Tanglewood Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Topeka, Kansas.
- Location
- 5015 Sw 28th Street, Topeka, Kansas 66614
- CMS Provider Number
- 175463
- Inspections on file
- 18
- Latest survey
- November 18, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Tanglewood Nursing & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to maintain safe and comfortable temperature levels, resulting in immediate jeopardy. Residents reported feeling extremely cold and unable to perform daily activities due to low temperatures ranging from 46.9 to 60 degrees Fahrenheit. Despite efforts to provide extra blankets and encourage residents to stay in warmer areas, the issue persisted for several days, causing physical discomfort and psychosocial impact.
A facility failed to implement fall prevention measures for a resident with multiple medical conditions, resulting in several falls and a femoral fracture. Additionally, another resident at risk for elopement due to dementia was found without a required WanderGuard bracelet, with staff unaware of its absence. These deficiencies placed residents at risk of accidents and injuries.
The facility failed to provide RN coverage for eight consecutive hours a day, seven days a week, as required. This deficiency was identified through PBJ data, showing multiple days of insufficient RN coverage from July 2023 to May 2024, with the most significant lapse in April 2024. Administrative staff confirmed these findings, and the facility could not provide a staffing policy.
The facility failed to ensure the director of food and nutrition services had the required CDM qualifications, placing residents at risk for unmet dietary and nutritional needs. Dietary BB, responsible for food services, had not completed the certification test, and Administrative Staff A, who held a CDM certification, did not actively use it. The registered dietician visited only twice a month, contrary to the facility's policy requiring a qualified manager to oversee daily functions.
A facility with 49 residents failed to store food items according to professional standards, risking foodborne illness and cross-contamination. Surveyors found unlabeled and undated cheese and ham in the refrigerator, brown-tinged towels under the stove, and opened bags of chips and gravy mix not sealed or labeled in the dry storage room. Dietary staff confirmed the need for proper labeling and sealing, as per the facility's policy.
The facility failed to submit accurate PBJ data, showing no licensed nurse coverage on eight days, despite payroll data indicating 24/7 coverage. Administrative Staff A suggested the error was due to unaccounted agency staff. No PBJ policy was provided, risking inadequate staffing.
A long-term care facility failed to provide consistent bathing for four residents, leading to poor hygiene risks. One resident with heart disease and dementia missed several scheduled baths, while another with diabetes and hypertension went unbathed for extended periods. A third resident, requiring substantial assistance, missed daily bed baths, and a fourth resident with multiple health issues went 27 days without bathing. Staff were often unaware of bathing schedules, and documentation practices were inadequate, with records being discarded.
The facility failed to ensure accurate reconciliation of controlled medications, with 44 missed signatures on the narcotics shift count sheet over a period of two months. This lack of verification by on-coming and off-going nurses, as required by the facility's policy, placed residents at risk of medication misappropriation and diversion.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling catheters, gastrostomy tubes, and wounds, as staff did not consistently use gowns and gloves during high-contact care. Additionally, eye medication was administered without gloves, and oxygen equipment was improperly stored, violating infection control standards. Staff interviews revealed a lack of awareness and understanding of EBP requirements, and facility policies were not consistently followed, placing residents at risk for infections.
A resident with a complex medical history, including stroke and COPD, was transferred to an acute hospital without proper documentation or communication of necessary health information. The facility failed to document the transfer in the medical record and did not provide a discharge summary or communicate with the receiving institution, placing the resident at risk for delayed treatment and impaired continuity of care.
The facility failed to provide written notification of transfer to two residents or their representatives for hospital transfers. One resident, with multiple health conditions, was transferred several times due to changes in condition, while another was transferred due to vomiting. In both cases, the facility did not mail the required written notice, despite notifying the ombudsman and representatives by phone.
The facility failed to provide two residents with the required bed hold notices during their transfers to hospitals, as mandated by policy. One resident, with multiple medical conditions, experienced several hospital transfers without receiving the necessary notice. Another resident, admitted to the hospital for vomiting, also did not receive the bed hold notice. This placed both residents at risk of being uninformed about their bed-hold rights.
A facility failed to document a resident's terminal condition and hospice services on the MDS assessment. Despite the resident's care plan indicating a terminal prognosis due to stomach cancer, the MDS did not reflect this, placing the resident at risk for unmet care needs. The MDS assessments were completed offsite, and the oversight was identified through nurse's notes and care plan documentation.
The facility failed to provide timely and appropriate care for two residents with Stage 2 pressure ulcers. One resident, with a history of cerebral infarction and other conditions, experienced a delay in treatment for multiple pressure ulcers. Another resident, with a traumatic brain injury, lacked a pressure-reducing cushion for her wheelchair and did not receive a nutritional assessment to aid wound healing. These deficiencies placed both residents at risk for delayed healing and further complications.
