The Healthcare Resort Of Olathe
Inspection history, citations, penalties and survey trends for this long-term care facility in Olathe, Kansas.
- Location
- 21250 West 151st Street, Olathe, Kansas 66061
- CMS Provider Number
- 175551
- Inspections on file
- 23
- Latest survey
- May 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at The Healthcare Resort Of Olathe during CMS and state inspections, most recent first.
The facility did not accurately report weekend staffing hours in its PBJ submissions to CMS for two consecutive quarters, despite internal records showing no missed coverage. Administrative staff acknowledged that agency and administrative nurse hours used to fill weekend shifts may not have been included in the reported data, leading to the deficiency.
The facility did not have a system in place for residents or their representatives to file grievances anonymously. Inspection revealed no grievance drop boxes or similar systems accessible to residents and visitors. Staff and Resident Council members confirmed that grievances had to be submitted directly to staff or through a hotline, with no anonymous drop-off option available, despite the facility's policy stating residents should be able to voice concerns without fear of reprisal.
A review of activity calendars and interviews with residents and staff revealed that consistent weekend activities were not provided, with only limited events such as movie matinees and occasional special events scheduled. Residents expressed a desire for more interactive, staff-led group activities on weekends, and staff confirmed the lack of regular weekend programming, which did not meet the facility's policy for supporting residents' psychosocial well-being.
Surveyors found that staff did not follow prescribed pressure ulcer prevention interventions for multiple residents, including incorrect settings on low air-loss mattresses and failure to float heels or apply soft boots as ordered. These lapses occurred despite care plans and facility policies requiring such measures, and were confirmed through observations and staff interviews.
A medication cart was observed left unlocked and unattended near the oxygen storage room, with medications and treatment supplies accessible without staff supervision. A CMA later secured the cart and confirmed that carts are required to be locked when not supervised. Interviews with an LN and an administrative nurse further confirmed that facility policy mandates medication carts be locked when not in use.
Surveyors found that respiratory equipment, including oxygen tubing and nebulizer masks, was not stored in sanitary bags, with items left on canisters, tables, and wheelchairs. Clean linens were left on an EBP cart in the hallway instead of inside rooms, and a Foley catheter drainage bag was observed lying on the floor without a privacy cover. Staff interviews confirmed these practices did not align with infection control policy.
Staff did not assist a resident with grooming her chin whiskers as she preferred, despite her dependence on staff for personal care and her clear communication of her wishes. The resident was observed with long chin hairs and stated she disliked them, but staff were unsure if this preference should be care planned. This failure did not align with facility policy requiring respect for resident dignity and grooming preferences.
Two residents with physical impairments were found without access to their call lights, as one call light was on the floor and another was pinned to a pillow across the room. Staff interviews confirmed that call lights were expected to be within reach, but this was not consistently ensured, and no specific policy on accommodation of needs was provided.
Three residents did not receive care as ordered by their physicians, including a missed fluid restriction for a resident with CHF, failure to consistently obtain and document daily weights for another resident with CHF, and improper use of ace wraps instead of prescribed compression devices for a resident with lymphedema. These lapses in following physician orders placed the residents at risk of delayed treatment and untreated illness.
Three residents with significant cognitive and physical impairments did not consistently receive required fall prevention interventions, such as anti-rollback devices, Dycem mats, fall mats, and low bed positioning, as outlined in their care plans. Staff observations and interviews confirmed that these interventions were not always in place, despite facility policy and care plan requirements.
A resident with a history of recurrent UTIs and an indwelling catheter was found with her catheter drainage bag placed directly on the floor under her recliner, without a privacy bag. Staff interviews confirmed that catheter bags should not be placed on the floor and should be kept in a privacy bag below the bladder. This failure to follow established protocols resulted in a deficiency related to catheter care and infection prevention.
A resident with multiple chronic conditions received a physician order for Voltaren gel without a specified dosage, resulting in staff administering the medication without clear dosing instructions. Nursing staff confirmed that all medication orders should include a dosage, and facility policy required accurate implementation of such orders.
