Topside Manor Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Goodland, Kansas.
- Location
- 210 Kansas Avenue, Goodland, Kansas 67735
- CMS Provider Number
- 175361
- Inspections on file
- 25
- Latest survey
- April 29, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Topside Manor Inc during CMS and state inspections, most recent first.
A facility failed to ensure that an LPN maintained a current license, resulting in the nurse working multiple shifts after her license had expired. The lapse was discovered when the LPN self-reported, and administrative staff confirmed there was no system in place to verify ongoing licensure for nursing staff.
An LPN worked multiple shifts after her license had expired, serving as the only licensed nurse on several evening shifts. The facility did not have a system in place to verify active licensure status, relying instead on staff to self-report and renew their licenses, which led to the deficiency.
The facility failed to maintain the required RN coverage for eight consecutive hours daily, seven days a week, as documented in the PBJ records. This deficiency occurred over several months, with multiple days each month lacking adequate RN presence. Administrative Nurse D confirmed the absence of RN coverage on the specified dates, which contravenes the facility's policy for sufficient and competent nursing staff. This failure placed all residents at risk of decreased quality of care.
The facility did not employ a full-time certified dietary manager for its 44 residents, risking inadequate nutrition. Dietary Staff BB, who oversaw meal preparation, lacked the necessary certification, contrary to the facility's policy requiring a qualified director of food and nutrition services.
The facility failed to follow professional standards for food service safety, with staff observed using the same gloves for multiple tasks, incomplete documentation of kitchen temperatures, and improper food storage practices. These actions risked cross-contamination and foodborne illness.
The facility failed to submit accurate staffing information through the PBJ system, with reports indicating no licensed nurse coverage on several dates. However, payroll data showed a licensed nurse was on duty 24/7. Administrative Staff A was unaware of submission issues, despite an increase in registered nurses. This placed residents at risk for inadequate staffing.
A resident with severe cognitive impairment was repeatedly addressed as "Honey" by staff, contrary to her care plan and the facility's dignity policy. Despite the resident's requests for help and preference for a specific TV show, staff did not address her by name or promptly respond to her needs.
The facility failed to provide the correct CMS Form 10055, Skilled Nursing Facility Advanced Beneficiary Notice (ABN), to three residents, instead using CMS-R-131 forms. This error meant residents were not informed of potential costs for services not covered by Medicare, risking uninformed decisions about their care.
The facility failed to provide written notice to residents or their representatives for hospital transfers and did not notify the LTCO, affecting three residents. This oversight involved residents with intact cognition and various medical conditions, who were transferred without receiving the required documentation, placing them at risk of uninformed care choices.
A resident with severe cognitive impairment and a history of falls experienced a fall due to staff failing to follow the care plan. The care plan required a bed and chair alarm to monitor the resident's movements, but a CNA did not place the alarm box on the bed alarm, leading to the fall. The incident was confirmed by an administrative nurse, highlighting a lapse in adherence to the facility's fall prevention protocol.
A resident with COPD and severe cognitive impairment did not receive adequate respiratory care when staff failed to provide her with oxygen during meals and did not store the oxygen tubing and cannula in a sanitary manner. The resident was dependent on staff for all activities of daily living and required continuous oxygen to maintain saturation levels. Observations showed that staff did not follow the facility's policy, placing the resident at risk for respiratory complications.
A resident with moderate dementia and other conditions did not receive appropriate care in a facility. Despite having a care plan with specific interventions, staff failed to implement these strategies consistently. Observations showed inadequate responses to the resident's needs, such as not changing the TV channel to her preferred program and delaying toileting assistance. Staff interviews revealed a lack of awareness of the care plan, leading to unmet needs and increased distress for the resident.
The facility's kitchen staff failed to prepare all menu items for two residents on a pureed diet, providing only partial meals and substituting some items with protein ice cream and V8 juice. This oversight was confirmed by the Dietary Manager and did not meet the Registered Dietitian's expectations, placing the residents at risk for impaired nutrition.
A facility failed to offer or document a declination for the pneumococcal PCV20 vaccination for a resident, as required by CDC guidelines. The resident's records showed they were admitted with an up-to-date influenza vaccine but lacked documentation for the pneumococcal vaccine. An administrative nurse confirmed the absence of documentation, despite the facility's policy requiring assessment and offering of the vaccine within thirty days of admission.
