Wheatridge Park Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Liberal, Kansas.
- Location
- 1501 S Holly Dr, Liberal, Kansas 67901
- CMS Provider Number
- 175459
- Inspections on file
- 19
- Latest survey
- October 16, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Wheatridge Park Care Center during CMS and state inspections, most recent first.
A resident with diabetes and reduced mobility developed stage three pressure injuries after the facility failed to provide a pressure-reducing device on the bed following a room change. Despite having closed previous pressure injuries, the resident's condition worsened due to the absence of an air mattress and improper application of off-loading devices. Staff interviews confirmed the lack of necessary equipment, leading to preventable, facility-acquired pressure injuries.
The facility failed to prevent accident hazards by improperly storing chemicals and sharp objects, and inadequately managing fall risks for residents with cognitive impairments. A resident with a history of falls suffered injuries due to insufficient interventions and lack of safety assessments for powered lift chairs. These deficiencies resulted in actual harm to residents.
The facility did not conduct annual performance reviews for five CNAs employed for over a year, as required by policy. Employee files lacked signed evaluations, and Administrative Staff A was unaware of this requirement. This oversight could negatively affect residents' well-being.
A treatment cart containing medications, including insulin and narcotics, was found unlocked and unattended in a resident-accessible hallway. A nurse confirmed the cart should have been locked when not in direct line of sight. The facility's policy mandates securing the cart during medication pass, which was not followed, leading to a deficiency in resident safety.
The facility failed to maintain sanitary conditions for food storage and dishwashing, risking foodborne illness spread. Issues included improperly stored dishes, undated food items, insufficient sanitizer levels, and a refrigerator operating above safe temperatures. Documentation errors in sanitization and temperature logs further contributed to the deficiency.
The facility failed to properly maintain and dispose of garbage, as observed with two dumpsters having broken lids and trash protruding. The Dietary Manager was unaware of the requirement to cover trash, and the facility lacked a policy on garbage handling. This could lead to pest issues.
The facility failed to maintain the kitchen's double-door oven in safe operating condition, as it was observed being held closed with a folding metal chair. The Dietary Manager confirmed the issue, and the facility lacked a policy for maintaining properly functioning equipment.
The facility failed to maintain an in-service training program for CNAs, with two CNAs receiving less than the required 12 hours of training annually. Additionally, two CNAs did not receive training on required topics, including dementia care and behavioral health. Administrative Nurse E confirmed the lack of records for additional training, despite the facility's policy requiring 12 hours of training per year, including specific topics.
The facility failed to administer care effectively, leading to harm and potential harm to residents. Issues included undignified colostomy care, incomplete advanced directives, and inadequate care planning. Additionally, the facility did not ensure a safe environment, with improper chemical storage and unsanitary food conditions. These deficiencies highlight significant lapses in administration and resource management.
The facility failed to ensure that four residents had accurately completed advanced directives, which are crucial for medical decision-making when residents cannot decide for themselves. One resident's DNR was only signed by a physician, lacking the necessary resident or DPOA signature. Another resident's DNR was missing a witness signature. A third resident's DNR lacked both the resident or DPOA and witness signatures, and a fourth resident had two DNRs, one signed only by a guardian and the other by a physician. These deficiencies could lead to uncommunicated needs, especially concerning end-of-life care.
The facility failed to notify residents' representatives and the LTCO about hospitalizations, affecting several residents. This deficiency involved a lack of documentation in the EHR and unawareness among staff about notification requirements, compromising residents' rights and care continuity.
The facility failed to provide bed-hold notices to several residents or their representatives during hospital transfers, as required by policy. This deficiency was identified through record reviews and staff interviews, revealing a lack of clarity and responsibility in completing bed-hold forms.
The facility failed to complete Care Area Assessments (CAAs) for several residents, leading to uncommunicated care needs. A resident with chronic respiratory failure and morbid obesity had incomplete CAAs, while another with sleep apnea and chronic respiratory failure had missing documentation for psychosocial well-being. Additionally, a resident with dementia had CAAs inaccurately stating they were deceased. The facility's policy lacked guidance on CAAs, and off-site MDS completion may have contributed to these deficiencies.
