Westview Of Derby Rehabilitation & Health Care Cen
Inspection history, citations, penalties and survey trends for this long-term care facility in Derby, Kansas.
- Location
- 445 N Westview Dr, Derby, Kansas 67037
- CMS Provider Number
- 175218
- Inspections on file
- 25
- Latest survey
- September 16, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Westview Of Derby Rehabilitation & Health Care Cen during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of constipation was not properly monitored for bowel movements, resulting in extended periods without a bowel movement or treatment. Staff failed to consistently document or respond to the lack of bowel movements, and follow-up after administering laxatives was incomplete. The facility lacked a policy for monitoring and preventing constipation, and staff interviews revealed inconsistent practices in documentation and follow-up.
A resident with severe cognitive impairment, a history of frequent falls, and significant mobility needs was left unattended and experienced a fall resulting in a femur fracture. Following this incident, the facility did not implement or document any new interventions to prevent further falls, and staff reported that fall interventions were inadequate and not consistently reviewed or updated according to facility policy.
Staff did not consistently test and record dish machine water temperatures, with numerous undocumented checks and missing logs. Dietary staff gave inconsistent information about temperature monitoring, and the facility's policy did not address this requirement.
The facility did not complete a thorough facility-wide assessment to determine specific staffing levels, gather resident input, or develop contingency plans for non-emergency events, resulting in a lack of clear resource planning for all residents.
A resident's protected health information (PHI), including medications, date of birth, allergy information, and code status, was left visible on an unlocked laptop atop a medication cart in a common area. The cart was unattended by staff, and the PHI was accessible to anyone passing by. Staff interviews confirmed the expectation that such information should be secured and not left open.
Several dependent residents did not consistently receive scheduled showers or baths as required by their care plans, with documentation gaps and missed opportunities for personal hygiene. Some residents reported feeling dirty and neglected, and observations confirmed poor hygiene and grooming. Staff interviews revealed that missed baths were sometimes due to staffing shortages or lack of proper documentation, despite facility policy requiring regular bathing and documentation of refusals.
Surveyors found that the facility did not provide consistent, resident-directed activities on weekends, with Sundays limited to televised church services, movies, and news, and no staff-led or interactive engagement. Residents reported boredom and lack of alternatives for those unable to attend outings, and staff confirmed there was no assigned responsibility or documentation for weekend activities.
Surveyors found that hazardous areas, including an unlocked oxygen storage room, unsecured cleaning chemicals, and exposed electrical panels, were accessible to cognitively impaired and mobile residents. Additionally, a resident with severe cognitive impairment and a history of falls did not have required fall prevention interventions, such as gripper strips, in place. Staff were unclear about responsibilities for ensuring interventions were implemented, and the facility could not provide a policy on environmental safety.
Staff failed to consistently reconcile and document controlled substance counts between shifts, as required by facility policy. Reviews of inventory count sheets showed missing signatures from both oncoming and off-going staff on multiple occasions. Interviews with CMAs and LNs revealed uncertainty about the process when signatures were missing, and the required reconciliation was not always completed, increasing the risk of medication misappropriation or diversion.
The facility did not ensure that monthly drug regimen reviews by the consultant pharmacist were properly reviewed and addressed by physicians for multiple residents, including those with dementia, depression, and severe cognitive impairment. In several cases, recommendations for gradual dose reduction, clarification of medication orders, and reeducation on analgesic dosages were not acted upon, and required documentation was missing due to process failures and changes in pharmacy providers.
A resident's oxygen and nebulizer tubing were not stored in a sanitary manner, and a nurse performed tracheostomy care for a resident on Enhanced Barrier Precautions using only gloves, without the required gown and mask. Facility staff were uncertain about training on EBP protocols, despite signage and policy requirements for infection prevention.
Two residents with significant cognitive and physical impairments were not provided with reasonable accommodations as required by their care plans. One resident's call light was left out of reach, preventing her from calling for assistance, while another was pushed in a wheelchair without foot pedals, causing her feet to slide on the floor. Staff interviews confirmed these actions were not in line with facility expectations or policies.