A resident with multiple health conditions and moderate cognitive impairment fell and sustained a fracture due to improper use of a mechanical lift by a CNA. The CNA failed to correctly attach the lift sling harness loops during a transfer, leading to the resident's fall. Despite previous training, the CNA's focus on the resident's leg pain resulted in neglecting the proper procedure, causing the incident.
A resident with severe cognitive impairment and multiple diagnoses fell and sustained fractures during a transfer using a ceiling-mounted full body lift. The CNA used an extra-large sling, which was intact but not the correct size, leading to the resident slipping out and falling. The facility's policy requiring two nursing assistants for safe transfers was not followed.
A resident with dementia, major depressive disorder, anxiety, and a UTI did not receive a prescribed antibiotic for five days due to the facility's failure to ensure the medication was available. Despite an order for Macrobid, the medication was not administered until five days later, placing the resident at risk for worsening health complications. The administrative nurse had directed staff to use the emergency kit but did not follow up.
The facility failed to monitor a resident's psychotropic medication, Trazodone, used off-label for insomnia after a trial increase in dosage. The resident's care plan directed staff to monitor for adverse reactions, but the clinical record lacked evidence of monitoring or notifying the physician about the outcomes. An administrative nurse acknowledged that the new orders were not properly entered, and the facility did not adhere to its medication administration policies.
A facility failed to develop and implement a comprehensive care plan for a resident with COPD and other conditions, neglecting to include necessary documentation and direction for the use of a non-invasive ventilator. The resident experienced shortness of breath and missed medications, and staff confirmed the absence of orders and care plan details for the ventilator, placing the resident at risk.
The facility failed to provide appropriate respiratory care for a resident using a Trilogy non-invasive ventilator. The resident, with multiple diagnoses including COPD, did not have physician orders or care plan documentation for the ventilator, leading to challenges in receiving proper respiratory support. This placed the resident at risk for respiratory failure.
A resident with chronic pain and other conditions did not receive her prescribed pain medications on multiple occasions due to unavailability, leading to unmanaged pain and emotional distress. Staff interviews revealed inconsistencies in the medication re-ordering process, and administrative staff acknowledged the need for review.
A resident with multiple diagnoses, including COPD and chronic pain, did not receive prescribed medications due to unavailability and lapses in the re-ordering process. The facility failed to notify the resident's physician about the missed doses, leading to potential medical complications.
LPN Worked Without Current License Due to Lack of Verification System
Penalty
Summary
The facility failed to ensure that nursing staff possessed current licensure as required, resulting in a deficiency affecting all 45 residents. Record review and interviews revealed that an LPN's license had expired, yet the nurse continued to work for eight days out of a twenty-three day period after the expiration. The expired license was confirmed through the Kansas State Board of Nursing License Verification. During this time, the LPN was the only licensed nurse on the evening shift for multiple days. Administrative staff confirmed that the LPN self-reported the expired license, at which point she was immediately removed from the schedule. Prior to this incident, the facility did not have a system in place to ensure that licensed nursing staff maintained current licensure. The deficiency was identified through review of the facility's working schedule, license verification, and staff interviews.
Failure to Monitor Nursing Licensure Status
Penalty
Summary
The facility failed to ensure adequate administrative oversight by not monitoring the licensure status of its nursing staff. Specifically, an LPN worked eight shifts over a period of twenty-three days after her nursing license had expired. During these shifts, the LPN was the only licensed nurse present on the evening shift, providing care to residents without a valid license. The lapse was discovered when the LPN self-reported to an administrative nurse that she had forgotten to renew her license. At the time of the incident, the facility did not have a system in place to verify that all licensed nursing staff maintained active licensure. Administrative staff confirmed that they relied on staff to be responsible for their own license renewals and did not conduct regular checks to ensure compliance. This oversight resulted in the LPN working without a valid license, contrary to state requirements and facility policy.
Failure to Provide Consistent RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week, as required. This deficiency was identified through the Payroll Based Journal (PBJ) records, which documented multiple instances of insufficient RN coverage across several months from April 2023 to August 2024. Specifically, the facility lacked the required RN coverage on various days each month, with the number of days ranging from four to eight. This failure was confirmed by Administrative Nurse D, who verified the absence of RN coverage on the specified dates. The facility's policy, dated September 2022, mandates sufficient and competent nursing staff to provide necessary care and services in accordance with resident care plans and facility assessments. The lack of consistent RN coverage placed all residents at risk of decreased quality of care, including potential lack of assessments and inappropriate care.