The facility failed to provide adequate respiratory care for several residents, including improper cleaning, labeling, and storage of respiratory equipment. A resident's nebulizer mask was improperly stored, and oxygen supplies were not labeled. Another resident's CPAP mask was improperly placed, and the humidifier bottle was empty. The facility lacked a policy for respiratory care supplies, contributing to these deficiencies.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents during wound and catheter care. A resident with a history of MRSA did not receive proper PPE during wound care, and the nurse failed to change gloves and perform hand hygiene appropriately. Another resident with severe cognitive impairment and a history of catheter-associated infections did not receive proper EBP during catheter care, as the nurse did not don the required PPE or ensure hand hygiene. Staff interviews confirmed these lapses, and the facility's EBP policy was not followed.
A resident with dementia and a colostomy was left undressed and without a colostomy bag for 40 minutes, with the door open, compromising privacy and dignity. The resident required total assistance with ADLs, and the facility's policy emphasized maintaining privacy and prompt care, which was not adhered to in this instance.
A resident requested his monthly benefits before a dialysis appointment but did not receive them upon return. Staff were unaware of procedures for accessing funds when the business office was closed. Administrative Staff I confirmed the oversight, despite a policy and available funds in a locked box. The facility did not adhere to its policy on managing residents' personal funds.
A facility failed to obtain the necessary signatures on Beneficiary Protection Notification forms for a resident before discharge. The forms, which indicated the resident's understanding of non-coverage and lack of appeal rights, were only signed by a Social Service Designee after the resident's discharge. This oversight was confirmed by multiple staff members, highlighting a lapse in the facility's policy adherence.
The facility failed to accurately complete the MDS for two residents, leading to uncommunicated care needs. One resident had a fall and dental issues not reflected in the MDS, while another was incorrectly documented as deceased and had a fall without proper investigation. The assessments were completed off-site by a consultant nurse, leading to critical information being missed.
The facility failed to review and revise care plans for residents with a history of falls, leading to uncommunicated care needs and deficiencies. A resident with severely impaired cognition experienced multiple falls resulting in injuries, including fractures and hospitalization, due to inadequate implementation of care plan interventions. Another resident with moderately impaired cognition also experienced falls without injury, with the facility failing to implement immediate interventions and update care plans. Staff interviews revealed a lack of awareness of specific interventions, and the facility did not meet policy expectations for care plan revisions.
A resident with sleep apnea and chronic respiratory failure was discharged without a proper plan in place. The facility did not involve the resident in the discharge planning process, and staff acknowledged the discharge was potentially unsafe. The resident expressed concerns about the lack of communication and was unaware of any appeal process for insurance denial. No home evaluation was conducted, and the resident was not set to receive home health services post-discharge.
The facility failed to document vaccination or declination for COVID-19 and pneumococcal vaccines for a resident. The EHR lacked records of pneumococcal vaccination or declination, and the COVID-19 vaccine declination was undated and unsigned. Administrative Nurse B confirmed the absence of documentation, which should be dated and witnessed according to facility policy.
A resident with intact cognition and significant medical conditions was not included in care plan meetings since their admission. Despite requiring total assistance with ADLs, the facility failed to document any care plan meetings or invitations, contrary to their policy. This placed the resident at risk for inadequate care and potential negative psychosocial effects.
The facility did not display accurate nurse staffing information daily for its 40 residents. Staffing sheets lacked the facility name and resident census, and an Administrative Nurse was unaware of the Federal requirement for these details. The facility also lacked a policy for posting nurse staffing information.
