Parkside Homes
Inspection history, citations, penalties and survey trends for this long-term care facility in Hillsboro, Kansas.
- Location
- 200 Willow Rd, Hillsboro, Kansas 67063
- CMS Provider Number
- 175387
- Inspections on file
- 18
- Latest survey
- March 17, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Parkside Homes during CMS and state inspections, most recent first.
A hospice resident with dementia and agitation received five times the prescribed dose of Ativan due to a nurse misreading the syringe. The error was discovered two days later, and the facility's policy requiring verification of medication details was not followed.
The facility failed to prevent falls and ensure safety for residents with high fall risks. One resident with severe cognitive impairment fell while attempting to put on socks, and another sustained deep lacerations requiring emergency treatment. The facility did not update care plans promptly or conduct thorough fall investigations, leaving residents at risk. Additionally, residents were left unattended in unsafe conditions, violating facility policies.
The facility failed to serve meals at safe and appetizing temperatures, as observed through resident complaints and staff actions. Two residents reported cold food, and dietary staff were seen serving food below acceptable temperatures. Food was left uncovered, and thermometers were not sanitized between uses, leading to potential cross-contamination. The facility's policy required food to be held at specific temperatures, but several items were served outside this range, placing residents at risk for impaired nutrition.
The facility failed to maintain sanitary conditions in food storage and preparation, with numerous food items improperly labeled and stored, and staff not adhering to hand hygiene protocols. Observations revealed opened and unsealed food items without dates or labels, and staff handling food without washing hands. The kitchen equipment was also found to be in poor condition, with burned food debris and damaged utensils.
The facility failed to maintain an effective infection control program, with deficiencies including improper cleaning and storage of respiratory equipment, lack of hand hygiene by dietary staff, and improper sterile technique during a PICC line dressing change. Additionally, a resident with open wounds was not placed on enhanced barrier precautions, and staff failed to perform hand hygiene after removing soiled gloves during catheter care.
The facility failed to adhere to antibiotic stewardship principles, resulting in inappropriate antibiotic use. The Infection Preventionist reported challenges in tracking antibiotic use due to incomplete infection evaluations and lack of adherence to McGeer's Criteria. Antibiotics were administered and completed before proper evaluation, and the Antibiotic Assessment Tool was not used. Unnecessary prophylactic antibiotics were prescribed without consulting the prescribing provider or medical director, violating the facility's Infection Control Policy.
The facility failed to address recurring food temperature concerns reported by the Resident Council over a year. Despite repeated complaints about cold food, such as icy corn dogs and cold hamburgers, no actions or outcomes were documented. The Social Services Designee could not produce a grievance log, and the kitchen's plate warmer was intermittently operational, violating the facility's grievance policy and risking residents' psychosocial well-being.
A medication cart was found unlocked and unattended in a common area, potentially affecting 14 residents. A CMA left the cart to get ice, acknowledging it should have been locked. The facility's policy lacked documentation on securing medication carts.
A resident with dementia and depression, requiring total assistance with ADLs, had a DNR order that was only signed by a physician, lacking necessary additional signatures. The facility's policy required a fully completed advanced directive, which was not met, potentially leading to uncommunicated end-of-life care needs.
A resident with dementia and encephalopathy experienced a change in their Seroquel dosage, but the facility failed to notify the responsible party. Interviews confirmed the lack of notification, and the facility lacked a policy on notification of change.
The facility failed to provide written bed hold notices to three residents during hospital transfers, placing them at risk of not returning to their original rooms. Despite having policies in place, the facility relied on verbal communication, which was insufficient and undocumented, leading to this deficiency.
A resident with hypertension experienced elevated blood pressure and low oxygen saturation levels, which were not reported to the physician as required. The resident also had episodes of involuntary movements and a significant headache, with medications held but no thorough investigation of symptoms. A new bruise was found but not documented or analyzed. Staff interviews revealed inconsistencies in care and documentation, highlighting a failure in communication and monitoring of the resident's health status.
The facility failed to accurately assess and document the care needs of several residents, leading to deficiencies in their care plans and MDS assessments. A resident with a history of falls experienced an uninvestigated fall, while another resident's MDS failed to document insulin injections and falls. Additionally, a third resident's MDS did not reflect the use of a Foley catheter and oxygen, despite their documented use in progress notes.
