Riverbend Post Acute Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Kansas.
- Location
- 7850 Freeman Avenue, Kansas City, Kansas 66112
- CMS Provider Number
- 175298
- Inspections on file
- 31
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Riverbend Post Acute Rehabilitation during CMS and state inspections, most recent first.
The facility did not notify the LTCO of several residents' hospital transfers or discharges, as required by policy. In multiple cases, residents with complex medical needs were transferred to the hospital, but the facility's records and staff interviews confirmed that the LTCO was not informed, particularly when residents were on bed hold or returned within the bed hold period.
Surveyors found that multiple insulin pens and vials used by several residents were not labeled with the date opened or the expiration date, and some expired insulin was not removed from storage as required by facility policy. This deficiency was identified through observation, interview, and record review, and involved various types of insulin including Aspart, Lispro, Lantus, Glargine, Humalog, Novolog, and Tresiba.
A nurse provided wound care to a resident with diabetic foot ulcers without wearing a gown as required by Enhanced Barrier Precautions (EBP), using only gloves and lacking appropriate PPE and signage in the room. The nurse stated she was instructed to use gloves only, and administrative staff confirmed that EBP protocols, including gown and glove use, were not followed or communicated as required by facility policy.
Two residents with complex medical needs did not have their care plans updated to include individualized, resident-centered instructions for ADLs such as toileting, transfers, bathing, oral hygiene, dressing, and eating. Despite documented dependence on staff and significant health conditions, care plans lacked specific guidance, and staff relied on verbal reports rather than written directions, contrary to facility policy.
A resident with severe cognitive impairment and multiple medical conditions did not receive consistent bathing and grooming assistance, as required by facility policy. Extended periods without showers or bed baths were documented, and observations showed the resident had tangled, matted hair and wore the same clothes for over a week. Staff reported repeated refusals of care, but documentation of multiple attempts was lacking, and only one staff member was permitted to attempt showers.
A resident with multiple neurocognitive and psychiatric diagnoses, including dementia, exhibited ongoing wandering and rummaging behaviors, such as going through staff belongings and attempting to take items from others. Despite care plan interventions like redirection and snacks, these actions were not consistently effective, and the behaviors persisted. Staff primarily responded by redirecting the resident and removing personal items from accessible areas, rather than implementing more effective individualized interventions.
A resident with hypotension and severe cognitive impairment received midodrine for low blood pressure on multiple occasions when their systolic blood pressure was above the physician-ordered threshold. Staff did not recognize or act on out-of-parameter readings, resulting in the medication being administered contrary to orders.
A resident with hypotension and severe cognitive impairment received midodrine on multiple occasions when their systolic blood pressure was above the physician-ordered hold parameter. Staff failed to recognize and act on the out-of-range blood pressure readings, resulting in the medication being administered contrary to orders and facility policy.
The facility failed to secure hazardous materials, such as alcohol-based disinfectant wipes, in a secured unit, placing seven cognitively impaired residents at risk. The wipes were accessible on the 2nd-floor nursing station, despite warnings of potential harm. Staff interviews confirmed that such products should be locked away to prevent access by residents, but the facility lacked a formal policy on safe chemical storage.
A resident with major depressive disorder, diabetes, and heart failure was found uncovered from the waist down with her groin area visible from the hallway due to an open door and undrawn privacy curtain. Despite requiring substantial assistance for daily activities, the facility did not ensure her privacy, contrary to their dignity and respect policy.
The facility failed to use wheelchair foot pedals for three severely cognitively impaired residents, resulting in their feet sliding on the ground while being pushed. Staff confirmed that foot pedals should be used to prevent such incidents, as per the facility's policy. This oversight placed the residents at risk for preventable accidents and injuries.
A resident with multiple health conditions refused daily weight checks, and the facility failed to notify the physician of these refusals. Staff interviews revealed inconsistent communication practices, and the facility lacked a policy for notifying the physician about such refusals.
A resident with a pressure ulcer on the right buttocks did not have a pressure-reducing heel supportive device in place as required by their care plan. Observations showed the resident's heels resting directly on the mattress, despite their medical history indicating a high risk for pressure ulcers. Staff interviews confirmed the oversight in implementing necessary pressure-relieving measures.