Failure to Employ Certified Dietary Manager
Penalty
Summary
The facility failed to employ a full-time certified dietary manager for its 44 residents, which placed them at risk for inadequate nutrition. During an observation of the noon meal preparation, it was noted that Dietary Staff BB was overseeing the process, despite not being a certified dietary manager. This was confirmed by Dietary Staff BB, who stated that she had enrolled in the necessary classes but had not yet obtained certification. Administrative Staff A also verified that Dietary Staff BB lacked the required certification. The facility's Dietitian Policy, revised in November 2022, mandates that if a dietitian is not employed full-time, a director of food and nutrition services must be designated. This individual should meet specific qualifications, such as being a certified dietary manager or having equivalent credentials or experience. The facility did not adhere to this policy, as Dietary Staff BB did not meet the necessary qualifications, thereby failing to ensure that residents received meals prepared under the supervision of a qualified dietary manager.
Improper Food Handling and Storage Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations of improper food handling and storage practices. During a meal service, a dietary staff member was observed using the same pair of gloves to touch various surfaces, including a refrigerator and counter, before handling food items such as roast beef and baked potatoes. The staff member also wiped her nose with the same gloves before serving dessert, and continued to use the same gloves while preparing and serving other food items. This practice of not changing gloves between tasks and not washing hands posed a risk of cross-contamination and foodborne illness. Additionally, the facility's documentation for kitchen and pantry temperatures, as well as dishwasher sanitizer levels, was found to be incomplete for several days in August. This lack of documentation was acknowledged by the dietary manager, who indicated that the facility was working on a new form for staff to use. Furthermore, during the preparation of pureed diets, a staff member used a soiled blender to process different food items without cleaning it between uses, which could lead to cross-contamination. The facility also failed to follow proper food storage procedures, as observed in the dry storage room where a turkey breast and pork chops were thawing in the same pan without a thermometer present in the refrigerator. The registered dietician confirmed that different food items should be stored separately to prevent cross-contamination. The facility's policies on food preparation and service, as well as refrigerator and freezer maintenance, were not followed, placing residents at risk for foodborne illness.
Inaccurate PBJ Data Submission
Penalty
Summary
The facility failed to submit complete and accurate staffing information through the Payroll-Based Journal (PBJ) system as required by the Centers for Medicare & Medicaid Services (CMS). The PBJ reports for Fiscal Year (FY) 2023 Quarter (Q) 3, FY 2023 Q4, and FY 2024 Q2 indicated no licensed nurse coverage on several dates. However, a review of the facility's licensed nurse payroll data for these dates revealed that a licensed nurse was on duty 24 hours a day, seven days a week. Administrative Staff A stated that the PBJ information was submitted by someone off campus, and she was unaware of any submission problems. She confirmed that there was always a licensed nurse in the building and noted an increase in registered nurses, which made her unsure why the PBJ data showed a lack of licensed nurses on certain days. This deficiency in submitting accurate PBJ data placed the residents at risk for unidentified and ongoing inadequate staffing, as the facility's staffing information was not accurately reported to CMS in the specified uniform format. The staffing information was supposed to be collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter.
Failure to Promote Resident Dignity
Penalty
Summary
The facility failed to promote dignity for Resident 22, who had diagnoses of moderate dementia with psychotic disturbance, depression, agitation, anxiety, and chronic obstructive pulmonary disease. The resident was dependent on staff for all activities of daily living and had severely impaired cognition, disorganized thinking, and altered levels of consciousness. Despite these conditions, staff repeatedly addressed the resident as "Honey" instead of using her proper name, which was not documented as a preferred term of address in her care plan. This behavior was observed during an incident where the resident was yelling for help, and a Certified Nurse Aid (CNA) addressed her as "Honey" multiple times, failed to change the television channel to the resident's preferred show, and made a shushing noise towards her. The facility's dignity policy, dated February 2021, required that residents be treated with dignity and respect at all times, and that staff should treat cognitively impaired residents with dignity and sensitivity. However, the CNA's actions did not align with this policy, as they did not address the resident by her proper name and did not promptly respond to her requests. Interviews with a Licensed Nurse and an Administrative Nurse confirmed that staff should call residents by their names unless given permission to use another term, and that calling the resident "Honey" was not considered dignified.
