Orchard Gardens
Inspection history, citations, penalties and survey trends for this long-term care facility in Wichita, Kansas.
- Location
- 1600 S Woodlawn Blvd, Wichita, Kansas 67218
- CMS Provider Number
- 175452
- Inspections on file
- 30
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Orchard Gardens during CMS and state inspections, most recent first.
A resident with intact cognition but extensive ADL dependence and morbid obesity, who relied on staff for wheelchair mobility, was propelled down a hallway slope by a CNA in a wheelchair without foot pedals, causing the resident’s right foot to drop under the chair and resulting in a right femoral neck fracture. The care plan noted the need for a Hoyer lift and that the resident could self-propel with foot pedals stored on the back of the wheelchair, but it did not specify non–weight-bearing limb status, did not address the fracture, and lacked clear interventions for safe wheelchair locomotion. Video evidence showed no foot pedals in use and contradicted nursing notes that described the resident self-propelling and catching her ankle on a foot pedal, and administrative staff reported there was no MDS nurse to update care plans and no incident report or witness statements completed.
A resident with schizoaffective disorder and borderline intellectual functioning, who had intact cognition and verbal behaviors toward others, was issued an involuntary discharge notice after behaviors that allegedly endangered others, including actions posing a serious fire risk. The facility did not develop a comprehensive care plan, did not obtain a physician discharge order, and did not complete a discharge summary with a recapitulation of the stay or documented medication reconciliation, even though the resident was discharged home with medications. The involuntary discharge notice omitted required elements, including instructions on how to file an appeal, identification of who at the facility would assist with an appeal, the Ombudsman’s name and email, and contact information for state protection and advocacy agencies for individuals with developmental disabilities and mental disorders.
A resident with suspected adrenal insufficiency, hypothyroidism, myxedema, prior stroke with one-sided impairment, visual changes, and multiple identified care needs (including mobility, incontinence, falls, nutrition, pressure injury risk, and psychotropic drug use) did not have a comprehensive, person-centered care plan. The MDS and CAAs documented that these areas would be addressed, and the resident had active orders for levothyroxine, trazodone, methadone, and continuous oxygen, yet the written care plan only noted the resident’s wish to remain in the facility and full-code status, with no specific interventions or measurable objectives. Staff reported that an offsite MDS nurse initiated care plans and the IDT was expected to update them, but acknowledged that updates had not been maintained, resulting in a care plan that did not reflect the resident’s actual care needs.
Two residents did not consistently receive ordered medications as prescribed, including thyroid replacement for a resident with hypothyroidism and myxedema and alprazolam for a resident with anxiety and bipolar disorder. MAR review showed multiple missed doses of levothyroxine without hold orders or documented reasons, despite the resident reporting prior hospitalizations for severe hypothyroidism and stating that staff sometimes gave the medication incorrectly or not at all. Another resident had multiple missed doses of alprazolam over several days, with EMAR notes indicating medication unavailability, pharmacy issues, and awaiting prescriptions, and several entries lacking reasons for non‑administration. Staff interviews revealed that CMAs and nurses were expected to administer medications per orders, use the emergency kit or contact the pharmacy when medications were not available, and document all administrations or omissions, but actual MAR and EMAR documentation was incomplete and inconsistent with these expectations.
A kitchen was found to have live and dead roaches in multiple areas, including behind refrigerators, under counters, and in storage, along with uncovered garbage cans. Dietary staff reported the pest issue had persisted for about six months, and administrative staff confirmed the ongoing problem despite regular pest control visits. These unsanitary conditions placed residents at risk for foodborne illness.
The facility did not ensure shower rooms and smoking areas were kept clean and free of mildew or unknown substances, with observations of black/brown stains, cigarette smoke odor, ashes, and water damage in two shower rooms, as well as numerous cigarette butts littering the entryway and courtyard. The entryway lacked a cigarette receptacle, and the exhaust fan in one shower room was not working, contrary to facility policy for maintaining a sanitary and homelike environment.