Failure to Provide Pressure-Relieving Devices Leads to Pressure Injuries
Penalty
Summary
The facility failed to provide a pressure-reducing device on the bed for a resident, identified as R2, which led to the development of a stage three pressure injury. Initially, R2's previous pressure injuries were noted to be closed, but after being moved to a different room, the facility neglected to transfer the air mattress that was previously on R2's bed. This oversight resulted in the reopening of R2's left heel pressure injury, which was identified as a stage three pressure injury. R2's medical history included diagnoses of diabetes mellitus type two and reduced mobility, with severely impaired cognition as indicated by a BIMS score of 99. R2 required total assistance with activities of daily living and was always incontinent of the bladder. Upon admission, R2 had a stage two pressure ulcer, and the facility had initially provided pressure-relieving devices on both the bed and chair. However, after the room change, these devices were not maintained, contributing to the deterioration of R2's condition. Observations and interviews revealed that R2's bed lacked an air mattress, and the wheelchair lacked a seat cushion. Staff interviews confirmed the absence of necessary equipment and the improper application of off-loading devices. Despite having extra air mattresses available, the facility did not ensure R2 had one after the room change. The facility's policy aimed to prevent and manage pressure ulcers, but the failure to implement necessary interventions resulted in R2 developing two preventable, facility-acquired stage three pressure injuries.
Deficiencies in Accident Hazard Prevention and Fall Risk Management
Penalty
Summary
The facility failed to provide an environment free of accident hazards, as evidenced by improper storage of hazardous chemicals and sharp objects. Chemicals were found stored in an unlocked cabinet and along a hallway rail, accessible to residents, including those with cognitive impairments. Additionally, a resident identified as confused and independently mobile with aggressive and wandering behaviors was observed with scissors in his pocket, posing a risk to himself and others. The facility also failed to adequately address fall risks for residents, particularly for a resident with a history of falls and severely impaired cognition. Despite multiple falls resulting in injuries, including fractures and hospitalization, the facility did not implement effective interventions or conduct thorough investigations to prevent further incidents. The resident's care plan lacked evidence of implemented interventions, and the facility's root cause analyses were insufficient in identifying causal factors for the falls. Furthermore, the facility did not conduct safety assessments for the use of powered lift chairs for residents with impaired cognition. This oversight contributed to the risk of falls, as evidenced by a resident who fell after raising a powered lift chair to its full height. The facility's failure to implement and document appropriate interventions and safety measures resulted in actual harm to the physical and psychosocial well-being of the residents involved.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for five Certified Nurse Aides (CNAs) who had been employed for over a year, as required by their policy. This deficiency was identified during a review of employee files, which revealed a lack of performance evaluations signed by management for CNAs P, Q, R, S, and T. Administrative Staff A admitted to being unaware of the requirement for annual performance evaluations for CNA staff. The facility's policy, dated September 2022, mandates that performance reviews for nurse aides be completed at least every 12 months. This oversight had the potential to negatively impact the physical and psychosocial well-being of all residents in the facility.
Unsecured Treatment Cart in Resident Area
Penalty
Summary
The facility failed to ensure the security of a nurse treatment cart containing medications such as insulin, topical ointments, creams, and narcotics. On two separate occasions, the treatment cart was observed unlocked and unattended in a hallway accessible to residents. The first observation occurred at 07:47 AM, and the second at 02:20 PM on the same day. Licensed Nurse G confirmed that the cart was left unlocked and unattended, acknowledging that it should have been secured when not within arm's reach of staff. Administrative Nurse B stated that it was her expectation for staff to lock all medication and treatment carts when not in the line of sight of the responsible staff member. The facility's policy, revised in April 2007, requires the medication cart to be locked and parked in the doorway outside the resident's room during medication pass and locked at the nurses' station when out of view. The failure to adhere to this policy resulted in a deficiency in providing a safe environment for the residents.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions for food storage and dishwashing, which could lead to the spread of foodborne illnesses among residents. During an initial kitchen tour, several issues were identified, including improperly stored bowls and plates, undated and open food items in the dry storage area, and a container of cheese left open in the refrigerator. The facility's three-basin sink system for dishwashing was found to have insufficient sanitizer levels, as indicated by a test strip that did not change color. Additionally, two cutting boards in the kitchen had deep gouges, making them uncleanable. The refrigerator was found to be operating at 50 degrees Fahrenheit, above the recommended temperature, and contained various perishable items such as milk, eggs, raw chicken, and luncheon meats. Further observations revealed continued improper storage of dishes and incorrect procedures for checking food temperatures, such as poking a thermometer through foil. A review of sanitization logs showed numerous documentation errors, including unrealistic water temperature entries and missing records. Similarly, refrigerator temperature logs were incomplete, with many entries missing or indicating temperatures above the safe threshold. The facility's policies required food to be labeled and dated, and refrigerator temperatures to be maintained at or below 41 degrees Fahrenheit, but these standards were not met, contributing to the deficiency.
