Plaza West Healthcare And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Topeka, Kansas.
- Location
- 1570 Sw Westport Drive, Topeka, Kansas 66604
- CMS Provider Number
- 175255
- Inspections on file
- 34
- Latest survey
- April 15, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Plaza West Healthcare And Rehab during CMS and state inspections, most recent first.
The facility did not consistently provide enough nursing staff to meet resident needs, as evidenced by multiple unfilled nurse, CNA, and CMA shifts and lack of documentation that these gaps were covered. Staff interviews confirmed frequent short-staffing, and the facility was unable to provide a staffing policy when requested.
Persistent strong urine odors and stained furniture were observed throughout Hall 400 and its commons area, with administrative staff confirming these unsanitary conditions. The facility was also unable to provide a clean environment policy when requested, resulting in residents being exposed to an unclean and unhomelike environment.
Several newly admitted residents did not have baseline care plans in the EMR that included required interventions for ADLs, dialysis, wound care, or colostomy care. Staff provided basic care but lacked documented guidance, and one resident dependent on dialysis did not have dialysis care reflected in her care plan or physician orders. Nursing staff interviews confirmed that baseline care plans were not consistently completed as required by facility policy.
Several residents with cognitive and physical impairments did not receive regular bathing or alternative hygiene care as required, with staff failing to consistently offer or document alternative options when showers were refused. Observations showed residents in the same clothing for days and with poor personal hygiene, and staff interviews confirmed inconsistent follow-up and documentation.
Several residents experienced lapses in care, including missing nursing assessments before hospital transfers, lack of documentation for skin injuries, and absence of care plan instructions for medical devices such as a back brace. These deficiencies resulted in residents not receiving care according to physician orders, facility policy, or their individual needs.
The facility did not serve meals at regular times aligned with resident needs and preferences, resulting in prolonged waiting periods for food in both the main dining room and Memory Care Unit. Staff struggled with meal ordering systems, served meals inconsistently, and could not provide a meal service policy when requested. Residents expressed frustration and hunger due to these delays, and staff acknowledged that late meal service was common.
Surveyors identified that the facility's QAA program failed to recognize and address multiple care issues, including incomplete assessments, care planning lapses, medication errors, inadequate staffing, and infection control breaches. These deficiencies affected all residents and were observed through interviews, record reviews, and direct observation, indicating widespread lapses in quality oversight.
A resident was not given the required CMS 10055 Advanced Beneficiary Notice (ABN) with an estimated cost when skilled services ended. Staff interviews and record review confirmed the ABN was not provided, and the facility's policy for timely Medicare coverage notification was not followed.
A resident with a history of stroke, cognitive-communication deficits, and significant care needs exhibited ongoing sexually inappropriate behaviors toward female staff and another resident. Despite care plan interventions such as paired care and one-to-one supervision, documentation and communication lapses occurred, including inconsistent physician notification and unclear staff understanding of monitoring reasons. The facility did not ensure these behaviors were consistently addressed, placing others at risk.
Three residents did not have their comprehensive admission MDS assessments completed on time or at all, as required by CMS RAI guidelines. Staffing shortages led to delays and incomplete assessments, with nursing staff reporting they were unable to keep up with MDS duties while covering floor shifts. This resulted in the affected residents lacking timely, accurate assessments and individualized care plans.
Two residents experienced changes in skin condition—one developed a skin tear and another a Stage 3 pressure ulcer—yet their care plans were not updated with appropriate interventions or wound care instructions. Staff interviews and record reviews confirmed that care plans were not revised in a timely manner, resulting in a lack of direction for staff and placing the residents at risk for further injury.
A resident with significant medical conditions and high risk for pressure ulcers developed an avoidable Stage 3 pressure ulcer due to the facility's failure to update the care plan with specific wound care interventions and to document detailed skin assessments. Nursing staff did not consistently implement or record necessary interventions, and care plan updates were delayed, resulting in inadequate prevention and management of the resident's pressure injury.
A resident with multiple serious health conditions was provided supplemental oxygen therapy without a physician's order, and staff did not monitor or document the effectiveness of the therapy as required. The care plan did not address oxygen therapy, and the nasal cannula was not properly stored when not in use, as confirmed by staff interviews and record review.
A resident dependent on dialysis did not have their dialysis needs documented in the care plan, lacked physician orders and progress notes for dialysis, and did not receive required assessments or communication sheets before and after treatments. Staff confirmed that standard procedures for monitoring and communicating dialysis care were not followed, resulting in a failure to meet professional standards.