A resident with chronic pain and depression, who was cognitively intact and required ADL assistance, was involved in a verbal altercation with a maintenance staff member that included yelling and profanities. Multiple witnesses confirmed the exchange, and the incident was not documented in the resident's health record. The facility's policy against abuse was not followed, resulting in the resident experiencing verbal mistreatment.
Surveyors identified multiple deficiencies in food storage and handling, including uncovered, undated, and unsealed food items in both refrigerated and dry storage, as well as the use of uncleanable cutting boards. Dietary staff confirmed that these practices did not meet facility policy, placing residents at risk for foodborne illness.
The facility did not complete required annual performance evaluations for five CNAs employed for over a year, as shown by missing signed evaluations in their files and confirmed by administrative staff. Facility policy requires annual reviews and links in-service training to these evaluations.
Five CNAs did not receive the required 12 hours of annual in-service training or education on mandated topics such as dementia care and abuse prevention. Training records were incomplete and outdated, and administrative staff could not provide documentation to show compliance with facility policy.
Staff did not consistently follow infection control protocols, including leaving clean clothes uncovered in a dusty laundry area, failing to use required PPE such as gowns and gloves during care for residents with tube feedings or wounds, and neglecting proper hand hygiene during peri-care and dressing changes. Interviews revealed staff were unaware of EBP protocols and correct procedures, and maintenance staff did not recognize environmental risks in the laundry area.
Multiple deficiencies were observed in the facility's environment, including damaged walls, missing tiles, broken furniture, makeshift window coverings, and built-up dirt in resident rooms and common areas. Staff interviews confirmed that maintenance issues were reported but not consistently addressed, and the facility lacked a policy for ensuring a homelike environment.
Multiple residents were found with prohibited items such as lighters, cigarettes, vape supplies, unsecured medications, alcohol, firecrackers, and a pocketknife in their rooms, including one resident with an oxygen cannula and another with a nebulizer. Hazardous chemicals and a mouse trap were also found unsecured in an unlocked cupboard. Staff interviews confirmed these items were not allowed per facility policy, and that staff were expected to confiscate such contraband when found.
A resident with multiple mental health diagnoses and on high-risk psychotropic medications did not receive a required PASARR Level 2 evaluation, despite documentation indicating the need for further assessment. Staff interviews revealed confusion about responsibility for PASARR compliance, and the necessary evaluation was not found in the EHR. Facility policy addressed CARE assessments but did not specify procedures for obtaining a Level 2 PASARR screening.
A resident with cognitive and physical care needs did not have their bathing preferences and required assistance accurately reflected in their care plan. The care plan lacked specific guidance for staff, and documentation showed the resident received fewer baths than scheduled, with no refusals recorded. Interviews and observations confirmed the resident's requests for baths were not addressed, and staff did not consistently document offers or refusals as required by facility policy.
Three residents with cognitive and physical impairments did not receive necessary assistance with ADLs, including bathing, eating, and personal hygiene. One resident received fewer showers than scheduled and requested, another was not assisted with eating despite care plan requirements, and a third did not receive full assistance with shaving due to lack of equipment and staff follow-through.
Two residents were not given the required CMS-10055 SNF Advanced Beneficiary Notice (ABN) when their Medicare Part A benefits ended before the 100-day limit, leaving them uninformed about their options and potential financial responsibility for continued skilled services. This was confirmed by an administrative nurse, and the facility's policy requiring ABN issuance was not followed.
Two residents were found to have beds in unsafe and inoperable conditions, including a broken bed frame and a bed with exposed wiring and a malfunctioning remote. Maintenance staff confirmed the deficiencies, and no policy on bed safety or maintenance was provided.
Surveyors found that trash bags were left on the ground next to an uncovered portable dumpster, and doors were left open on a stationary dumpster. Dietary staff were unaware of the requirement to keep all trash covered, which is contrary to facility policy stating dumpsters must be kept closed and free of litter.