A resident with severe cognitive impairment and multiple medical conditions was inappropriately charged for services that should have been covered by Medicaid/Medicare due to incorrect billing codes and admission status errors. The facility failed to prevent multiple unauthorized withdrawals from the resident's personal bank account and could not provide a policy on resident personal funds when requested.
A resident who transitioned from Medicare Part A to custodial care was not given the required SNF ABN form 10055, as confirmed by record review and staff interview. The responsible staff member reported never having issued the form and lacked training on the process, resulting in the resident not being informed about potential financial liability for services not covered by Medicare.
A resident with multiple medical conditions and impaired mobility did not receive required pressure ulcer prevention interventions, including the use of heel protectors and offloading of heels while in bed. Staff also failed to monitor and correctly set the resident's low air loss mattress according to her weight, and there was a lack of staff knowledge regarding mattress settings. These failures were not in accordance with the care plan and physician orders.
A resident requiring hemodialysis did not have consistent monitoring and documentation of their dialysis shunt for bruit, thrill, and dressing. Although care plans and physician orders required this monitoring, staff interviews revealed a lack of clear documentation procedures and uncertainty about monitoring on non-dialysis days. The facility's policy did not address access site monitoring, leading to inconsistent practices.
A resident with severe cognitive impairment and multiple medical conditions was prescribed Diclofenac Sodium External Gel for pain, but the physician's order did not specify the dosage amount. Despite a consultant pharmacist's recommendation to clarify the order, the facility did not document any follow-up, and the medication continued to be administered without a defined dosage. Nursing staff confirmed that all medication orders should include dosage and application site, but the facility could not provide a relevant policy when asked.
Surveyors found that a medication cart contained an opened, undated insulin pen. A nurse confirmed that insulin pens should be labeled when removed from refrigeration, and an administrative nurse stated that all opened pens should be dated and labeled. The facility could not provide a medication storage policy, resulting in a failure to properly label medications.
A resident who required two-person assistance for mechanical lift transfers sustained a fractured kneecap when a staff member operated the lift alone, contrary to the care plan and facility expectations. The incident occurred when the staff member, described as impatient, did not wait for a second staff member, resulting in the resident's legs striking a metal object during the transfer. Facility staff interviews confirmed that two-person assistance is required for mechanical lift use, but the policy lacked specific guidance on safe operation.
A cognitively impaired resident at risk for elopement was able to leave the facility unsupervised due to a CNA's failure to verify the source of a WanderGuard alarm. The resident was found 90 feet from the facility, heading toward a busy 4-lane road. The incident revealed lapses in the facility's supervision and monitoring procedures.
The facility failed to provide adequate bathing services for three residents, resulting in significant periods without proper hygiene. One resident went without a shower for up to 15 days, another for 29 days, and a third received only one shower in 57 days. Staff interviews and records revealed inconsistencies in following bathing schedules and a lack of proper documentation.
The facility failed to suspend an alleged perpetrator in response to an abuse allegation, allowing the CNA to work a night shift before suspension. This action was against the facility's policy, which mandates immediate suspension pending investigation.
Failure to Monitor and Respond to Resident Constipation
Penalty
Summary
The facility failed to adequately monitor and respond to a resident's lack of bowel movements, despite the resident having a history of severe cognitive impairment, incontinence, and a diagnosis of constipation. The resident's care plan directed staff to monitor for constipation and administer laxatives as needed if no bowel movement occurred in three days. However, electronic medical records showed that the resident went up to nine consecutive days without a bowel movement or treatment, and up to eight consecutive days on another occasion, with no medication given for constipation and no assessment documented during these periods. Documentation of bowel movements and follow-up after administration of laxatives was incomplete or missing. Interviews with staff revealed inconsistencies in monitoring and documentation practices. Certified Medication Aides and Licensed Nurses stated that bowel movements were supposed to be tracked and that nurses should assess and notify providers if a resident went three days without a bowel movement. However, the administrative nurse acknowledged that Certified Nurse Aides did not always document bowel movements in the EMR, and that nurses did not consistently follow up on EMR alerts for missed bowel movements. The facility did not provide a policy addressing the monitoring of residents to prevent constipation.