A resident with a complex medical history, including obstructive uropathy, was at risk for UTIs due to improper catheter care. The CNA placed the catheter bag on the floor, contrary to the facility's procedures, which require keeping catheter tubing and drainage bags off the floor to prevent infections. This action was confirmed as inappropriate by both a Licensed Nurse and an Administrative Nurse.
A facility failed to ensure a resident had a proper flush order for their G-tube before and after bolus feeding. The resident, with a history of cerebral infarction and other conditions, was dependent on enteral nutrition. The care plan initially required a 150 cc water flush, but this was discontinued without a new order. A nurse administered a Glucerna bolus with only a 30 cc flush, assuming it was correct. An administrative nurse later confirmed the need for a 150 ml flush, indicating an omission of the previous order, placing the resident at risk of complications.
The facility failed to ensure proper respiratory care for residents, with issues including lack of physician orders for oxygen therapy and improper storage of respiratory equipment. One resident used oxygen without a physician's order, and their equipment was left unbagged. Another resident's nebulizer mask and tubing were not stored properly, and there were no directions for cleaning. A third resident's equipment was unlabeled and improperly stored, increasing the risk of respiratory infections.
A resident with a history of hypertension, end-stage renal disease, and type 2 diabetes did not receive her physician-ordered Norco medication for pain management, leading to unmanaged pain and a missed dialysis appointment. The medication was unavailable due to a delay in pharmacy delivery, and the facility's emergency kit was inaccessible to the agency nurse on duty. This deficiency highlights issues with medication refill protocols and pharmacy communication.
A resident with end-stage renal disease did not have consistent communication between the LTC facility and the dialysis clinic. The facility lacked dialysis communication sheets for several months, and staff did not follow up to retrieve missing information, placing the resident at risk for complications.
A resident with a history of depression and other medical conditions expressed self-harm intentions, but the facility failed to notify the physician or document monitoring as required by policy. Despite hospice involvement, the care plan lacked specific interventions for self-harm, placing the resident at risk for unmet mental health needs.
A facility failed to ensure a Consultant Pharmacist identified and reported missed insulin administrations for a resident with diabetes. The resident's MAR showed missing documentation for insulin aspart and insulin glargine on specific dates, and the CP's review did not address these omissions. This oversight placed the resident at risk for physical decline and an ineffective medication regimen.
Two residents in the facility did not receive their medications as ordered, leading to potential risks. One resident's antihypertensive medication was not administered when their blood pressure was elevated, and another resident missed several doses of insulin. The facility's policies on medication administration were not followed, and there was a lack of documentation explaining the missed doses.
A resident with multiple health conditions reported receiving cold food, which was confirmed by dietary staff to be below safe temperatures. Despite complaints, the issue persisted, and the resident refused intervention when staff attempted to replace the meal. The facility's policy on safe food handling was not followed, placing the resident at risk for foodborne illness.
A resident with severe cognitive impairment and swallowing disorders was not provided with nectar-thickened liquids as ordered, placing them at risk of aspiration. Despite documented needs and physician orders, the resident was given thin-liquid cranberry juice by staff, who later confirmed the mistake. The facility also lacked a policy on thickened liquids.
The facility failed to maintain essential kitchen equipment, as the stand-up freezer was non-functional and the plate warmer was unplugged due to safety concerns. Dietary staff noted the freezer had been out of order for over a month, and the plate warmer sparked when used, prompting its disconnection. No maintenance policy was available.
A resident with a seizure disorder repeatedly refused morning doses of Keppra, a medication used to control seizures, over a specified period. The facility staff failed to notify the physician of these refusals, as required by policy. This oversight resulted in the resident experiencing a severe seizure episode, requiring emergency medical intervention and hospitalization, where the resident later died. Interviews revealed a lack of communication and documentation regarding the medication refusals.