Improper Garbage Disposal and Maintenance
Penalty
Summary
The facility failed to maintain and dispose of garbage and refuse properly, which was observed during an initial tour of the outside trash dumpsters. Two dumpsters were found with lids in the open position, and one had trash debris protruding from it. Both lids were broken and unable to completely cover the trash cans. The Dietary Manager was unaware of the requirement to keep trash covered, and the Administrative Staff mentioned that the dumpsters belonged to the city. Additionally, the facility lacked a policy related to garbage and refuse handling and disposal. This deficiency had the potential to lead to the harborage and feeding of pest animals.
Unsafe Kitchen Equipment
Penalty
Summary
The facility failed to ensure the kitchen's double-door oven was in safe operating condition. During an observation, it was noted that the oven doors were being held closed with a folding metal chair. The Dietary Manager confirmed that the oven doors would not stay closed on their own and required the chair to keep them shut. Additionally, the facility did not provide a policy related to maintaining properly functioning equipment, indicating a failure to maintain mechanical equipment in safe operating condition.
Deficiency in CNA In-Service Training Program
Penalty
Summary
The facility failed to develop, implement, and permanently maintain an in-service training program for Certified Nurse Aides (CNAs) with the required topics and no less than 12 hours per year. During a review of training records for five CNAs employed by the facility for more than one year, it was found that two CNAs had less than the required 12 hours of documented in-service training for the previous 12 months. Specifically, CNA S had only eight hours, and CNA T had 10.5 hours of documented training. Additionally, two CNAs did not receive training on the required topics; CNA Q lacked dementia care training, and CNA R lacked behavioral health training. Administrative Nurse E confirmed that CNAs were required to have 12 hours of training annually and acknowledged the absence of records for additional training for these CNAs. The facility's policy, revised in August 2022, stipulated that annual in-services should be no less than 12 hours per calendar year and must include required training topics such as dementia care and behavioral health. The facility's failure to adhere to these requirements resulted in the identified deficiency.
Deficiencies in Care and Resource Management
Penalty
Summary
The facility failed to administer care in a manner that ensured the effective and efficient use of resources, resulting in harm to residents. One resident was left undressed and exposed during colostomy care, compromising their dignity and psychosocial well-being. Another resident was not included in care plan meetings, potentially leading to inadequate care and uncommunicated needs. Additionally, the facility did not ensure timely receipt of monthly benefits for a resident, which could negatively impact their physical and psychosocial well-being. The facility also failed to maintain accurate and complete advanced directives for several residents, with documents either missing necessary signatures or containing conflicting information. This oversight placed residents at risk for impaired rights and uninformed care choices. Furthermore, the facility did not provide necessary notifications to residents' representatives or the Long-Term Care Ombudsman, which could lead to uncommunicated needs and continuity of care issues. Several other deficiencies were noted, including the failure to provide a pressure-reducing device for a resident, leading to the reopening of a pressure injury. The facility also did not ensure a safe environment, as chemicals were improperly stored, and a resident with wandering behaviors accessed hazardous items. Additionally, the facility did not maintain sanitary conditions for food storage and failed to implement Enhanced Barrier Precautions during certain care activities, increasing the risk of infection. These failures highlight significant lapses in the facility's administration and resource management, resulting in harm and potential harm to residents.