A resident with CHF, chronic kidney disease, and edema did not receive a physician-ordered low sodium, fluid-restricted diet due to an error in entering and communicating the new order in the EMR. The resident continued to receive a regular diet, and staff interviews confirmed the oversight in updating dietary instructions and notifying the appropriate departments.
A resident with a history of falls and physical limitations fell while attempting to transfer himself to the toilet without assistance. He remained on the bathroom floor for several hours until discovered by a nurse. The facility's investigation revealed that a CNA failed to complete the required two-hour rounding, contributing to the resident's prolonged time on the floor. Staff interviews highlighted a lack of adherence to neglect prevention policies, placing the resident in immediate jeopardy.
A cognitively impaired resident with Alzheimer's disease eloped from the facility after pressing the emergency exit door release bar. Despite the door alarm sounding, no staff responded, allowing the resident to wheel herself outside. She was found near the dumpsters by a therapy consultant and brought back inside without injury. The resident's care plan did not address elopement potential, and staff may have been complacent in responding to the alarm.
A resident with Alzheimer's and severe cognitive impairment eloped from the facility, remaining outside for six minutes before being returned by staff. The facility's door alarm functioned but was not loud enough to alert staff, who were occupied with other residents. The resident's care plan did not address elopement risk, and the incident was not reported to the State Agency as required, placing the resident at risk for ongoing neglect.
A resident with significant physical impairments, including legal blindness and bilateral lower extremity amputations, was left outside overnight after wheeling himself out without notifying staff. Despite a care plan requiring checks every two to three hours, staff failed to monitor him, resulting in the resident tipping over in his wheelchair and remaining outside until found by a family member the next morning.
A resident experienced verbal abuse when a CNA made inappropriate comments about the resident's genitals during peri-care. The incident caused significant emotional distress, and the facility's investigation was incomplete, lacking detailed witness statements and failing to substantiate the abuse.
A facility failed to ensure staff identified and immediately reported an incident of verbal abuse involving a resident with significant ADL needs. A CNA made an inappropriate comment during peri-care, which embarrassed the resident. The incident was reported the following day, contrary to the facility's policy requiring immediate reporting, creating a risk of ongoing abuse.
A resident with muscle weakness and reduced mobility did not receive timely assistance with ADLs, including toileting hygiene and bed mobility. The resident was observed in a soiled state with food crumbs and a foul odor present in the room. Staff members acknowledged the delay, citing being busy and taking lunch breaks as reasons. Administrative staff and a licensed nurse confirmed that the delay was unacceptable and that the resident should have received prompt care.
Inaccurate PBJ Staffing Data Submission for Weekend Coverage
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS through Payroll Based Journaling (PBJ) for two consecutive quarters, specifically regarding weekend staffing hours. Although the facility's schedules, time sheets, and posted staffing hours showed no missed coverage or gaps for the periods reviewed, the PBJ data submitted to CMS triggered for low weekend staff. Interviews with administrative staff revealed that some agency staff hours and administrative nurse hours used to fill weekend shifts may not have been accurately reported in the PBJ submissions. The facility's policy required complete and accurate payroll data that could be validated and audited, but this was not followed, resulting in inaccurate reporting.
Failure to Provide Anonymous Grievance Filing System
Penalty
Summary
The facility failed to implement a system that allowed residents and their representatives to file grievances anonymously. During an inspection, it was observed that there were no designated grievance drop boxes or similar systems available in areas accessible to residents and visitors. Resident Council members reported they were unaware of any method to submit anonymous grievances and stated that grievances had to be taken directly to a staff member, who would assist in filling them out, or to the social services person. The Activities Director confirmed the absence of an anonymous grievance box but mentioned that residents could call a facility hotline to leave an anonymous report. The Administrator also confirmed there was no anonymous reporting box and that grievances were typically given to staff or administrative personnel, with staff available to assist residents in calling the hotline if needed. The facility's grievance policy stated that residents should have a way to voice concerns or grievances without fear of discrimination or reprisal, and that information on how to file a grievance would be made available. However, the lack of an anonymous grievance system was inconsistent with this policy, as confirmed by staff interviews and the absence of accessible anonymous reporting mechanisms during the inspection.