A facility failed to develop a person-centered baseline care plan for a resident with a complex medical history, including a high risk for falls. Despite the resident's history of falls and a high Morse Fall Scale score, the care plan lacked necessary interventions, leading to a fall with serious injuries. Staff interviews revealed that the baseline care plan was not adequately completed, contributing to an unsafe environment.
A facility failed to implement enhanced barrier precautions for a resident with venous stasis ulcers, compromising infection control. The resident frequently refused prescribed Tubigrip bandages, and staff inconsistently used PPE during care activities. Observations noted the absence of dressings on the resident's legs, and staff interviews revealed confusion about precautionary measures, highlighting a deficiency in care planning and infection control.
The facility failed to update care plans for two residents after falls, leading to uncommunicated care needs and increased fall risk. One resident's care plan lacked an intervention after a fall, and another resident's care plan was not updated until ten days post-fall. Both residents were at high risk for falls, and the facility did not adhere to its policy of timely care plan updates.
A resident with a history of chronic conditions and venous ulcers experienced inadequate care for her skin issues in the facility. Despite documented potential for skin impairment, the care plan lacked specific interventions, and the resident frequently refused prescribed treatments without documented follow-up. Observations showed untreated open areas and drainage on the resident's legs, and staff interviews revealed inconsistent adherence to skin integrity policies, leading to increased risk for further complications.
The facility failed to provide proper respiratory care and equipment storage for several residents, including improper cleaning and storage of a nebulizer for a resident with asthma, and inadequate labeling and storage of oxygen equipment for two other residents. These deficiencies posed a risk of respiratory complications.
The facility failed to document declination forms for pneumococcal and influenza vaccines for several residents, as required by policy. The EHRs lacked necessary documentation, and administrative nurses could not locate the forms. One resident did not receive a requested pneumococcal vaccine due to therapy concerns, and a verbal declination for the influenza vaccine was accepted without proper documentation.
A cognitively impaired resident with dementia and amnesia eloped from the facility due to inadequate supervision and failure to implement safety measures like a Wanderguard bracelet. The resident exhibited exit-seeking behaviors throughout the day, but staff did not take sufficient action to prevent the elopement, placing the resident in immediate jeopardy.
Medication Error: Overdose of Ativan Administered to Hospice Resident
Penalty
Summary
The facility failed to prevent a significant medication error involving a hospice resident diagnosed with dementia and agitation. The resident's care plan required the administration of medications as ordered, with monitoring for side effects and effectiveness. However, a Licensed Nurse administered five times the prescribed dose of topical Ativan, a medication used to treat anxiety, due to misreading the syringe. The error was not discovered until two days later when another nurse identified the mistake. The facility's policy on medication administration mandates that the individual administering medication must verify the right medication, dosage, time, and method of administration by checking the label three times. Despite this policy, the Licensed Nurse did not adhere to these procedures, resulting in the medication error. The incident was reported to the physician, but no new orders were received, and the facility's documentation lacked details on the resident's response to the overdose.
Failure to Prevent Falls and Ensure Safety
Penalty
Summary
The facility failed to provide an environment free from accident hazards for several residents, leading to multiple deficiencies. One resident, with a history of falls and severe cognitive impairment, was found on the floor attempting to put on socks, indicating a lack of effective fall prevention interventions in their care plan. Despite being at high risk for falls, the resident's care plan lacked safety interventions until after a fall occurred. Additionally, the facility did not conduct a fall investigation following the incident. Another resident, who had a history of falls and was at high risk according to the Morse Fall Scale, fell and sustained deep lacerations requiring emergency treatment. The facility failed to include fall prevention interventions in the resident's care plan, and there was inadequate documentation of neurological assessments and follow-up care. The resident's care plan was not updated promptly to address the fall risk, and the facility did not provide a thorough investigation into the fall. The facility also failed to ensure adequate supervision for residents with high fall risks. One resident was left unattended in a bathroom while attached to a mechanical lift, and another resident was left in a wheelchair in their room, despite being at high risk for falls. These actions demonstrate a lack of adherence to the facility's policies on fall prevention and care planning, resulting in an environment that was not free from accident hazards.
