Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
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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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Goodland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cheyenne County Village Inc | 28.6 mi | ★★★★★ | 5 | 0 |
| Grace Manor Care Center | 29.1 mi | ★★★★★ | 7 | 0 |
| Citizens Medical Center Ltcu | 35.8 mi | ★★★★★ | 0 | 0 |
| Colby Operator, Llc | 35.8 mi | ★★★★★ | 0 | 0 |
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