Newton Presbyterian Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Newton, Kansas.
- Location
- 1200 E 7th Street, Newton, Kansas 67114
- CMS Provider Number
- 175302
- Inspections on file
- 22
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Newton Presbyterian Manor during CMS and state inspections, most recent first.
A resident with dementia, impaired mobility, and documented risk for pressure ulcers returned from a hospital stay after hip fracture surgery without an air mattress, heel booties, or a turn/reposition schedule in place. Initial assessments noted no heel wounds, but the resident’s Braden scores showed at least moderate risk, and staff later reported red heels to a nurse without preventive measures being initiated at that time. The resident subsequently developed an open blister on the left heel that progressed into a full-thickness Stage 3 pressure ulcer acquired in-house, while documentation showed that pressure-relieving devices and heel-floating interventions were added to the care plan only after the wound appeared, contrary to the facility’s own skin integrity and pressure ulcer prevention policy.
Two residents with dementia and documented fall risks experienced falls resulting from inadequate supervision and improper transfer techniques. One resident, with severe cognitive impairment and a high fall risk, continued to ambulate while carrying heavy bags in congested areas despite care plan directives for staff assistance, and sustained a wrist fracture and later a hip fracture after separate falls, including one where she reportedly tripped over another resident’s foot. Facility documentation of this fall was inconsistent and lacked timely review and preservation of available video evidence. Another resident with abnormal gait and multiple prior falls was assisted in a one-person pivot transfer without a gait belt; her knees buckled and she fell to the floor, leading to a later care plan change requiring a two-person assist with a gait belt. These events occurred despite a facility falls policy requiring identification of residents at risk for falls and implementation of appropriate interventions.
Surveyors found multiple failures to follow infection control policies, including Enhanced Barrier Precautions, hand hygiene, and equipment cleaning. Staff provided direct care, including catheter and wound care, to a resident under EBP using only gloves and no gowns, and wound care consultants also treated open wounds without gowns. An LN administered insulin without appropriate hand hygiene and used a nebulizer for a recently admitted resident without rinsing or air-drying the components or discarding residual liquid as required. Two staff performed peri-care on a resident, then used the same contaminated gloves to access supplies and apply powder, and did not perform hand hygiene after glove removal. Another LN performed foot wound care on a resident without changing gloves between dirty and clean tasks or using a barrier for supplies. Housekeeping staff transported a resident’s clean clothing uncovered through the hallway, contrary to infection control expectations.
The facility failed to adhere to its antibiotic stewardship policy by not maintaining infection and antibiotic surveillance logs for an extended period and by lacking evidence of tracking, trending, or documenting the appropriateness of antibiotic prescriptions using McGeer’s Criteria. During this time, a resident was started on Nitrofurantoin for a presumed UTI based on preliminary UA results before culture and sensitivity findings were available; the final culture later showed no UTI, yet the antibiotic had already been initiated. Nursing leadership acknowledged that antibiotic use was not being adequately monitored for trends, patterns, or appropriate indication, dose, and duration as required by the facility’s antibiotic stewardship program.
A resident with moderately impaired cognition was moved from a dining table to a nearby lounge area that remained visible to others while an LN performed a fingerstick blood glucose test and administered an insulin injection by lifting the resident’s shirt and exposing the abdomen. The LN reported that this was her usual practice and that other residents in the dining room could observe these procedures, contrary to facility expectations and policy requiring that such care be provided in a private manner that maintains resident dignity.
A resident with dementia and a left hip fracture experienced a marked decline in ADLs, changing from being independent or needing only supervision/touching assistance with bed mobility, transfers, toileting, and short-distance ambulation to requiring total assistance, use of a mechanical lift with two staff for transfers, and dependence on a wheelchair. Care plans and GG evaluations were revised to reflect this decline, and CNAs reported the resident now needed total assistance with ADLs. Despite these documented changes in condition and function, the EMR contained no significant change MDS, and a Regional RN confirmed that such an assessment should have been completed.
A resident with right-sided hemiplegia, benign prostatic hyperplasia, and total dependence for ADLs had an indwelling Foley catheter and a right hand carrot positioning device in use, but these interventions were not included in the resident’s care plan. The MDS showed intact cognition and right-sided impairment, and physician orders directed routine catheter changes. Observation noted the positioning device at the bedside, while interviews with an LPN and an administrative nurse revealed that nursing staff were expected and able to update care plans but were unaware that the plan lacked these catheter and positioning device interventions, contrary to the facility’s person-centered care plan policy.