A cognitively impaired resident at high risk for elopement was allowed to exit the facility unsupervised, despite having a WanderGuard alarm. The alarm was turned off without checking which resident triggered it, and the resident was not noticed missing until three hours later. The resident was found and returned by law enforcement after being outside for five and a half hours.
Failure to Prevent Wheelchair Fall Due to Missing Foot Pedals and Inadequate Supervision
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision and equipment use for a wheelchair-dependent resident, resulting in a right femur fracture. The resident had intact cognition with a BIMS score of 15 and was dependent on staff for most ADLs, including transfers, toileting, showers, and wheelchair mobility. The care plan documented that the resident had an ADL self-care deficit, required a Hoyer lift for transfers, had limited physical mobility related to morbid obesity, and could self-propel in a wheelchair, with foot pedals to be kept in a bag on the back of the wheelchair when not in use and staff to monitor safety on an ongoing basis. However, the care plan lacked specific mention of the right femur fracture, did not specify which limb was non-weight-bearing, and did not include clear interventions directing staff regarding the use of foot pedals for locomotion. On the date of the incident, camera footage showed a CNA propelling the resident in a wheelchair down a hallway slope without foot pedals attached, with the resident’s legs extended and not supported. As the wheelchair moved down the incline, the resident’s right foot dropped to the floor, became entangled under the wheelchair, and the resident fell to the floor, later confirmed by mobile X-ray and hospital records as a displaced right femoral neck fracture. The resident reported that the CNA pushed the wheelchair too fast and that no foot pedals were in place when her right foot went under the chair. Nursing notes contained conflicting descriptions of the event, including references to the resident self-propelling and the right ankle catching on a foot pedal, which were inconsistent with the video evidence of no foot pedals in use. Administrative staff acknowledged that the camera footage contradicted the nursing note about foot pedal use, that there was no MDS nurse to update care plans, and that no incident report, witness statements, or staff education were completed for this incident.
Failure to Complete Discharge Recapitulation and Provide Complete Involuntary Discharge Notice
Penalty
Summary
The deficiency involves the facility’s failure to complete a discharge summary with a recapitulation of the resident’s stay, including medication reconciliation, and failure to issue a fully compliant involuntary discharge notice. The resident had schizoaffective disorder and borderline intellectual functioning, with an admission MDS showing intact cognition (BIMS 15), no depression, and verbal behaviors toward others. The MDS indicated no plans for discharge and that the resident planned to remain at the facility. A Cognitive Loss/Dementia CAA identified potential for altered cognitive patterns related to schizoaffective disorder and noted verbal behaviors, but the electronic health record lacked evidence that a comprehensive care plan was developed for this resident. An involuntary discharge notice was issued, citing that the safety of individuals in the facility was endangered due to the resident’s behaviors, including an incident in which the resident engaged in actions that posed an immediate and serious risk of fire requiring staff intervention. The notice referenced ongoing explosive, aggressive, and unsafe behaviors and specified a discharge date 30 days from the notice, as well as discharge locations and appeal rights. However, the notice did not include information on how to file an appeal or identify who in the facility would assist the resident with the appeal. It also omitted the Ombudsman’s name and email contact information, and lacked contact information for the State Agency responsible for protection and advocacy for individuals with developmental disabilities and for individuals with a mental disorder. The resident’s physician orders did not contain a discharge order, and there was no recapitulation of the resident’s stay or documented medication reconciliation at the time of discharge, despite facility policy requiring a discharge summary that includes a recapitulation of the stay. Progress notes documented that the resident was to receive an involuntary discharge and be discharged with 30 days of medications, and that the family was educated to call 911 if aggression occurred. Another progress note documented that the resident was discharged home with family with medications and belongings, and a subsequent note indicated the family returned seeking clarification on how to administer the medications. During interviews, staff and a consultant confirmed that administrative staff prepared discharge paperwork, that no narcotics were sent with residents, and that no recapitulation or medication list could be produced for what was sent with the resident at discharge, confirming the lack of required discharge documentation and complete notice content.