Deficiency in Food Temperature Management
Penalty
Summary
The facility failed to ensure that meals were served at safe and appetizing temperatures, as evidenced by multiple observations and resident complaints. Two residents, including the President of the Resident Council, reported that food was often served cold when it should have been hot. During meal service, dietary staff were observed serving food at temperatures below the acceptable range. For instance, pureed sausage gravy and toast were served at 100 degrees Fahrenheit, which was acknowledged as unacceptable by the Dietary Manager. Additionally, food items such as chicken and hamburger patties were not consistently temped before being placed in delivery carts, leading to further temperature discrepancies upon arrival at the dining areas. The report highlights several instances where dietary staff failed to maintain proper food handling procedures. Food was left uncovered, and thermometers were not sanitized between uses, leading to potential cross-contamination. The facility's policy required food to be held at temperatures between 41 degrees F and 135 degrees F, yet several food items were served outside this range. The Dietary Manager and Administrative Staff confirmed the concerns regarding food temperatures, acknowledging the multiple complaints from residents about the palatability of food due to temperature issues. This deficiency placed residents at risk for impaired nutrition, as stated in the report.
Sanitation and Hygiene Deficiencies in Food Service
Penalty
Summary
The facility failed to store, prepare, and serve food in a sanitary manner, which could potentially lead to food-borne illnesses among residents. During observations, numerous food items in both the small dining room kitchen and the main kitchen were found to be improperly stored. These items included opened and unsealed bags of various foods such as French toast, ice cream, muffins, bagels, and more, all lacking open dates or labels. Additionally, some food items, like a bag of salami, showed signs of spoilage with dried brown and green edges. The Dietary Manager confirmed these concerns, acknowledging the lack of proper labeling and sealing as unacceptable. Further issues were observed with staff hygiene practices. Dietary Staff G was seen handling food and interacting with residents without performing proper hand hygiene, even after touching his face and handling soiled dishes. This was confirmed by the Dietary Manager as a concern. Additionally, the kitchen equipment was found to be in poor condition, with ovens containing burned food debris and cutting boards and fry pans showing significant wear and damage. The facility's policies on hand hygiene and food preparation were not adhered to, as staff failed to follow proper procedures for hand washing and food storage.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by several deficiencies observed during the survey. A resident's nebulizer was not properly cleaned and stored, with the nebulizer cup and mouthpiece left intact on the machine and not disassembled or rinsed after use. Additionally, oxygen concentrators in residents' rooms were found with undated tubing and humidifier bottles containing cloudy liquid, indicating improper maintenance and storage of respiratory equipment. Dietary staff were observed lacking proper hand hygiene during meal service, touching their face and handling soiled dishes without washing hands before serving food to residents. This was confirmed as a concern by both the Dietary Manager and the Administrative Nurse. Furthermore, a resident with open wounds and drainage was assisted to the dining area without appropriate enhanced barrier precautions, as there was no signage or PPE bag indicating the need for such precautions. The facility also demonstrated improper sterile technique during a PICC line dressing change, where the sterile field was contaminated by touching the outside of the package with sterile gloves. Additionally, staff failed to perform hand hygiene after removing soiled gloves during catheter care. These actions and inactions contributed to the facility's failure to implement an effective infection prevention and control program, potentially leading to the spread of infections among residents.
Failure in Antibiotic Stewardship and Monitoring
Penalty
Summary
The facility failed to ensure adherence to antibiotic stewardship principles, leading to inappropriate antibiotic use among residents. The Infection Preventionist, Administrative Nurse C, reported difficulties in tracking antibiotic use due to incomplete infection screening evaluations and lack of adherence to McGeer's Criteria by the nursing staff. This resulted in antibiotics being administered and completed before a proper evaluation could be conducted. Additionally, the Antibiotic Assessment Tool in the Electronic Health Record (EHR) was not utilized during the antibiotic treatment period, further complicating the monitoring process. Both Administrative Nurse C and Administrative Nurse B acknowledged the presence of unnecessary prophylactic antibiotics being prescribed without consultation with the prescribing provider or the medical director. The facility's Infection Control Policy, which includes guidelines for antibiotic stewardship, was not followed, as there was no collaboration with the Medical Director, Pharmacist, or Director of Nursing to monitor antibiotic use. This lack of communication and adherence to policy contributed to the failure in providing ongoing antibiotic stewardship, increasing the risk of antibiotic resistance and the spread of multidrug-resistant organisms within the facility.