Incomplete Advanced Directives for Residents
Penalty
Summary
The facility failed to ensure that four residents had accurately completed advanced directives, which are crucial documents indicating medical decisions for healthcare professionals when a resident cannot make their own decisions. Resident 2 had a Do Not Resuscitate (DNR) order that was only signed by a physician, lacking the necessary signature from the resident or their durable power of attorney (DPOA). This oversight was confirmed by the Social Service Designee and Administrative Nurse, who acknowledged that the DNR required both the resident or DPOA signature and the physician's signature as per the facility's policy. Resident 10's DNR was missing a witness signature, which is a required component for the document to be valid. The Social Service Designee confirmed this deficiency, and it was further corroborated by the Administrative Nurse and Administrative Staff, who recognized the issue with incomplete advanced directives. The facility's policy clearly states the need for a witness signature, yet this was not adhered to in Resident 10's case. Resident 20's DNR was only signed by a physician, lacking both the resident or DPOA signature and a witness signature. Similarly, Resident 8 had two DNR orders, one signed only by a guardian and the other only by a physician, without the necessary resident or DPOA and witness signatures. The Social Service Designee confirmed that guardians cannot sign a DNR without a court order, highlighting another layer of non-compliance with the facility's policy. These deficiencies in completing advanced directives could lead to uncommunicated needs, particularly concerning end-of-life care.
Failure to Notify Representatives and LTCO of Resident Transfers
Penalty
Summary
The facility failed to provide timely written notification to the residents' representatives and the Office of the State Long-Term Care Ombudsman (LTCO) regarding the transfer or discharge of several residents. This deficiency was identified during a survey of the facility, which had a census of 40 residents, including 12 sampled residents. Specifically, the facility did not notify the representatives of five residents, nor did it inform the LTCO about the hospitalizations of these residents. This lack of notification placed the residents at risk for impaired rights and uninformed care choices. The survey findings revealed that the facility's Electronic Health Records (EHR) for the residents lacked documentation of notifications to the residents' representatives and the LTCO. For instance, Resident 8 was hospitalized, but there was no documentation of notification to their representative or the LTCO. Similarly, Resident 26 was hospitalized, and again, there was no record of notification to the representative or the LTCO. The Social Services Designee and Administrative Staff were unaware of the requirement to notify the LTCO, and the facility lacked a policy related to these notifications. The deficiency extended to other residents, including Resident 2, who had a significant change in condition and was hospitalized for a worsened foot ulcer. Despite the family being notified, there was no documentation of notification to the LTCO. Resident 10, who had a colostomy due to stomach pain, and Resident 21, who had multiple hospitalizations, also lacked documentation of LTCO notification. The facility's failure to notify the LTCO and the residents' representatives about these hospitalizations compromised the residents' rights and the continuity of care.
Failure to Provide Bed-Hold Notices
Penalty
Summary
The facility failed to provide a bed-hold notice to several residents or their representatives at the time of their transfer to the hospital, as required by the facility's policy. This deficiency was identified through a review of the facility's records and interviews with staff. The policy, dated October 2022, mandates that residents and their representatives be informed in writing about the facility's bed-hold policies at the time of transfer or within 24 hours if the transfer was an emergency. However, the facility did not adhere to this policy for Residents 2, 10, 21, and 26. Resident 2, who had severe cognitive impairment and required total assistance with activities of daily living, was transferred to a hospital for a worsened foot ulcer. Despite the transfer, there was no documentation of a bed-hold notice being provided to the resident or their representative. Similarly, Resident 10, who had moderately impaired cognition and required assistance with personal care, was transferred to a hospital due to abdominal pain and a refusal to have a catheter placed. Again, no bed-hold notice was documented. Resident 21, who had intact cognition but required total assistance with most activities of daily living, was transferred multiple times to the hospital for various medical issues, including altered mental status and respiratory failure. Each time, the facility failed to provide a bed-hold notice. Resident 26, who had moderate cognitive impairment and was transferred to the hospital for an infection and other medical conditions, also did not receive a bed-hold notice. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of bed-hold forms, contributing to the deficiency.