Failure to Provide Correct Medicare ABN Forms
Penalty
Summary
The facility failed to provide the correct CMS Form 10055, Skilled Nursing Facility Advanced Beneficiary Notice (ABN), to three residents or their representatives, which is required to inform them of potential liability for services not covered by Medicare. Instead, the facility provided CMS-R-131 forms, which do not include the necessary information about estimated costs for continued services. This oversight was identified during a review of records and interviews, revealing that the facility's staff did not realize they were using the incorrect form. The facility's policy, dated September 2023, mandates that residents be informed in advance of any changes to their billing, specifically through the use of the correct SNF ABN form for initiation, reduction, or termination of Medicare benefits. However, the failure to provide the correct form placed the residents at risk for making uninformed decisions regarding their skilled services, as they were not adequately informed about the potential financial implications of their care choices.
Failure to Provide Written Notice for Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents or their representatives regarding facility-initiated transfers to the hospital, as well as failing to notify the Office of the Long-Term Care Ombudsman (LTCO). This deficiency was identified for three residents, R5, R11, and R1, who were transferred to the hospital without receiving the required written notice. The facility's policy, revised in March 2024, mandates that a copy of the transfer or discharge notice be sent to the LTCO simultaneously with the notice provided to the resident and their representative. Resident R5, who had intact cognition and required assistance with daily activities, was transferred to the hospital on two occasions as documented in the progress notes. However, there was no evidence in R5's clinical record that written notice was provided to the resident or their representative. Similarly, Resident R11, who had a diagnosis of heart failure and intact cognition, was transferred to the hospital without receiving the necessary written notice. Both residents' representatives were only provided with a bed hold notice, and the LTCO was not notified. Resident R1, who had multiple diagnoses including dementia and diabetes, was transferred to the hospital on three separate occasions due to various medical issues. Despite these transfers, R1's clinical record lacked evidence of written notice to the resident or their representative. Social Service X and Administrative Nurse D both stated they were unaware of the requirement to notify the LTCO or provide written notification to the residents or their representatives. This oversight placed the residents at risk of making uninformed care choices.
Failure to Follow Care Plan Results in Resident Fall
Penalty
Summary
The facility failed to ensure that staff followed the care plan to prevent accidents for a resident identified as R9. R9 had a history of anxiety, muscle weakness, unsteadiness, and falls, and was assessed as having severe cognitive impairment. The care plan required the use of a bed and chair alarm to monitor R9's movements and prevent falls. However, on one occasion, a CNA did not place the alarm box on R9's bed alarm, which was a deviation from the care plan. This oversight resulted in R9 falling from her bed. The incident was documented in the resident's progress notes, and it was confirmed by an administrative nurse that the fall occurred because the alarm box was not placed as instructed. Observations and interviews with staff revealed that the alarm was intended to alert staff when R9 attempted to get up from her bed or wheelchair. The facility's policy on falls required staff to continue with successful interventions and re-evaluate situations if falls continued, but in this case, the staff did not adhere to the care plan, leading to the fall incident.
Inadequate Respiratory Care for a Resident
Penalty
Summary
The facility failed to provide adequate respiratory care and services for Resident 22, who had diagnoses including moderate dementia, chronic obstructive pulmonary disease (COPD), and severely impaired cognition. The resident was dependent on staff for all activities of daily living and required continuous oxygen at 2 liters per minute via nasal cannula to maintain oxygen saturation above 90%. However, during observations, it was noted that the staff did not provide the resident with her oxygen during the breakfast meal. On one occasion, a CNA stated that the resident refused her oxygen, and therefore, it was not brought to the table. After being questioned, the CNA brought the oxygen concentrator to the resident, who then agreed to use it. Additionally, the staff failed to store the oxygen tubing and cannula in a sanitary manner when not in use. Observations revealed that the oxygen tubing was laid over the handles of the wheelchair and rested against the resident's back, and on another occasion, it was placed in the resident's lap instead of in the provided bag. The facility's policy required that if a resident refused oxygen, the reason and interventions should be documented, and the oxygen tubing should be stored in a sanitary manner. The failure to adhere to these procedures placed the resident at risk for respiratory complications.