Inconsistent Weekend Activities Provided for Residents
Penalty
Summary
The facility failed to provide consistent weekend activities for its residents, as evidenced by a review of the activity calendars for February, March, and April 2025. The calendars showed that weekend activities were limited to a movie matinee and a 'residents' choice' activity, with only a few additional events such as an Easter egg hunt and a jazz concert in April. Resident Council members reported that activities rarely occurred on weekends and that the available activities, such as movie matinees, were held on the assisted living floor. The council expressed a desire for more interactive, staff-led group activities on weekends. Interviews with staff confirmed the lack of consistent weekend activities. The activities staff acknowledged the deficiency and stated that efforts were being made to improve weekend programming. A CNA interviewed was unsure about the presence of weekend activities, indicating a lack of awareness or communication regarding the activity schedule. The facility's own policy requires that activities be available to meet residents' needs and interests to support their physical, mental, and psychosocial well-being, but this standard was not met on weekends.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
Surveyors identified that the facility failed to follow preventative wound care practices for several residents at risk for pressure ulcers. Specifically, two residents with low air-loss mattresses had their mattress settings incorrectly set much higher than their actual weights, contrary to manufacturer recommendations and facility policy. Documentation in the care plans for these residents lacked specific instructions regarding mattress settings or care, and staff interviews confirmed that mattress settings should be based on resident weight and checked each shift, but this was not consistently done. Additionally, two other residents who had physician orders and care plan interventions for heel protection did not have their heels floated or soft boots applied as required. Observations showed these residents lying in bed with their heels directly on the mattress, without any pressure-reducing devices in place. Staff interviews revealed that while nurses were responsible for ensuring these interventions were completed, the tasks could be delegated to CNAs, but verification and documentation were lacking. The facility's own policies on skin and wound management, as well as infection prevention and control, required the use of pressure-reducing devices, regular assessments, and adherence to specific interventions to prevent pressure injuries. Despite these policies and individualized care plans, the facility did not ensure that preventative measures were implemented as ordered, placing residents at risk for complications related to skin breakdown and pressure ulcers.
Unsecured Medication Cart Found Unattended
Penalty
Summary
A medication cart on the west wing was found unsecured and unattended next to the oxygen storage room, with prescribed medications, ointments, and treatment care supplies accessible without staff supervision. This observation was made during an inspection, and the cart was later secured by a Certified Medication Aide who confirmed that carts are supposed to be locked when not supervised. Additional interviews with a Licensed Nurse and an Administrative Nurse confirmed that facility policy requires medication carts to be locked when not in use or unsupervised. The facility's Medication Storage policy, revised in December 2024, also specifies that all medication must be secured in a locked manner to ensure safe handling and administration.
Infection Control Deficiencies in Respiratory Equipment, Linen, and Catheter Care
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection prevention and control practices. During a walkthrough, it was observed that one resident's oxygen nasal tubing was wrapped around a standing oxygen canister handle without any sanitary storage, while another resident's nebulizer mask was placed directly on a bedside table without a sanitary storage bag. Additionally, a third resident's supplemental oxygen tank tubing and nasal cannula were found resting on the seat of a wheelchair, again without a sanitary storage bag. These observations indicate that respiratory equipment was not stored in a sanitary manner as required. Further deficiencies were noted in the handling of clean linens and urinary catheter care. Clean linens were found placed on an Enhanced Barrier Precautions (EBP) cart outside a resident's room, rather than being stored in a sanitary manner within the room. In another instance, a resident's Foley catheter drainage bag, containing urine, was observed lying directly on the floor and lacking a privacy cover. Interviews with nursing staff confirmed that these practices were inconsistent with facility policy and proper infection control procedures.