Failure to Develop Comprehensive, Person-Centered Care Plan for Medically Complex Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and interventions for a resident with multiple complex medical conditions. The resident’s EMR documented diagnoses including suspected adrenal insufficiency, hypothyroidism, myxedema, and a prior cerebral infarction, with associated right-sided impairment, use of a walker, and need for supervision or touching assistance with care. The admission MDS and multiple Care Area Assessments (CAAs) identified issues in visual function, functional abilities (self-care and mobility), urinary incontinence/indwelling catheter, falls, nutritional status, pressure ulcer/injury, and psychotropic drug use, and each CAA stated these areas would be addressed in the care plan. Despite this, the resident’s care plan dated 08/12/25 only documented that the resident wished to stay in the facility and was a full code, and lacked any additional information or specific interventions related to the identified care areas. The resident had active physician orders for levothyroxine for myxedema, trazodone for insomnia, methadone for pain, and continuous oxygen at two liters, but these treatments and related care needs were not reflected in a comprehensive care plan. Staff interviews showed that a CMA stated staff should follow the care plan to care for residents, while an LN reported she did not enter information into the care plan. An administrative nurse explained that an offsite MDS nurse started the care plan and the interdisciplinary team was supposed to add to it as needed, but acknowledged the team had not kept up with updating the care plan. Another administrative nurse stated it was her expectation that care plans reflect the resident’s care and be started and updated as needed. These findings demonstrated that, contrary to the facility’s policy requiring a comprehensive, person-centered care plan with measurable objectives and timetables for each resident, the resident’s care plan was incomplete and did not address the resident’s identified physical, psychosocial, and functional needs.
Failure to Administer and Document Ordered Medications for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, resulting in ordered medications not being administered as prescribed for two residents. One resident with diagnoses including hypothyroidism, myxedema, and prior cerebral infarction had an order for levothyroxine 200 mcg daily starting in early November, later changed to 137.5 mcg daily in January. Review of the Medication Administration Record (MAR) showed multiple dates in November when the 200 mcg levothyroxine dose was not given, with no corresponding order to hold the medication and no documented reason for omission. The resident, who was cognitively intact, reported multiple hospitalizations for hypothyroidism, including a coma prior to admission and an ICU stay with a 10‑day hospitalization in November, and stated that staff had not been giving thyroid medications correctly, sometimes administering them after meals with other medications or not at all. Staff interviews revealed inconsistent practices and documentation related to medication administration and availability. A Certified Medication Aide (CMA) stated that she did not give the thyroid medication because she believed the night shift nurse had already administered it between 5:00 AM and 6:00 AM, and also described that when medications were not available, staff would look for them and mark them as not given with a specific reason in a note. However, the MAR for the resident with hypothyroidism lacked documentation of reasons for the missed levothyroxine doses. A Licensed Nurse (LN) stated that if a CMA reported a medication could not be found, she would search for it, contact the pharmacy, use the emergency medication kit if needed, and document the reason on the MAR, emphasizing that the MAR should never be left blank and that all medications should be given and documented as ordered. For the second resident, who had anxiety and bipolar disorder and was cognitively intact, physician orders required alprazolam 0.5 mg every morning and at bedtime for anxiety. The MAR documented nine missed doses over several consecutive days. EMAR administration notes showed repeated notations that the pharmacy was notified, that the medication was not on hand, that the pharmacy reported no prescription on file, and that staff were awaiting a prescription and delivery. On several occasions, the EMAR lacked documentation explaining why alprazolam was not administered. The resident reported that staff missed several doses of his alprazolam. Facility policy on administering medications stated that medications were to be administered in accordance with prescriber orders, in a safe and timely manner, and that administration times should be based on resident need and benefit rather than staff convenience, but the documented omissions and incomplete MAR entries for both residents showed that medications were not consistently administered or documented as ordered.
