Wichita Presbyterian Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Wichita, Kansas.
- Location
- 4700 W 13th Street North, Wichita, Kansas 67212
- CMS Provider Number
- 175301
- Inspections on file
- 19
- Latest survey
- July 7, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Wichita Presbyterian Manor during CMS and state inspections, most recent first.
Surveyors found that medication refrigerator temperatures were not consistently documented, and an unlocked treatment cart contained both scissors and expired or improperly labeled insulin pens. Staff interviews confirmed that these practices did not align with facility policies requiring daily temperature checks, proper dating and disposal of insulin, and locked storage of medications.
Staff did not disinfect a shared mechanical lift between residents and failed to follow proper procedures for cleaning and storing respiratory equipment, such as nebulizers and oxygen tubing. There was also confusion among staff about cleaning responsibilities, and a cart of clothing was left uncovered in common areas, all of which contributed to lapses in infection prevention and control.
A CNA did not receive the required 12 hours of annual in-service training, with records showing only ten and one-half hours completed. The Administrative Nurse confirmed the deficiency and the absence of additional training documentation, despite facility policy mandating appropriate staff training for resident safety.
A resident with severe cognitive impairment and behavioral symptoms was administered psychotropic medications, including lorazepam and Seroquel, without documented evidence that the resident or their representative received education or provided informed consent regarding the risks, benefits, and alternatives of the medications, as required by facility policy. Nursing staff confirmed the lack of documentation, and the administrative nurse acknowledged the omission.
Staff left multiple medications at a resident's bedside without completing a self-administration assessment or documenting care plan authorization. The resident was not observed taking the medications and was unaware of their identity or purpose, contrary to facility policy requiring staff observation during medication administration.
A resident with severe cognitive impairment and behavioral symptoms was prescribed Seroquel, but the facility did not document required AIMS assessments to monitor for abnormal involuntary movements, despite facility policy and staff statements indicating these should be performed at regular intervals.
A resident with severe cognitive impairment and a need for ADL assistance was observed with facial hair and dirty fingernails, despite care plans and staff expectations for regular grooming and hygiene. Staff confirmed that ADL support, including shaving, should be provided, and refusals documented, but records showed only one refusal in the past month. The facility could not provide a policy for ADL care when asked.
A resident with spina bifida who required nebulizer treatments did not receive sanitary respiratory care, as staff failed to clean the nebulizer after each use. Observations showed the device was left with liquid in the chamber and not cleaned between treatments, contrary to facility policy and staff expectations.
A consultant pharmacist did not identify or report missing documentation of pulse monitoring for a resident receiving metoprolol, as required by physician orders. Despite monthly medication regimen reviews, the lack of pulse documentation was not addressed, and staff confirmed that such monitoring should have been flagged and reported.
A resident with multiple diagnoses, including dementia and hypertension, did not have required pulse monitoring documented before administration of antihypertensive medication, as ordered by the physician. Additionally, the resident experienced multiple episodes of constipation while receiving pain medication, but there was no evidence that the facility assessed for complications or initiated the bowel protocol as directed in the care plan. The consultant pharmacist did not identify the lack of monitoring, and the facility lacked policies to address medication administration outside prescribed parameters or to ensure monitoring for side effects.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed multiple failures in the facility's medication management practices. The medication refrigerator lacked temperature documentation for numerous days across several months, specifically missing records for 15 days in January, 17 days in February, 24 days in March, 15 days in April, and 12 days in May. Additionally, an unlocked treatment cart was found containing scissors and insulin, including a Humalog insulin pen that had been opened on 04/23/25 and was still present after its discard date of 05/20/25. A Lantus insulin pen was also found opened but not dated. Interviews with nursing staff and administrative personnel confirmed that the facility's policy required daily documentation of refrigerator temperatures, dating of insulin pens upon opening, and discarding insulin after expiration. Staff also acknowledged that medication and treatment carts should be locked when unattended. The facility's policies further specified that medications requiring refrigeration should be kept within a specific temperature range and that expired medications should be promptly removed and disposed of. These observations and staff statements indicate that the facility did not consistently follow its own medication storage and labeling protocols.