Failure to Address Resident Council's Food Temperature Concerns
Penalty
Summary
The facility failed to address and resolve recurring issues reported by the Resident Council, specifically concerning food temperatures. Over the course of a year, from September 2023 to September 2024, the Resident Council minutes documented repeated concerns about food being served at inappropriate temperatures. Specific instances included corn dogs being served icy inside, and hamburgers and tater tots being served cold. Despite these recurring complaints, the minutes lacked documentation of actions taken or outcomes achieved to address these issues. Interviews and observations revealed further deficiencies in the facility's grievance handling process. The Social Services Designee (SSD) was unable to produce a grievance log reflecting the residents' multiple concerns about food temperatures. Additionally, the SSD mentioned that the kitchen staff had access to a plate warmer that was intermittently operational, but was unsure of its current status. The facility's policy on the right to voice grievances stated that residents had the right to expect prompt efforts by the facility staff to resolve grievances, yet this was not adhered to, placing residents at risk for decreased psychosocial well-being and impaired quality of life.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure that one of the four medication carts observed was locked while unattended, which had the potential to affect 14 residents on the main campus. During an observation, an unlocked medication cart was found unattended in the main common area, with all medication drawers easily accessible. No staff was present for approximately two minutes until a Certified Medication Aide (CMA) returned from obtaining ice for the cart. The CMA acknowledged that the cart should have been locked when unattended and not in her line of sight. Administrative Staff confirmed the concern, noting that the cart should have been secured when not attended by staff. The facility's policy on Medication Labeling and Storage did not include documentation requiring medication carts to be locked or secured.
Incomplete Advanced Directive for Resident with DNR Order
Penalty
Summary
The facility failed to ensure that a resident's advanced directives were thoroughly completed, specifically for a resident with a Do Not Resuscitate (DNR) order. The resident, identified as R16, had a DNR order that was only signed by a physician, lacking the necessary additional signatures to validate the document according to the facility's policy and state law. This oversight was confirmed by the Social Service Designee, who acknowledged that the DNR uploaded in the Electronic Health Record (EHR) was incorrect. R16 was a resident with diagnoses of dementia and depression, exhibiting severely impaired cognition and requiring total assistance with activities of daily living. The resident's care plan and physician orders indicated a DNR status, which was visually represented by a red dot on the resident's name tag outside their room. Despite these indicators, the facility's failure to ensure a fully completed advanced directive had the potential to lead to uncommunicated needs, particularly concerning end-of-life care.
Failure to Notify Responsible Party of Medication Change
Penalty
Summary
The facility failed to notify the responsible party of a resident when there was a change in the resident's medication order. The resident, who had diagnoses of dementia and encephalopathy, was receiving Seroquel, an antipsychotic medication, for delusional behaviors. On September 6, 2024, the physician ordered a decrease in the Seroquel dosage to once daily at bedtime for a gradual dose reduction. However, the facility's progress notes did not show evidence that the resident's responsible party was informed of this medication change. Interviews with the resident's family member and facility staff confirmed the lack of notification. The family member reported that the last notification received from the facility was regarding a fall in August 2024. Licensed Nurse K and Social Service Designee E stated that it was the charge nurse's responsibility to notify the responsible party of any medication change and document it in the electronic health record. Administrative Nurse C also confirmed this procedure. Despite these protocols, the facility did not have a policy regarding notification of change, leading to the deficiency.
Failure to Provide Written Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to three residents or their representatives during hospital transfers. This deficiency was identified for residents R2, R10, and R31, who were transferred to hospitals without receiving the required written notice about the facility's bed hold policy. The absence of this documentation placed these residents at risk of not being able to return to their original rooms upon discharge from the hospital. For Resident R2, the electronic health record indicated diagnoses including cellulitis, pseudomonas, urinary tract infection, and dementia. Despite having intact cognition, as evidenced by a BIMS score of 15, there was no documentation in the care plan or progress notes regarding the notification of the bed hold policy during hospital transfers on two occasions. Interviews with facility staff revealed that the licensed nurse on duty was responsible for completing bed hold documentation, but this was not done, and no written notice was provided to the resident or their representative. Resident R31, who had severe cognitive impairment and required substantial assistance with activities of daily living, was also transferred to a hospital without receiving a written bed hold notice. Similarly, Resident R10, with moderately impaired cognition and multiple diagnoses including dementia and West Nile virus, was transferred without the required documentation. Facility staff confirmed that the bed hold policy was communicated verbally, but no written documentation was provided, contrary to the facility's policy requiring written notice at the time of transfer.