A resident with cerebral palsy and contractures did not have their orthotic device applied, as required by their care plan, leading to a risk of discomfort and decreased range of motion. Observations showed the resident's wrist was consistently curled, and staff interviews revealed confusion over responsibility for applying the splint. The facility lacked a policy for positioning or ROM, and the restorative aide responsible for these tasks was on maternity leave without a replacement.
A resident with COPD and other health conditions had their CPAP mask improperly stored, increasing the risk of respiratory infection. Observations showed the mask was left on surfaces without sanitary protection, contrary to facility policy and staff statements that equipment should be stored in plastic bags when not in use.
A facility failed to document a risk assessment and obtain consent for a resident's use of side rails, as required by their policy. The resident, who had multiple health issues requiring assistance, was using side rails without documented safety assessments or informed consent. This oversight placed the resident at risk for uninformed decision-making and potential safety hazards.
A resident with multiple medical conditions, including foot drop and pressure ulcers, was not seen by their attending physician for six months, contrary to the facility's policy requiring quarterly visits. Staff were unaware of the physician's visit schedule, leading to a lack of documentation and oversight, placing the resident at risk of complications.
A resident with severe cognitive impairment and dementia experienced multiple non-injury falls and incidents due to inadequate supervision and care in an LTC facility. Despite documented needs for assistance with ADLs and incontinence, the facility failed to implement effective interventions, leading to the resident being found on the floor or in inappropriate locations. Staff interviews revealed a lack of consistent monitoring and supervision, compromising the resident's safety and well-being.
The facility failed to properly store respiratory equipment for three residents, including a CPAP mask, tracheal tubing, and nasal cannula, leading to potential infection risks. Staff interviews confirmed that equipment should be stored in plastic bags when not in use, as per the facility's infection prevention policy.
A resident with complex medical needs, including a colostomy and indwelling catheter, was neglected by staff, resulting in maggot infestation in her genital area. Despite requiring substantial assistance, the resident was left unsupervised outside without proper clothing, and staff failed to provide necessary catheter and perineal care. The facility's care plan lacked specific interventions for the resident's care refusals, and staff inconsistently documented and provided care, leading to significant harm.
Failure to Notify Ombudsman of Resident Hospital Transfers and Discharges
Penalty
Summary
The facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO) regarding the discharge or hospital transfer of several residents, as required by both federal regulations and the facility's own Admission, Transfer, and Discharge policy. The policy specified that a list of residents who had an emergency transfer and/or discharge would be sent to the LTCO monthly. However, documentation and staff interviews revealed that this notification was not consistently completed for residents who were transferred to the hospital but remained on bed hold or returned within the bed hold period. One resident with diagnoses including diabetes mellitus, major depressive disorder, and muscle weakness was transferred to the hospital for evaluation of increased pain, swelling, and an open area on the foot. The clinical record showed that while emergency services and the responsible party were notified, there was no documentation that the LTCO was informed of the discharge. Similar deficiencies were found for other residents with complex medical conditions, such as rhabdomyolysis, lactic acidosis, acute respiratory failure, and chronic respiratory failure, who were also transferred to the hospital. In each case, the facility's records lacked evidence of LTCO notification at the time of transfer or discharge. Interviews with administrative and social services staff confirmed that the facility's reporting system did not capture residents who were transferred to the hospital and remained on bed hold, unless they did not return within the 10-day period. As a result, the LTCO was not notified of these residents' transfers or discharges, contrary to the facility's policy. This failure was observed in multiple cases reviewed during the survey, indicating a pattern of non-compliance with required notification procedures.