A resident with dementia, severe cognitive impairment, prior left femur fracture, muscle weakness, and total dependence for ADLs was care-planned for transfers requiring two staff and a mechanical lift. Instead, staff transferred the resident using two staff and a gait belt, not in accordance with the documented care plan. The resident was later found with a large, painful bruise on the left chest under the arm, and could not explain how it occurred. Facility documentation and staff interviews confirmed that the EMR Kardex and care plan should guide transfer methods and that nursing is responsible for coordinating resident care, but the ordered mechanical lift was not used during the transfer that preceded the injury.
A resident with diabetes, impaired cognition, and a complex hypoglycemic regimen (including insulin and oral agents) had physician orders for periodic CBC, CMP, and HbA1c to monitor her condition and medication effectiveness. While some labs were completed earlier, the EMR showed that a later scheduled CBC and HbA1c were not done, and there was no documentation explaining the omission or any rescheduling. An administrative nurse confirmed the labs were missed, despite facility policy requiring monthly pharmacist drug regimen review using lab values and ensuring pharmacist access to lab results, resulting in a failure to adequately monitor the effectiveness of the resident’s hypoglycemic medications.
The facility did not follow its policy requiring daily posting of nurse staffing information for each shift. Surveyors observed that three houses lacked accurate or current staffing sheets, with the last posted date more than a month old, despite an active resident census. An administrative staff member confirmed that staffing sheets were expected to be completed and posted daily for all licensed and unlicensed staff directly responsible for resident care.
Surveyors found that the facility did not properly maintain and dispose of kitchen garbage and refuse in accordance with its own policy. Observations showed outside garbage bins with trash placed on top rather than inside, and bins located across the street with bags of trash on top and lids left open. In an interview, the CDM confirmed that trash was expected to be placed inside the bins and that lids should be closed, consistent with the facility’s written policy on dumpster and trash compactor use.
A resident with severe cognitive impairment and mobility issues sustained a laceration requiring sutures after a CNA attempted a transfer alone, contrary to the care plan requiring two staff members. The incident highlighted a failure to adhere to the facility's lifting and transferring policy, resulting in the resident's injury and emergency medical treatment.
A resident with heart failure, hypertension, atrial fibrillation, and anxiety experienced two falls due to staff failing to provide necessary equipment, including a call light and mobility devices. The resident's care plan directed staff to ensure these items were within reach, but this was not followed, leading to falls and injury.
A facility failed to implement a physician-ordered fluid restriction for a resident with heart failure, hypertension, atrial fibrillation, and anxiety. Staff were unaware of the restriction, and the resident's records lacked documentation of fluid intake, placing the resident at risk for dehydration or fluid overload.
The facility failed to complete a trauma-informed care assessment and develop a comprehensive care plan for a resident with PTSD, depression, and anxiety. Staff were unaware of the resident's PTSD diagnosis and triggers, and the required assessment was not conducted, placing the resident at risk for unmet behavioral and mental health needs.