Failure to Provide Adequate Dementia Care for a Resident
Penalty
Summary
The facility failed to provide appropriate dementia care and services for Resident 22, who was diagnosed with moderate dementia with psychotic disturbance, depression, agitation, anxiety, and COPD. The resident was dependent on staff for all activities of daily living and exhibited physical and verbal behaviors, including rejecting care. Despite having a care plan that included interventions such as reminiscing with photos, offering sweets, and providing personal space, staff did not consistently implement these strategies. Observations revealed that staff did not respond adequately to the resident's needs, such as failing to change the television channel to the resident's preferred program and not providing timely toileting assistance. The resident's care plan was updated multiple times to address her behaviors, including offering a fidget board and modifying her environment to reduce noise and adjust room temperature. However, staff interviews indicated a lack of awareness and understanding of these interventions. Some staff members were unsure of what interventions to offer when the resident exhibited behaviors, and others did not engage with the resident as directed in the care plan. This lack of consistent and informed care placed the resident at risk for abuse and decreased her quality of life. The facility's dementia clinical protocol required staff to identify a resident-centered care plan and provide initial and annual training for nursing assistants in dementia care. Despite this protocol, the facility did not ensure that staff were adequately trained or that the care plan was effectively implemented. The failure to provide appropriate dementia care and services for Resident 22 resulted in unmet needs and increased distress for the resident, as evidenced by her frequent yelling for help and aggressive behaviors towards staff.
Failure to Provide Complete Pureed Diet for Residents
Penalty
Summary
The facility's kitchen staff failed to prepare all the food items on the noon menu for residents on a pureed diet, specifically affecting two residents, R20 and R22. During the preparation of the noon meal, which included chicken parmesan, buttered penne pasta, asparagus tips, fruit crisp, and garlic toast, the dietary staff only prepared mashed potatoes and gravy for R22 and a partial pureed diet for R20. The dietary staff blended chicken parmesan with red marinate sauce to a consistency of mashed potatoes and prepared mashed potatoes using boxed potato flakes without measuring the ingredients. Additionally, the staff blended cooked noodles with hot water to a similar consistency but did not prepare the bread, asparagus, or fruit crisp for the pureed diet. Instead, the residents received protein ice cream as dessert and a can of V8 juice as a vegetable replacement. The Dietary Manager confirmed that not all food items were prepared for the pureed diet, and the Registered Dietitian stated that the expectation was for the same menu items to be prepared for residents on a pureed diet as for other residents. The facility did not provide a pureed diet recipe upon request. This oversight in food preparation placed residents R20 and R22 at risk for impaired nutrition, as they did not receive the full range of menu items in a pureed form, which could potentially affect their nutritional intake.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer or obtain an informed declination or a physician-documented contraindication for the pneumococcal PCV20 vaccination for Resident 9, as per the latest guidance from the Centers for Disease Control and Prevention (CDC). This oversight was identified during a review of the resident's clinical medical records, which lacked evidence of the vaccination being offered or a signed declination. Resident 9's Admission Minimum Data Set documented that the resident was admitted to the facility and had received the influenza vaccine prior to admission, but the pneumococcal vaccination was not up to date and was not offered. Administrative Nurse D confirmed the absence of documentation regarding the offer of the PCV20 vaccine to Resident 9 upon admission. The facility's policy, revised in October 2023, mandates that all residents be assessed for eligibility and offered the pneumococcal vaccine series within thirty days of admission unless medically contraindicated or the series is already completed. The failure to adhere to this policy placed Resident 9 at risk of acquiring, spreading, and experiencing complications from pneumonia.
Resident Injury Due to Improper Use of Mechanical Lift
Penalty
Summary
The facility failed to ensure the safety of a resident during a mechanical lift transfer, resulting in a fall and injury. The incident occurred when a Certified Nurse Aide (CNA) prepared the resident for a transfer using a ceiling lift but did not correctly attach the lift sling harness loops. This error led to the resident falling from the sling to the floor, causing a right comminuted distal femoral fracture. The resident required emergency medical attention and was transferred to a higher level of care for treatment. The resident involved had a history of polyneuropathy, chronic obstructive pulmonary disease, heart failure, and hypertension, with moderately impaired cognition. The resident was dependent on staff for most activities of daily living and was at risk for falls, as documented in their care plan and fall risk evaluations. The care plan specified the use of a ceiling lift for transfers, with detailed instructions on the sling size and method of transfer. Despite these instructions, the CNA did not follow the correct procedure, leading to the resident's fall. The incident was witnessed by other staff members, who noted that the sling straps were uneven and not correctly attached. The CNA involved had previously received training on using the ceiling lift and was considered competent. However, during the transfer, the CNA was focused on the resident's complaints of leg pain and ensuring the resident's legs were crossed, which led to neglecting the proper attachment of the sling. This oversight resulted in the resident's fall and subsequent injury.