Failure to Label and Remove Expired Insulin Products
Penalty
Summary
Surveyors observed that multiple insulin flex pens and vials belonging to several residents were not labeled with the date opened or the date expired. Specific types of insulin, including Aspart, Lispro, Lantus, Glargine, Humalog, Novolog, and Tresiba, were found on the South Hall medication cart without proper labeling. In one instance, an insulin flex pen was labeled with the date opened but lacked an expiration date, and the insulin had already expired according to the 28-day in-use guideline. The facility's policy requires that medications which are expired, contaminated, or in containers without secure closures be immediately removed and disposed of, but this was not followed for the insulin products observed. The failure to label insulin products with the date opened and the expiration date was identified through observation, interview, and record review. The report specifically notes that the affected insulin products were not removed from storage after their expiration, as required by facility policy and professional standards. The sample included 24 residents out of a census of 113, and the deficiency was documented for insulin belonging to at least eleven residents.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency occurred when a licensed nurse provided wound care to a resident with diabetic neuropathy ulcers on the right great toe and right second toe without adhering to Enhanced Barrier Precautions (EBP). The nurse washed her hands and wore gloves but did not don a gown while removing and reapplying dressings to the resident's open wounds. There was no personal protective equipment (PPE) available in the resident's room, nor were there instructions or signage regarding the required use of PPE for EBP during care activities involving the resident's wounds. The nurse confirmed during an interview that she was instructed to use gloves only and did not believe a gown or additional PPE was necessary. Administrative staff later verified that staff should have been using PPE for EBP when providing care to the resident and acknowledged the absence of PPE and signage. Facility policy required the use of gown and gloves for high-contact care activities involving residents with wounds, in accordance with EBP, but these procedures were not followed during the observed wound care.
Failure to Revise Care Plans for Resident-Centered Functional Abilities
Penalty
Summary
The facility failed to revise and update the care plans for two residents to include individualized, resident-centered functional abilities and specific directions for staff regarding activities of daily living (ADLs). For one resident with chronic respiratory failure, congestive heart failure, obstructive sleep apnea, anxiety, major depressive disorder, and diabetes mellitus, the care plan did not provide instructions for staff on essential ADL support such as toileting hygiene, transfers, bed mobility, bathing, oral hygiene, dressing, and eating. This resident required substantial to maximal assistance with these activities, as documented in the Minimum Data Set (MDS), and had multiple hospitalizations for decreased oxygen levels during the review period. Observations showed the resident needed repositioning for safe meal intake, and staff interviews confirmed that care plan directions were missing due to a mishap in the care planning process. Another resident with neuromuscular bladder dysfunction, hypertension, paraplegia, major depressive disorder, traumatic brain injury, anxiety, morbid obesity, a stage four pressure ulcer, and dependence on a wheelchair also had a care plan lacking specific interventions for ADLs. The MDS and Care Area Assessment (CAA) documented the resident's dependence on staff for toileting, transfers, dressing, and personal hygiene, as well as the need for a mechanical lift and limited time in a chair due to a wound vac. Despite these needs, the care plan did not include detailed instructions for staff on how to provide necessary assistance with toileting hygiene, transfers, bathing, oral hygiene, dressing, and eating. Staff interviews revealed that CNAs relied on verbal reports from previous shifts or nurses to determine the care needs of residents, rather than written care plan instructions. Administrative nursing staff acknowledged that the care plans should have included detailed directions for staff and that the omission was an error. The facility's own policy required comprehensive, individualized care plans to guide staff in providing person-centered care, but this was not followed for the two residents identified in the sample.
Failure to Provide Consistent Bathing and Grooming for a Resident with Impaired Cognition
Penalty
Summary
The facility failed to provide consistent bathing and grooming care for one resident with multiple diagnoses, including dementia, anxiety, hypertension, atrial fibrillation, cognitive communication deficit, and depression. The resident was assessed as having severely impaired thinking and required partial staff assistance for activities of daily living (ADLs) such as dressing, mobility, transfers, ambulation, personal hygiene, and showers. Documentation showed that the resident frequently refused showers or bed baths, with extended periods where no bathing occurred, including gaps of up to 26 days. The care plan directed staff to explain care activities, negotiate ADL times, and provide consistency in caregivers and routines, but records indicated that only one staff member was allowed to attempt showers, and documentation of repeated attempts was lacking. Observations over several days revealed the resident had uncombed, tangled, and matted hair and wore the same clothes for over a week. Staff interviews confirmed that the resident often refused showers and changes of clothes, and that only one staff member was permitted to attempt showers, which limited opportunities for care. Nursing staff and administration acknowledged the resident's resistance to care and stated that the family was aware of the situation and did not wish to be contacted for each refusal. Despite these challenges, the facility's policy required that residents unable to perform ADLs receive services to maintain good hygiene and grooming, which was not consistently provided in this case.