Failure to Maintain Safe Temperature Levels
Penalty
Summary
The facility failed to maintain safe and comfortable temperature levels for its residents, resulting in immediate jeopardy. On November 22, 2024, Administrative Staff B received reports of cold temperatures in one of the halls. Despite arranging for a maintenance company to assess the problem, the necessary part for repair was not expected to arrive until November 26, 2024. During this period, residents were provided with extra blankets and wore coats indoors, but they continued to report feeling extremely cold and experiencing physical discomfort. Observations on November 26, 2024, revealed that temperatures in several rooms were alarmingly low, ranging from 46.9 to 60 degrees Fahrenheit. Multiple residents expressed their discomfort and inability to perform daily activities due to the cold. Some residents reported that their rooms had been cold for two weeks, and they had informed staff about the issue. The cold temperatures persisted despite efforts to provide additional blankets and encourage residents to stay in warmer areas of the facility. The facility's Quality of Life-Homelike Environment policy, dated October 2009, directed the facility to provide a safe, clean, comfortable, and homelike environment, including maintaining comfortable temperatures. However, the facility's failure to address the heating issue promptly resulted in residents experiencing physical discomfort and psychosocial impact. The surveyor's observations and resident interviews confirmed the deficiency, leading to the identification of immediate jeopardy for the affected residents.
Removal Plan
- The facility purchased safe-touch space heaters to provide additional heat. Staff were assigned to monitor the space heaters continuously.
- The facility audited the number of available blankets and purchased additional blankets to ensure availability to any resident who wanted or needed one.
- Ambient temperatures were assessed hourly until the temperature reached 71 degrees F.
- Staff interviewed residents every hour to assess resident comfort and provide additional blankets until residents expressed comfort.
- The part for the heater was ordered and expected to arrive at the facility.
Failure to Implement Safety Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement fall prevention interventions for a resident, identified as R45, who was at risk for falls due to multiple medical conditions including acute respiratory failure, congestive heart failure, and muscle weakness. Despite being care planned for fall prevention measures such as ensuring the bed was in a low position and personal items were within reach, R45 experienced multiple falls. On one occasion, R45 was found on the floor with a laceration to the nose after falling from bed, and on another occasion, R45 sustained a right femur non-displaced femoral neck fracture after a fall. The facility's failure to have a fall mat in place was noted as a significant oversight. Additionally, the facility did not ensure that another resident, R17, who was at risk for elopement due to dementia, had a functioning WanderGuard bracelet. The resident's care plan required the use of a WanderGuard to prevent wandering, but during an observation, it was found that R17 did not have the bracelet on. Staff were unaware of how long the resident had been without the WanderGuard, and there was no documentation to support the removal of the bracelet, despite a claim that the family had requested it. These deficiencies in implementing safety interventions for residents at risk of falls and elopement placed the residents at risk of accidents and related injuries. The facility's failure to adhere to care plans and ensure the presence and functionality of safety devices contributed to these incidents.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week, which is a requirement for maintaining quality care in long-term care facilities. This deficiency was identified through a review of the Payroll-Based Journal (PBJ) data submitted to the Centers for Medicare and Medicaid Services (CMS), which documented multiple instances of insufficient RN coverage across several months. Specifically, the facility lacked the required RN coverage on various days from July 2023 to May 2024, with the most significant lapse occurring in April 2024, when there were seventeen days without adequate RN coverage. Administrative Staff A confirmed these findings upon review. Additionally, the facility was unable to provide a policy for staffing when requested, further highlighting the deficiency in maintaining the required RN presence.
Deficiency in Food and Nutrition Services Management
Penalty
Summary
The facility failed to ensure that the director of food and nutrition services possessed the required qualifications of a certified dietary manager (CDM). This deficiency was identified during an observation, record review, and interview process. The facility had a census of 49 residents, with one main kitchen and dining area. Dietary BB, who was responsible for the food and nutrition services, admitted to not having completed the certification test for a dietary manager, although she had started the necessary courses. Administrative Staff A, who held a CDM certification, did not actively use it, and the registered dietician only visited the facility twice a month to review residents' diets. The facility's policy required that the daily functions of the Food Services Department be supervised by a qualified Food Services Manager, who should be licensed by the state and knowledgeable in various aspects of food service management. However, the facility did not comply with this policy, as the director of food and nutrition services did not meet the required qualifications. This oversight placed residents at risk for unmet dietary and nutritional needs, as the facility did not have a qualified individual overseeing the food services department as per their own policy and state requirements.
Failure to Adhere to Food Storage Standards
Penalty
Summary
The facility, with a census of 49 residents and one main kitchen, failed to adhere to professional standards for food service safety, as observed during a survey. During an initial tour of the kitchen, surveyors found a block of cheese and a sealed bag of ham slices in the refrigerator that were not labeled or dated. Additionally, several brown-tinged towels were found on the floor under the stove. In the dry storage room, opened bags of potato chips, tortilla chips, and gravy mix were not stored in sealed and labeled bags. These observations indicate a failure to properly store food items, which is a violation of the facility's Food Receiving and Storage policy. Dietary Staff BB confirmed that all food items should be placed in sealed bags and labeled and dated upon opening. The facility's policy, revised in December 2008, requires that dry foods stored in bins be removed from their original packaging, labeled, and dated, and that all foods stored in the refrigerator or freezer be covered, labeled, and dated. The policy also mandates that refrigerated foods be stored to allow adequate air circulation and that refrigerators not be overcrowded. The facility's failure to comply with these standards placed residents at risk of foodborne illness and cross-contamination.