Failure to Disinfect Shared Equipment and Maintain Respiratory Infection Control
Penalty
Summary
Staff failed to disinfect a shared sit-to-stand mechanical lift between uses with different residents. Observations showed that after using the lift with one resident, staff moved it directly to another resident's room and used it again without cleaning. Interviews with CNAs and housekeeping staff revealed confusion about responsibility for cleaning the lift, with both groups indicating it was the other's duty. Administrative nursing staff clarified that nursing staff were responsible for cleaning the equipment between residents, but this protocol was not being followed in practice. Additional infection control lapses were observed regarding respiratory equipment. A nebulizer was left attached to tubing with liquid remaining in the chamber overnight, and oxygen tubing was found on the floor with the nasal cannula resting on the ground. Staff interviews indicated that nebulizer cleaning procedures were not consistently followed, and oxygen tubing was not stored in a plastic bag as required by facility policy. Furthermore, a cart of lost and found clothing was left uncovered in common areas, contrary to infection control expectations.
Failure to Provide Required Annual In-Service Training for CNA
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs) received the required annual in-service training of at least 12 hours, as mandated by regulations. Specifically, a review of training records revealed that one CNA had only ten and one-half hours of documented training for the year. This deficiency was confirmed by the Administrative Nurse, who acknowledged that the CNA did not meet the required training hours and that there were no additional records of training for this staff member. The facility's own education policy requires all staff to receive appropriate training to ensure resident safety and well-being.
Failure to Provide Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to inform a resident or the resident's representative about the risks, benefits, and alternatives associated with the use of psychotropic medications, specifically lorazepam and Seroquel. The resident in question had a history of Pick's Disease, unspecified dementia with behavioral disturbance, and anxiety disorder, and was noted to have severe cognitive impairment and behavioral symptoms. Documentation in the Electronic Health Record (EHR) showed orders for Seroquel and lorazepam, both scheduled and as needed, but lacked evidence that education or informed consent regarding the use of lorazepam was provided to the resident or their representative. Interviews with nursing staff confirmed that it was their responsibility to provide education and obtain informed consent prior to initiating or changing psychotropic medications, but in this case, no such documentation was present. The administrative nurse acknowledged the absence of informed consent documentation and noted that the provider had refused to provide medication education to the resident's representative. Facility policy required that residents and/or their representatives be informed of the benefits, risks, and alternatives of psychotropic medications prior to initiation or dosage changes, but this was not followed for this resident.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
Facility staff failed to assess a resident for the ability to self-administer medications before leaving multiple medications at the resident's bedside. During an observation, a resident was found with a cup containing various prescription and over-the-counter medications, including Plavix, gabapentin, Miralax, potassium, pramipexole, Eliquis, Lasix, and others, on her bedside table. The resident reported that staff did not observe her taking her medications except at night and was unaware of what medications were in the cup or their purposes. Review of the resident's care plan and medical record revealed no documentation or assessment indicating that it was clinically appropriate for the resident to self-administer medications or to have medications left at her bedside. Interviews with staff confirmed that medications were routinely left in the resident's room without a completed self-administration assessment or care plan authorization. Facility policy required staff to observe residents taking medications to ensure they were swallowed, which was not followed in this case.
Failure to Assess for Antipsychotic Side Effects
Penalty
Summary
The facility failed to perform an assessment for side effects related to ongoing antipsychotic medication use for a resident diagnosed with Pick's Disease, unspecified dementia with behavioral disturbance, and anxiety disorder. The resident was unable to complete cognitive assessments and exhibited physical and verbal behaviors directed toward others, as well as rejection of care. The care plan included monitoring for side effects and changes in cognitive function, and the resident had an active order for Seroquel, an antipsychotic medication. However, the electronic medical record did not contain evidence of any assessment, such as the Abnormal Involuntary Movement Scale (AIMS), to identify abnormal involuntary movements associated with antipsychotic use. Interviews with nursing staff revealed inconsistent understanding of the facility's policy regarding the frequency of AIMS assessments, with some staff stating it should be done quarterly, others at admission and quarterly, and another stating every six months. Facility policy required AIMS assessments on admission, every six months, and as needed for residents on antipsychotic medications. Despite these requirements, there was no documentation that the required AIMS assessments were completed for the resident receiving Seroquel.