Failure to Assist with Resident Grooming Preferences
Penalty
Summary
Staff failed to assist a resident, who had multiple medical conditions including lymphedema, diabetes, muscle weakness, dementia, and depression, with grooming her chin whiskers according to her stated preference. The resident was observed on multiple occasions with long grey hairs on her chin and expressed that she did not like having long whiskers. She stated that she could cut the whiskers herself if staff provided assistance, and that staff typically cut her hair during showers. The resident required assistance with personal care and was dependent on staff for bathing and toileting, as documented in her care plan and assessments. Interviews with staff revealed uncertainty regarding whether shaving a female resident's chin should be included in the care plan, and staff were not consistently aware of individual resident preferences. The facility's policy required residents to be treated with dignity and respect, including being well groomed and having their preferences respected. Despite this, the resident's grooming preference was not addressed, resulting in a failure to honor her dignity and self-determination.
Call Lights Left Out of Reach for Dependent Residents
Penalty
Summary
Staff failed to ensure that two residents, both with physical impairments and unable to self-transfer, had access to their call lights. On separate occasions, one resident's call light was found on the floor out of reach while the resident was asleep in bed, and another resident's call light was pinned to a pillow on a recliner across from the bed, also out of reach. Both residents were unable to independently retrieve the call lights due to their physical and, in one case, cognitive limitations. Interviews with staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that facility expectations required call lights to be within residents' reach at all times, either pinned to the resident or their bed. The facility's Fall Management System policy emphasized providing appropriate equipment and interventions to ensure resident safety and prevent falls. However, the facility did not provide a specific policy related to the accommodation of needs as requested during the survey.
Failure to Implement and Monitor Physician Orders for Fluid Restriction, Daily Weights, and Compression Management
Penalty
Summary
The facility failed to implement and monitor physician orders for three residents, resulting in deficiencies in the provision of care. For one resident with diagnoses including edema, chronic kidney disease, and congestive heart failure (CHF), a physician's order for a two-liter fluid restriction was not documented or monitored in the electronic medical record (EMR). Staff interviews revealed that the order was entered incorrectly and overlooked, and the required documentation and departmental notifications were not completed as per facility policy. Another resident with CHF and an indwelling catheter had a physician's order for daily weights to monitor for fluid retention, with instructions to notify the physician if certain weight gains occurred. Review of the medication and treatment administration records, as well as vital signs documentation, showed that daily weights were not consistently obtained or recorded on multiple dates, and there was no evidence that the physician was notified when weights were missed or refused. Staff interviews indicated that all staff were responsible for obtaining weights and that physician notification should occur if refusals were frequent, but this was not documented in the clinical record. A third resident with lymphedema, diabetes, and a history of venous ulcers had physician orders for specific pressure-relieving devices and compression management, including the use of tubi grips and avoidance of ace wraps as directed by a vascular physician. Observation found that the resident's lower extremities were wrapped with ace wraps instead of the ordered tubi grips, contrary to the physician's instructions. Staff interviews confirmed that ace wraps were applied in error and that all physician orders should be followed. These failures to implement and monitor physician orders placed the residents at risk of delayed treatment and untreated illness.
Failure to Consistently Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards by not consistently implementing fall prevention interventions as outlined in the care plans for three residents. One resident with severe cognitive impairment, a history of falls, and dependence on staff for mobility and ADLs was observed multiple times without the required anti-rollback device and Dycem mat on her wheelchair, despite these being documented interventions following previous falls. Staff interviews revealed that the resident's wheelchair may have been switched without ensuring the interventions were reapplied, and staff were expected to review and implement all care plan interventions. Another resident, also with severe cognitive impairment and total dependence on staff, was care planned to have a fall mat next to his bed due to a high risk of falls. However, on several occasions, the fall mat was observed propped against the wall rather than placed on the floor as required. Staff confirmed that the mat should have been in place and acknowledged the expectation to follow care plan interventions for fall prevention. A third resident, with multiple diagnoses including dementia, muscle weakness, and a history of falls, was care planned to have her bed in the lowest position and her call light within reach. On repeated observations, her bed was found elevated and not in the low position as required. Staff interviews confirmed that all nursing staff had access to care plans and were expected to ensure interventions were in place. The facility's own Fall Management System policy required the environment to be as free of accident hazards as possible and for interventions to be implemented to prevent falls, but these were not consistently followed for the residents reviewed.