Inaccurate PBJ Data Submission
Penalty
Summary
The facility failed to submit complete and accurate staffing information through Payroll-Based Journaling (PBJ) as required by the Centers for Medicare & Medicaid Services (CMS). The PBJ report for Fiscal Year 2024 Quarter 2 indicated that there was no licensed nurse coverage on eight specific days. However, a review of the facility's licensed nurse payroll data for those dates revealed that a licensed nurse was on duty 24 hours a day, seven days a week. Administrative Staff A explained that the PBJ data was submitted by someone off-campus and suggested that the error might have been due to agency staff not being accounted for. Additionally, the facility was unable to provide a policy for Payroll-Based Journal upon request. This deficiency placed the residents at risk for unidentified and ongoing inadequate staffing.
Inconsistent Bathing Practices in LTC Facility
Penalty
Summary
The facility failed to provide consistent bathing for four residents, identified as R17, R24, R44, and R45, which placed them at risk for poor hygiene and related complications. R17, who had diagnoses including heart disease and dementia, required substantial assistance with bathing. Despite a care plan indicating supervision assistance for bathing, records showed R17 did not receive a bath or shower for extended periods in August and October 2024. Observations noted R17 was unshaven with dried liquid stains on his clothing, and staff reported that refusals were documented but shower sheets were discarded. R24, diagnosed with diabetes mellitus and hypertension, required partial assistance with showers. Her care plan indicated limited staff participation with bathing, yet records revealed she did not receive a bath or shower for significant stretches in August, September, and October 2024. Observations found R24's hair disheveled and greasy, and staff were unsure about her refusals, with documentation practices involving discarded shower sheets. R44, with conditions such as hypertension and diabetes, required substantial assistance for bathing. Despite receiving daily bed baths, records indicated she missed several days in September and October 2024 without documented refusals. Observations noted her hair disheveled, and she reported nausea and vomiting. R45, with multiple diagnoses including acute respiratory failure and congestive heart failure, required substantial assistance for bathing. Her records showed a 27-day period without bathing between September and October 2024. Staff were unaware of her bathing schedule, and documentation practices involved discarded records, highlighting a failure to provide necessary assistance.
Failure in Controlled Medication Reconciliation
Penalty
Summary
The facility failed to ensure accurate reconciliation of controlled medications, which placed residents at risk of medication misappropriation and diversion. A review of the Tanglewood Narcotics Shift Count Sheet from August 1 to October 15 revealed 44 instances where staff did not sign off on the narcotic reconciliation, indicating a lack of verification by the on-coming and off-going nurses. This failure to adhere to the established protocol for narcotic counts was confirmed through interviews with Licensed Nurse G and Administrative Nurse D, who acknowledged the expectation for both nurses to sign the narcotic sign-off sheet after each shift. The facility's Controlled Substances policy mandates that only authorized licensed nursing and pharmacy personnel have access to Schedule II controlled drugs, and that these substances must be counted upon delivery and at the end of each shift. The policy also requires that any discrepancies in the count be reported to the Director of Nursing Services. Despite these clear guidelines, the facility did not consistently complete the required reconciliation process, as evidenced by the numerous missed signatures on the narcotics shift count sheet. This oversight in following the policy for controlled substances management compromised the security and accountability of medication handling within the facility.
Inadequate Implementation of Enhanced Barrier Precautions and Infection Control
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for several residents, which are infection control interventions designed to reduce the transmission of resistant organisms. Specifically, the facility did not ensure the use of gowns and gloves during high-contact care for a resident with an indwelling catheter, another with a gastrostomy tube, and a third with a wound. Observations revealed that personal protective equipment (PPE) caddies were inadequately stocked, lacking necessary gowns, and staff did not consistently wear gowns during care procedures, despite the presence of wounds and medical devices that warranted EBP. Additionally, the facility did not adhere to adequate infection control standards during the administration of eye medication for a resident. A Certified Medication Aide administered eye drops without wearing gloves, which is contrary to the facility's policy. Furthermore, the facility failed to ensure that oxygen equipment was stored in a sanitary manner. Observations showed that oxygen tubing and cannulas were left unbagged and improperly stored, which could compromise their cleanliness and safety. Interviews with staff revealed a lack of awareness and understanding of EBP requirements and proper infection control practices. Some staff members were unsure of the necessity of EBP for certain residents, and there was a lack of signage and PPE availability in resident rooms. The facility's policies on EBP, oxygen use, and eye drop administration were not consistently followed, placing residents at risk for infectious processes.