Failure to Maintain Sanitary Kitchen Conditions Due to Ongoing Roach Infestation
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by the presence of both live and dead roaches in various stages of life throughout the kitchen area, including behind and on the sides of refrigerators and freezers, under the clean dish storage rack, under the meal prep counter, behind doors, and in the dry storage room. Observations also revealed two garbage cans in the kitchen without lids, which staff stated were left uncovered for convenience. Dietary staff confirmed ongoing issues with roaches and reported that the problem had persisted for approximately six months, despite regular pest control visits. Interviews with dietary and administrative staff confirmed awareness of the pest issue, with staff reporting the problem to the Certified Dietary Manager and the administrator being responsible for contacting pest control services. The facility's pest control policy requires an effective program to keep the building free of insects and rodents, but the ongoing presence of roaches indicated a failure to meet this standard. The unsanitary conditions in the kitchen placed residents at risk for foodborne illnesses.
Failure to Maintain Cleanliness and Homelike Environment in Shower Rooms and Smoking Areas
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment in two of three shower rooms and in designated smoking and entryway areas. Observations revealed the presence of mildew or an unknown black/brown substance on the walls of the 400-hall and 200-hall shower rooms, with the 400-hall shower room also exhibiting a strong odor of cigarette smoke and ashes around the toilet. The paint in the 400-hall shower room showed bubbling consistent with water damage, and the exhaust fan in the 200-hall shower room was not operational. These findings were confirmed by facility consultants, who identified the substance in the 400-hall shower room as mildew and noted the similarity of the substance in the 200-hall shower room. Additionally, the exterior entryway and smoking courtyard were observed to be littered with dozens of used cigarette butts. The entryway lacked a cigarette receptacle, while the courtyard had several receptacles present. The facility's policies required a clean and sanitary environment and specified the use of metal containers with self-closing covers in smoking areas, but did not provide further guidance on the disposal of cigarette butts. Staff interviews confirmed that the entryway is a non-smoking area and that expectations were for shower rooms and smoking areas to be kept clean, with maintenance notified of any damage or discoloration.
Resident Exposed to Verbal Abuse by Maintenance Staff
Penalty
Summary
A deficiency occurred when a resident with chronic pain and major depressive disorder, who was cognitively intact and required assistance with activities of daily living, was subjected to verbal abuse and mistreatment by a maintenance staff member. The incident took place in the facility's parking lot, where the resident and the staff member engaged in a verbal argument that included yelling and the exchange of profanities. Multiple witnesses, including other residents and staff, confirmed the altercation and the use of inappropriate language. The facility's investigation documented that the situation was de-escalated by administrative staff who intervened and separated the individuals involved. Despite the occurrence of the incident, there was no documentation of the event in the resident's electronic health record for the relevant period. Witness statements were collected from staff and bystanders, but a statement from the maintenance staff member involved was not obtained. The facility's policy prohibits any form of resident abuse, including verbal abuse and intimidation, but this policy was not upheld in this instance, resulting in the resident being exposed to verbal mistreatment.
Improper Food Storage and Handling Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage, preparation, and serving practices. During an inspection of the kitchen and storage areas, several food items were found uncovered, undated, or unsealed in both the refrigerator and dry storage. Examples included an uncovered and undated tray of chocolate pie dessert, individually portioned cranberry sauces and dressings past their date, staff personal food items without dates, and various bags of cheese, ham, turkey, and breadsticks that were either unsealed, undated, or stored with meat juices at the bottom of containers. Additionally, a box of recalled shakes was found, and several dry storage items such as Oreos, potato chips, cocoa powder, baking powder, and pancake mix were unsealed or past their best-by dates. Two cutting boards were also noted to have deep gashes, making them uncleanable. Interviews with dietary staff confirmed that the observed storage and labeling practices did not meet facility policy, which requires all opened food items to be labeled, dated, and sealed. Staff acknowledged that the presence of undated, unsealed, and improperly stored food items was unacceptable and not in accordance with professional standards or facility policy. These actions and inactions placed residents at risk for foodborne illness due to improper food handling and storage.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for five Certified Nurse Aides (CNAs) who had been employed for more than 12 months. A review of employee files revealed that none of the five CNAs had performance evaluations signed by management, as required by the facility's policy. During an interview, an administrative staff member acknowledged difficulty in producing the requested evaluations and was unaware that annual performance evaluations for CNA staff were required. The facility's policies state that job performance should be reviewed at least annually and that in-service training is based on the outcomes of these reviews.