Staff failed to consistently sign controlled medication count logs at the beginning and end of shifts, as required by facility policy. Observations showed missing signatures on multiple dates, and interviews confirmed that staff were expected to complete this process to ensure accurate reconciliation of controlled substances.
A consultant pharmacist did not identify or report that staff failed to notify a physician when a resident's blood glucose readings were outside of ordered parameters. The resident, who had diabetes and other chronic conditions, received daily insulin and had specific orders for blood glucose monitoring and physician notification. Despite multiple out-of-range results over several months, the pharmacist's monthly medication reviews did not document or communicate these issues to facility administration.
Staff failed to notify a physician when a resident's blood glucose readings were outside ordered parameters and did not document the administration of prescribed medications for two residents. These actions were not in accordance with facility policy and placed the residents at risk for adverse effects related to their medication regimens.
A resident with multiple chronic conditions received the wrong dosage of a prescribed Zinc supplement for six consecutive administrations. The error occurred when a CMA administered 50 mg instead of the ordered 30 mg, without verifying the physician's order, resulting in a significant medication error.
A medication cart was found to contain an opened Humalog insulin Kwik pen for a resident without an open date, as confirmed by a nurse. Staff acknowledged that the pen should have been dated upon opening, and administrative staff confirmed this expectation. The facility did not provide a policy on dating insulin pens, resulting in a deficiency related to proper storage and labeling of biologicals.
A resident with multiple serious health conditions was admitted to hospice care, but the facility failed to maintain the required hospice plan of care and documentation of medications and equipment provided by hospice. Staff interviews confirmed that this information was missing from the resident's records, contrary to facility policy, resulting in a lack of documented collaboration between the facility and the hospice provider.
Staff did not follow Enhanced Barrier Precautions (EBP) for two residents with indwelling medical devices, including a feeding tube and a urinary catheter. During high-contact care activities, such as transferring, dressing, and catheter care, staff wore gloves but failed to don gowns as required by facility policy. Staff involved were unaware of EBP requirements and had not received adequate training, despite care plans and signage indicating the need for EBP. This resulted in a failure to maintain a sanitary environment and prevent infection transmission.
A resident with COPD and other health issues did not receive necessary respiratory care, missing numerous scheduled nebulizer treatments over several months. Observations showed improper storage of nebulizer equipment, and the resident reported not receiving treatments as scheduled. Staff interviews revealed inconsistencies in treatment administration and documentation, with facility policies lacking guidance on nebulizer tubing storage.
A CNA failed to receive effective communication training, leading to improper interactions with a resident. Video footage showed the CNA using a raised voice and not addressing the resident's discomfort. The facility lacked documentation and a policy on communication training, contributing to the deficiency.
A CNA at the facility failed to receive required training on resident rights, leading to interactions with a resident that compromised dignity and care standards. Video footage showed the CNA using a raised voice, handling the resident roughly, and using unsanitary wipes. The facility could not provide documentation of the CNA's training, and administrative staff confirmed the oversight.
A resident with cognitive impairment and end-stage renal disease was treated without dignity by a CNA, as captured on video. The CNA spoke in a raised voice, dismissed the resident's discomfort, and used unsanitary wipes during incontinence care. Facility policies emphasize respectful treatment, but the CNA's actions did not align with these standards.
A facility failed to prevent cross-contamination during incontinence care and did not disinfect a Hoyer lift between uses. CNAs did not change gloves or perform hand hygiene between dirty and clean tasks, and the lift was not disinfected before being used for another resident. Staff interviews confirmed that facility policies were not followed, posing a risk of infection.
Failure to Maintain Adequate Nursing Staff Coverage
Penalty
Summary
The facility failed to ensure adequate daily nursing staff were always available to meet the needs of all residents. The Facility Assessment, revised on 12/19/24, indicated that staffing needs and assignments should vary based on census and resident acuity, with additional staffing provided according to resident preferences when possible. However, a review of daily nursing staffing schedules from 12/01/24 to 03/18/25 revealed numerous unfilled slots for nurses, certified nurse aides (CNA), and certified medication aides (CMA) across different halls and shifts. There was no documentation that these open slots were filled by other staff members. Interviews with staff confirmed ongoing staffing issues. One CMA responsible for daily staffing stated that if she was not on duty and staff called in or did not show up, the charge nurse or Administrative Nurse would attempt to find replacements, but sometimes failed to update the schedule to reflect these changes. Another CMA reported that she was often required to assist CNAs due to being short-staffed about half the time. Additionally, the facility was unable to provide a staffing policy when requested. These findings demonstrate that the facility did not consistently maintain adequate nursing staff to meet resident needs.