Failure to Document and Communicate Resident Transfer
Penalty
Summary
The facility failed to ensure proper documentation and communication during the transfer or discharge of a resident, identified as R7, to an acute hospital. R7 had a complex medical history, including cerebral infarction, respiratory failure, dysphagia, aspiration pneumonia, and COPD, and was dependent on enteral nutrition. Despite these conditions, the facility did not document R7's transfer in the medical record or communicate necessary health information to the receiving healthcare institution. This lack of documentation and communication was evident in the absence of a change of condition assessment, physician notification, and details about the mode of transport and destination in R7's clinical records. The deficiency was further highlighted by the lack of a discharge summary in the electronic medical record (EMR) and the absence of a facility policy related to discharge preparation. Administrative Nurse D confirmed that nursing staff were expected to document any change in a resident's condition and complete a discharge summary, which was not done in R7's case. The failure to document and communicate R7's transfer placed the resident at risk for delayed treatment and impaired continuity of care.
Failure to Provide Written Notification of Transfer
Penalty
Summary
The facility failed to provide timely written notification of transfer to two residents, R33 and R44, or their representatives, for facility-initiated transfers to the hospital. This deficiency was identified during a survey that included a sample of 13 residents, with a focus on those reviewed for hospitalization. The lack of written notification posed a risk of miscommunication between the facility and the residents or their families, potentially impairing the rights of the residents involved. Resident R33 had multiple documented diagnoses, including fibromyalgia, epilepsy, hypertension, diabetes mellitus, chronic respiratory failure, major depressive disorder, muscle wasting, and peripheral vascular disease. The resident experienced several transfers to the hospital due to changes in condition, as documented in the progress notes. However, the clinical record lacked evidence of written notice being provided to R33 or their representative for these transfers. Administrative staff confirmed that while the ombudsman and the resident's representative were notified by phone, the written notice was not mailed. Similarly, Resident R44, who had diagnoses of hypertension, diabetes mellitus, urinary tract infection, and lymphedema, was transferred to the hospital due to vomiting. The clinical record also lacked evidence of written notification for this transfer. Observations and interviews revealed that R44 had been experiencing nausea and vomiting, which led to the hospital admission. As with R33, the facility's administrative staff acknowledged that the written notice was not mailed to the resident's representative, despite the facility's policy requiring such notification.
Failure to Provide Bed Hold Notices
Penalty
Summary
The facility failed to provide two residents, R33 and R44, with the appropriate bed hold policy as required during their transfers to hospitals. This deficiency was identified through record reviews and interviews, which revealed that the facility did not provide written notices specifying the duration of the bed-hold policy to the residents or their representatives at the time of transfer or discharge. The facility's policy, dated 11/28/17, mandates that such notices be given at the time of transfer or within 24 hours in cases of emergency transfer, but this was not adhered to in these cases. Resident R33, who had multiple medical conditions including fibromyalgia, epilepsy, hypertension, diabetes mellitus, and chronic respiratory failure, experienced several transfers to the hospital due to changes in condition. Despite these transfers, there was no evidence in R33's clinical record that a bed hold notice was provided to the resident or their representative. Administrative Staff A confirmed that while the representative was called regarding the discharges, the bed hold notice was not provided. Similarly, Resident R44, who had diagnoses including hypertension, diabetes mellitus, and lymphedema, was admitted to the hospital due to vomiting. The clinical record for R44 also lacked evidence of a bed hold notice being provided at the time of transfer. Administrative Staff A acknowledged that the bed hold policy was not discussed with R44's family, and the necessary paperwork was not completed. This failure to provide the required notices placed both residents at risk of being uninformed about their bed-hold rights and potentially impaired their ability to return to the facility.
