Westy Community Care Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Westmoreland, Kansas.
- Location
- 105 N Highway 99, Westmoreland, Kansas 66549
- CMS Provider Number
- 175471
- Inspections on file
- 15
- Latest survey
- October 14, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Westy Community Care Home during CMS and state inspections, most recent first.
The facility did not employ a full-time Certified Dietary Manager for its 31 residents, risking inadequate nutrition. Observations showed kitchen staff preparing meals without a Certified Dietary Manager present. One staff member was off, and another was still obtaining certification. The facility's policy required a Certified Dietary Manager credential, which was not fulfilled.
The facility failed to submit accurate staffing information through the PBJ, as required by CMS, indicating a lack of licensed nurse coverage on multiple days. However, a review showed that a licensed nurse was on duty 24/7. Administrative Staff A noted that payroll data was sent to a corporate office for submission, leading to inaccuracies. This failure placed residents at risk for inadequate staffing.
The facility did not ensure that the designated Infection Preventionist (IP) completed the required specialized training in infection prevention and control. Administrative Nurse E, responsible for the IPCP, was in the process of taking the necessary class and confirmed she was not certified. The facility's policy required the IP to have relevant professional training and certification, work part-time at the facility, and participate in the QAA committee. This deficiency placed 31 residents at risk for inadequate infection identification and treatment.
The facility did not follow CDC guidance for pneumococcal vaccinations, failing to offer or document informed declinations or contraindications for five residents. The facility's policy required documentation of vaccine administration or refusal, but records lacked evidence of consent or informed declination. An Administrative Nurse admitted the vaccine was only offered to new residents, contrary to policy, placing residents at risk of pneumococcal disease.
A resident with severe cognitive impairment and pressure ulcers was found with a malfunctioning ROHO-type cushion in their recliner, which had lost air and gone flat. Despite a care plan that included pressure-reducing devices, the nursing staff failed to ensure the cushion was properly inflated, compromising the resident's pressure ulcer care and placing them at risk for delayed healing.
A facility failed to ensure a Consultant Pharmacist identified and reported missed doses of insulin and Parkinson's medication for a resident with multiple diagnoses, including diabetes and Parkinson's disease. The resident's Medication Administration Records for several months showed missed doses, which were not communicated to the physician or Director of Nursing, placing the resident at risk for physical decline.
A resident with Parkinson's disease and diabetes did not receive medications as ordered, with missing documentation for Sinemet and insulin on multiple occasions. The facility's policy required accurate documentation, but observations and staff interviews revealed inconsistencies, risking ineffective medication management.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a pressure ulcer. Despite having an EBP sign and PPE available, a nurse did not wear a gown during a dressing change, contrary to the facility's policy. This oversight was acknowledged by the nurse and confirmed by an administrative nurse, placing the resident at risk for facility-acquired infections.
Lack of Full-Time Certified Dietary Manager
Penalty
Summary
The facility failed to employ a full-time Certified Dietary Manager for its 31 residents, which placed them at risk of inadequate nutrition. During the survey, it was observed that the kitchen staff was preparing meals without the presence of a Certified Dietary Manager. On one occasion, the Dietary Staff CC mentioned that the Dietary Manager was off for the day but would return during the survey period. Another staff member, Dietary Staff BB, reported that he was in the process of obtaining a certified dietary manager course. The facility's policy from 2020 indicated that the Dining Service Manager should have a Certified Dietary Manager credential, but this standard was not met.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit complete and accurate staffing information through the Payroll Based Journal (PBJ) as required by the Centers for Medicare & Medicaid Services (CMS). The PBJ report for Fiscal Year 2023 Quarter 4 and Fiscal Year 2024 Quarters 1, 2, and 3 indicated that the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple days. Specifically, there were 11 days in FY 2023 Quarter 4, 5 days in FY 2024 Quarter 1, 25 days in Quarter 2, and 5 days in Quarter 3 where the facility reportedly lacked licensed nurse coverage. However, a review of the facility's licensed nurse data for the dates listed on the PBJ revealed that a licensed nurse was on duty 24 hours a day, seven days a week. On September 18, 2024, an observation confirmed the presence of a licensed nurse on duty in the facility. Administrative Staff A reported that the facility sent payroll information to a corporate office, which then submitted it to the PBJ. She stated that there was always a nurse on duty, but the information submitted was inaccurate. The facility's policy on the Mandatory Submission of Uniform Format Staffing Information, dated September 18, 2024, documented the requirement to electronically submit complete and accurate direct care staffing information to CMS. The failure to submit accurate PBJ data placed the residents at risk for unidentified and ongoing inadequate staffing.