Catheter Drainage Bag Placed on Floor for Resident with UTI History
Penalty
Summary
A deficiency occurred when a resident with a history of recurrent urinary tract infections (UTIs), congestive heart failure, dementia, and neuromuscular dysfunction of the bladder was observed with her indwelling catheter drainage bag placed directly on the floor under her recliner. The resident required substantial to maximum assistance with toileting and had received diuretic medications during the observation period. The care plan specified that catheter care should be provided every shift and as needed, and the facility's policy required daily and as-needed catheter care to promote hygiene and decrease infection risk. Despite these requirements, the catheter drainage bag was found on the floor without a privacy bag, as observed during a morning check. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that catheter bags should never be placed on the floor and should be kept in a privacy bag below the bladder. The failure to follow these protocols resulted in a deficiency related to catheter care and infection prevention for the resident.
Medication Order Lacked Dosage for Topical Pain Reliever
Penalty
Summary
A deficiency was identified when a resident's physician order for Voltaren gel, a topical anti-inflammatory medication, lacked a specified dosage. The order instructed staff to apply the gel to the resident's knee and shoulder every 12 hours as needed for pain, but did not indicate the amount to be applied. This omission was noted in the resident's electronic medical record and confirmed during interviews with nursing staff, who acknowledged that all medication orders should include a dosage. The resident involved had multiple medical conditions, including edema, chronic kidney disease, congestive heart failure, muscle weakness, and pain, and required significant assistance with activities of daily living. The resident's care plan indicated that medications were to be administered as ordered and monitored for side effects or effectiveness. The facility's policy required that drugs be administered only upon written orders from authorized prescribers, with accurate implementation of those orders. The lack of a specified dosage in the Voltaren gel order constituted a failure to ensure the resident's drug regimen was free from unnecessary drugs.
Failure to Implement Physician-Ordered Therapeutic Diet for Resident with CHF
Penalty
Summary
A deficiency occurred when the facility failed to implement a physician-ordered therapeutic diet for a resident diagnosed with congestive heart failure, chronic kidney disease, and edema. The resident's medical record included a physician order for a two-gram low sodium diet and a two-liter fluid restriction due to congestive heart failure, but the dietary meal ticket listed the resident's diet as regular. Staff interviews revealed that the new diet and fluid restriction order had been entered incorrectly into the electronic medical record and was overlooked, resulting in the resident not receiving the prescribed therapeutic diet. The process for communicating new diet orders involved notifying dietary and documenting fluid restrictions on the Treatment Administration Record, but this was not followed in this instance. The resident's care plan specified that the facility would provide the diet as ordered by the physician, and the facility's policy required assessment and implementation of nutritional needs based on medical conditions. Despite these requirements, the resident continued to receive a regular diet rather than the ordered low sodium, fluid-restricted diet. Observations confirmed the resident's diet was not consistent with the physician's order, and staff acknowledged the oversight in updating and communicating the new dietary order.
Neglect Leads to Resident's Prolonged Time on Floor
Penalty
Summary
The facility failed to ensure a resident remained free from neglect, resulting in a significant incident. The resident, who had a history of contractures, lack of coordination, repeated falls, and osteoarthritis, attempted to transfer himself to the toilet without assistance. During this attempt, he fell from his wheelchair and landed on the bathroom floor, unable to reach the call light due to his physical limitations. The resident remained on the floor for several hours until discovered by a licensed nurse the following morning. The resident's care plan indicated that he required assistance with activities of daily living, including toilet transfers, due to his physical and cognitive conditions. Despite this, the resident attempted to transfer himself, leading to the fall. The facility's investigation revealed that a certified nurse aide failed to complete the required two-hour rounding on her assigned residents, which contributed to the resident's prolonged time on the floor without assistance. Interviews with staff highlighted a lack of adherence to the facility's policies on resident care and neglect prevention. Staff members acknowledged that neglect included not completing rounds and not checking on residents regularly. The facility's policy defined neglect as the failure to provide necessary goods and services to avoid harm or distress to residents. This incident placed the resident in immediate jeopardy, as he was left unattended and in distress for an extended period.