Failure to Implement Post-Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement an intervention to prevent further falls after a resident experienced a fall resulting in a serious injury. The resident had multiple diagnoses, including severe cognitive impairment, a nonunion femur fracture, muscle weakness, anxiety, and a history of frequent falls. The resident required extensive assistance for transfers and mobility, including the use of a mechanical lift and wheelchair. Despite being identified as high risk for falls and having several care plan interventions in place, after a significant fall in which the resident was left unattended in the dining room and sustained a femur fracture, the facility did not document or implement any new intervention to prevent further falls. Staff interviews revealed that interventions following falls were not consistently chosen by direct care staff and that the interventions in place were considered inadequate by some staff members. Additionally, there was a lack of documentation for previous fall investigations, and the process for reviewing and updating interventions was not consistently followed. The facility's policy required completion of an occurrence report, root cause determination, and implementation of interventions after each fall, but these steps were not fully carried out in this case.
Failure to Document Dish Machine Water Temperatures
Penalty
Summary
The facility failed to ensure that staff members properly tested and recorded dish machine water temperatures, as evidenced by 34 undocumented temperature checks out of 84 opportunities in February and eight undocumented checks in March. During the initial tour, it was observed that the Dish Machine Log for March was not available in the kitchen, and staff provided inconsistent information regarding the location and posting of the log. Dietary staff confirmed that dish machine water temperatures should be checked at least daily, but documentation was lacking. Additionally, the facility's Food Storage policy did not address dish machine water temperatures.
Incomplete Facility-Wide Assessment for Resource and Staffing Needs
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment provided by the administrative nurse was last updated on 08/12/24 and did not specify required staffing levels for each unit, including the number of RNs, LPNs/LVNs, CMAs, and CNAs needed based on patient acuity and census. Additionally, the assessment did not address staffing requirements for all shifts, such as evenings and weekends. The assessment also lacked documentation of input from residents and their representatives in its formulation. Furthermore, it did not include contingency plans for events that could impact resident care but do not require activation of the facility's emergency plan. These deficiencies were identified through observations, interviews, and record reviews, and affected all 69 residents in the facility.
Resident PHI Left Visible on Unattended Medication Cart
Penalty
Summary
A medication cart was observed parked in a hallway with a laptop computer on top, displaying a resident's protected health information (PHI) on the screen. The information visible included the resident's medications, date of birth, allergy information, and code status. At the time of observation, no nursing staff were present to monitor the cart or the computer, making the PHI accessible to anyone passing by. A Certified Medication Aide (CMA) later confirmed that she had left the cart unattended for a short period and acknowledged that the computer should not have been left open with PHI visible. Interviews with facility staff, including a Licensed Nurse and an Administrative Nurse, confirmed that the expectation was for the laptop to be closed or locked when unattended, and that PHI should not be accessible to unauthorized individuals. The facility's policy on electronic medical records specifies that only authorized personnel should have access and that efforts should be made to limit the disclosure of PHI to the minimum necessary. The failure to secure the laptop resulted in a breach of the resident's privacy regarding their PHI.