Failure to Accurately Document Terminal Condition on MDS
Penalty
Summary
The facility failed to accurately assess and document a resident's terminal condition on the Minimum Data Set (MDS) assessment. The resident, who had a diagnosis of stomach cancer, depressive disorder, heart failure, and hypertension, was not documented as having a terminal condition or being on hospice services in the MDS assessment. This oversight was identified despite the resident's care plan indicating a terminal prognosis related to gastric cancer and the need for hospice care. The care plan included directives for staff to manage the resident's pain, consult with a physician, and ensure the resident's emotional and spiritual needs were met. The deficiency was further highlighted by the fact that the resident had been evaluated and admitted into hospice services, as documented in the nurse's notes. However, the MDS assessment, completed offsite, failed to reflect this critical information. The facility's policy required a comprehensive assessment within fourteen days of admission to describe the resident's capabilities and impairments, which was not adhered to in this case. This failure placed the resident at risk for an inaccurate care plan and unmet care needs.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate and timely treatment for a resident, R7, who had multiple Stage 2 pressure ulcers. R7, who had a history of cerebral infarction, respiratory failure, dysphagia, aspiration pneumonia, and COPD, was at risk for pressure ulcers and required a feeding tube for nutrition. After returning from a hospital stay, R7's care plan directed staff to perform weekly skin assessments and administer treatments as ordered. However, there was a delay in treating R7's pressure ulcers, as evidenced by the lack of documentation for wound treatment before a physician's order on 10/03/24. This delay placed R7 at risk for complications related to skin breakdown. Another resident, R43, who had a traumatic brain injury, delusional disorder, and functional impairment in both lower extremities, was also affected by the facility's failure to provide adequate care. R43 had a Stage 2 pressure ulcer on the right buttock and required a pressure-reducing device for her wheelchair. Despite the care plan's directives, observations revealed that R43's wheelchair lacked a cushion, and there was no evidence of a nutritional assessment by a registered dietician to promote wound healing. This oversight placed R43 at risk for further skin breakdown and delayed healing. The facility's Prevention of Pressure Ulcers policy emphasized the importance of timely assessments and appropriate interventions to prevent and treat pressure ulcers. However, the facility did not adhere to these guidelines, as demonstrated by the lack of timely treatment for R7's pressure ulcers and the absence of a pressure-reducing cushion and nutritional support for R43. These deficiencies in care placed both residents at risk for delayed healing and further complications.
Failure in Sanitary Catheter Care for a Resident
Penalty
Summary
The facility failed to provide sanitary indwelling urinary catheter care for Resident 45, which placed the resident at risk for urinary tract infections and other catheter-related complications. Resident 45 had a complex medical history, including acute respiratory failure, congestive heart failure, chronic obstructive pulmonary disease, and obstructive uropathy, necessitating the use of an indwelling catheter. The care plan for Resident 45 included specific instructions for catheter maintenance, such as changing the catheter as ordered, checking for patency and urinary output each shift, and ensuring the catheter bag and tubing were positioned below the bladder level. During an observation, a Certified Nurse Aide (CNA) was seen emptying the catheter bag and placing it directly on the floor, which is against the facility's urinary catheter care procedure. This procedure, dated March 31, 2016, explicitly states that catheter tubing and drainage bags should be kept off the floor to prevent catheter-associated urinary tract infections. Both a Licensed Nurse and an Administrative Nurse confirmed that the catheter bag should not have been placed on the floor, indicating a failure in adhering to the facility's established protocols for catheter care.
Failure to Ensure Proper G-tube Flush Order for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R7, had a proper flush order for their gastrostomy tube (G-tube) before and after the administration of a bolus feeding. R7, who had a history of cerebral infarction, respiratory failure, dysphagia, aspiration pneumonia, and COPD, was dependent on enteral nutrition due to a swallowing disorder. The resident's care plan initially directed staff to flush the G-tube with 150 cc of water before and after feedings. However, this order was discontinued upon the resident's return from the hospital, and no new order was established for the flush amount prior to and after the Glucerna bolus feeding. During an observation, a licensed nurse administered the Glucerna bolus and flushed the G-tube with only 30 cc of water, assuming it was the correct amount based on medication flush orders. An administrative nurse later confirmed that the G-tube should have been flushed with 150 ml of water before and after the bolus feeding, indicating that the previous order was omitted. The facility's failure to ensure a proper flush order placed the resident at risk of G-tube complications and adverse effects, such as dehydration or fluid overload.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to ensure proper respiratory care for several residents, leading to deficiencies in oxygen therapy management. Resident 30, diagnosed with conditions such as COPD and heart failure, was observed using oxygen therapy without a physician's order. The resident's oxygen tubing and cannula were improperly stored, being left unbagged around the oxygen tank and concentrator. Despite the care plan indicating the need for continuous oxygen therapy, the lack of a physician's order and improper storage practices were confirmed by staff, placing the resident at risk for respiratory complications. Resident 7, with a history of cerebral infarction and respiratory failure, also lacked a physician's order for oxygen therapy. The resident's nebulizer mask and oxygen tubing were not stored in a sanitary manner, as they were left on a table stand and bed without proper bagging. The facility's records did not provide directions for cleaning or changing the respiratory equipment, and staff confirmed the absence of necessary orders and storage protocols. This oversight increased the risk of respiratory infections and complications for the resident. Resident 45, who had acute respiratory failure and other chronic conditions, was found with improperly stored and unlabeled respiratory equipment. The oxygen tubing and CPAP mask were left uncovered and undated, contrary to the facility's policy requiring weekly changes and labeling. Observations revealed that the equipment was not stored in a sanitary manner, with the nasal cannula lying on the floor and bed. The facility's failure to maintain and label the respiratory equipment exposed the resident to potential respiratory infections.