Failure to Maintain Clean, Odor-Free Environment on Hall 400
Penalty
Summary
The facility failed to maintain a clean, odor-free, and homelike environment on Hall 400, as evidenced by persistent strong urine odors detected throughout the hall and commons area on multiple days. Observations also revealed two blue-colored couches in the Hall 400 commons area with visible brown stains. Administrative staff confirmed the presence of the odor and the stained furniture. Additionally, the facility was unable to provide a clean environment policy upon request. These conditions resulted in residents on Hall 400 being exposed to unclean and unhomelike surroundings.
Failure to Develop and Implement Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for several residents, as required by its own policy. Specifically, the baseline care plans for multiple newly admitted residents did not include care areas or interventions for activities of daily living (ADLs), dialysis care, wound care, or colostomy care. Staff interviews revealed that while basic care was provided, the necessary documentation and direction for staff regarding these care needs were missing from the electronic medical record (EMR) care plans. For example, one resident with a history of end-stage renal disease and dependence on dialysis did not have dialysis care or treatment documented in the baseline care plan. There were also no physician orders or progress notes reflecting the need for or participation in dialysis, despite the resident and staff confirming that the resident attended dialysis sessions regularly. Additionally, the resident reported that staff had not assessed her arteriovenous (AV) shunt after dialysis and that no communication sheet was sent with her to dialysis appointments. Interviews with certified nurse aides, licensed nurses, and administrative nursing staff confirmed that the responsibility for completing baseline care plans was not consistently fulfilled. The facility's policy required that baseline care plans include instructions for effective and person-centered care, including ADL assistance and any special needs such as dialysis or wound care. The lack of these care plan elements placed residents at risk of delayed care, possible decline, and injury, as directly stated in the report.
Failure to Provide Consistent Bathing and Hygiene Assistance
Penalty
Summary
The facility failed to provide consistent bathing and hygiene assistance to several residents who were unable to perform activities of daily living independently. Multiple residents with severe cognitive impairments, such as dementia and vascular dementia, as well as other medical conditions including depression, chronic kidney disease, and incontinence, did not receive regular baths or showers as scheduled. Documentation revealed that when residents refused showers, staff did not consistently offer alternative bathing options, such as sponge baths, or attempt bathing at different times, despite care plans and facility policy directing them to do so. In several cases, there was a lack of follow-up documentation regarding the attempts made to provide bathing or alternative hygiene measures. Observations during the survey found that residents often wore the same clothing for multiple days, had greasy or uncombed hair, and appeared disheveled, indicating a lack of adequate personal hygiene. Staff interviews confirmed that while refusals were sometimes documented, alternative bathing methods were not always offered, and documentation of these efforts was inconsistent or missing. In some instances, staff stated they would try again later if a resident refused, but there was no evidence that these follow-up attempts or alternative hygiene measures were consistently implemented or recorded. The facility's own policies required staff to assist residents with bathing to maintain hygiene and prevent skin issues, and to provide clean washcloths for perineal care. However, the records and staff statements indicated that these policies were not consistently followed. The lack of regular bathing and inadequate documentation of refusals and alternative hygiene measures placed residents at risk for poor hygiene, as directly observed and noted in the report.
Failure to Document Assessments and Implement Care Plans
Penalty
Summary
Multiple deficiencies were identified in the facility's provision of care and documentation for several residents. In one case, a resident with a history of stroke, atrial fibrillation, and a gastrostomy tube was transferred to the hospital, but the electronic medical record (EMR) lacked any nursing assessment or documentation regarding the reason or timing of the transfer. This was contrary to the facility's policy, which required staff to document assessment findings and relevant information for emergency transfers. The absence of this documentation placed the resident at risk for lack of quality care. Another resident with vascular dementia, depression, and epilepsy was found to have a red, bloody area on her forearm, but there was no documentation in the EMR regarding an assessment of the area or the cause of the injury. Staff were unaware of how the injury occurred, and the care plan did not include interventions to prevent skin tears or bruises. The facility's policy required thorough skin assessments and documentation of any skin conditions, but this was not followed, placing the resident at risk of further injury. Additional deficiencies included the lack of a nursing admission assessment and baseline care plan for a resident admitted with hospice services, as well as the absence of nursing assessments prior to the hospital transfer of a resident with epilepsy and dementia. In another case, a resident admitted with a lumbar vertebrae fracture did not have a physician's order for a back brace or care plan instructions for its use, despite recommendations from the hospital. These failures to assess, document, and implement appropriate care and interventions placed the residents at risk for inappropriate care, unmet goals, and delays in recovery.