Failure to Implement Timely Pressure Ulcer Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to identify and implement pressure ulcer prevention measures for a resident following readmission from the hospital after surgical repair of a left hip fracture. The resident had dementia with severely impaired cognition, behavioral symptoms including wandering and rejection of care, and required increasing assistance with ADLs, progressing from moderate assistance to total assistance with bed mobility, transfers, and toileting. The resident was documented as at risk for pressure ulcers on multiple MDS assessments, with contributing factors including incontinence and impaired mobility. Despite this identified risk, the resident initially had no pressure-reducing device on the bed or wheelchair and was not on a turning and repositioning program. After the resident returned from the hospital, an admission skin and wound assessment documented no wounds to the back, bottom, feet, or heels, and a Braden Scale score of 13 indicated moderate risk for pressure injury. A subsequent dietary note also documented no open skin issues. However, the EMR lacked evidence of a significant change in condition MDS following the resident’s decline in functional status and the development of an open lesion on the foot. A CNA later reported that upon the resident’s readmission, the resident did not have an air mattress or heel booties, was not on a turn and reposition schedule, and that the CNA had informed a nurse that the resident’s heels were red. Preventive interventions such as an air mattress and heel offloading were reported as being implemented only after a wound developed on the left heel. The resident’s left heel wound was first documented as an open blister that had opened, with a pink wound bed and dark center, and minimal drainage. A progress note described staff finding dry red streaks of blood on the fitted sheet and locating an open blister on the left heel, with a flap of skin hanging, and staff assumed the resident had rubbed the heel against the bed or sheet. Over time, the wound was measured repeatedly and treated with various dressings and topical agents, and later documented as an in-house acquired Stage 3 pressure ulcer to the left heel, present for greater than three months and staged by a wound clinic. The facility’s own policy stated that all residents are considered at potential risk for pressure ulcers and that nursing staff would evaluate skin integrity and implement preventive measures to maintain intact skin, but the resident’s care plan and staff interviews showed that preventive skin interventions were not in place until after the pressure ulcer had developed. The EMR documented that the resident’s care plan for pressure relief, including a pressure-reducing mattress and floating both heels while in bed, was dated after the wound had already been identified. Physician’s orders for heel protection and low air loss mattress were also dated after the wound was present. The EMR lacked wound clinic notes, despite documentation that the resident was to be followed by a wound clinic. Administrative and consultant nursing staff acknowledged that they expected preventive skin interventions to be in place to avoid pressure ulcers and that the resident’s preventive interventions were not provided until after the pressure ulcer occurred. This sequence of documented risk, absence of early preventive measures, staff reports of red heels without timely intervention, and subsequent development and progression of a left heel wound to a Stage 3 pressure ulcer formed the basis of the cited deficiency.
Failure to Prevent Falls and Ensure Safe Transfers for Residents at Risk
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision and assistance to prevent falls for two residents with dementia and documented fall risks. One resident had severe cognitive impairment, a history of falls, and was assessed as high risk for falls over multiple months. Her MDS and care plans showed a progression from independence with transfers and ambulation to requiring staff assistance with transfers, limited ambulation, and use of a wheelchair, with specific care plan directions that staff should provide assistance with transfers, offer a wheelchair, ensure non-skid footwear, provide non-slip strips in front of her recliner, and keep staff close when she was alone. Despite these identified risks and interventions, she continued to ambulate with heavy bags and purses, and staff reported she was very unsteady, could not walk long distances, and required a staff member to walk with her. This resident experienced multiple falls. In one incident, she was found on the floor in a hallway with two full purses and a book next to her, with a large hematoma on her forehead and hand, and was later diagnosed with a left wrist fracture. A post-fall root cause analysis identified that she had been carrying extremely heavy bags, which contributed to her loss of balance and fall. In a later incident, she fell in a living room area described as highly congested, with furniture and other residents present. Staff reported she lost her balance and fell on her left side, and she was later admitted to the hospital with a left hip fracture. Facility documentation of this fall was inconsistent: the facility’s reportable incident form stated she tripped on another resident’s foot while walking between furniture and other residents, while witness statements from a nurse and a CNA indicated they heard or saw her fall but did not clearly document a witnessed fall. The facility’s investigation also lacked documentation that available video footage was reviewed, even though an administrative staff member later stated she had watched the video and determined the resident tripped over another resident’s foot. The second resident involved in the deficiency had dementia, abnormal gait and mobility, and a history of multiple falls since admission. Her care plan identified her as at moderate risk for falls related to safety awareness and dementia, but it initially lacked specific direction to staff regarding transfer technique. During a one-person pivot transfer from a recliner to a wheelchair, her knees buckled and she fell to the floor, landing on her right knee and left cheek. Subsequent nursing documentation reviewing the fall stated that the staff member performing the transfer was not using a gait belt at the time of the incident. Only after this fall was an intervention added to the care plan specifying that she should be transferred with a two-person assist and a gait belt. Administrative nursing staff later confirmed that the resident had been transferred without a gait belt, which caused her to fall, despite the facility’s falls policy stating that residents at risk for falls would have interventions implemented and documented on the comprehensive plan of care.