Failure to Provide ADL Assistance with Grooming and Hygiene
Penalty
Summary
A resident with diagnoses of dementia and anxiety disorder, and a severely impaired cognitive status as indicated by a BIMS score of seven, was identified as requiring assistance with activities of daily living (ADLs) such as toileting, showering, dressing, and personal hygiene. The resident's care plan directed staff to provide bathing, showering, and grooming, including checking and cleaning nails on bath days and as needed. The resident's electronic medical record showed only one refusal of care in the past 30 days. Despite these documented needs and care directives, observations revealed that the resident had facial hair and dirty fingernails, indicating a lack of assistance with grooming and hygiene. Staff interviews confirmed that ADL assistance, including shaving, was expected during morning care or showers, and refusals were to be documented and reported. The facility was unable to provide a policy for activities of daily living when requested.
Failure to Clean Nebulizer After Use
Penalty
Summary
Staff failed to provide sanitary respiratory care for a resident diagnosed with spina bifida, who required nebulizer treatments as ordered by a physician. Observations revealed that the nebulizer was left attached to the tubing on the bedside table with clear liquid remaining in the chamber after use, and it was not cleaned between treatments. The resident confirmed that the nebulizer had not been cleaned since the previous night’s treatment. The care plan for the resident did not include information regarding the use or care of the nebulizer. Interviews with nursing staff and review of facility policy confirmed that the expected protocol was to separate, rinse, and air dry the nebulizer after each use, and to store it in a bag. The facility’s written policy also required daily washing and disinfection of the nebulizer components. Despite these protocols, the required cleaning procedures were not followed, resulting in unsanitary respiratory care for the resident.
Pharmacist Failed to Identify and Report Medication Monitoring Irregularities
Penalty
Summary
A deficiency occurred when the facility's consultant pharmacist failed to identify and report irregularities in the medication monitoring process for a resident prescribed metoprolol succinate for hypertension. The physician's order required the resident's pulse to be monitored and the medication to be held if the pulse was less than 60 beats per minute, with documentation of the pulse in the medical record. However, a review of the resident's Medication Administration Records (MAR) and Treatment Administration Records (TAR) over several months showed a lack of documentation regarding pulse measurements as ordered by the physician. Despite monthly medication regimen reviews by the consultant pharmacist, there was no evidence that the absence of required pulse documentation was identified or reported to the attending physician, medical director, or director of nursing. Interviews with facility staff confirmed that the MAR should have included a flagged area for documenting pulse and that the pharmacist was expected to review and identify such monitoring issues. The facility did not provide a policy addressing the pharmacist's responsibility to identify and report irregularities in medication monitoring outside of prescribed parameters.
Failure to Monitor Medication Parameters and Side Effects
Penalty
Summary
The facility failed to monitor the effectiveness and side effects of antihypertensive and pain medications as ordered by the physician for a resident with multiple diagnoses, including slow transit constipation, pain, dementia, and hypertension. Physician orders required that the resident's pulse be checked before administering metoprolol, with instructions to hold the medication and notify the nurse if the pulse was below 60 BPM or systolic blood pressure was below 110 mmHg. However, medication administration records and treatment records lacked documentation of the resident's pulse as required by the physician's order. Both a certified medication aide and a licensed nurse confirmed that the resident's record did not include the necessary pulse documentation, and the facility did not provide a policy addressing the administration of medication outside prescribed parameters or monitoring for side effects. Additionally, the resident was prescribed tramadol for pain, which is associated with a black box warning and known to cause constipation. The resident's care plan directed staff to monitor for adverse reactions, including constipation, and to follow a bowel protocol if the resident had not had a bowel movement for three days. Despite this, the resident's records showed multiple periods of three or more days without a documented bowel movement, and there was no evidence that the facility assessed for complications of constipation during these times. Staff interviews revealed that while a bowel protocol existed and reports were generated to flag residents without bowel movements, there was a lack of awareness and follow-through regarding this resident's constipation. The consultant pharmacist's monthly medication regimen reviews did not identify or report the lack of pulse monitoring as required by the physician's order. The facility's standing orders included a protocol for treating constipation, but there was no documentation that this protocol was initiated for the resident during the periods of constipation. The facility did not provide a policy to address the administration of medication outside of prescribed parameters or to ensure monitoring for side effects or adverse effects for residents taking medications.
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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