Failure to Address Dementia Care Needs for Resident with Persistent Wandering and Rummaging Behaviors
Penalty
Summary
The facility failed to adequately address the dementia care needs of a resident who exhibited persistent wandering and rummaging behaviors, including going through staff members' belongings at the nurse's station and attempting to take items from other residents and staff. The resident had a documented history of multiple neurocognitive and psychiatric diagnoses, including Wernicke's encephalopathy, alcohol-induced persisting amnestic disorder, alcohol dementia, schizoaffective disorder, mood disorder, and anxiety. Over time, the resident's cognitive status declined from intact to moderately impaired, as reflected in the Minimum Data Set (MDS) assessments, and the care plan was updated to include interventions such as distraction with snacks, structured activities, and redirection. Despite these interventions, nursing notes repeatedly documented incidents where the resident attempted to take food, beverages, and other items from staff and other residents, rummaged through drawers, and entered unauthorized areas such as the nurse's station and other residents' rooms. Staff responses primarily involved redirection, providing snacks, and educating the resident that the behavior was inappropriate. However, these interventions were not consistently effective, as the resident continued to display the same behaviors over an extended period, and staff adapted by removing their personal belongings from accessible areas rather than addressing the underlying behavioral issues. Interviews with staff confirmed that the resident's behaviors were ongoing and that the primary approach was redirection and provision of snacks. The facility's policy on dementia care required individualized care plans and specialized staff training, but the documentation and staff interviews indicated that the interventions in place did not sufficiently address the resident's persistent behaviors. The lack of effective, individualized interventions placed the resident at risk for decreased quality of life and potential accidents.
Failure to Hold Blood Pressure Medication per Physician Parameters
Penalty
Summary
Staff failed to follow physician-ordered parameters for administering blood pressure medication to a resident with a history of hypotension, cognitive impairment, depression, and anxiety. The physician's order specified that midodrine should be held if the resident's systolic blood pressure (SBP) exceeded 130 mmHg. Despite this, the Medication Administration Record showed multiple instances over several months where the medication was administered when the resident's SBP was above the ordered threshold. The resident's care plan directed staff to administer medications as ordered and observe for adverse effects, but these instructions were not followed. Certified Medication Aides and Licensed Nurses involved in the resident's care did not recognize or act upon the out-of-parameter blood pressure readings, resulting in the medication being given inappropriately. Staff interviews confirmed a lack of awareness regarding the need to hold the medication when the SBP was above the specified limit. The facility's policy required medications to be administered as prescribed and in accordance with written orders, but this was not adhered to in the resident's case.
Failure to Hold Blood Pressure Medication per Physician Order
Penalty
Summary
A medication administration error occurred when a resident with a history of hypotension, cognitive impairment, depression, and anxiety received midodrine, an antihypotensive medication, despite their systolic blood pressure (SBP) being above the physician-ordered parameters. The physician's order specified that midodrine should be held if the SBP exceeded 130 mmHg. However, the Medication Administration Record documented multiple instances across several months where the resident received the medication when their SBP was above this threshold. The resident's care plan directed staff to administer medications as ordered and observe for adverse effects, but these instructions were not followed. Staff interviews confirmed that the medication was not held as required, and the certified medication aide administering the medication was unaware that the resident's blood pressure was out of the prescribed range. The facility's policy required immediate reporting and documentation of medication errors, as well as close monitoring of the resident's condition, but the error was only recognized after the fact. The failure to adhere to physician orders and facility policy resulted in the resident receiving medication outside of safe parameters.