Failure to Implement Enhanced Barrier Precautions and Basic Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, including Enhanced Barrier Precautions (EBP), hand hygiene, peri-care practices, medication administration, nebulizer cleaning, and handling of clean clothing. Surveyors observed that a resident with EBP signage requiring gown and glove use for direct care, including catheter and wound care, was assisted back to bed by multiple staff who only donned gloves and did not wear gowns as required. During this care, one aide emptied the resident’s urinary catheter without a gown, another aide placed gloved hands in pockets, and one aide removed gloves and handled linens and exited the room without performing hand hygiene. Later, wound care consultants and an administrative nurse provided wound care to the same resident’s coccyx and lower extremity wounds without wearing gowns, despite the posted EBP requirements and the presence of open wounds. Additional observations showed repeated failures in hand hygiene and aseptic technique during medication administration and personal care. A licensed nurse adjusted a resident’s feet on wheelchair pedals, then applied gloves without prior hand hygiene, checked blood sugar, administered insulin, and handled the medication cart and keys after glove removal without sanitizing hands. For another resident, the same nurse found a nebulizer mask and chamber lying directly on a nightstand with unidentified liquid remaining from a prior treatment; she added new medication to the chamber without disassembling, rinsing, or air-drying the equipment as required by facility policy, and only performed hand hygiene after removing gloves worn throughout the process. The nurse acknowledged the nebulizer should have been rinsed and stored properly. Surveyors also observed improper glove use and lack of hand hygiene during peri-care and wound care, as well as improper handling of clean clothing. Two staff members provided peri-care to a resident, opening a wet brief, cleansing the peri-area and buttocks, then using the same contaminated gloves to open a drawer, retrieve powder, and apply it to the resident’s groin before applying a clean brief and transferring the resident without performing hand hygiene after glove removal. In another case, a nurse performing wound care on a resident’s feet donned gloves and a gown but used the same gloves to move the wheelchair, reposition the resident, open wound supplies, remove soiled dressings, cleanse wounds, apply ointment, and place dressings without changing gloves or performing hand hygiene between dirty and clean tasks. Housekeeping staff were seen carrying a resident’s clean personal clothing on hangers, uncovered, through the hallway. Facility policies in place required EBP with gowns and gloves for high-contact care, specific hand hygiene indications, and detailed nebulizer cleaning and drying procedures, which were not followed in these instances.
Failure to Monitor and Appropriately Steward Antibiotic Use
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain an effective antibiotic stewardship program and to monitor antibiotic use. For the period from 02/01/26 through 02/24/26, the facility could not provide antibiotic and infection surveillance logs, demonstrating that infections and antibiotic use were not tracked during that month. As a result, there was no evidence that staff identified commonalities, patterns, or trends in infections or antibiotic usage, nor documentation of how determinations were made regarding the appropriateness of prescribed antibiotics. An administrative nurse stated that the facility used McGeer’s Criteria to determine appropriate antibiotic use but verified there was no evidence of antibiotic tracking, trending, or documentation supporting decisions about antibiotic prescriptions. The deficiency also includes an individual case in which a resident received an antibiotic for a urinary tract infection (UTI) without confirmation of infection by culture. An incident note showed that the resident’s physician ordered a urinalysis (UA) with culture and sensitivity, and a progress note documented preliminary positive UA results with culture and sensitivity pending. A subsequent progress note recorded that the UA results led to an order for Nitrofurantoin 100 mg by mouth twice daily for five days for UTI. A licensed nurse reported that providers generally would not start an antibiotic without a culture and sensitivity report and that the facility used McGeer’s Criteria and opened an Antibiotic Stewardship Assessment. The nurse contacted the lab and obtained the final culture and sensitivity report, which was negative for UTI, even though the resident had already been started on antibiotics two days earlier. An administrative nurse confirmed that the resident should not have received antibiotics for a UTI when the final culture report was negative and acknowledged that antibiotic stewardship should be tracked and monitored for trends, patterns, and appropriate use, consistent with the facility’s Antibiotic Stewardship policy dated 02/04/25.
Failure to Maintain Resident Dignity During Insulin Administration
Penalty
Summary
The facility failed to provide dignified care during medication administration to a resident with a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. During breakfast, a licensed nurse moved the resident away from the dining room table where she was eating and propelled her approximately 10 feet toward a lounge area that remained visible to residents in the dining room. In this lounge area, the nurse donned gloves, performed a fingerstick blood glucose test, lifted the resident’s shirt, exposed her abdomen, and administered an insulin injection, all in a location observable to others. The nurse stated that she always completed the resident’s blood sugar checks and insulin injections in this lounge area, and acknowledged that residents seated in the dining room could see this. The facility’s dignity policy, dated 02/2015, documented that the community would promote care in a manner and environment that maintains or enhances each resident’s dignity and respect in recognition of individuality. This practice of performing blood glucose testing and insulin injections in a visible lounge area, rather than in a private location, constituted a failure to honor the resident’s right to dignity and privacy during care.