Deficiency in Monitoring and Reporting Resident's Health Status
Penalty
Summary
The report highlights a deficiency related to the monitoring and reporting of a resident's vital signs and health status. A resident with a history of hypertension had a blood pressure reading of 163/112, which exceeded the parameters set for reporting to the primary care physician. However, there is no documentation indicating that this elevated blood pressure was reported to the physician or hospice, as expected by the facility's protocol. Additionally, there was an incident where the resident's oxygen saturation level dropped to 73, yet it was not reported, which is considered unacceptable by the facility's standards. The resident experienced several health episodes, including involuntary movements, rapid respirations, and a significant headache, which were not adequately addressed. The resident's medications were held due to her altered state, but there is no indication that the underlying causes of her symptoms were thoroughly investigated or that appropriate interventions were implemented. Furthermore, the resident's skin assessment revealed a new bruise on her lower arm, which was not documented or analyzed for root cause, as required by the facility's procedures. Interviews with staff members revealed inconsistencies in the care provided, particularly in the monitoring and documentation of the resident's condition. The LPN acknowledged the need to manually recheck abnormal vital signs and notify the doctor, but there was a lack of follow-through in documenting these actions. The facility's policy on checking and changing residents was also noted to have been altered, potentially impacting the resident's care. Overall, the report indicates a failure in communication and documentation, leading to inadequate monitoring and response to the resident's health needs.
Inaccurate MDS Assessments and Care Plan Documentation
Penalty
Summary
The facility failed to accurately assess and document the care needs of several residents, leading to deficiencies in their care plans and Minimum Data Set (MDS) assessments. Resident 24, who had a history of falls and was at high risk for future falls, experienced a fall on 06/21/24 that was not properly investigated or documented in the care plan. The fall investigation report was delayed, lacked immediate interventions, and was missing a staff signature. This oversight resulted in uncommunicated care needs and placed the resident at risk for ongoing falls. Resident 35's MDS was inaccurately completed, failing to document insulin injections and falls with minor injuries. Despite having a history of falls and receiving insulin injections, these were not captured in the MDS, which could lead to uncommunicated care needs. The facility's policy required accurate MDS assessments, but the failure to adhere to this policy resulted in a lack of proper documentation and communication regarding the resident's care needs. Resident 31's MDS also contained inaccuracies, as it did not reflect the use of a Foley catheter and oxygen, which were part of the resident's care. The resident's care plan and physician orders lacked documentation of these interventions, despite progress notes indicating their use. This discrepancy between the resident's actual care needs and the documented MDS assessments could lead to uncommunicated care needs and potential risks to the resident's health.
Failure to Develop Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop a person-centered baseline care plan for a resident, identified as R238, within 48 hours of admission, as required by their policy. The resident had a complex medical history, including conditions such as extradural and subdural abscess, MRSA infection, sepsis, anxiety, severe protein-calorie malnutrition, acute kidney failure, and management of a vascular device. Despite these significant health issues, the baseline care plan did not include necessary interventions to prevent falls, even though the resident had a documented history of falls prior to admission. The resident was assessed with a high risk for falls, as indicated by a Morse Fall Scale score of 95. However, the baseline care plan lacked specific interventions to address this risk. The resident experienced a fall on 09/26/24, resulting in serious injuries, including multiple lacerations to the head and face, which required medical attention and stitches. The incident note from the fall indicated that the resident was found on the floor with blood present, and the resident was not able to recall how the fall occurred. Interviews with facility staff revealed that the baseline care plan was supposed to be completed by a nurse and reviewed with the resident and/or their family. However, the care plan did not adequately address the resident's fall risk or provide enhanced barrier precautions for the resident's surgical wound. The facility's failure to implement a comprehensive baseline care plan contributed to an environment that was not free from accident hazards, as evidenced by the resident's fall and subsequent injuries.