Failure to Provide Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required annual in-service training, both in terms of content and duration. A review of training records for five CNAs who had been employed for over a year revealed that none had completed the mandated 12 hours of in-service training within the previous 12 months. The only documented training for two CNAs was on Abuse, Neglect, and Exploitation, with no evidence of additional required topics. Further review showed that none of the five CNAs had received in-service training on all required topics, including care for residents with cognitive impairment, dementia management, and abuse prevention, as outlined in the facility's policy. During an interview, administrative staff were unable to provide documentation for the required training and were unaware that the available records were outdated. The facility's policy mandates at least 12 hours of in-service training per year, covering specific topics, but this was not met for the reviewed CNAs.
Failure to Implement and Adhere to Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow established infection prevention and control practices in several areas of the facility. Clean clothes were left uncovered in the laundry folding area, directly beneath exposed insulation and pipes covered with dust, contrary to facility policy requiring personal clothing to be stored in clean, dust-free areas. During observations, there was no Enhanced Barrier Precautions (EBP) signage or precautions outside any resident doors, and staff did not consistently use required personal protective equipment (PPE) such as gowns and gloves when providing care to residents with conditions requiring EBP, including those with tube feedings, open wounds, or catheters. Direct care staff were observed not performing proper hand hygiene or using correct techniques during peri-care and dressing changes. For example, a CNA used the same part of a washcloth for multiple strokes during incontinence care, applied ointment with soiled gloves, and failed to remove gloves and wash hands before re-gloving. Another CNA picked up a dropped glove from the floor and reused it, placed soiled linen directly on the floor, and did not perform hand hygiene after glove removal. A licensed nurse did not perform hand hygiene before applying gloves for a dressing change. These actions were inconsistent with the facility's hand hygiene policy, which requires hand hygiene before and after glove use. Interviews with staff revealed a lack of awareness and understanding of EBP protocols and proper infection control procedures. Staff admitted to not using gowns when required, not posting EBP signage, and not following correct hand hygiene and linen handling practices. Maintenance staff were unaware of the exposed insulation and dust above the laundry area where clean clothes were stored. These deficiencies in infection control practices had the potential to contribute to the spread of infections among residents.
Failure to Maintain a Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's physical environment, including missing thresholds, broken or missing tiles, chipped paint, exposed drywall, and damaged or missing baseboards in resident rooms and common areas. Several rooms had makeshift window coverings such as blankets instead of curtains, broken window blinds, and missing dresser drawers. In one instance, a standing floor fan was missing its front cover, and a room had a strong smell of cigarettes. Built-up dirt was noted on walls and floors, and the activity room had several missing floor tiles, which staff reported had caused tripping incidents. These conditions were directly observed in the rooms of several residents and in common areas. Interviews with staff revealed that maintenance concerns were to be reported through a computer system, and all staff had access to submit work orders. However, some staff acknowledged that issues such as missing curtains and environmental hazards had persisted, and administrative staff were aware of ongoing concerns but had not fully addressed them. The facility did not provide a policy regarding maintaining a homelike environment. These actions and inactions resulted in a failure to promote a sanitary, safe, and homelike environment for residents.