Failure to Complete Significant Change MDS After Resident’s Functional Decline
Penalty
Summary
The deficiency involves the facility’s failure to identify a significant change in condition and complete a corresponding significant change MDS assessment for one resident following a left hip fracture. The resident had dementia with severely impaired cognition, a displaced intertrochanteric fracture of the left femur, and muscle weakness. A 07/15/25 significant change MDS documented a BIMS score of four and indicated the resident required moderate assistance with transfers, maximal assistance with toileting hygiene, and was independent with bed and wheelchair mobility, with ambulation not attempted due to medical or safety concerns. A 07/21/25 Cognitive Loss/Dementia CAA documented impaired judgment and safety and the need for 24-hour nursing care in a secure setting, while the ADL Functional/Rehabilitation Potential CAA did not trigger. Subsequent MDS assessments on 09/16/25 and 10/21/25 continued to show severely impaired cognition and documented that the resident required total assistance with bed mobility, toileting hygiene, and transfers, with ambulation not attempted due to medical or safety concerns. Despite this clear decline in functional status, the EMR lacked evidence of a required significant change in condition MDS after the resident fractured her left hip on 09/02/25. Care plans dated 01/30/25, 07/24/25, and 10/31/24 were revised on 09/25/25 to reflect that the resident, who previously could make major position changes in bed, ambulate very short distances, and required only moderate or maximal assistance for transfers and toileting, now required total assistance with two staff and a mechanical lift for transfers, total assistance for toileting, and maximal assistance for repositioning in bed. A Discharge GG Evaluation on 09/04/25 showed the resident had been independent or required only supervision/touching assistance for bed mobility, transfers, and walking prior to the decline, while a Restorative Nursing Screener/GG Evaluation on 09/17/25 documented total assistance for bed mobility, transfers, and toileting, with walking not attempted due to medical or safety concerns. A 09/25/25 health status note confirmed the resident was now a mechanical lift transfer with two staff, used incontinence products, and was dependent on a wheelchair. CNAs reported the resident required total assistance with ADLs after the hip fracture, and the Regional RN confirmed that a significant change MDS should have been completed, but none was present in the record.
Failure to Update Care Plan for Positioning Device and Indwelling Catheter
Penalty
Summary
The facility failed to update a resident’s comprehensive care plan to include interventions for a right hand positioning device and an indwelling urinary catheter. The resident had diagnoses including right-sided hemiplegia and benign prostatic hyperplasia, and the Annual MDS documented intact cognition with a BIMS score of 13, right-sided impairment of upper and lower extremities, and total dependence on staff for all ADLs. The existing care plan, dated 09/06/24, addressed an ADL self-care deficit associated with cerebral infarction and total dependence for personal hygiene and oral care, but did not include any information or interventions related to the indwelling Foley catheter or the right hand positioning device. Physician orders dated 2/19/26 directed that the resident’s indwelling catheter be changed every four weeks or as needed, and observation showed the resident seated in a recliner with a carrot positioning device lying on the bedside table, indicating the device was in use but not reflected in the care plan. During interviews, a licensed nurse stated that any staff member could update care plans with interventions such as the positioning device and catheter, but she was unaware that this resident’s care plan lacked that information. An administrative nurse stated she expected all nursing staff to update care plans. The facility’s care plan policy, revised 2/3/25, required development of a person-centered plan of care that identifies needs, strengths, preferences, health status, and establishes goals and services to ensure the highest level of functioning, which was not fully implemented for this resident regarding the catheter and hand positioning device.
Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Injury
Penalty
Summary
The facility failed to follow a resident’s care plan requiring use of a mechanical lift with two staff for transfers, instead transferring the resident with two staff and a gait belt. The resident had dementia with severely impaired cognition, a history of an intertrochanteric left femur fracture, muscle weakness, behaviors including wandering and rejection of care, and required increasing assistance with ADLs over time. Earlier assessments documented moderate assistance with transfers, but a later MDS showed the resident required total assistance with bed mobility, toileting hygiene, and transfers, and was at risk for pressure ulcers with one unhealed, unstageable pressure injury not present on admission. The care plan dated 09/25/24 specifically identified the need for total assistance of two staff with a mechanical lift for transfers. On 11/04/25, staff identified a large bruise on the resident’s left chest under the arm, measuring 22.5 cm by 9.5 cm, purple with red areas, and painful to touch; the resident could not state how the bruise occurred. Subsequent facility risk management documentation dated 11/17/25 revealed staff had been transferring the resident with two staff and a gait belt, contrary to the care-planned requirement for a mechanical lift. Staff interviews confirmed that CNAs and CMAs were expected to follow the care plan and use the EMR Kardex to determine required interventions, and that nursing was responsible for coordinating resident care. Despite these expectations and policies, the resident’s transfer was performed without the ordered mechanical lift, resulting in an injury.
Failure to Complete Ordered Lab Monitoring for Hypoglycemic Regimen
Penalty
Summary
Surveyors identified a deficiency related to failure to monitor the effectiveness of a resident’s hypoglycemic medication regimen. The resident had a diagnosis of diabetes mellitus, impaired judgment, and memory deficits, and required staff support. Her MDS documented that she received insulin injections and hypoglycemic medications, and her care plan noted altered endocrine status related to hyperglycemia and hypoglycemia due to diabetes mellitus. However, the care plan dated 02/23/26 did not include monitoring of laboratory tests for diabetes mellitus. Physician orders included multiple diabetes-related medications (Jardiance, glargine insulin, Januvia, and Humalog insulin) and also ordered a CBC, CMP, and HbA1c every six months. The EMR showed that an HbA1c was completed on 07/01/25, a CBC on 08/01/25, and a CMP on 01/02/26, but there was no evidence that the CBC and HbA1c ordered for 01/02/26 were completed. During interviews, Administrative Nurse E confirmed that the CBC and HbA1c were not completed and that the January medication administration record listed the CBC, CMP, and HbA1c without any documentation explaining why they were not done or rescheduled. Nurse E stated that physician orders were expected to be followed and explained that routine lab draws were performed weekly by an outside laboratory, with the charge nurse responsible for ensuring completion. The facility’s Drug Regimen Review policy indicated that a resident’s medication regimen would be reviewed monthly and as needed by a licensed pharmacist, using laboratory values as indicated, and that the pharmacist would have access to residents’ lab tests. Despite these requirements, the necessary laboratory monitoring for the resident’s diabetes management was not carried out or documented, resulting in a failure to ensure the resident’s drug regimen was monitored for effectiveness.
Failure to Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was accurately posted as required. Surveyor observation on 02/24/26 at 1:38 PM showed that none of the three houses, identified as [NAME], [NAME], and Ute, had an accurate or current staffing sheet posted; the most recent date displayed was 01/13/26, despite the facility reporting a current census of 53 residents. In an interview on 02/25/26 at 12:30 PM, an administrative staff member acknowledged that staffing sheets were supposed to be posted daily with each shift’s information completed. The facility’s policy, “Daily Nurse Staffing Report,” last reviewed on 08/18/25, required nursing services to identify at the beginning of each shift the number of staff and actual hours worked for licensed and unlicensed staff directly responsible for resident care, but this process was not being followed as evidenced by the outdated postings. No specific resident medical histories or conditions were mentioned in relation to this deficiency.
Improper Maintenance and Use of Garbage Bins
Penalty
Summary
The facility failed to properly maintain and dispose of kitchen garbage and refuse as required by its own policy. With a reported census of 53 residents, surveyors observed during an initial kitchen tour that one outside garbage bin had trash placed on top of the bin rather than inside it. On a subsequent observation, a garbage bin located across the street from the facility was noted to have a bag of trash on top of the bin. During another observation, the same garbage bins across the street were found with their lids not closed. In an interview, the Certified Dietary Manager stated that his expectation was that trash should be inside the bins, not on top, and that the lids should be closed, which was consistent with the facility’s undated “Dumpster and Trash Compactor” policy requiring lids to be correctly closed after use. No specific residents, medical histories, or clinical conditions were mentioned in relation to this deficiency.