Failure to Provide Consistent Bathing and ADL Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide consistent bathing and assistance with activities of daily living (ADLs) for several residents who were dependent on staff for personal care. Multiple residents, including those with intact cognition and those with severe cognitive impairment, did not receive scheduled showers or baths as documented in their care plans and medical records. For example, one resident with muscle weakness and depression was documented as requiring staff assistance for bathing but had only one recorded shower over a 61-day period, with no evidence of being offered or refusing care during that time. The resident reported feeling dirty and neglected due to missed baths. Another resident with chronic medical conditions, including COPD, morbid obesity, and diabetes, was dependent on two staff for ADLs and had a history of moisture-associated skin damage. This resident had no documented bathing opportunities for over a month, and reported feeling unclean, with staff providing only peri-care and not assisting with full bathing or showering. Similarly, a resident with hemiplegia and other significant health issues did not consistently receive bathing twice weekly as per her care plan, and reported not having a shower for 15 days, noting that showers were missed when staff were short. Additionally, a resident with vascular dementia and multiple comorbidities, who required substantial to maximum assistance for bathing and grooming, had no documentation of showers given over nearly two months. Observations noted poor grooming and hygiene, with matted and tangled hair. Staff interviews confirmed that while policies required offering showers twice weekly and documenting refusals, there were lapses in both the provision and documentation of care, particularly when staffing was insufficient or when residents refused care. The facility's own policy required individualized care based on assessment and care plans, but this was not consistently followed for the residents reviewed.
Lack of Resident-Directed Activities on Weekends
Penalty
Summary
The facility failed to provide resident-directed, interactive activities based on resident preferences during weekends. Review of activity calendars for three consecutive months showed that Sundays only included church services via television or internet, movies in the afternoon, and the evening news, with no staff-led or engaging activities. Resident Council feedback confirmed that activities were rarely provided on weekends, with Sundays being particularly inactive. While outings sometimes occurred on Saturdays, not all residents could participate due to limited transportation, and no alternative activities were offered for those unable to attend. Staff interviews revealed that weekend activities were expected to be completed by staff, but there was no assignment of specific staff to lead activities, and no documentation of which activities were provided or which residents attended. An activity basket with puzzles, coloring pages, and games was available, but there was no evidence of consistent or interactive engagement. The facility was unable to provide a policy related to activities when requested. These findings indicate a lack of consistent, resident-centered activities on weekends, as directly observed and reported.
Failure to Secure Hazardous Areas and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to secure areas containing hazardous materials and potential accident hazards, leaving them accessible to seven cognitively impaired and independently mobile residents in a secured unit. During a walkthrough, surveyors observed an unlocked supplemental oxygen storage room containing 46 fully charged oxygen cylinders, a propped-open shower room with unsecured bleach wipes and disinfectant, an unsecured closet with a gallon of floor cleaner, and two unlocked utility closets with exposed electrical panels labeled as high voltage. Staff acknowledged that these areas should have been locked and that residents should not have access to such hazards. The facility was unable to provide a policy related to environmental safety when requested. Additionally, the facility failed to implement and maintain fall prevention interventions for a resident with a history of falls, severe cognitive impairment, muscle weakness, COPD, and hypertension. The resident required substantial to maximum staff assistance for transfers and had experienced multiple falls, some resulting in injuries such as skin tears and bruising. The care plan included interventions such as ensuring the resident wore gripper socks, keeping the call light and personal items within reach, and using gripper strips on the floor next to the bed. However, on inspection, gripper strips were not in place, and staff interviews revealed uncertainty about who was responsible for ensuring interventions were implemented. The facility's fall management policy outlined the need for an interdisciplinary approach to fall prevention, but documentation and staff interviews indicated lapses in following and updating care plans and interventions. The lack of environmental safety measures and failure to consistently implement fall prevention strategies placed residents, particularly those with cognitive impairment and mobility, at risk for preventable injuries and accidents.
Failure to Reconcile and Document Controlled Substance Counts Between Shifts
Penalty
Summary
The facility failed to ensure that controlled substances were properly accounted for and reconciled between shifts, as required by their policy. A review of the Shift Change Controlled Substance Inventory Count Sheets for multiple months revealed missing signatures from both oncoming and off-going nurses on several dates. Certified Medication Aides (CMAs) and Licensed Nurses (LNs) confirmed that the process required both parties to count the medication cards and pills and sign the count sheet at each shift change. However, there was a lack of clarity among staff regarding the procedure to follow when signatures were missing, and the required reconciliation was not consistently completed. The facility's policy mandated that all controlled substances be counted every shift, with both the oncoming and off-going nurse or CMA responsible for verifying and signing the count. Despite this, documentation showed repeated failures to obtain the necessary signatures, indicating that the reconciliation process was not reliably followed. This deficiency was identified through observation, record review, and staff interviews, and it placed residents at risk for misappropriation or diversion of controlled substances.