Failure to Ensure Resident Safety During Transfer
Penalty
Summary
The facility failed to ensure the safety of a resident during a transfer using a ceiling-mounted full body lift. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was being transferred from her bed to her wheelchair by a Certified Nurse Aide (CNA). During the transfer, the resident slid out of the lift sling and fell to the floor, resulting in a left femoral fracture and a left fibular fracture. The incident caused the resident significant pain and required emergency medical attention. The resident's medical records indicated that she had multiple diagnoses, including dementia, anxiety, obesity, and diabetes mellitus. She was non-ambulatory and required the use of a mechanical lift for transfers. The care plan specified that staff should use a full body lift for transfers but did not indicate the number of staff required. On the day of the incident, the CNA used an extra-large sling, which was inspected and found to be intact with no rips or holes. However, the resident slipped out of the sling during the transfer, leading to her injuries. Witness statements and the facility's incident report confirmed that the CNA had retrieved a different-sized sling because she believed the one in the resident's room was not big enough. The CNA checked the sling for tears and ensured it was secure before starting the transfer. Despite these precautions, the resident slipped out of the sling. The facility's policy on using mechanical lifts required at least two nursing assistants for safe transfers, but this was not followed. The root cause analysis identified the size of the lift sling as a contributing factor to the incident.
Failure to Administer Prescribed Antibiotic
Penalty
Summary
The facility failed to ensure that an antibiotic for a urinary tract infection (UTI) was available for administration to a resident (R2). R2 had diagnoses of dementia, major depressive disorder, anxiety, and a UTI. The resident's care plan directed staff to administer medications as ordered. Despite receiving a new order to administer Macrobid 100 mg twice a day for five days, the medication was not available from the pharmacy, and the resident did not receive the antibiotic for five days. The facility's records documented that the Macrobid was unavailable from 02/08/24 to 02/13/24, and the first dose was only administered on 02/13/24. The administrative nurse had directed staff to use the Macrobid from the emergency kit but did not follow up to ensure the resident received the antibiotic. The facility's policy on administering medications, revised in April 2019, stated that medications are to be administered in a safe and timely manner as prescribed. The Director of Nursing is responsible for supervising and directing all personnel who administer medications. The facility's failure to ensure the availability and administration of the antibiotic placed the resident at risk for a worsening UTI and health complications. The deficiency was identified through record review and interviews, highlighting a lapse in the facility's medication administration process.
Failure to Monitor Psychotropic Medication Effectiveness
Penalty
Summary
The facility failed to monitor a resident's psychotropic medication, Trazodone, which was used off-label for insomnia after a trial increase in dosage. The resident had severe cognitive impairment and was dependent on staff for daily activities. The resident's care plan directed staff to monitor for adverse reactions to Trazodone, but the clinical record lacked evidence of monitoring the effectiveness of the trial dose or notifying the physician about the outcomes. The resident's Medication Administration Record (MAR) showed that the increased dosage was administered, but there was no documentation of the effectiveness or any follow-up with the physician after the trial period ended. An administrative nurse acknowledged that the new orders for the trial dosage were not properly entered, and the resident's previous dosage should have been placed on hold during the trial. The facility's policy on administering medications required that medications be administered safely, timely, and as prescribed, with any medication errors documented and reviewed by the QAPI committee. However, the facility did not adhere to these policies, resulting in inadequate oversight and lack of physician involvement in the resident's care.