Failure to Secure Hazardous Materials in Secured Unit
Penalty
Summary
The facility failed to secure areas containing hazardous materials, placing seven cognitively impaired and independently mobile residents at risk for preventable injuries and accidents. During an inspection of the 2nd-floor nursing station, alcohol-based disinfectant wipes were found on the outside counter and on a shelf next to the sensory room. These containers had warnings indicating they were hazardous to humans, could cause eye irritation, and were harmful if swallowed. Despite the presence of these warnings, the wipes were accessible to residents, including one severely cognitively impaired resident who was observed wandering around the area where the wipes were accessible. Interviews with staff revealed that cleaning products should be secured in locked closets or rooms to prevent access by cognitively impaired residents. A CNA confirmed that these residents should not have access to such products due to the risk of accidental poisoning. An administrative nurse stated that staff were expected to lock up cleaning products and areas with potential hazards to prevent accidents. However, the facility was unable to provide a policy related to accidents or safe chemical storage when requested, indicating a lack of formal procedures to ensure the safety of residents in this regard.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure the dignity and privacy of a resident, identified as R32, who was observed uncovered from the waist down with her incontinence brief pulled to the side, exposing her groin area. This occurred while the door to her room was open, and the privacy curtain was not drawn, allowing visibility from the hallway. The incident was noted during an observation on January 21, 2025, at 08:06 AM. The facility's policy on dignity and respect, revised in October 2023, mandates that residents should be examined and treated in a manner that maintains the privacy of their bodies, which includes closing doors or drawing curtains during personal hygiene activities. R32's medical records indicate she has major depressive disorder, type 2 diabetes mellitus, and congestive heart failure. Her cognitive status, as assessed by the Brief Interview for Mental Status (BIMS), showed a decline from intact cognition to moderately impaired cognition over time. She requires substantial assistance from staff for various activities of daily living, including toileting and personal hygiene. Despite these needs, the facility did not provide the necessary privacy, as confirmed by interviews with staff who acknowledged the expectation to maintain privacy by closing the door or drawing the curtain when the resident is exposed.
Failure to Use Wheelchair Foot Pedals for Cognitively Impaired Residents
Penalty
Summary
The facility failed to utilize wheelchair foot pedals for three residents, all of whom were severely cognitively impaired. Observations revealed that these residents were pushed in wheelchairs without foot pedals, causing their feet to slide on the ground. This occurred multiple times for each resident, including during transport to and from dining areas and their rooms. Staff were observed pushing the residents without ensuring their feet were properly supported, which is contrary to the facility's policy on accommodating residents' needs. Interviews with staff, including a CNA and an administrative nurse, confirmed that foot pedals should be used to prevent residents' feet from sliding or touching the ground while being pushed. The facility's Accommodation of Needs Policy, revised in August 2024, mandates the use of assistive devices to prevent accidents or injuries. Despite this policy, the facility did not provide the necessary accommodations for these residents, placing them at risk for preventable accidents and injuries.
Failure to Notify Physician of Resident's Refusal of Daily Weights
Penalty
Summary
The facility failed to notify a resident's physician about the resident's refusal to comply with daily weight monitoring, as ordered by the physician. The resident, identified as R13, had a complex medical history including hypertension, rheumatoid arthritis, diabetes mellitus, obesity, and congestive heart failure, among other conditions. The resident's care plan indicated a potential risk for nutrition and hydration issues, and the physician had ordered daily weight checks to monitor the resident's condition. However, the resident's electronic medical record noted that the resident refused these weight checks, and there was no documentation that the physician was informed of these refusals. Interviews with facility staff revealed a lack of consistent communication with the physician regarding missed weights. A licensed nurse indicated that it was the responsibility of the evening nurse to notify the physician if a weight was not recorded by a certain time, but this was not done regularly. An administrative nurse confirmed that the facility did not routinely call the physician for habitual refusals of weight checks. Additionally, the facility did not provide a policy for notifying the physician about such refusals, contributing to the deficiency in care.
Failure to Implement Pressure-Relieving Measures for Resident
Penalty
Summary
The facility failed to ensure that a pressure-reducing heel supportive device was in place for Resident 51, who had a pressure-related injury on his right buttocks. Observations revealed that Resident 51 was lying in bed with his heels resting directly on the mattress, contrary to the care plan that required his heels to be elevated on a supportive device. This oversight was noted on multiple occasions, indicating a lack of adherence to the prescribed care plan. Resident 51's medical records documented a history of conditions that increased his risk for pressure ulcers, including foot drop, muscle weakness, reduced mobility, and contractures. Despite these risk factors and the facility's policy to prevent pressure ulcers, the necessary pressure-relieving measures were not consistently implemented. Interviews with facility staff, including a licensed nurse and an administrative nurse, confirmed that the responsibility to ensure pressure-relieving devices were in place was not adequately fulfilled, placing Resident 51 at risk for further skin breakdown.