Failure to Provide Timely Meal Service According to Resident Needs and Preferences
Penalty
Summary
The facility failed to provide meals and snacks at regular times in accordance with residents’ needs, preferences, and requests, as evidenced by multiple observations in both the main dining room and the Memory Care Unit. On several occasions, residents were seated in the dining areas well before the posted mealtimes but experienced significant delays before being served their meals. For example, in the large dining room, residents began arriving before noon, but the first meals were not served until after 1:00 PM, with some residents waiting even longer. Staff were observed struggling with a malfunctioning computer system for meal orders, resorting to paper and pencil, and serving meals in a random order, resulting in some residents being served much later than others at the same table. In the Memory Care Unit, similar delays were observed, with residents seated and provided drinks but not receiving their meals for extended periods. On one occasion, residents waited over an hour and a half before being served lunch, and on another, breakfast was delayed, leading to visible frustration and repeated requests for food from residents. Staff confirmed that late meal service was more common than timely service. Residents were observed expressing hunger and distress due to the delays, and staff were unable to provide clear answers about when meals would be served. Additionally, the facility was unable to provide a policy for serving meals or for mealtimes when requested by surveyors. The lack of a consistent and timely meal service, combined with the absence of a documented policy, resulted in residents having to wait extended periods before receiving meals, contrary to their needs, preferences, and plans of care.
Systemic Failures in Quality Assessment and Assurance Program
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) program failed to identify and address multiple care issues affecting all 130 residents. Surveyors found that the QAA program did not make good faith efforts to recognize deficiencies, resulting in a range of unaddressed problems. Specific deficiencies included failure to provide required CMS forms, maintain a safe and comfortable environment, address a resident's history of sexually aggressive behavior, and complete timely comprehensive assessments and baseline care plans for several residents. Additional issues involved not revising care plans, inconsistent bathing, incomplete nursing assessments before hospital discharges and after admissions, and failure to implement necessary interventions for skin integrity and medical devices. Further findings showed failures in obtaining and documenting physician orders for treatments such as oxygen therapy and dialysis, inadequate daily nursing staff, lack of staff competencies, insufficient physician involvement for behavioral issues, and medication management errors. The facility also did not ensure proper storage and labeling of medications, timely meal service, care planning for hospice residents, and maintenance of a safe, sanitary environment to prevent infections. These deficiencies were observed through record reviews, interviews, and direct observation, indicating systemic lapses in the facility's QAA processes.
Failure to Provide Required Medicare Advanced Beneficiary Notice
Penalty
Summary
The facility failed to provide the required CMS 10055 Advanced Beneficiary Notice (ABN) to a resident or their representative when skilled services ended. Specifically, the ABN form, which should have included an estimated cost for continued services, was not given to the resident when their skilled services were discontinued. Documentation was lacking to show that the resident or their representative received the ABN form at the appropriate time. Interviews with staff confirmed that the form was not provided, and the responsible social service staff member was no longer employed at the facility, resulting in a gap in the process. The facility's policy required timely notification regarding Medicare eligibility and coverage, including the provision of the SNFABN, Form CMS-10055. However, this policy was not followed in the case of the resident whose skilled services ended, as the necessary notice and cost estimate were not provided. This omission was confirmed by both social services and nursing administration during interviews.
Failure to Address Sexually Aggressive Behaviors
Penalty
Summary
The facility failed to adequately address a resident's sexually aggressive behaviors, resulting in a deficiency related to the protection of residents from abuse. The resident in question had a history of cerebral infarction, spastic hemiplegia, cognitive-communication deficits, and required significant assistance with activities of daily living. Despite having intact cognition, the resident exhibited sexually inappropriate behaviors towards female staff, including groping, making inappropriate comments, and attempting to pull staff into bed during care. The care plan identified these behaviors and directed staff to provide care in pairs and encourage the resident not to engage in such actions. Multiple progress notes documented ongoing sexually inappropriate behaviors, including groping staff, making sexual remarks, and inappropriately touching another resident. The care plan was updated to include one-to-one supervision, and staff were assigned to monitor the resident. However, there was a lack of clear communication and understanding among staff regarding the reason for the monitoring, and the electronic medical record did not consistently document physician notification of the sexual behaviors involving staff. The facility's policy required the identification, assessment, and care planning for residents with behaviors that could lead to abuse or neglect. Despite this, the facility did not ensure that the resident's sexually aggressive behaviors were consistently addressed, documented, or communicated to all relevant parties. This failure placed other residents at risk of sexual abuse.