Failure to Prevent Accident Hazards and Secure Prohibited Items
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, as evidenced by multiple residents possessing prohibited items such as lighters, cigarettes, vape supplies, unsecured medications, alcohol, firecrackers, and a pocketknife in their rooms. Observations revealed that one resident with an oxygen cannula had a lighter and vape supplies in his room and reported vaping there. Another resident had a lighter and cigarettes on her dresser while not present in the room. Additional residents were found with lighters, cigarettes, and in one case, a nebulizer with tubing hooked up next to smoking materials. One resident had unsecured prescription medications on his bedside dresser, and another had a large bottle of vodka, firecrackers, and a pocketknife in his closet, along with medicated chest rub and an albuterol inhaler at bedside. Staff interviews confirmed that these items were not permitted per facility policy, and that staff were expected to confiscate such contraband when found. Further, the facility failed to secure hazardous chemicals in a safe manner. An unlocked cupboard under a workstation sink contained a spring-loaded mouse trap, a full gallon of drain cleaner, a gallon of disinfectant cleaner, and a spray bottle of germicidal cleaner, all labeled as harmful and to be kept out of reach of children. Staff interviews indicated a lack of awareness regarding the presence of these chemicals and the expectation that such items should be locked away. Facility policies required that smoking materials not be kept in residents' possession and that maintenance storage areas be locked to prevent unauthorized access to hazardous chemicals.
Failure to Obtain Required PASARR Level 2 Evaluation
Penalty
Summary
The facility failed to obtain a required PASARR Level 2 evaluation for a resident with multiple significant mental health diagnoses, including suicidal ideations, auditory hallucinations, major depressive disorder, generalized anxiety disorder, schizoaffective disorder, and primary insomnia. The resident's records indicated the use of high-risk antipsychotic, antianxiety, and antidepressant medications, and the care plan documented ongoing behavioral and mood problems. The resident's CARE assessment specifically indicated the need for further evaluation (Level 2), but there was no documentation in the electronic health record that this evaluation had been completed. Interviews with facility staff revealed a lack of clarity regarding responsibility for PASARR compliance, with the administrative staff deferring to the Assistant DON and the business office manager unable to locate the required documentation. The social service designee reported discovering the missing Level 2 evaluation during a chart audit and subsequently submitting paperwork to the state, but this action occurred after the deficiency was identified. The facility's policy outlined responsibilities for completing and submitting CARE assessments but did not address the process for obtaining a PASARR Level 2 screening when recommended.
Failure to Update Care Plan and Honor Bathing Preferences
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident regarding bathing preferences and needs. The resident had multiple diagnoses, including dementia with behavioral disturbances, generalized anxiety disorder, insomnia, and psychotic disorder with hallucinations. Despite being cognitively intact according to the BIMS score, the resident required staff assistance for bathing and expressed a strong preference for the type and frequency of baths. The care plan did not include specific guidance for staff about the resident's bathing preferences, schedule, or required assistance. Documentation in the electronic medical record and bath sheets showed that the resident received only five baths in a 30-day period, instead of the twelve scheduled, and there was no record of the resident refusing any offered baths. Observations and interviews revealed that the resident repeatedly requested baths without receiving a response from staff and needed help with certain aspects of bathing for safety reasons. Staff interviews confirmed that resident preferences should be care planned and that offers and refusals should be documented, but this was not consistently done. The facility's policy required assessments and resident interviews to develop person-centered care plans, but this was not followed in the case of the resident's bathing needs.
Failure to Provide Assistance with ADLs Including Bathing, Eating, and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services and assistance with activities of daily living (ADLs) for three residents, resulting in unmet care needs. One resident with diagnoses including dementia, disorientation, and psychotic disorder had a care plan that lacked specific guidance regarding bathing preferences, such as type, frequency, and time of day. Although the resident was scheduled for showers three times a week, documentation showed only five showers were provided in a 30-day period, instead of the twelve scheduled. The resident reported repeatedly requesting a bath without response from staff, and there was no documentation of refusals. Another resident with severe cognitive impairment and aphasia required set-up and supervision for eating, as documented in the care plan and dietary notes. Observations revealed that the resident was left with food and drink out of reach, with no tray table available, and was not provided the necessary assistance to eat. The resident remained in the same position for extended periods, and staff interviews confirmed that the resident required assistance, which was not consistently provided. A third resident with dementia and Parkinson's disease required maximal assistance with personal hygiene, including shaving. Documentation indicated the resident was dependent on staff for these tasks. Observations showed the resident had significant facial hair and reported wanting a shave but was not allowed to have a razor. Staff interviews confirmed that shaving was only partially performed due to lack of appropriate equipment, and the care plan for personal hygiene was not fully followed. The facility did not provide policies on ADL assistance for these cases.