Failure to Implement Enhanced Barrier Precautions for Resident's Wounds
Penalty
Summary
The facility failed to develop a comprehensive care plan with interventions to address enhanced barrier precautions for a resident's wounds, which compromised infection control measures and placed other residents at risk. The resident, identified as R12, had a history of hypertension, chronic kidney disease, venous thrombosis, and vascular implants. She was assessed to have venous stasis ulcers on both lower legs, which required nonsurgical dressing. Despite the presence of these wounds, the care plan lacked specific interventions related to enhanced barrier precautions, and the resident frequently refused to wear prescribed Tubigrip bandages due to pain. Observations and interviews revealed that the facility did not consistently implement enhanced barrier precautions for R12. Staff members, including a licensed nurse and certified nurse aides, were observed not using appropriate personal protective equipment (PPE) during care activities. The facility's policy required enhanced barrier precautions for wounds that could serve as a reservoir for multidrug-resistant organisms, yet there was no consistent signage or PPE setup to indicate the need for such precautions. Interviews with staff indicated confusion and inconsistency in the application of these precautions, with some staff unaware of the need for enhanced barrier precautions for R12. The resident's wounds were documented to have increased drainage, redness, and inflammation, with observations noting the absence of dressings or coverings on her legs. Despite the presence of drainage and the resident's mobility in common areas, the facility did not ensure that enhanced barrier precautions were consistently applied. This oversight in infection control measures, coupled with the resident's refusal to adhere to treatment orders, highlighted a significant deficiency in the facility's care planning and infection control practices.
Failure to Update Care Plans for Fall Prevention
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for two residents, R24 and R31, related to falls and accident hazards. For Resident 24, the care plan did not include an intervention related to a fall that occurred on 06/21/24. The resident was found on the floor in the pantry area after attempting to get a soda, and although the fall was documented, there was no immediate intervention to prevent further falls. Additionally, the fall investigation report was not completed in a timely manner and lacked a signature from the staff member or licensed nurse who completed it. Resident 31's care plan also lacked timely updates following a fall. The resident, who had severely impaired cognition and required maximal assistance with activities of daily living, experienced a fall on 02/17/24 while attempting to put on socks. The care plan was not updated with fall prevention interventions until ten days after the incident. The facility failed to provide a fall investigation report upon inquiry, and observations revealed that the resident's call pendant was not always within reach, which could have contributed to the risk of falls. The facility's policy required care plans to be updated with interventions related to changes such as falls, but this was not adhered to in the cases of R24 and R31. The lack of timely updates to the care plans placed both residents at risk for uncommunicated care needs and further falls, potentially impacting their physical and psychosocial well-being.
Failure to Address Skin Issues in Resident
Penalty
Summary
The facility failed to adequately assess and address skin issues for a resident, identified as R12, who had a history of hypertension, chronic kidney disease, and venous thrombosis, among other conditions. Despite having a potential for skin impairment documented in the resident's care assessments, the facility did not implement or document any interventions related to the resident's skin or wounds in the comprehensive care plan. The resident had venous ulcers on her lower extremities, but the care plan lacked specific interventions to manage these conditions. The resident's medical records revealed multiple refusals of prescribed treatments, such as Tubigrip, which were intended to manage her skin condition. Despite these refusals, there was no documented follow-up or alternative interventions noted in the records. Observations showed that the resident's legs were swollen, red, and had open areas with drainage, yet there were instances where no dressings or coverings were applied. The facility's documentation was inconsistent, with missing assessments and a lack of follow-up on identified skin issues. Interviews with facility staff indicated a lack of adherence to the facility's policy on skin integrity, which required documentation and follow-up on skin deviations. The staff failed to consistently document skin assessments and did not perform regular evaluations as expected. This lack of action and documentation placed the resident at an increased risk for further medical complications, as the facility did not adequately address the resident's skin issues in a timely and effective manner.