Failure to Complete Timely Admission MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive admission Minimum Data Set (MDS) assessments for three residents in accordance with Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) guidelines. Specifically, one resident's admission MDS was not completed until several days after the assessment reference date, another resident's admission MDS was not completed at all, and a third resident's admission MDS was incomplete following readmission. These lapses were identified through observation, record review, and staff interviews. Licensed nursing staff reported being behind on MDS assessments due to staffing shortages and having to cover floor duties, which contributed to the delays and omissions. The facility's policy required the MDS/RAI coordinator to track and complete all MDS assessments within specified timeframes, but this was not adhered to for the affected residents. As a result, the residents were at risk for having inaccurate assessments of their status and not having individualized, comprehensive, person-centered care plans developed in a timely manner.
Failure to Revise Care Plans After Changes in Skin Condition
Penalty
Summary
The facility failed to revise and update care plans for two residents following significant changes in their skin condition, as required by policy. For one resident with vascular dementia, depression, and epilepsy, the care plan did not include interventions to prevent skin tears and bruises, despite the resident being dependent on staff for all activities of daily living and having severely impaired cognition. An observation revealed a red, bloody area on the resident's left forearm, but there was no documentation in the electronic medical record regarding an assessment of the area or the cause. Staff interviews confirmed a lack of awareness and documentation regarding the skin tear, and the care plan was not updated to address prevention of further skin injuries. Another resident with diagnoses including atrial fibrillation, congestive heart failure, embolism, and thrombosis, and who was at high risk for pressure ulcers, developed a Stage 3 pressure ulcer on the right buttock. The care plan for this resident was not updated to include interventions for wound care or specify the level of assistance required, even after the wound was identified and dressing changes were ordered. Weekly skin assessments were documented, but lacked detailed descriptions or measurements of the wound when it first appeared. Staff interviews revealed that care plans had not been updated due to staff being behind on documentation, and the necessary interventions for the pressure ulcer were not included in the care plan at the time of the survey. The facility's policy required that care plans be reviewed and revised upon a change in resident status, with new or modified interventions communicated to all staff involved in care. In both cases, the failure to update care plans following changes in the residents' skin condition resulted in a lack of direction for staff and placed the residents at risk for further injury and unmet care needs. The deficiencies were identified through observation, record review, and staff interviews, which confirmed that care plans were not promptly or adequately revised as required.
Failure to Implement and Update Pressure Ulcer Interventions
Penalty
Summary
A resident with multiple medical conditions, including atrial fibrillation, congestive heart failure, embolism, and thrombosis of the lower extremities, was identified as being at high risk for pressure ulcer development upon admission. The resident was dependent on staff for all functional abilities, always incontinent of bowel and bladder, and required a wheelchair for mobility. The care plan and medical orders indicated the need for weekly skin assessments, use of pressure-reducing devices, and interventions to maintain skin integrity. Despite these documented risks and interventions, the care plan was not updated to include specific wound care instructions or the level of assistance required after the development of a pressure ulcer. The resident's electronic medical record showed that weekly skin checks were performed, but documentation was incomplete, lacking detailed descriptions or measurements of the affected skin area when a new pressure-related wound was identified. The first measurement and staging of the wound as a Stage 3 pressure ulcer occurred several weeks after the initial skin issue was noted. Interviews with nursing staff revealed that care plans had not been updated in a timely manner to reflect the new wound and necessary interventions, and staff responsible for updating care plans had fallen behind due to other duties. Facility policy required prompt assessment, documentation, and care plan updates for pressure injuries, but these steps were not followed. The failure to implement and document appropriate interventions and to update the care plan resulted in the avoidable development of a Stage 3 pressure ulcer for the resident, placing them at risk for further complications.
Failure to Obtain Physician Order and Monitor Supplemental Oxygen Therapy
Penalty
Summary
A resident with diagnoses of end-stage renal disease, congestive heart failure, and respiratory failure was admitted to the facility and required supplemental oxygen therapy. Upon review, it was found that the resident did not have a physician's order for supplemental oxygen documented in the electronic medical record, and the care plan lacked a section addressing oxygen therapy. Additionally, the treatment administration record did not include instructions for staff to monitor and document the resident's oxygen saturation levels each shift. Observations showed the resident using a nasal cannula connected to an oxygen concentrator, with an additional oxygen canister and nasal cannula present in the room. The nasal cannula attached to the canister was not stored in a bag when not in use, contrary to facility expectations. Interviews with staff confirmed that an order for oxygen therapy should have been present, and that oxygen saturation should be monitored and documented each shift. Staff acknowledged that the omission of the oxygen order and monitoring instructions was an oversight following the resident's return from the hospital.
