care after their Medicare Part A episodes ended. Instead, the facility issued form CMS-R-131, which was not the appropriate form for this situation. This oversight was identified during a review of the residents' Electronic Medical Records (EMR), which documented the Medicare Part A episodes for R3 from 07/09/24 to 07/16/24 and for R132 from 01/31/24 to 03/12/24. The facility's policy, dated 11/01/19, required the use of the correct SNF ABN form CMS-10055 for Part A items and services. However, Social Services X indicated that she had been instructed to use a different form, CMS-R-131, until she received the updated CMS-10055 form from the regional manager two weeks prior to the survey. This miscommunication and failure to adhere to the facility's policy placed the residents at risk for making uninformed decisions regarding their Medicare coverage and potential liability for services not covered.
Failure to Notify Resident and Ombudsman of Transfers
Penalty
Summary
The facility failed to provide written notification of transfer to Resident 45 or their representatives for facility-initiated transfers. Additionally, the facility did not notify the long-term care ombudsman (LTCO) regarding these transfers. This deficiency was identified through observations, record reviews, and interviews, revealing that the facility did not issue written notifications for Resident 45's hospitalizations on three separate occasions. The resident's electronic medical record documented severe cognitive impairment and dependency on staff for all functional abilities, highlighting the importance of proper communication regarding transfers. Interviews with facility staff confirmed the lack of written notifications and notifications to the LTCO. Administrative Staff B acknowledged that the facility had not been adhering to the required procedures for bed hold and written notifications. Social Services X also confirmed that written notifications of transfers had not been completed, despite the initiation of a Performance Improvement Plan aimed at improving discharge report submissions to the LTCO. The facility was unable to provide a policy regarding notification of transfer or notification to the LTCO when requested.
Failure to Provide Bed Hold Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold policy notice to a resident or their representatives during transfers to a hospital, as required. The resident, identified as R45, had multiple hospitalizations, and the facility did not issue a bed hold notice for these events. This oversight was confirmed through observations, record reviews, and interviews with administrative staff. The facility's policy required that a written notice specifying the duration of the bed-hold policy be provided at the time of transfer, but this was not adhered to. R45 had a history of severe cognitive impairment, hemiplegia, hemiparesis, and required enteral nutrition. The resident was dependent on staff for all functional abilities and had an unplanned discharge to a short-term acute hospital with a return anticipated. Despite these needs, the facility did not provide the necessary bed hold notices during hospital transfers, which posed a risk to the resident's ability to return to the facility or their previous room.
Incomplete MDS Documentation for Resident
Penalty
Summary
The facility failed to fully complete the annual comprehensive Minimum Data Set (MDS) for a resident, identified as R45, by not completing documentation analysis for triggered care areas. This deficiency was identified through observation, record review, and interviews. R45's electronic medical record documented diagnoses including cerebral infarction, hemiplegia, hemiparesis, and a pressure ulcer. The resident was severely cognitively impaired, required a Broda chair for mobility, was dependent on staff for all functional abilities, and required enteral nutrition. Despite these needs, the Cognition Care Area Assessment (CAA) dated 08/01/24 lacked documented analysis for several triggered care areas such as communication, urinary incontinence, psychosocial well-being, activities, falls, feeding tube, pressure ulcer, and pain. Interviews with facility staff revealed that the MDS coordinator was responsible for completing the CAA and updating care plans. However, the facility's policy on Resident Assessment - RAI was not followed, as it required documentation of summary information regarding additional assessments performed on care areas triggered by the MDS. The failure to complete the documentation analysis for triggered care areas placed R45 at risk for inaccurate reflections of the resident's status and an incomplete comprehensive plan of care.
Failure to Provide Required ADL Assistance
Penalty
Summary
The facility failed to provide the required assistance for a resident, identified as R11, in performing activities of daily living (ADLs), specifically dressing. R11 had a medical history that included altered mental status, cognitive communication deficit, major depressive disorder, and unsteadiness on his feet. His Minimum Data Set (MDS) indicated he required supervision or touch assistance for dressing and personal hygiene, and partial to moderate assistance for other ADLs such as bathing, transfers, and toileting. Despite these documented needs, observations revealed that R11 struggled to dress himself without the necessary assistance from staff, as he was seen attempting to pull up his pants without success until he managed to do so independently after some time. Interviews with staff, including a Certified Nurses Aide (CNA) and a Licensed Nurse (LN), confirmed that staff were aware of the care plan requirements and the level of assistance R11 needed. However, the staff did not consistently provide the required supervision and assistance, as evidenced by R11's report of difficulty in dressing and the lack of supervision during meals. The facility's policy on ADLs emphasized the need for staff to follow care-planned interventions and monitor their effectiveness, yet this was not adhered to in R11's case, leading to a deficiency in care.
Failure to Monitor Weight and Administer PRN Diuretic
Penalty
Summary
The facility failed to adhere to a physician's order for weight monitoring and administration of a PRN diuretic for a resident identified as R73. The resident had multiple diagnoses, including congestive heart failure (CHF), which required careful monitoring for fluid overload. The physician's orders specified weekly weight checks and administration of furosemide, a diuretic, if the resident experienced a weight gain of more than three pounds in one day or five pounds in two days. However, the facility did not administer the PRN diuretic from 09/20/24 to 10/01/24, despite significant weight fluctuations recorded during this period. Observations and interviews revealed that the facility's process for weight monitoring involved CNAs obtaining weights and reporting them to nurses, who were then responsible for following up and contacting the physician if necessary. Despite this process, the facility did not ensure that the weights were consistently monitored or that the physician's orders were followed, placing the resident at risk for fluid overload and related complications. The facility's Accommodation of Needs policy emphasized treating residents with respect and dignity and making reasonable accommodations for their individual needs, which was not upheld in this instance.