Failure to Address Consultant Pharmacist Recommendations and Medication Order Irregularities
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed adequate monthly drug regimen reviews and that physicians reviewed and addressed the consultant pharmacist's (CP) recommendations for several residents. For one resident with dementia, depression, and anxiety, the medical record showed ongoing use of antipsychotic, antianxiety, and antidepressant medications without evidence of a gradual dose reduction (GDR) or documentation that a GDR was clinically contraindicated. The monthly medication review (MMR) for this resident indicated a 14-day stop date was required for as-needed antipsychotic medication, but the physician did not review and sign the MMR until several months later. Additionally, the facility was unable to provide MMRs for certain months, and administrative staff acknowledged that the process for addressing MMRs was incomplete. Another resident with a history of stroke, muscle weakness, and severe cognitive impairment had a physician's order for topical Diclofenac gel that lacked a specified dosage and site of application. The CP identified this irregularity and recommended clarification, but there was no documented response from the facility or evidence that the order was updated. Nursing staff and administration confirmed that all medication orders should include dosage and application site, and that pharmacy recommendations should be acted upon, but this was not done in this case. Additional deficiencies were identified for two other residents receiving psychotropic medications. For one resident with depression and multiple comorbidities, the facility could not provide evidence that the CP's recommendations regarding antidepressant and analgesic medications were reviewed or addressed by the physician. For another resident with severe cognitive impairment and depression, the facility was unable to produce documentation of the MMR or evidence that the physician addressed the CP's recommendations for antidepressant medication. In both cases, administrative staff stated that records were missing due to changes in pharmacy providers and acknowledged a breakdown in the process for handling CP recommendations.
Failure to Maintain Sanitary Storage of Respiratory Equipment and Proper PPE Use During Tracheostomy Care
Penalty
Summary
The facility failed to maintain sanitary storage of respiratory equipment and did not ensure proper use of personal protective equipment (PPE) during tracheostomy care. During a facility walk-through, one resident's oxygen tubing and cannula were found wrapped over a walker, and nebulizer tubing was left on a side table, both not stored in a sanitary manner. Additionally, a licensed nurse performed tracheostomy care for a resident on Enhanced Barrier Precautions (EBP) but only donned sterile gloves, omitting the required gown and mask. The nurse stated he was unaware that additional PPE was necessary beyond gloves. Administrative staff confirmed that respiratory equipment not in use should be bagged and that there are signs on doors for residents on EBP, but there was uncertainty about whether staff had been adequately trained on EBP protocols. The facility's own infection prevention and control policy emphasizes maintaining a safe and sanitary environment to prevent the transmission of communicable diseases, but these practices were not followed, resulting in the identified deficiencies.
Failure to Accommodate Resident Needs: Inaccessible Call Light and Missing Wheelchair Foot Pedals
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents, resulting in deficiencies related to resident safety and care. For one resident with a history of heart failure, hemiparesis following a stroke, muscle weakness, neurogenic bladder, major depressive disorder, and dementia, the call light was observed to be out of reach while the resident was asleep in bed. The resident's care plan specifically required that the call light be within reach and that staff encourage its use for assistance. Interviews with staff confirmed that call lights should always be accessible to residents, but the facility did not provide a policy on accommodations of needs. Another resident, diagnosed with acute respiratory failure, bipolar disorder, unsteadiness of feet, and catatonic disorder, was observed being pushed in a wheelchair without foot pedals on two separate occasions. The resident's feet were seen sliding on the floor as staff pushed the wheelchair. The care plan indicated the resident was at risk for falls due to impaired balance and poor safety awareness, and staff interviews confirmed that foot pedals should be used, especially for cognitively impaired residents, to prevent falls during transport. The facility's fall prevention policy required the implementation of preventative interventions to ensure resident safety, but this was not followed in the observed cases. The lack of accessible call lights and the absence of wheelchair foot pedals during transport represented failures to accommodate the residents' needs as outlined in their care plans and facility policy.