Failure to Follow Transfer Protocol Results in Resident Injury
Penalty
Summary
The facility failed to prevent an injury to a dependent resident when staff did not adhere to the resident's care plan, which required two staff members to assist with transfers. The resident, who had diagnoses including dementia, hallucination, and osteoarthrosis, required maximum assistance for transfers and was severely cognitively impaired. Despite these needs, a Certified Nurse Aide (CNA) attempted to transfer the resident alone, resulting in the resident sustaining a 2-to-3-centimeter laceration on her left lower extremity. The incident occurred when the CNA assisted the resident to stand using a gait belt, during which the resident complained of leg pain and was immediately seated back in her wheelchair. The CNA observed bleeding from the resident's left lower extremity and reported the incident to a Licensed Nurse (LN). The laceration was treated at the facility before the resident was transported to the Emergency Department, where she received 10 sutures. The resident's care plan clearly documented the need for two staff members during transfers, a requirement that was not followed by the CNA involved in the incident. The facility's policy on lifting and transferring residents emphasized the importance of using safety materials and equipment to prevent injuries, which was not adhered to in this case. This oversight led to the resident's injury and subsequent medical treatment.
Failure to Provide Necessary Equipment Resulting in Falls
Penalty
Summary
The facility failed to ensure Resident 40 remained free from avoidable falls when staff did not provide the necessary equipment to ensure safety, including a call light and mobility devices, on two separate occasions. This resulted in falls on both occasions. Resident 40 had diagnoses of heart failure, hypertension, atrial fibrillation, and anxiety, and required extensive assistance for bed mobility, transfers, ambulation, dressing, and toileting. The resident's care plan directed staff to ensure his walker and wheelchair were within reach and to check on him frequently to ensure safety and call light placement. However, these directives were not followed, leading to the falls. On the first occasion, Resident 40 was found lying on the floor next to his bed with his call light on the floor, which caused him to roll out of bed while trying to retrieve it. This resulted in a laceration to the top of his head. On the second occasion, the resident was found on the floor in his room after attempting to get out of his recliner to use the bathroom without his walker or wheelchair within reach, and his call light was also not accessible. Both incidents highlight the staff's failure to ensure the resident's call light and mobility devices were within reach, as directed by the care plan.
Failure to Implement Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to establish and implement a physician-ordered fluid restriction for a resident diagnosed with heart failure, hypertension, atrial fibrillation, and anxiety. The resident's care plan and physician's order specified a fluid restriction of 1800 ml every 24 hours, with 75% of the fluid to be provided by nutrition and 25% by nursing. However, the resident's Treatment Administration Records (TAR) for several months lacked documentation of the fluid restriction, and staff members, including a Certified Medication Aide, a Licensed Nurse, and a dietary staff member, were unaware of the restriction. Observations revealed that the resident had multiple fluid containers at their bedside, indicating that the fluid restriction was not being followed. Interviews with staff confirmed that they were not informed or aware of the fluid restriction, and the facility's policy on fluid restrictions was not adhered to. The administrative nurse verified that the fluid restriction was never implemented, placing the resident at risk for dehydration or fluid overload.
Failure to Complete Trauma-Informed Care Assessment for Resident with PTSD
Penalty
Summary
The facility failed to complete a trauma-informed care assessment and develop a comprehensive trauma-informed care plan for a resident diagnosed with PTSD, depression, and anxiety. The resident's electronic medical record documented these diagnoses, and the admission Minimum Data Set indicated the resident had intact cognition and required supervision with certain activities. Despite these documented needs, the care plan lacked direction for staff on the resident's trauma triggers and coping strategies. Additionally, the resident's electronic medical record did not show evidence of a trauma-informed assessment being completed after admission. Interviews with staff revealed a lack of awareness regarding the resident's PTSD diagnosis and associated triggers. A Certified Nurse Aide and a Licensed Nurse both stated they were not informed of the resident's PTSD or any specific triggers. Social Services admitted to not completing a trauma-informed care assessment for the resident's most recent admission and had not communicated with staff about the resident's PTSD triggers. The facility's Trauma Informed Care policy required such an assessment within 72 hours of admission, but this was not adhered to, placing the resident at risk for unmet behavioral and mental health needs and retraumatization.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