Failure to Provide Safe and Appropriate Dialysis Care and Communication
Penalty
Summary
A resident with diagnoses including a left tibia fracture, arteriovenous fistula, dependence on renal dialysis, end-stage renal disease, bipolar disorder, and anxiety disorder was admitted to the facility. The resident's baseline care plan did not include documentation or instructions regarding the dialysis process, and there were no physician orders or progress notes reflecting the need for or participation in dialysis. The Minimum Data Set (MDS) had not been completed due to the recent admission. Staff interviews confirmed that the resident attended dialysis twice weekly, but there was no evidence of required assessments before or after dialysis, nor was there a communication sheet sent with the resident to the dialysis center. Further interviews with facility staff revealed that the standard practice of sending a communication sheet with vital signs, changes in condition, or medications for dialysis residents was not followed for this resident. The administrative nurse verified that assessments before and after dialysis and proper documentation were not completed, and the care plan did not reflect the resident's dialysis needs. The facility's own hemodialysis policy required ongoing assessment, monitoring, and communication with the dialysis provider, but these procedures were not followed, resulting in a failure to provide care and services consistent with professional standards of practice.
Failure to Accurately Reconcile Controlled Medications at Shift Changes
Penalty
Summary
The facility failed to ensure accurate reconciliation of controlled medications during daily work shifts. Observations of the treatment and medication carts on the 400-hall revealed missing signatures for both coming on and going off shifts on multiple dates. Specifically, the controlled medication count logs lacked required staff signatures for several consecutive days, indicating that the mandated verification process was not consistently followed. Interviews with a licensed nurse and a certified medication aide confirmed that staff were expected to sign the controlled medication logs at the beginning and end of each shift to ensure accuracy. The facility's own Controlled Substance Administration and Accountability policy required two licensed nurses to account for all controlled substances and access keys at the end of each shift, in the absence of automated dispensing systems. Despite this policy, administrative staff acknowledged the expectation for staff to sign the logs, but the observed records showed this was not being done. This failure to accurately reconcile controlled medications at shift changes placed residents at risk for misappropriation of medications by staff.
Consultant Pharmacist Failed to Report Missed Physician Notifications for Out-of-Range Blood Glucose Results
Penalty
Summary
The facility's Consultant Pharmacist (CP) failed to identify and report that staff had not notified the physician when a resident's blood glucose (accu-check) results were outside of the physician-ordered parameters. The resident in question had multiple diagnoses, including diabetes mellitus, depressive disorder, vascular dementia, hypertension, and epilepsy, and required daily insulin administration. The resident's care plan and physician's orders specifically directed staff to monitor fasting blood sugars and notify the physician if results exceeded a certain threshold. However, electronic medical records showed that, over several months, there were numerous instances where blood glucose readings were outside the ordered parameters and the physician was not notified as required. The monthly medication regimen reviews conducted by the CP for January and February did not document any identification or notification to facility administration regarding these missed notifications. Interviews with facility staff confirmed a lack of awareness or adherence to the physician's orders regarding blood glucose notifications. The facility's pharmacy services policy required the CP to provide consultation on all aspects of pharmacy services, but the CP did not report the failure to notify the physician about out-of-parameter blood glucose results, as required by facility policy.
Failure to Notify Physician and Document Medication Administration
Penalty
Summary
The facility failed to ensure proper management and documentation of medication administration for two residents, resulting in deficiencies related to unnecessary drugs. For one resident with diagnoses including diabetes mellitus, depressive disorder, vascular dementia, hypertension, and epilepsy, staff did not notify the physician when blood glucose (Accu-check) results were outside the physician-ordered parameters. The physician's order required notification if fasting blood sugar exceeded a specific threshold, but review of the electronic medical record showed multiple instances over three months where this did not occur. Staff interviews confirmed a lack of awareness or adherence to the order, and facility policy required such notifications to promote resident well-being. For another resident with a history of left tibia fracture, arteriovenous fistula, end-stage renal disease, bipolar disorder, and anxiety, the facility failed to document the administration of prescribed medications, including bupropion and levothyroxine, on several dates. The medication administration record (MAR) lacked signatures or reasons for missed doses, and there was no documentation of physician notification regarding the missed or unsigned administrations. Staff interviews indicated uncertainty about medication availability and responsibility for administration, while facility policy required medications to be given as ordered and documented in the MAR. These failures in following physician orders and documenting medication administration placed the residents at risk for adverse effects related to their medication regimens. The facility's own policies required staff to manage and monitor drug regimens to avoid unnecessary drugs and ensure resident safety, but these were not followed in the cases identified.