Inadequate Training for Infection Preventionist
Penalty
Summary
The facility failed to ensure that the staff member designated as the Infection Preventionist (IP) for the Infection Prevention and Control Program (IPCP) completed the necessary specialized training in infection prevention and control. This deficiency was identified during an interview and record review, where Administrative Nurse E, who was responsible for the IPCP, admitted to being in the process of taking the required class and confirmed that she was not certified. The facility's Infection Control Policy, dated 03/13/23, stipulated that the IP must have primary professional training in relevant fields and be qualified by education, training, experience, or certification. Additionally, the policy required the IP to work at least part-time at the facility, complete specialized training, and participate in the Quality Assurance Performance Improvement (QAA) committee regularly. The lack of certification for the designated IP placed the 31 residents at risk for inadequate identification and treatment of infections.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to adhere to the latest guidance from the Centers for Disease Control and Prevention (CDC) regarding the administration of pneumococcal vaccinations. Specifically, the facility did not offer or administer the pneumococcal PCV20 vaccine to five residents, nor did they obtain informed declinations or physician-documented contraindications for these residents. This oversight was identified through a review of clinical medical records, which lacked evidence of consent or informed declination for the vaccine. The facility's policy, dated January 31, 2024, stated that vaccines would be administered by qualified personnel without the need for individual physician orders, and that documentation should include whether the resident received the vaccine or refused it due to medical contraindications or personal choice. During an interview, the Administrative Nurse revealed that the facility only offered the PCV20 vaccine to new residents and did not maintain documentation of it being offered or declined. This practice was inconsistent with the facility's policy, which required that each resident be provided with current information from the CDC and FDA regarding the benefits and risks of the vaccine. The failure to offer the pneumococcal PCV20 vaccinations as per CDC recommendations placed the residents at risk of acquiring, spreading, and experiencing complications from pneumococcal disease.
Failure to Maintain Pressure-Reducing Devices
Penalty
Summary
The facility failed to ensure that pressure-reducing devices functioned correctly for a resident with pressure ulcers, leading to a deficiency in care. The resident, who had severe cognitive impairment and a history of pressure ulcers, was observed sitting in a recliner with a ROHO-type cushion that had lost air and gone flat. This malfunctioning cushion was intended to relieve pressure on the resident's coccyx area, where they had a Stage 2 pressure ulcer. Despite having a care plan that included the use of pressure-reducing devices and regular dressing changes, the cushion's failure to maintain proper inflation compromised the resident's pressure ulcer care. The resident's medical records indicated a history of cognitive impairment, urinary incontinence, and pressure ulcers, with a care plan that included the use of an air mattress and pressure-relieving cushions. However, the nursing staff did not ensure the cushion was properly inflated, as they were responsible for checking its function. This oversight placed the resident at risk for delayed healing or worsening of the existing pressure ulcer, as the cushion was not providing the necessary pressure relief. The facility's wound management policy emphasized the importance of controlling causative factors such as pressure, but the failure to maintain the cushion's functionality demonstrated a lapse in adhering to these guidelines.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported staff's failure to follow physician's orders for administering insulin and medications for Parkinson's disease to a resident. The resident, identified as R2, had multiple diagnoses including Parkinson's disease, diabetes mellitus type two, dementia, hypertension, delusional disorder, and anxiety. The resident's care plan required staff to administer medications as ordered and monitor their effectiveness. However, the Medication Administration Records for July, August, and September 2024 showed missed doses of Sinemet and insulin, which were not identified or reported by the CP. Observations and interviews revealed that the CP did not communicate these medication administration issues to the responsible physician or the Director of Nursing. The facility's policy required the CP to review medication regimens monthly and document findings in the clinical record, but this was not done. The failure to administer the prescribed medications placed the resident at risk for physical decline and an ineffective medication regimen.
Failure to Administer and Document Medications as Ordered
Penalty
Summary
The facility failed to administer medications as ordered by the physician for a resident, identified as R2, who was receiving treatment for Parkinson's disease and diabetes mellitus type two. The resident's medical records indicated that Sinemet, a medication for Parkinson's disease, was not documented as administered on several occasions in July, August, and September 2024. Additionally, there were instances where insulin, prescribed for diabetes management, was not documented as administered on specific dates in July, August, and September 2024. These omissions in medication administration documentation were observed despite the facility's policy requiring accurate and timely documentation of all medication administration. The resident, R2, had a complex medical history including Parkinson's disease, diabetes mellitus type two, dementia, hypertension, delusional disorder, and anxiety. The resident's care plan directed staff to administer medications as ordered and to monitor and document side effects and effectiveness. However, the lack of documentation for the administration of Sinemet and insulin suggests a failure to adhere to these directives. Observations and interviews with facility staff revealed inconsistencies in the administration and documentation process, placing the resident at risk for unnecessary medication side effects and an ineffective medication regimen.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that Enhanced Barrier Precautions (EBP) were properly implemented for a resident with an ongoing pressure ulcer requiring dressing changes. During an observation, it was noted that the resident's room had an EBP sign and a supply tote with personal protective equipment (PPE) such as gloves, gowns, and eye protection shields. However, a Licensed Nurse (LN) did not adhere to the EBP protocol during a dressing change. The nurse washed her hands and wore gloves but did not don a gown while assisting the resident into the bathroom and during the dressing change. The nurse acknowledged the oversight of not wearing a gown, which was confirmed by an Administrative Nurse. The facility's EBP policy, aligned with CDC recommendations, mandates the use of targeted PPE during high-contact care activities to prevent healthcare-acquired infections. The failure to use a gown during the dressing change placed the resident at risk for facility-acquired infections, as the EBP was not followed as per the facility's policy.
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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