Failure to Implement Comprehensive Care Plan for Resident's Respiratory Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with significant respiratory needs. The resident, who had diagnoses including chronic obstructive pulmonary disease (COPD), polyneuropathy, chronic pain, hypokalemia, and edema, required oxygen and a non-invasive ventilator. Despite these needs, the resident's care plan lacked documentation or direction regarding the use of the Trilogy non-invasive ventilator. Observations revealed that the resident experienced shortness of breath and had difficulty receiving timely assistance with the ventilator, particularly at night. The resident reported missing medications multiple times and experiencing uncontrollable pain, which she attributed to the facility's failure to ensure medication availability and proper respiratory support. Interviews with staff confirmed that there were no orders for the resident's Trilogy non-invasive ventilator and that the care plan did not reflect its usage. The facility's policy required a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's needs, but this was not followed. The lack of a comprehensive care plan for the resident's respiratory needs and equipment placed the resident at risk for compromised respiratory well-being due to uncommunicated care needs.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident using a Trilogy non-invasive ventilator. The resident, who had diagnoses including COPD, polyneuropathy, chronic pain, hypokalemia, and edema, did not have any orders from the primary care physician regarding the settings, operation, or cleaning of the ventilator. The resident's care plan also lacked documentation or direction regarding the use of the Trilogy ventilator, which placed the resident at risk for respiratory failure. Observations and interviews revealed that the resident experienced difficulty in receiving proper respiratory care. The resident reported missing medications multiple times and having uncontrollable pain in February. Additionally, the resident faced challenges at night getting staff to assist with the Trilogy ventilator and adjusting oxygen settings. The resident expressed frustration over the lack of assistance and the staff's reluctance to handle the ventilator, leading to the resident often falling asleep without proper respiratory support. Licensed Nurse G confirmed that there were no orders for the Trilogy ventilator, and Administrative Staff A was unaware of the lack of orders and care plan documentation. The facility's policy on CPAP/BIPAP machines, which includes guidelines for respiratory care, was not followed. This failure to provide appropriate care and services for the Trilogy ventilator placed the resident at risk for respiratory failure.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident received her pain medication as ordered, leading to unmanaged pain and emotional distress. The resident, who had diagnoses including COPD, polyneuropathy, chronic pain, and fibromyalgia, was prescribed hydrocodone/acetaminophen and duloxetine for pain management. However, the resident's Medication Administration Record (MAR) documented that she did not receive her hydrocodone/acetaminophen on one day in February and missed her duloxetine for three consecutive days due to the medications being unavailable. There was no evidence that the staff notified the resident's physician about the missed medications. The resident reported experiencing uncontrollable pain and difficulty moving or sleeping during the period when her medications were unavailable. Observations confirmed that the resident was in distress, and interviews with the staff revealed a lack of clarity and consistency in the medication re-ordering process. The Certified Medication Aides (CMAs) and Licensed Nurses (LNs) involved were uncertain about the specific dates and reasons for the missed medications, indicating a breakdown in communication and procedure. Administrative staff acknowledged the problem and the need to review the medication re-ordering process. The facility's Pain Clinical Protocol Policy emphasized the importance of identifying and managing pain through appropriate interventions, but the failure to administer the prescribed pain medications as ordered demonstrated a significant lapse in following this protocol. This deficiency placed the resident at risk of pain and emotional distress from being in pain.
Failure to Ensure Resident Receives Prescribed Medications
Penalty
Summary
The facility failed to ensure that a resident (R1) was free from significant medication errors, which placed R1 at risk of medical complications. R1 had multiple diagnoses, including chronic obstructive pulmonary disease (COPD), polyneuropathy, chronic pain, hypokalemia, and edema. Despite having intact cognition and requiring various medications such as diuretics, opioids, and anti-depressants, R1 did not receive her medications as ordered by her physician. Specifically, R1 missed doses of potassium chloride, hydrocodone/acetaminophen, and duloxetine due to the medications being unavailable, and the facility failed to notify R1's physician about these missed doses. The report detailed that R1's Electronic Medical Record (EMR) documented orders for hydrocodone/acetaminophen, potassium chloride, and duloxetine, which were not administered as prescribed. The January and February Medication Administration Records (MAR) showed that R1 missed several doses of these medications. Observations and interviews revealed that the facility's process for re-ordering medications was flawed. Certified Medication Aides (CMAs) were responsible for identifying medications that needed to be re-ordered, but there were lapses in communication and documentation, leading to the unavailability of R1's medications. Interviews with staff members, including Licensed Nurses and CMAs, indicated that there was confusion and uncertainty regarding the re-ordering process. One CMA admitted to not knowing how to run a report on medications that needed to be ordered, and another CMA did not inform anyone when R1's potassium chloride was unavailable. Administrative staff acknowledged the problem and stated that the re-ordering process needed to be reviewed. The facility's policy on administering medications emphasized the importance of timely and accurate medication administration, but this policy was not followed, resulting in R1 not receiving her medications as ordered.
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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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