Failure to Provide Palm Splint for Resident
Penalty
Summary
The facility failed to ensure that a palm splint was available for a resident, identified as R47, who was at risk for discomfort and decreased range of motion. R47 had a medical history that included congestive heart failure, hypertension, hemiparesis following a stroke affecting the right side, aphasia, and anemia. The resident's care plan required the use of a palm protector for the right hand throughout the day to prevent skin breakdown and maintain range of motion. However, observations on two separate occasions revealed that R47 did not have the splint in place, and there was no documentation in the electronic medical record (EMR) indicating any refusal to wear the splint. Interviews with facility staff, including a Certified Nurse's Aide and a Licensed Nurse, indicated that staff were expected to know the devices each resident needed through care plans or morning nursing reports. Despite this, the EMR lacked specific instructions for applying the palm splint, and there was no evidence of a system to ensure the splint was consistently used. The facility's policy on preventing a decline in range of motion stated that residents should not experience a reduction in range of motion unless clinically unavoidable, yet the failure to apply the palm splint as required placed R47 at risk for decreased range of motion.
Failure to Monitor and Report Medication Administration Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported when a resident's blood pressure medication, midodrine, was administered outside of the physician-ordered parameters. The resident, who had diagnoses of respiratory and hepatic failure, was prescribed midodrine to be given three times a day, with instructions to hold the medication if the systolic blood pressure (SBP) exceeded 130 mm/Hg. However, a review of the Medication Administration Records (MAR) from June to September 2024 revealed multiple instances where midodrine was administered despite the SBP being above the specified threshold. The CP did not make any recommendations to the attending physician or prescriber regarding the administration of midodrine outside the ordered parameters. This oversight was confirmed during an interview with Administrative Nurse D, who stated that the CP was expected to make such recommendations and that it was also the responsibility of the administering nurse to adhere to the physician's parameters. The facility did not provide a policy for pharmacy recommendations when requested, further highlighting the deficiency in ensuring proper medication administration and monitoring.
Failure to Administer Blood Pressure Medication Within Prescribed Parameters
Penalty
Summary
The facility failed to ensure that a resident's blood pressure medication, midodrine, was administered within the physician-ordered parameters. The resident, who had diagnoses of respiratory and hepatic failure, was prescribed midodrine to be given three times a day, with the instruction to hold the medication if the systolic blood pressure (SBP) exceeded 130 mm/Hg. However, a review of the Medication Administration Record (MAR) revealed that the medication was administered outside of these parameters multiple times over several months, specifically in June, July, August, and September 2024. Interviews with facility staff indicated a lack of adherence to the physician's orders. A licensed nurse acknowledged the existence of parameters for the medication but noted that the system did not flag when the blood pressure reading was outside the prescribed range. An administrative nurse confirmed that it was the responsibility of the administering nurse to ensure compliance with the physician's parameters. The facility's medication administration policy required that medications be given as ordered by the physician and that vital signs be recorded, with medications held if vital signs were outside prescribed parameters. The failure to adhere to these guidelines placed the resident at risk for unnecessary medication administration and potential adverse side effects.
Lack of Coordinated Hospice Care Plan
Penalty
Summary
The facility failed to ensure a coordinated plan of care for a resident receiving hospice services, which placed the resident at risk for inappropriate end-of-life care. The resident, identified as R3, had multiple diagnoses including muscle weakness, dysphagia, dementia, and diabetes mellitus, and was receiving hospice services for cerebral atherosclerosis. Despite being on hospice care, the resident's care plan did not specify the services hospice would provide, such as medication, supplies, or hospice worker visits. This lack of coordination was evident in the care plan, which failed to document the hospice's role in providing necessary equipment and services. Interviews with facility staff revealed a lack of clarity and communication regarding the hospice services provided to the resident. A CNA was unsure of what hospice provided and relied on the charge nurse or care plan for information. A licensed nurse acknowledged that the hospice services should be included in the care plan but believed that details like medication and staff visits were documented in the hospice binder instead. The administrative nurse admitted to being unfamiliar with the facility's care plans and agreed that hospice services should be part of the resident's care plan. The facility's policy on the coordination of hospice services was not followed, leading to the deficiency.
Failure to Administer PCV20 Vaccine
Penalty
Summary
The facility failed to administer the Pneumococcal Conjugate Vaccine (PCV20) to Resident 10, despite having a signed consent for the vaccination dated 04/30/24. A review of Resident 10's clinical record showed that a Pneumovax was administered on 05/07/15, but there was no documentation in the electronic medical record (EMR) indicating that the PCV20 vaccine had been administered. On 10/01/24, the facility's Infection Preventionist, Administrative Nurse D, confirmed the absence of documentation for the PCV20 vaccination in April 2024. The facility's policy, last reviewed on 01/31/22, stated that it was their policy to offer immunization against pneumococcal disease in accordance with CDC guidelines. The failure to provide the PCV20 vaccination as consented placed Resident 10 at increased risk for complications related to pneumococcal disease.
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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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