Failure to Prevent Significant Medication Error in Supplement Administration
Penalty
Summary
A resident with diagnoses including diabetes mellitus, depressive disorder, vascular dementia, hypertension, and epilepsy was prescribed Zinc 30 mg by mouth in the morning for a specified period. The resident's care plan directed staff to administer medications as ordered and monitor for side effects. However, the Medication Administration Record (MAR) showed that the resident received six doses of Zinc at the wrong dosage, specifically 50 mg instead of the prescribed 30 mg, for six consecutive administrations. The error was identified when a Certified Medication Aide (CMA) noticed the discrepancy between the Zinc supplement bottle and the physician's order during a medication pass. The CMA had been administering the higher dose since the order was written, without verifying the correct dosage. The facility's policy required medications to be administered per physician's orders and for staff to evaluate medication errors once identified. The failure to administer the correct dosage constituted a significant medication error.
Failure to Label Opened Insulin Pen with Date
Penalty
Summary
Surveyors observed that one of seven medication carts contained a Humalog insulin Kwik pen for a resident that lacked an open date, despite the pen having been previously opened. A licensed nurse confirmed that the pen had been opened and acknowledged that staff should have documented the open date at that time. An administrative nurse also stated that staff are expected to place an open date on insulin pens when they are opened. The facility was unable to provide a policy regarding the dating of Humalog pens. This failure to label the insulin pen with an open date constituted a deficiency in the storage and labeling of biologicals as required.
Failure to Collaborate with Hospice Provider for Resident Care
Penalty
Summary
The facility failed to ensure proper collaboration of care between a resident's hospice provider and the facility. The resident in question had multiple significant diagnoses, including lung cancer, stroke, chronic kidney disease, and peripheral vascular disease, and was admitted to hospice care. Documentation in the resident's care plan indicated that hospice services had started, and staff were directed to assess and manage symptoms, provide emotional support, and coordinate with hospice for significant changes or complications. However, the care plan did not specify which medications or supplies were provided by hospice, and a review of the hospice provider's notebook revealed the absence of a hospice plan of care. Interviews with facility staff confirmed that the hospice plan of care, as well as a list of medications and equipment provided by hospice, should have been present in the resident's hospice book but were not. Staff could not provide a reason for this omission. The facility's policy required coordination and documentation of hospice services, including a coordinated plan of care, but this was not followed for the resident, resulting in a lack of documented collaboration and potentially inadequate end-of-life care.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Staff failed to implement Enhanced Barrier Precautions (EBP) as required for two residents with indwelling medical devices. One resident with a feeding tube, who had moderate cognitive impairment and required supervision with eating, was observed being assisted by a Certified Nurse Aide (CNA) who donned gloves but did not wear a gown during high-contact care activities such as transferring, dressing, and toileting. The CNA was unaware of the resident's EBP status and reported not having received training on EBP. Another resident with a urinary catheter, who was cognitively intact and independent with most activities of daily living, was assisted by a Licensed Nurse (LN) who also failed to don a gown while emptying the urinary catheter bag. The LN did not disinfect the drainage ports and placed the uncovered catheter bag on the bed, allowing it to touch the floor. The LN stated she had not been trained to disinfect the ports and was unaware of any residents on EBP in the unit. Both residents had care plans and medical records indicating the need for EBP due to their indwelling devices. Facility policy required the use of gloves and gowns during high-contact care for residents at increased risk of multi-drug resistant organism (MDRO) acquisition. Despite signage and supplies being available, staff did not follow EBP protocols, resulting in a failure to maintain a sanitary environment and prevent the potential transmission of infections.
Failure to Provide Necessary Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services for a resident diagnosed with chronic obstructive pulmonary disease (COPD), tobacco use, dementia with behavioral disturbance, and a personal history of pulmonary embolism. The resident's care plan indicated altered respiratory status and difficulty breathing related to COPD and emphysema, requiring administration of medications and monitoring for effectiveness. However, the Treatment Administration Record (TAR) revealed that the resident missed a significant number of scheduled ipratropium-albuterol nebulizer treatments over several months, with 26 out of 90 treatments missed in November, 17 out of 93 in December, and nine out of 81 in January. Observations on January 28 revealed that the resident's nebulizer mask was improperly stored, with the tubing disconnected and laid on the floor. The resident reported not receiving breathing treatments as scheduled, although she could request them. Interviews with nursing staff indicated that treatments were supposed to be administered and documented in the TAR, including any refusals. However, the resident had previously reported that staff refused to provide or offer the treatments. The facility's policies on medication administration and oxygen safety did not adequately address the storage of nebulizer tubing, contributing to the deficient practice that placed the resident at risk for infection and unwarranted physical complications.