Failure to Apply Orthotic Device for Resident
Penalty
Summary
The facility failed to ensure that a resident's orthotic device was in place, which placed the resident at risk for discomfort and decreased range of motion. The resident, identified as R26, had a history of cerebral palsy, hypertension, and other medical conditions, including contractures of the left hand, right ankle, and left ankle. The resident's care plan required the use of a left elbow extension splint and a left hand medical device to immobilize the hand as tolerated. However, observations over several days revealed that the resident's left wrist was consistently curled upwards toward the chest, indicating that the orthotic device was not being applied. Interviews with facility staff, including a CNA, a licensed nurse, and a consult therapist, revealed a lack of clarity and responsibility regarding the application of the splint. The CNA stated that therapy was responsible for applying the splints, while the licensed nurse acknowledged the care plan requirement but was unsure why the splint was not being applied. The consult therapist confirmed that the splint was not being monitored or applied at the time. Additionally, the facility's administrative nurse mentioned that the restorative aide responsible for applying splints and performing range of motion exercises was on maternity leave, and no replacement had been arranged. The facility did not provide a policy for positioning or range of motion, contributing to the deficiency in care for the resident.
Improper Storage of CPAP Mask Increases Infection Risk
Penalty
Summary
The facility failed to ensure the sanitary storage of a CPAP mask for a resident, identified as R27, which increased the risk of respiratory infection and complications. R27's medical history included conditions such as hypertension, dependence on dialysis, hyperlipidemia, COPD, and hemiparesis affecting the left side. The resident required assistance with activities of daily living and used a CPAP device nightly due to COPD and shortness of breath when lying flat. Observations revealed that R27's CPAP mask was not stored in a sanitary manner, as it was found laid directly on the bedside table and outside of the CPAP bag on separate occasions. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that respiratory equipment should be stored in a plastic bag when not in use to maintain sanitation. The facility's policy on non-invasive ventilation required adherence to physician's orders and current standards of practice, including following the manufacturer's recommendations for equipment storage. Despite these guidelines, the facility did not ensure the CPAP mask was stored properly, leading to the identified deficiency.
Failure to Document Risk Assessment and Obtain Consent for Side Rail Use
Penalty
Summary
The facility failed to ensure that a resident, identified as R51, had a documented risk assessment for the use of side rails, consent for their use, and failed to inform the resident and/or responsible party of the risks and benefits associated with side rails. R51's medical records indicated several diagnoses, including foot drop, pressure ulcers, and muscle weakness, requiring assistance with personal care and mobility. Despite these conditions, the facility did not provide documentation of a safety assessment addressing the risk of entrapment between the side rails and the mattress, nor was there evidence of informed consent or communication of risks and benefits to the resident or their representative. Observations and interviews revealed that R51 was using side rails without the necessary assessments and consents in place. The facility's policy on side rails, which emphasizes limiting their use and ensuring thorough assessments and informed consent, was not followed. This oversight placed R51 at risk for uninformed decision-making and potential safety hazards related to side rail use. The facility's failure to adhere to its own policy and regulatory requirements resulted in a deficiency concerning the safety and informed consent processes for side rail use.
Failure to Ensure Timely Physician Visits for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R51, was seen by their attending physician as required by state and federal regulations. R51's electronic medical record documented several diagnoses, including foot drop, pressure ulcer, muscle weakness, and contractures, indicating a need for regular medical oversight. Despite these conditions, there were no physician progress notes for R51 in the past six months, and the facility was unable to provide documentation of any attending physician visits during this period. Observations and interviews revealed that the facility's administrative and nursing staff were unaware of the attending physician's visit schedule, with some staff assuming visits occurred every three months. The facility's policy required residents to be seen by their attending physician at least once every quarter, but this was not adhered to for R51. This oversight placed R51 at risk of unrealized changes in condition, potentially leading to unnecessary complications in their well-being.