Improper Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents, leading to potential respiratory complications. Resident 13, who had a diagnosis of asthma, was observed with a nebulizer that was not properly cleaned or stored. The nebulizer was left intact and draped over the arm of a recliner, contrary to the facility's policy which required disassembly, rinsing with tap water, and air drying on a paper towel after each use. The care plan for Resident 13 lacked documentation related to the care and use of the nebulizer, and the staff did not follow the cleaning schedule outlined in the physician's orders. Resident 31, who had severe cognitive impairment and required substantial assistance with activities of daily living, had an oxygen concentrator in her room with tubing that was not dated and a humidifier bottle filled with cloudy liquid. The nasal cannula was improperly stored, wrapped around the concentrator and exposed to the environment. The facility's policy did not include proper labeling and storage instructions for oxygen equipment, and there was no physician order reflecting Resident 31's oxygen use, despite hospital admission orders indicating the need for supplemental oxygen. Resident 3, who had multiple diagnoses including congestive heart failure and obstructive sleep apnea, was observed with oxygen tubing that lacked a date and was improperly stored, with nasal prongs resting on the floor. The facility's policy required oxygen tubing to be changed and dated regularly, but this was not adhered to. The improper storage of oxygen equipment for Resident 3 posed a risk of contamination and potential respiratory complications.
Deficiency in Vaccine Declination Documentation
Penalty
Summary
The facility failed to provide the necessary declination forms for pneumococcal and influenza vaccines for several residents, as required by their policies. Specifically, the electronic health records for four residents lacked documentation of the pneumococcal vaccine declination form, and one resident's record lacked documentation of the influenza vaccine declination form. The facility's policy mandates that residents or their legal representatives receive education about the benefits and potential side effects of these vaccines, and that the medical record should document whether the vaccine was administered or declined due to medical contradictions or refusal. During interviews, it was revealed that the administrative nurses could not locate the signed consent or declination forms for the pneumococcal vaccine for the affected residents. Additionally, one resident who requested the pneumococcal vaccine had not received it due to ongoing therapy and concerns about the vaccine's side effects interfering with therapy. The administrative nurse also confirmed that a verbal declination for the influenza vaccine was considered acceptable by the pharmacy, although this was not documented in the resident's record.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for a cognitively impaired resident, leading to an elopement incident. The resident, diagnosed with dementia and amnesia, exhibited severe cognitive impairment and was independently mobile. On the day of the incident, the resident attempted to leave the facility multiple times, expressing agitation and a desire to leave. Despite these clear exit-seeking behaviors, the staff did not apply a Wanderguard bracelet or take sufficient measures to prevent the resident from eloping. The resident first attempted to exit the front door and then moved to the gated courtyard, followed by staff. After spending approximately 45 to 60 minutes outside with staff, the resident was brought back inside the main building. Later in the day, the resident was let out of the front entrance by a visitor and was found 11 minutes later in the parking lot by a CNA. The staff was unaware of the resident's elopement until the CNA saw the resident outside. Interviews with staff revealed that the resident had been displaying exit-seeking behaviors throughout the day, including packing belongings and expressing a desire to leave. Despite these behaviors, the staff did not implement the facility's elopement policy, which included placing a Wanderguard bracelet on the resident. The facility's failure to provide adequate supervision and implement necessary safety measures placed the resident in immediate jeopardy.
Removal Plan
- R1 placed on one-to-one observation following the elopement until she went to bed and LN G educated the visitor about not letting others out without speaking to the nurse first.
- An elopement assessment completed, care plan updated, and a Wanderguard bracelet placed on R1.
- An elopement action plan completed.
- A Root Cause completed for R1 which determined she was on isolation for COVID prior to the day of the incident.
- The facility medical director, who was also R1's primary care physician, contacted and reviewed the action plan, root cause, policy changes, education plans and advised to place a sign on the exit doors to keep visitors from allowing exit advising them to see the nurse for assistance before opening the door.
- The facility contacted the resident representative to inform about care plan updates with interventions to new elopement risks.
- A full audit on elopement assessments completed and updated pictures placed at all nurse's stations for all residents with identified elopement risks to educate all staff and all agency staff of residents at risk.
- All staff provided immediate education on elopement policy update.
- Signs placed on all exit doors: Elopement Risk - do not open the door for someone you do not know or allow someone to follow you out the door unless they are with your party. For assistance please call [specified number] and a nurse will come to assist you. Thank you for keeping our resident's safe.
- Elopement Drill completed to test staff competency of elopement policy and procedure with an incident after action plan completed. A new intervention to add sign to the gate exits: Make sure gate is closed behind you, if you find the gate door open notify a nurse immediately.
- All staff educated on non-pharmacological approaches to support individuals living with dementia, maintain isolation precautions, interventions to help prevent behaviors and exit seeking, Abuse, Neglect, and Exploitation policy, and updated policy for resident isolation procedures.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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