Unnecessary Charges to Resident's Personal Funds Due to Billing Errors
Penalty
Summary
The facility failed to prevent unnecessary charges to a resident's personal bank account, resulting in multiple inappropriate withdrawals. The resident, who had diagnoses including COPD, senile degeneration of the brain, and dementia with severe cognitive impairment, was admitted for hospice services and was eligible for Medicaid/Medicare coverage. Despite this, the facility's records showed that the resident's bank account was charged several times for services that should have been covered by Medicaid/Medicare, with amounts ranging from $215.27 to $2,494.73. The resident's representative reported these unauthorized transactions to the state agency and provided the facility with documentation of the resident's Medicaid/Medicare eligibility. Interviews with facility staff revealed that the resident's billing code was set up incorrectly, which led to the inappropriate charges. Staff acknowledged that the resident was admitted under both hospice pay and private pay, which may have contributed to the billing errors. Additionally, the facility was unable to provide a policy related to resident personal funds when requested. This series of actions and inactions resulted in the resident being inappropriately charged for services that should have been covered by public insurance programs.
Failure to Provide SNF ABN Notification at End of Medicare Part A Coverage
Penalty
Summary
The facility failed to issue the required CMS Skilled Nursing Facility Advance Beneficiary Notification (SNF ABN) form 10055 to a resident whose Medicare Part A episode ended, despite the resident remaining in the facility for custodial care. Review of the electronic medical record confirmed the resident's Medicare Part A coverage period and subsequent stay, but no evidence was provided that the SNF ABN was given. An interview with a social services staff member revealed that she had never provided the SNF ABN to residents ending Medicare Part A coverage and had not been trained to do so. The facility's own policy states that the SNF ABN is intended to inform patients about potential financial responsibility for services not covered by Medicare, but this process was not followed in this case. The failure to provide the required notification meant that the resident was not given the necessary information to make informed decisions regarding their care and financial obligations at the end of their Medicare Part A coverage.
Failure to Implement Pressure Ulcer Prevention Interventions and Monitor Support Surfaces
Penalty
Summary
A deficiency was identified when staff failed to provide appropriate pressure ulcer prevention and care for a resident with multiple medical conditions, including heart failure, hemiparesis following a stroke, muscle weakness, hypertension, neurogenic bladder, major depressive disorder, and dementia. The resident was assessed as having severely impaired cognition and required assistance with mobility and repositioning. Despite care plan instructions and physician orders for heel protectors and offloading of heels while in bed, staff did not ensure these interventions were implemented. Observations revealed that the resident was lying in bed with her heels directly on the mattress, without heel protectors or offloading, contrary to physician orders and the care plan. Additionally, the low air loss mattress, intended to reduce pressure and prevent ulcers, was set at 350 pounds, which did not correspond to the resident's actual weight of 116 pounds. Staff interviews indicated a lack of knowledge regarding the correct mattress settings and monitoring procedures, and there was no documentation in the care plan for staff to monitor the mattress settings as required by manufacturer recommendations. The facility's policy required individualized plans to address pressure injury prevention, including the use of mechanical support surfaces and regular monitoring. However, the failure to apply heel protectors, offload the resident's heels, and monitor the low air loss mattress as specified in the care plan and physician orders placed the resident at increased risk for developing pressure ulcers.
Failure to Consistently Monitor and Document Dialysis Shunt Care
Penalty
Summary
The facility failed to consistently monitor and document a resident's dialysis shunt for bruit, thrill, and dressing as required. The resident, who had diagnoses including diabetes mellitus, hypertension, end-stage renal disease, and a fractured shoulder, required hemodialysis three times a week. The care plan and physician's orders specified that nursing staff should monitor the shunt's bruit and thrill and obtain vital signs before and after dialysis. However, the electronic medical record lacked clear documentation or direction for daily monitoring of the shunt's dressing, bruit, and thrill. Observations and staff interviews revealed that there was no designated place for nurses to document daily monitoring of the shunt, and it was unclear whether monitoring occurred or was recorded on non-dialysis days. The facility's dialysis communication policy did not address access site monitoring, and administrative staff were unsure about the documentation process. This resulted in inconsistent monitoring and documentation practices for the resident's dialysis access site.