Incomplete and Inaccurate Care Area Assessments in LTC Facility
Penalty
Summary
The facility failed to complete Care Area Assessments (CAAs) for several residents, leading to uncommunicated care needs. For Resident 7, the CAAs related to functional abilities, urinary incontinence, nutritional status, and pressure ulcer/injury were incomplete and repetitive, failing to address the individual underlying causes and contributing factors. This resident, who had chronic respiratory failure and morbid obesity, required total assistance with activities of daily living (ADLs) and was at risk for falls and skin breakdown. The facility's policy on Resident Assessment Instrument (RAI) completion lacked documentation about CAAs, contributing to the deficiency. Resident 144 also experienced incomplete CAAs, with missing documentation for psychosocial well-being and activities. This resident had sleep apnea and chronic respiratory failure, requiring total assistance with ADLs and frequent bladder incontinence. The facility's failure to accurately complete the CAAs for this resident placed them at risk for uncommunicated care needs. The facility's policy did not adequately address the completion of CAAs, and the MDS assessments were completed off-site by a consultant nurse, which may have contributed to the oversight. Resident 8's CAAs were inaccurately documented, with multiple assessments incorrectly stating the resident was deceased, despite being observed in the facility on several occasions. This resident had osteoporosis, a history of falls, and dementia, requiring substantial assistance from staff. The facility's failure to accurately complete the CAAs for this resident, including those related to cognitive loss, visual function, communication, and other areas, placed the resident at risk for uncommunicated care needs. The facility's policy on RAI completion did not provide sufficient guidance on CAAs, and the off-site completion of MDS assessments may have contributed to the errors.
Deficiencies in Respiratory Care Practices
Penalty
Summary
The facility failed to provide adequate respiratory care for several residents, as evidenced by improper cleaning, labeling, and storage of respiratory equipment. For Resident 7, the nebulizer mask was found with a clear liquid substance in the chamber and was improperly stored, touching the floor. The oxygen supplies, including the nasal cannula and tubing, were not labeled with dates, and the resident reported not seeing the nebulizer mask or chamber rinsed after medication administration. Additionally, the facility did not follow up on a physician's order for a BiPAP sleep study, leaving the resident without the necessary equipment. Resident 21 also experienced deficiencies in respiratory care. The oxygen tubing was not labeled, and the CPAP mask was improperly placed on the nightstand. The prefilled humidifier bottle was empty and not properly dated. The resident was unsure about the schedule for changing oxygen supplies, indicating a lack of communication and adherence to care protocols. The facility lacked a policy for respiratory care supplies, contributing to these deficiencies. Resident 144 and Resident 22 faced similar issues with unlabeled oxygen supplies and improper storage of nasal cannulas. The facility did not have a policy for respiratory care supplies, and the treatment administration record lacked directions for checking and changing humidified bottles. These oversights in respiratory care practices were consistent across multiple residents, highlighting a systemic issue within the facility's management of respiratory care equipment and protocols.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, R39 and R26, during wound care and urinary catheter care, respectively. R39, who had a history of Methicillin Resistant Staphylococcus Aureus (MRSA) infection and an amputation, did not receive proper EBP during wound care. The Licensed Nurse (LN) G did not use the appropriate personal protective equipment (PPE) and failed to change gloves and perform hand hygiene between dirty and clean phases of the dressing change. Additionally, the wound was not re-cleansed after it came into contact with a contaminated surface. R26, who had severe cognitive impairment and a history of catheter-associated infections, also did not receive proper EBP during catheter care. Licensed Nurse H did not don the required PPE and failed to ensure hand hygiene was performed by both herself and the resident during the procedure. The facility's policy required EBP for residents with multidrug-resistant organisms (MDRO) and indwelling medical devices, but this was not adhered to in these instances. Interviews with staff confirmed the lapses in following EBP protocols. Administrative Nurse B acknowledged that residents requiring EBP should have indicators outside their rooms and that PPE should be readily available. The facility's policy on EBP was not followed, leading to a failure in infection control practices for residents with a history of MDRO and indwelling medical devices.
Failure to Provide Dignified Colostomy Care
Penalty
Summary
The facility failed to provide care in a dignified manner to Resident 10 during colostomy care. The resident, who had diagnoses of dementia and required assistance with personal care, was left lying in bed undressed from the waist up with no colostomy bag covering his stoma for 40 minutes. During this time, the door to the resident's room was left open, compromising his privacy and dignity. The resident expressed anger and frustration over the delay in care, which was reported to have occurred in June. Resident 10's electronic health record indicated a need for total assistance with activities of daily living, including toileting and dressing, due to conditions such as rheumatoid arthritis and a colostomy. The facility's policy on dignity emphasized the importance of maintaining resident privacy and promptly responding to requests for assistance. However, the delay in providing colostomy care and the exposure of the resident's body without proper coverage of the stoma were inconsistent with these guidelines, leading to a deficiency in the care provided.