Failure to Provide Timely Pain Medication
Penalty
Summary
The facility failed to provide a resident, identified as R19, with her physician-ordered Norco medication for pain management, resulting in unmanaged pain and a missed dialysis appointment. R19, who has a medical history of hypertension, end-stage renal disease, and type 2 diabetes, relies on Norco for pain relief. The medication was unavailable for administration as scheduled, specifically missing doses on the evening of 10/13/24 and the following morning, leading to R19 experiencing significant pain and being unable to attend her dialysis session. The deficiency was attributed to a delay in receiving the medication from the pharmacy, despite it being ordered before the weekend. The facility had an emergency medication kit, but the agency nurse on duty did not have access to it. Additionally, there were issues with the pharmacy service not receiving refill requests in a timely manner. The facility's policy required staff to ensure pain medications were sent for refill five days before depletion, but this protocol was not effectively followed, contributing to the deficiency.
Failure in Communication with Dialysis Facility
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding a resident's health status with each dialysis procedure. The resident, who had diagnoses of hypertension, end-stage renal disease, and type 2 diabetes mellitus, was on a dialysis schedule of three times a week. However, the facility lacked dialysis communication sheets for a significant period, indicating a gap in the documentation and communication process. The resident reported missing a dialysis appointment due to pain and mentioned that the communication sheet did not always return with her from the dialysis clinic. Licensed Nurse G confirmed that the communication sheet was sent with the resident but did not always come back, and there was no follow-up to retrieve the missing information. Administrative Nurse D acknowledged the absence of a medical records person and stated that the nurses should have been calling the dialysis clinic to obtain the necessary information. The facility's policy required agreements with the contracted ESRD facility to include how information would be exchanged, but this was not adhered to, placing the resident at risk for complications related to dialysis.
Failure to Address Resident's Self-Harm Statements
Penalty
Summary
The facility failed to immediately involve the physician and provide supportive mental health services for a resident, identified as R30, who made statements of self-harm. R30 had a history of stomach cancer, depressive disorder, heart failure, hypertension, and COPD. Despite having intact cognition and being independent in most activities, R30 expressed feelings of depression and a desire to harm himself. The care plan for R30 included administering medications and documenting signs of depression and suicidal ideation, but it lacked specific interventions for addressing self-harm statements. On a particular date, R30 expressed a desire to leave and kill himself, and although hospice was notified, there was no documentation of physician notification or staff monitoring following the incident. Observations and interviews revealed that R30 was on hospice care and had expressed a desire to go home, but staff were not aware of any self-harm intentions. The facility's policy on suicide threats required immediate notification of the physician and monitoring of the resident, but these actions were not documented in R30's case. The failure to follow the policy and involve the physician placed R30 at risk for unmet mental health care needs, as the facility did not adequately address the resident's statements of self-harm.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported the staff's failure to administer insulin as per the physician's orders to a resident, identified as R44. The resident had a documented medical history of hypertension, diabetes mellitus, urinary tract infection, and lymphedema. The care plan for R44 included directives for administering diabetes medication, obtaining dietary consultations, and monitoring for hypoglycemia. However, the Medication Administration Record (MAR) for September 2024 showed missing documentation for the administration of insulin aspart and insulin glargine on specific dates. The CP's Medication Regimen Review for October 2024 did not reflect any identification or reporting of the missed insulin administrations for R44. An observation on October 4, 2024, noted the resident lying in bed with eyes closed, and an interview with Administrative Nurse D on October 17, 2024, revealed that she had not been informed by the CP about the missed insulin doses. The facility's policy required the CP to identify and communicate medication-related issues, but this was not adhered to, placing the resident at risk for physical decline and an ineffective medication regimen.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident's as-needed antihypertensive medication, hydralazine, was administered according to physician-ordered parameters. The resident, who had diagnoses of hypertension, end-stage renal disease, and type 2 diabetes mellitus, was supposed to receive hydralazine when their systolic blood pressure exceeded 160 mmHg. However, the medication administration record showed that the resident did not receive the medication on multiple occasions when it was indicated. Interviews with nursing staff revealed uncertainty about why the medication was not administered as ordered. Another resident with diagnoses of hypertension, diabetes mellitus, urinary tract infection, and lymphedema did not receive their prescribed insulin aspart and insulin glargine on several occasions. The medication administration record lacked documentation for these missed doses, and staff interviews confirmed that there should have been progress notes explaining why the insulin was not given. The facility's policy required that medications be administered as prescribed and that any deviations be documented, which was not followed in this case. These failures in medication administration placed the residents at risk for medication-related complications and adverse reactions. The facility's policies on administering medications were not adhered to, leading to these deficiencies in care. The lack of documentation and adherence to physician orders contributed to the risk of physical decline for the affected residents.