Medication Order Lacked Required Dosage for Topical Pain Medication
Penalty
Summary
A deficiency was identified when a resident with multiple medical diagnoses, including cerebral infarction, muscle weakness, aphasia, chronic kidney disease, and heart failure, was found to have a physician's order for Diclofenac Sodium External Gel that lacked a specified dosage amount. The resident's electronic medical record indicated severe cognitive impairment and a need for substantial to maximal assistance with daily activities. The care plan noted the use of medications with Black Box Warnings and instructed staff to monitor for pain and medication side effects. Despite these precautions, the Diclofenac order did not include the required dosage information. A consultant pharmacist's monthly medication review highlighted the missing dosage and site of application for the Diclofenac order and recommended clarification, but there was no documented response from the facility. Observations confirmed that the medication was administered without a specified dosage, and interviews with nursing staff and administration affirmed that all medication orders should include an accurate dosage and application site. The facility was unable to provide a policy regarding physician's orders when requested.
Failure to Properly Label Opened Insulin Pen in Medication Cart
Penalty
Summary
Surveyors observed that one of three medication carts contained an opened and undated insulin pen. A licensed nurse confirmed that all insulin pens should be labeled once removed from the refrigerator and placed into the medication cart. An administrative nurse also stated that her expectation was for all insulin pens to be dated and labeled upon opening. The facility was unable to provide a policy related to medication storage. These findings indicate that the facility failed to properly label medications as required, specifically with respect to insulin pens in the medication cart. The sample included 18 residents, three medication carts, and one medication room, with a total facility census of 69 residents at the time of the survey.
Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with cerebral palsy, blindness, diabetes mellitus type 2, and restless leg syndrome, who was dependent on staff for transfers and required a mechanical lift with two-person assistance, sustained a fracture to the left patella during a transfer. On the evening of the incident, an unknown staff member operated the mechanical lift alone, contrary to the resident's care plan and facility expectations, which required two staff members for such transfers. The staff member was described as impatient and did not wait for a second staff member to assist. During the transfer, the resident's legs struck a metal object, resulting in a popping sensation and immediate pain. The resident reported the incident to the nurse and requested to be sent to the emergency department, where a non-displaced fracture of the left patella was diagnosed. Interviews with multiple CNAs, a licensed nurse, and an administrative nurse confirmed that facility policy and standard practice required two staff members for mechanical lift transfers to ensure resident safety. The facility's policy on safe lifting and movement of residents lacked specific direction regarding the safe and appropriate use of mechanical lifting devices. The care plan also lacked documentation or intervention related to the injury following the incident.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure a safe and secure environment to prevent the elopement of a cognitively impaired resident identified at risk for elopement. On the specified date, a CNA mistakenly let the resident out the front doors of the building, thinking the resident had an appointment and was leaving to get on the facility transport vehicle. The resident's WanderGuard alarm activated, but the CNA did not check which resident caused the alarm. The facility did not realize the resident was missing until almost 15 minutes later when a staff member driving by saw the resident outside, unsupervised, and notified the facility. The resident was found approximately 90 feet from the facility, heading toward a busy 4-lane road. These failures placed the resident in immediate jeopardy. The resident had a history of paraplegia, cognitive communication deficit, reduced mobility, and chronic pain syndrome. The resident's care plan indicated an elopement risk, wandering behavior, and a desire to leave the facility. The care plan required frequent monitoring by staff and specified that the resident could only go outside with staff supervision. Despite these precautions, the resident was able to leave the facility unsupervised due to the CNA's failure to verify the source of the WanderGuard alarm. Interviews with staff revealed that the CNA who let the resident out was unaware of the resident's elopement risk and did not follow the facility's elopement policy. The facility's investigation confirmed that the WanderGuard alarm functioned correctly, but staff failed to respond appropriately. The facility's policy required all residents to be assessed for elopement risk and have these issues addressed in their care plans, but this was not effectively implemented in this case. The incident highlighted a significant lapse in the facility's supervision and monitoring procedures for residents at risk of elopement.