Failure to Provide Timely Access to Resident's Personal Funds
Penalty
Summary
The facility failed to ensure a resident received his monthly benefits in a timely manner. The resident had requested his monthly benefits of $62.00 on the morning of his dialysis appointment. However, upon returning to the facility in the afternoon, the check was not available, and the administrative staff responsible for handling such requests was not present. Interviews with various staff members, including a Certified Medication Aide, a Licensed Nurse, and a Social Service Designee, revealed a lack of awareness regarding the availability of funds for residents when the business office was closed. Administrative Staff I confirmed that the facility was the resident's payee and acknowledged the failure to deliver the requested funds on the day of the request. It was noted that there was $100.00 in a locked box in the medication room for residents to access personal funds when the business office was closed, but this information was not effectively communicated to the staff. The facility's policy on managing residents' personal funds was not adhered to, resulting in the resident not receiving his benefits as requested.
Failure to Obtain Beneficiary Notification Signatures
Penalty
Summary
The facility failed to ensure that the correct and complete Beneficiary Protection Notification forms were issued to a resident, identified as R146, before her discharge. The Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage Form (SNFABN) and the Notification of Medicare Non-Coverage Form (NOMNC) lacked R146's signature before her discharge home. The forms were marked to indicate that the resident did not want the care listed and understood that she was not responsible for paying and could not appeal to see if Medicare would pay. However, these forms were only signed by the Social Service Designee (SSD) on the day of discharge, with a handwritten note stating that the resident was discharged before her signature was obtained. The discharge process for R146 was planned, with discharge orders received from her physician and therapy services concluding as she met maximal potential. Despite this, the facility did not provide the required forms to R146 in advance, as per their policy, which mandates that residents are informed at least two calendar days before benefits end. The failure to obtain the resident's signature on the necessary forms was confirmed by multiple staff members, including the SSD and Administrative Staff, indicating a lapse in the facility's adherence to its policy on Medicare notifications.
Inaccurate MDS Completion for Two Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for two residents, leading to uncommunicated care needs. Resident 7, who had medical diagnoses including diabetes mellitus, end-stage renal disease, and anxiety, was inaccurately assessed in terms of falls and dentition. Despite having a fall incident documented in the progress notes, the MDS did not reflect this event, and there were no physician orders for falls or oral care. Additionally, Resident 7 reported needing to see a dentist due to discolored and missing teeth, which was not communicated to the staff, indicating a gap in the assessment process. Resident 8, diagnosed with osteoporosis, a history of falls, and dementia, was also inaccurately assessed. The MDS and several Care Area Assessments (CAAs) incorrectly documented Resident 8 as deceased, despite the resident being observed alive in the facility on multiple occasions. Furthermore, the MDS failed to document a fall that resulted in a minor injury, and the facility lacked a fall investigation related to this incident. The care plan intervention involved family bringing a television to the resident's room, but there was no documentation of additional interventions to prevent further falls. The inaccuracies in the MDS for both residents were attributed to the assessments being completed off-site by a consultant nurse, who was not reachable for clarification. The facility's interdisciplinary team was expected to ensure accurate completion of the MDS, but the process failed to capture critical information, placing the residents at risk for uncommunicated care needs.