Failure to Respond to Door Alarms Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate staff response to door alarms, resulting in a cognitively impaired resident eloping from the facility. The resident, diagnosed with Alzheimer's disease and severe cognitive impairment, was independently mobile in a wheelchair. On the morning of the incident, the resident pressed the release bar on the northwest emergency exit door for 15 seconds, opened the door, and exited the facility. Despite the door alarm sounding, no staff responded, and the resident was able to wheel herself down the sidewalk of the rear parking lot. The resident was found outside near the facility dumpsters by a therapy consultant arriving for work, who then alerted the facility staff. The staff assisted the resident back inside and assessed her for injuries, finding none. The resident's care plan did not address elopement potential, and there was no documentation of exit-seeking behavior prior to the incident. The facility's investigation revealed that the door alarm was functioning properly, but staff may have been complacent in responding to it, possibly assuming someone else would attend to the alarm. Interviews with staff indicated that the door alarms could be heard throughout the hallway, and all staff were expected to respond to them. However, during the incident, staff were either in the dining room or assisting other residents, and no one was in the hallway to respond to the alarm. The facility's policy required appropriate assessment, interventions, and supervision to prevent accidents related to unsafe wandering or elopement, which was not adequately followed in this case.
Removal Plan
- R1's Care Plan was updated to include the current status of R1's exit seeking.
- Staff placed a Wander Guard on R1.
- A full in-service was given to nursing staff to discuss R1 and the procedure for answering door alarms.
- The maintenance director assessed the door, door alarms, and added a louder door alarm for the northwest door.
- Nursing staff were educated on answering alarms immediately.
- Any resident suspected of exit seeking would be assessed by the interdisciplinary team (IDT) and protective action taken immediately.
- An all-staff in-service on elopement prevention and response to door alarms was scheduled.
Failure to Report Resident Elopement as Potential Neglect
Penalty
Summary
The facility failed to identify and report an elopement incident involving a resident with Alzheimer's Disease and severe cognitive impairment. The resident, who was independently mobile in a wheelchair, left the facility through a northwest exit door and was outside for approximately six minutes before being brought back inside by staff. The facility's investigation revealed that the door alarm was functioning but may not have been loud enough to alert staff, who were busy assisting other residents at the time. The resident's care plan did not address elopement potential, despite the resident's cognitive impairments and need for assistance with personal care. The facility's policy required reporting such incidents to the State Agency within 24 hours, but the facility did not report the elopement, as they believed it was not necessary due to the quick resolution and lack of harm. The facility's staff, including the Assistant Directors of Nursing and Administrative Nurse, were informed of the incident shortly after it occurred. The facility's policies on elopement and reporting alleged violations of neglect were not followed, as the elopement was not reported to the State Agency. The facility's failure to report the incident as potential neglect placed the resident at risk for unidentified and ongoing neglect, contrary to the facility's policy to provide a safe environment and notify the appropriate authorities in accordance with state requirements.