Inadequate Dementia Care and Supervision for Resident
Penalty
Summary
The facility failed to provide adequate dementia-related behavioral services for Resident 14, who was diagnosed with severe cognitive impairment, dementia, and other medical conditions. The resident's care plan indicated she required assistance with activities of daily living, was at risk for falls, and had occasional bladder incontinence. Despite these documented needs, the facility did not implement effective interventions to manage her dementia-related behaviors and incontinence, leading to multiple incidents where the resident was found on the floor or in inappropriate locations. Resident 14 experienced several non-injury falls and incidents due to inadequate supervision and care. She was found on the floor in her restroom's doorway, on a fall mat between her bed and bathroom entryway, and in the sensory room, which she mistook for a bathroom. These incidents highlight the facility's failure to provide consistent and effective toileting assistance and supervision, as the resident was often confused and unable to call for help. Additionally, the facility did not ensure that potentially hazardous items, such as disinfectant containers, were stored out of the resident's reach, further compromising her safety. Interviews with staff revealed that Resident 14 required close monitoring due to her wandering and confusion, yet she was left unsupervised in areas like the sensory room. The facility's dementia care policy emphasized the importance of providing person-centered care to ensure residents' well-being, but the lack of proper supervision and intervention for Resident 14 demonstrated a deficiency in meeting these standards. This failure placed the resident at risk for decreased quality of life, isolation, and impaired dignity.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage of respiratory equipment for three residents, leading to potential infection risks. Resident 27's CPAP mask was observed on multiple occasions to be improperly stored, either directly on the bedside table or outside of its designated bag. Similarly, Resident 315's tracheal tubing was found disconnected and placed unsanitarily in a drawer. Resident 48's nasal cannula was observed lying on the floor, which is against the facility's infection prevention protocols. Interviews with facility staff, including a Licensed Nurse and an Administrative Nurse, confirmed that respiratory equipment should be stored in provided plastic bags when not in use to prevent contamination. The facility's Infection Prevention and Control Program policy, last revised in October 2022, mandates adherence to these guidelines to prevent infections. Despite these policies, the improper storage of respiratory equipment for Residents 27, 315, and 48 was noted, placing them at risk for infection and respiratory complications.
Neglect Leads to Harm in Resident with Complex Needs
Penalty
Summary
The facility failed to protect a resident, identified as R1, from neglect, resulting in significant harm. R1, who was legally blind and dependent on staff for hygiene, had a colostomy and an indwelling urinary catheter. Despite requiring substantial assistance with activities of daily living, R1 was left outside without staff supervision for extended periods, without a brief or underwear, and with exposed urinary catheter tubing. On one occasion, R1 complained of a burning sensation in her genital area, and upon assessment, maggots were discovered in her genital area and vagina, leading to her being sent to the hospital for evaluation. R1's medical records indicated she had multiple health issues, including neuromuscular dysfunction of the bladder, bilateral leg amputations, and type two diabetes mellitus. Despite these conditions, the facility's care plan lacked specific interventions for R1's refusal to allow care related to changing her clothing or refusal of catheter and perineal care. The facility's documentation also lacked records of R1 refusing catheter and perineal care, and staff were found to have signed off on care that was not provided. Interviews with staff revealed inconsistencies in the provision of care and training. Some staff members reported that R1 rarely refused care, while others stated she often refused to change clothes or allow catheter care. Additionally, some staff had not received recent training on catheter and perineal care. The facility's policy required daily catheter care to promote hygiene and reduce infection risk, but this was not consistently followed, leading to the neglect and subsequent harm experienced by R1.
Removal Plan
- The staff cleaned the resident and the resident room completely.
- The facility in-serviced the nursing staff for notification of resident refusals, changes in resident preferences, refusal of resident cares, refusal of peri-care, residents who go outside without wearing a brief. Staff were inserviced on what to do in the event a resident refused care and to notify the nurse and then reattempt to go and render the care as necessary.
- The facility would provide on-going nursing in-services to staff regarding documenting only the cares that are completed and charting refusals as refusals. The facility will in-service on thorough and complete catheter and peri-care for all nursing staff. Inservice staff on how neglecting this practice is both harmful to the resident psychologically and physically and that it is neglectful treatment. All nursing staff will be inserviced now and any staff who come to work will be inserviced prior to starting their shift.
- The Director of Nursing (DON) provided education to the resident on the importance of always wearing a brief. Educated on necessity of sanitary care of peri area and catheter care given to resident.
- The DON and ADON would complete frequent checks on the resident to ensure care was provided and there was no reoccurrence of the issue.
- The facility conducted an audit of all residents who were potentially affected to ensure appropriate peri-care and catheter care.
- The facility will conduct ongoing audits on appropriate pericare, catheter care and monitoring for correct documentation by nursing staff, and complete nursing in-services recompleted quarterly to ensure correct peri care and catheter care per doctor's orders.
- The facility would monitor to ensure on-going compliance by following up monthly in QAPI, with review of all audits completed and changes made as needed. ED to ensure that ANE is discussed in the next three all staff meetings.
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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