Failure to Revise Care Plans and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to adequately review and revise care plans for several residents, leading to uncommunicated care needs and deficiencies in care. Resident 8, who had a history of falls and severely impaired cognition, experienced multiple falls resulting in injuries, including fractures and hospitalization. Despite being identified as high risk for falls, the facility did not implement or document appropriate interventions, such as providing a smaller recliner or switching to a manual recliner, as outlined in the care plan. Observations revealed that Resident 8 continued to use a powered lift chair, contrary to care plan directives. Resident 22, with a history of falls and moderately impaired cognition, also experienced multiple falls without injury. The facility's root cause analysis identified issues such as the resident being left unattended in a powered lift chair in the full upright position. However, the facility failed to implement immediate interventions to mitigate fall risks for the remainder of the shift and did not consistently update the care plan with permanent interventions. The care plan lacked documentation of interventions related to specific falls, and there was no evidence of a safety assessment for the use of a powered lift chair. Interviews with staff revealed a lack of awareness and recall of specific interventions for residents at risk of falls. The facility's policy required comprehensive care plans to be developed, implemented, and periodically reviewed, but the facility did not meet these expectations. The care plans were not revised with new and unique interventions after each fall, and there was a lack of appropriate follow-up documentation in the residents' progress notes. The facility's failure to address these deficiencies resulted in actual harm to the residents' physical and psychosocial well-being.
Failure to Implement Discharge Plan for Resident
Penalty
Summary
The facility failed to implement a discharge plan for Resident 144, who was being discharged from the facility. The resident, who had medical diagnoses including sleep apnea and chronic respiratory failure, required total assistance with activities of daily living and was frequently incontinent of bladder. Despite these needs, the discharge planner did not involve the resident in the discharge planning process. The resident expressed concerns about the discharge, stating that no staff had discussed the plan with him, and he was unaware of any appeal process for the insurance company's denial of continued stay. The facility's staff, including the Social Service Designee and Administrative Nurse, acknowledged that the discharge was potentially unsafe and that there were no progress notes in the electronic health record regarding the discharge planning. Additionally, a home evaluation was not completed, and the resident was not set to receive home health or therapy services post-discharge due to insurance coverage issues. The facility's policy required a discharge summary and post-discharge plan to be developed with the resident's involvement, which was not adhered to in this case.
Deficiency in Vaccine Documentation
Penalty
Summary
The facility failed to provide proper documentation of vaccination or declination for COVID-19 and pneumococcal vaccines for one of the five residents reviewed, specifically Resident 5. The review of the Electronic Health Record (EHR) for Resident 2 revealed a lack of documentation for any pneumococcal vaccine being administered or declined. Additionally, the EHR for Resident 2 also lacked proper documentation for the COVID-19 vaccine declination, as the declination form was undated and unsigned. On a specific date, Administrative Nurse B confirmed that the requested proof of vaccines or declinations could not be found. Nurse B stated that a valid consent or declination form should be dated and double witnessed, with one witness being a licensed healthcare provider. The facility's policies for both pneumococcal and COVID-19 vaccines require documentation of either vaccination or declination in the medical record, but these requirements were not met for Resident 2.
Failure to Include Resident in Care Plan Meetings
Penalty
Summary
The facility failed to include Resident 7 in the development and continued planning of their care plan on a quarterly basis. Resident 7, who has intact cognition as indicated by a BIMS score of 15, was not invited to any care plan meetings since their admission in April 2024. Despite having significant medical conditions such as diabetes mellitus, end-stage renal disease, and anxiety, and requiring total assistance with activities of daily living, the facility did not document any care plan meetings or invitations for Resident 7. This oversight was confirmed by both the Social Service Designee and Administrative Staff, who acknowledged the absence of documentation and the lack of a care plan meeting invitation. The facility's policy mandates that a comprehensive, person-centered care plan be developed, implemented, and reviewed quarterly, annually, and with any significant change in the resident's condition. However, the facility did not adhere to this policy, as evidenced by the lack of care plan meetings for Resident 7. The failure to include Resident 7 in care plan meetings placed them at risk for inadequate care and services, with potential negative psychosocial effects related to safety and uncommunicated needs.
Failure to Display Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to display accurate and identifiable nurse staffing information daily for its 40 residents. On a specific date, the daily staffing sheets were observed to be hanging near the nurse's station, but they lacked the facility name and the daily resident census. A review of the Daily Schedule Nursing Hours sheets from a week-long period revealed that these sheets consistently lacked the required information. An Administrative Nurse confirmed that the posting sheets were incomplete and admitted to being unaware of the Federal requirement to include the facility name and daily resident census on the staffing sheets. Additionally, the facility did not have a policy in place for posting nurse staffing information.
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Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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