Removal Plan
- The facility located R1 and brought him back to the building. A skin assessment was performed by the Director of Nursing, with no issues found. A WanderGuard was found in place and functioning at the time of the event. R1's Physician and Durable Power of Attorney were notified of the event. Elopement evaluation completed and care plan reviewed.
- A headcount of all residents was performed.
- Community review of all residents at risk for elopement was completed by the Director of Nursing and Assistant Director of Nursing. Residents identified as having the potential to be affected were evaluated for elopement risk by the Assistant Director of Nursing.
- Care plan review of residents identified as having the potential to be affected was completed by the Assistant Director of Nursing to verify prevention interventions were in place as indicated.
- Current associates were re-educated by the Assistant Director of Nursing and/or designee on the community Elopement Policy and the community Elopement Evaluation process. Associates who had not completed the required education were required to complete education prior to working their next scheduled shift.
- An ADHOC QAPI meeting was completed with the community interdisciplinary team.
- The facility Medical Director was notified of elopement and further notified of the facility compliance plan.
- Exit doors were evaluated and noted to be functioning without discrepancy. Front door code changed and communicated to the staff.
- Residents identified with a new risk for elopement or change in elopement risk will be reviewed by clinical/interdisciplinary team during routine clinical huddle to verify elopement risk assessment accuracy, provider notification, and preventative measures.
Inadequate Bathing Services for Residents
Penalty
Summary
The facility failed to provide adequate bathing services for three residents, resulting in significant periods without proper hygiene. Resident 1, who had diagnoses of muscle weakness and required assistance with personal care, experienced multiple instances where bathing was delayed for up to 15 days. Despite having a care plan that specified a preference for showers at least twice weekly, the facility's documentation revealed inconsistent bathing schedules and missed showers. Resident 1 expressed confusion about the bathing schedule and reported instances where staff did not assist her in getting a shower even after she requested one upon returning from the hospital. Resident 2, who also had muscle weakness and required substantial assistance for bathing, went without a shower for 29 days and then again for 21 days. The resident reported that she preferred showers twice a week but was only receiving them once a week, despite her son's repeated requests to the nursing staff. The facility's records corroborated these gaps in bathing services, and staff interviews revealed that the lack of a designated bath aide contributed to the inconsistency. Resident 3, diagnosed with muscle weakness and dementia, required moderate assistance for bathing and had a care plan that specified showers twice weekly. However, the facility's records showed that Resident 3 received only one shower in 57 days. The resident's fingernails were observed to be long and dirty, indicating a lack of proper hygiene care. Staff interviews confirmed that bathing schedules were not consistently followed, and refusals were not adequately documented or addressed. The facility lacked a policy for bathing services, contributing to the failure to provide adequate care for these residents.
Failure to Suspend Alleged Perpetrator During Abuse Investigation
Penalty
Summary
The facility failed to suspend an alleged perpetrator in response to an allegation of abuse, neglect, exploitation, or mistreatment, thereby not preventing further potential abuse while an investigation was in progress. The incident involved a resident who was allegedly restrained and dragged to her room and forced to take medication by a CNA and a licensed nurse. The administrative nurse received the report of the allegation on 02/27/24 but allowed the CNA to work the night shift on the same day before suspending both the CNA and the licensed nurse the following day. The facility's policy mandates that any employee alleged to have committed abuse or neglect should be immediately barred from further contact with residents through suspension, pending the outcome of the investigation. However, the administrative nurse confirmed that the CNA worked the night shift on 02/27/24, which was corroborated by the nursing staff schedule and daily assignment sheets. This failure to immediately suspend the alleged perpetrator compromised the safety of the residents during the investigation period.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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