Failure to Provide Required Medicare ABN Notice at Termination of Benefits
Penalty
Summary
The facility failed to provide two residents with the required CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice (ABN) when their Medicare Part A benefits were terminated prior to the exhaustion of the 100-day benefit period. Both residents began receiving Medicare Part A services and, upon discharge from these services, remained in the facility. However, neither resident was given the ABN form, which is necessary to inform them of their right to choose continued skilled services and the associated financial responsibility for services not covered by Medicare. This deficiency was confirmed by an administrative nurse, who acknowledged that the facility did not issue the appropriate SNF ABN notice at the time of Medicare Part A termination. The facility's own policy requires that the ABN be provided to residents or their representatives to enable informed decisions regarding continued skilled services and potential costs, but this procedure was not followed for the two affected residents.
Failure to Maintain Safe and Operable Bed Equipment
Penalty
Summary
The facility failed to ensure that beds used by two residents were maintained in a safe and operable condition. One resident's bed frame was observed to be broken and unable to sit level, with the bed being an older crank style. Another resident's bed had a remote that was stuck under the bed and caught in the frame, with stripped sheathing and unraveled wires, and the bed was resting almost completely on the ground. The resident reported that while the bed could go up and down, the head of the bed could not be raised or lowered. Maintenance staff confirmed the issues with both beds and acknowledged that the conditions were unacceptable. The facility did not provide a policy related to bed safety or maintenance.
Improper Disposal and Storage of Garbage and Refuse
Penalty
Summary
During an inspection, surveyors observed that three bags of trash were left on the ground next to a portable dumpster that did not have a lid, and two doors were open on one of the two stationary dumpsters outside the facility. Dietary staff present at the time stated they were unaware that all trash, including that in portable dumpsters, was required to be covered. The facility's policy, dated January 2024, specifies that outside dumpsters provided by garbage pickup services must be kept closed and free of surrounding litter. These observations indicate that the facility failed to maintain and dispose of garbage and refuse in a sanitary manner, as required by their policy.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
The facility failed to ensure a safe and secure environment to prevent the elopement of a cognitively impaired resident identified at high risk for elopement. On the specified date, the charge nurse allowed the resident to exit the front doors of the building to smoke, not realizing the resident was not permitted to leave unescorted. The resident's WanderGuard alarm activated, but the CNA who turned off the alarm did not check which resident had triggered it. The facility did not realize the resident was missing until three hours later when the certified medication aide could not find the resident to administer medications. The resident was eventually found and returned by local law enforcement after being outside the facility for five and a half hours. The resident had a diagnosis of dementia and was identified as having severely impaired cognition. The care plan indicated the resident was at high risk for elopement and had a WanderGuard in place, which was supposed to be checked each shift. Despite these measures, the resident was able to leave the facility unsupervised. The facility's policy required staff to ensure the placement and function of the WanderGuard each shift and to document its status, but these procedures were not followed effectively. Interviews with staff revealed that there was a lack of understanding and adherence to the facility's elopement and alarm policies. The administrative nurse stated that staff should have known the difference between door alarms and WanderGuard alarms and should not have turned off the alarm without checking its cause. The facility's failure to provide adequate supervision and to respond appropriately to the WanderGuard alarm placed the resident in immediate jeopardy.
Removal Plan
- All staff were re-educated regarding the elopement policy, missing person policy, and resident sign out policy.
- Elopement drills were completed on each shift.
- All residents at risk for elopement received a WanderGuard bracelet and they were checked for function and placement.
- All residents had updated wandering assessments completed.
- The Risk for Elopement Book was reviewed and updated.
- All residents identified as being at risk for elopement had care plans updated as needed.
- Agency staff would be educated on the audible wander alarm sounds prior to working a shift.
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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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