Deficiency in Effective Communication Training for CNA
Penalty
Summary
The facility failed to ensure that Certified Nurse Aide (CNA) M received the required effective communication training, which placed residents at risk for impaired communication. The deficiency was identified through a review of video footage and interviews. The footage revealed multiple interactions between CNA M and a resident, R1, where CNA M used a raised voice and did not effectively communicate with R1. During these interactions, R1 expressed discomfort and pain, which CNA M did not adequately address. CNA M also used wipes that had fallen on the floor on R1, further indicating a lack of proper communication and care. The facility was unable to provide documentation that CNA M had completed the necessary education on effective communication. Interviews with administrative staff confirmed that while onboarding education included topics such as resident rights and infection control, it did not include effective communication training. The facility also did not have a policy on effective communication training, which contributed to the deficiency. This lack of training and policy oversight led to the observed interactions that compromised the quality of care provided to R1.
Failure to Provide Resident Rights Training to CNA
Penalty
Summary
The facility failed to ensure that Certified Nurse Aide (CNA) M received the required training on resident rights, which is a critical component of staff education. This deficiency was identified through a review of video footage and interviews, revealing that CNA M engaged in interactions with a resident, R1, that compromised the resident's dignity and rights. During these interactions, CNA M displayed a lack of sensitivity and respect towards R1, including using a raised voice, handling the resident roughly, and failing to maintain proper hygiene standards by using wipes that had fallen on the floor. Additionally, CNA M did not provide appropriate assistance to R1, who expressed discomfort and pain multiple times during the care process. The facility was unable to provide documentation that CNA M had completed the necessary training on resident rights, as required. Interviews with administrative staff confirmed that while onboarding education was supposed to include resident rights, infection control, hand washing, and abuse, CNA M did not receive this training. The absence of a policy on resident rights training further highlighted the facility's failure to ensure compliance with training requirements, placing residents at risk for impaired rights and loss of dignity.
Failure to Treat Resident with Dignity
Penalty
Summary
The facility failed to ensure that staff treated a resident, identified as R1, with dignity, as evidenced by interactions captured on video footage. R1, who had diagnoses including end-stage renal disease, cognitive communication deficit, and required assistance with personal care, was subjected to undignified treatment by a Certified Nurse Aide (CNA) identified as M. The resident's medical records indicated moderate cognitive impairment and a need for substantial assistance with toileting hygiene. The care plan emphasized the need for staff to approach R1 in a gentle and friendly manner. On two separate occasions, video footage revealed CNA M interacting with R1 in a manner that lacked respect and dignity. During the first incident, CNA M entered R1's room, spoke in a raised voice, and handled R1's incontinence care without regard for her comfort, using wipes that had fallen on the floor. R1 expressed discomfort multiple times, but CNA M dismissed her concerns. In the second incident, CNA M again entered R1's room, turned off her call light, and attempted to transfer R1 to a wheelchair without proper communication or consideration for R1's expressed discomfort. Interviews with other staff members, including a CNA, a Licensed Nurse, and an Administrative Nurse, highlighted the facility's expectations for treating residents with dignity, such as maintaining a respectful tone, ensuring privacy, and addressing residents by their preferred names. Despite these expectations, the actions of CNA M did not align with the facility's policies on resident rights and dignity, as outlined in their undated policies. This deficiency placed R1 at risk for decreased self-esteem and dignity.
Infection Control Deficiency in Incontinence Care and Equipment Disinfection
Penalty
Summary
The facility failed to ensure proper infection prevention and control during incontinence care for a resident and did not disinfect a Hoyer lift between resident uses. During an observation, two CNAs were seen performing incontinence care for a resident without changing gloves between the dirty and clean portions of the care. The CNAs did not perform hand hygiene after removing soiled gloves and before donning new ones, which is a critical step in preventing cross-contamination. Additionally, the CNAs did not disinfect the Hoyer lift after using it for one resident before moving it to another resident's room. Interviews with staff, including a CNA, a licensed nurse, and an administrative nurse, revealed that the facility's expectations and policies were not followed. The staff acknowledged the importance of changing gloves and performing hand hygiene during incontinence care and disinfecting equipment between uses. The facility's policies on perineal care and cleaning and disinfection of resident-care equipment were not adhered to, leading to a risk of infection and related complications for the residents involved.
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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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