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain safe food temperatures for a resident's room tray, placing the resident at risk for foodborne illness. The resident, who had a medical history including diabetes mellitus, hypertension, chronic obstructive pulmonary disease, and other conditions, reported receiving cold food. Observations revealed that the food temperatures were below the safe holding temperature, with fried eggs at 97.7 degrees Fahrenheit and cream of wheat at 139 degrees Fahrenheit, while the required temperature should have been above 145 degrees Fahrenheit. Despite the resident's complaint about cold food, the issue persisted. Dietary staff measured the food temperatures and confirmed they were below the safe range. When staff attempted to replace the cold meal, the resident became agitated and refused the intervention, insisting on keeping the meal. The facility's policy on food preparation and service, which mandates compliance with safe food handling practices, was not adhered to, as evidenced by the failure to maintain food temperatures outside the danger zone of 41 to 135 degrees Fahrenheit.
Failure to Provide Thickened Liquids as Ordered
Penalty
Summary
The facility failed to ensure that a resident, identified as R37, received thickened liquids as per his medical orders, placing him at risk of aspiration. R37's medical history included hypertension, alcohol abuse, tobacco use, delirium, vascular dementia, cerebral aneurysm, cerebral infarction, and abnormalities of gait and mobility. The resident had severe cognitive impairment, swallowing disorders, and was on a mechanically altered diet requiring nectar-thickened liquids. Despite these documented needs, the facility did not provide the necessary speech therapy evaluation or treatment, and staff failed to adhere to the dietary orders. On a specific observation, R37 was given a glass of thin-liquid cranberry juice by Activity Staff Z, contrary to the nectar-thickened liquid requirement. Initially, the staff member did not acknowledge the error but later confirmed the mistake. The facility also failed to provide a policy related to thickened liquids upon request. This oversight in providing the correct liquid consistency as per the resident's care plan and physician orders constituted a deficiency in care, as it placed R37 at risk of complications related to aspiration.
Kitchen Equipment Maintenance Deficiency
Penalty
Summary
The facility failed to ensure that essential kitchen equipment, specifically the stand-up freezer and plate warmer, were in safe operating condition. During an initial tour of the kitchen, it was observed that the stand-up freezer was not functioning, and the plate warmer was unplugged with no plates present. Dietary staff reported that the freezer had been out of order since early September and had not yet been replaced. Additionally, the plate warmer had sparked and emitted smoke when plugged in, leading to its disconnection and notification to maintenance and administrative staff. The facility was unable to provide a policy regarding the maintenance of kitchen equipment.
Failure to Notify Physician of Medication Refusals Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that Resident 1 received care consistent with the standards of practice by not notifying and involving a physician regarding the resident's multiple refusals of seizure medication, Keppra. Resident 1, who had a diagnosis of seizures and anxiety disorder, refused all morning doses of Keppra from a specified period. The clinical record lacked evidence that staff reported these refusals to the physician for medical evaluation. This oversight led to a severe seizure episode that required emergency medical intervention. On the day of the incident, Resident 1 was in the dining room when he began experiencing seizure activity. Despite receiving oral Ativan and subsequent injections, the seizures continued, leading to the involvement of Emergency Medical Services (EMS) and the resident's transfer to the hospital. The resident was admitted to the hospital and later died. Interviews with facility staff revealed a lack of communication and documentation regarding the medication refusals, with some staff unaware of the refusals and others failing to notify the physician as required by the facility's policy. The facility's policy directed that the nurse should notify the resident's attending physician or physician on call when there had been a refusal of treatment or medications. However, this protocol was not followed, as evidenced by the lack of documentation in the resident's medical record. The failure to provide nursing care within the standards of practice, including the necessary medical oversight for repeated and ongoing seizure medication refusals, placed Resident 1 in immediate jeopardy.
Removal Plan
- The facility educated the CMA and nurses in the facility on medication refusals and notifications following medication refusals.
- The facility completed an audit of all missed medications and the physician was notified during the Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting.
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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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