Neglect Leads to Resident Left Outside Overnight
Penalty
Summary
The facility failed to ensure a resident remained free from neglect, resulting in the resident being left outside overnight. The resident, who was cognitively intact but had significant physical impairments including legal blindness and bilateral lower extremity amputations, wheeled himself outside without notifying staff and without his cell phone. He tipped over in his wheelchair and was unable to get up or contact staff for assistance, remaining outside on the ground from around 8:00 PM until early the next morning. The resident's care plan required staff to check on him every two to three hours, but this was not done. The resident was found the next morning by another resident's family member, who alerted the staff. The facility's neglect in providing the necessary care and following the resident's care plan placed him in immediate jeopardy. The resident had a history of diabetes, hemiplegia, and other conditions that required assistance with activities of daily living and mobility. Staff statements and facility records indicated that the resident was seen outside by a licensed nurse, who was informed by another nurse that the resident was fine to be outside by himself. However, the resident became disoriented in the dark, got lost, and his wheelchair tipped over. The facility's failure to monitor the resident and ensure his safety led to him being left outside overnight, which was a clear case of neglect.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to ensure that a resident remained free from verbal abuse when a Certified Nurse Aide (CNA) made inappropriate comments about the resident's genitals. The incident occurred when CNA M, while providing peri-care, made disparaging remarks about the size of the resident's penis. This incident was reported by another CNA, who witnessed the event and later informed the administrative nurse. The resident involved confirmed that inappropriate comments were made, which caused embarrassment and fear of potential punishment from the staff. The facility's investigation into the incident was incomplete, lacking witness statements from all involved staff members and failing to substantiate the abuse due to insufficient documentation of what was said during the incident. The resident's medical records indicated a history of muscle weakness, reduced mobility, anxiety, and depression, requiring substantial assistance with activities of daily living (ADLs) and personal care. The resident had a Foley catheter and was dependent on staff for toileting hygiene and bed mobility. Despite the resident's intact cognition, as indicated by a BIMS score of 15, the inappropriate comments made by the CNA during care caused significant emotional distress. Interviews with other staff members and residents revealed that there were instances of staff being rude to residents, although not considered heavy abuse. The administrative nurse and other staff members acknowledged the incident but were unable to substantiate the abuse due to the lack of detailed witness statements and the resident's reluctance to discuss the specifics of the comments made. The facility's policy on abuse prevention emphasized the right of residents to be free from all forms of abuse, including verbal and mental abuse, but the investigation did not fully adhere to these guidelines, resulting in an incomplete resolution of the incident.
Failure to Report Verbal Abuse Incident Immediately
Penalty
Summary
The facility failed to ensure staff identified an incident as verbal abuse and reported the incident to the Administrator immediately. The incident involved a resident with diagnoses of muscle weakness, reduced mobility, anxiety, and depression, who required substantial assistance with activities of daily living (ADLs). During peri-care, a CNA made an inappropriate comment about the resident's anatomy, which embarrassed the resident. Although another CNA witnessed the incident and felt uncomfortable, the report was delayed until the following day, contrary to the facility's policy requiring immediate reporting of abuse allegations. The resident's care plan indicated a need for significant assistance with transfers, bed mobility, and toileting hygiene due to weakness and neuropathy. The incident was eventually reported, and the involved staff members were interviewed. The delay in reporting the incident was acknowledged by the staff, who expressed uncertainty about how to handle the situation. The facility's policy on abuse prevention and reporting mandates immediate notification to the Administrator, which was not followed in this case, creating a risk of unidentified and ongoing abuse.
Failure to Provide Timely ADL Assistance
Penalty
Summary
The facility failed to ensure that Resident 1 received the required assistance with activities of daily living (ADL). Resident 1 had diagnoses of muscle weakness, reduced mobility, and needed assistance with personal care, among other conditions. The resident's care plan indicated that they required substantial to maximum assistance with various ADLs, including toileting hygiene and bed mobility. On multiple occasions, Resident 1 was observed lying in bed in a soiled state, with food crumbs and a foul odor present in the room. The resident had been waiting for assistance since breakfast and expressed distress over the situation. Staff members acknowledged the delay in providing care, citing being busy and taking lunch breaks as reasons for the delay. Certified Nurses Aid (CNA) O and other staff members confirmed that Resident 1 had requested assistance but had to wait due to staff being occupied with other tasks or on breaks. Administrative staff and a licensed nurse verified that it was unacceptable for a resident to wait for such an extended period for assistance and that the resident should have received prompt care. The facility's policy on ADL services directed that residents should receive necessary services to maintain good nutrition, grooming, personal hygiene, and oral hygiene. The facility's failure to provide timely ADL assistance placed Resident 1 at risk for skin breakdown, decreased quality of life, and impaired psychosocial well-being.
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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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