Newton Presbyterian Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Newton, Kansas.
- Location
- 1200 E 7th Street, Newton, Kansas 67114
- CMS Provider Number
- 175302
- Inspections on file
- 22
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Newton Presbyterian Manor during CMS and state inspections, most recent first.
A resident with dementia, impaired mobility, and documented risk for pressure ulcers returned from a hospital stay after hip fracture surgery without an air mattress, heel booties, or a turn/reposition schedule in place. Initial assessments noted no heel wounds, but the resident’s Braden scores showed at least moderate risk, and staff later reported red heels to a nurse without preventive measures being initiated at that time. The resident subsequently developed an open blister on the left heel that progressed into a full-thickness Stage 3 pressure ulcer acquired in-house, while documentation showed that pressure-relieving devices and heel-floating interventions were added to the care plan only after the wound appeared, contrary to the facility’s own skin integrity and pressure ulcer prevention policy.
Two residents with dementia and documented fall risks experienced falls resulting from inadequate supervision and improper transfer techniques. One resident, with severe cognitive impairment and a high fall risk, continued to ambulate while carrying heavy bags in congested areas despite care plan directives for staff assistance, and sustained a wrist fracture and later a hip fracture after separate falls, including one where she reportedly tripped over another resident’s foot. Facility documentation of this fall was inconsistent and lacked timely review and preservation of available video evidence. Another resident with abnormal gait and multiple prior falls was assisted in a one-person pivot transfer without a gait belt; her knees buckled and she fell to the floor, leading to a later care plan change requiring a two-person assist with a gait belt. These events occurred despite a facility falls policy requiring identification of residents at risk for falls and implementation of appropriate interventions.
Surveyors found multiple failures to follow infection control policies, including Enhanced Barrier Precautions, hand hygiene, and equipment cleaning. Staff provided direct care, including catheter and wound care, to a resident under EBP using only gloves and no gowns, and wound care consultants also treated open wounds without gowns. An LN administered insulin without appropriate hand hygiene and used a nebulizer for a recently admitted resident without rinsing or air-drying the components or discarding residual liquid as required. Two staff performed peri-care on a resident, then used the same contaminated gloves to access supplies and apply powder, and did not perform hand hygiene after glove removal. Another LN performed foot wound care on a resident without changing gloves between dirty and clean tasks or using a barrier for supplies. Housekeeping staff transported a resident’s clean clothing uncovered through the hallway, contrary to infection control expectations.
The facility failed to adhere to its antibiotic stewardship policy by not maintaining infection and antibiotic surveillance logs for an extended period and by lacking evidence of tracking, trending, or documenting the appropriateness of antibiotic prescriptions using McGeer’s Criteria. During this time, a resident was started on Nitrofurantoin for a presumed UTI based on preliminary UA results before culture and sensitivity findings were available; the final culture later showed no UTI, yet the antibiotic had already been initiated. Nursing leadership acknowledged that antibiotic use was not being adequately monitored for trends, patterns, or appropriate indication, dose, and duration as required by the facility’s antibiotic stewardship program.
A resident with moderately impaired cognition was moved from a dining table to a nearby lounge area that remained visible to others while an LN performed a fingerstick blood glucose test and administered an insulin injection by lifting the resident’s shirt and exposing the abdomen. The LN reported that this was her usual practice and that other residents in the dining room could observe these procedures, contrary to facility expectations and policy requiring that such care be provided in a private manner that maintains resident dignity.
A resident with dementia and a left hip fracture experienced a marked decline in ADLs, changing from being independent or needing only supervision/touching assistance with bed mobility, transfers, toileting, and short-distance ambulation to requiring total assistance, use of a mechanical lift with two staff for transfers, and dependence on a wheelchair. Care plans and GG evaluations were revised to reflect this decline, and CNAs reported the resident now needed total assistance with ADLs. Despite these documented changes in condition and function, the EMR contained no significant change MDS, and a Regional RN confirmed that such an assessment should have been completed.
A resident with right-sided hemiplegia, benign prostatic hyperplasia, and total dependence for ADLs had an indwelling Foley catheter and a right hand carrot positioning device in use, but these interventions were not included in the resident’s care plan. The MDS showed intact cognition and right-sided impairment, and physician orders directed routine catheter changes. Observation noted the positioning device at the bedside, while interviews with an LPN and an administrative nurse revealed that nursing staff were expected and able to update care plans but were unaware that the plan lacked these catheter and positioning device interventions, contrary to the facility’s person-centered care plan policy.
A resident with dementia, severe cognitive impairment, prior left femur fracture, muscle weakness, and total dependence for ADLs was care-planned for transfers requiring two staff and a mechanical lift. Instead, staff transferred the resident using two staff and a gait belt, not in accordance with the documented care plan. The resident was later found with a large, painful bruise on the left chest under the arm, and could not explain how it occurred. Facility documentation and staff interviews confirmed that the EMR Kardex and care plan should guide transfer methods and that nursing is responsible for coordinating resident care, but the ordered mechanical lift was not used during the transfer that preceded the injury.
A resident with diabetes, impaired cognition, and a complex hypoglycemic regimen (including insulin and oral agents) had physician orders for periodic CBC, CMP, and HbA1c to monitor her condition and medication effectiveness. While some labs were completed earlier, the EMR showed that a later scheduled CBC and HbA1c were not done, and there was no documentation explaining the omission or any rescheduling. An administrative nurse confirmed the labs were missed, despite facility policy requiring monthly pharmacist drug regimen review using lab values and ensuring pharmacist access to lab results, resulting in a failure to adequately monitor the effectiveness of the resident’s hypoglycemic medications.
The facility did not follow its policy requiring daily posting of nurse staffing information for each shift. Surveyors observed that three houses lacked accurate or current staffing sheets, with the last posted date more than a month old, despite an active resident census. An administrative staff member confirmed that staffing sheets were expected to be completed and posted daily for all licensed and unlicensed staff directly responsible for resident care.
Surveyors found that the facility did not properly maintain and dispose of kitchen garbage and refuse in accordance with its own policy. Observations showed outside garbage bins with trash placed on top rather than inside, and bins located across the street with bags of trash on top and lids left open. In an interview, the CDM confirmed that trash was expected to be placed inside the bins and that lids should be closed, consistent with the facility’s written policy on dumpster and trash compactor use.
A resident with severe cognitive impairment and mobility issues sustained a laceration requiring sutures after a CNA attempted a transfer alone, contrary to the care plan requiring two staff members. The incident highlighted a failure to adhere to the facility's lifting and transferring policy, resulting in the resident's injury and emergency medical treatment.
A resident with heart failure, hypertension, atrial fibrillation, and anxiety experienced two falls due to staff failing to provide necessary equipment, including a call light and mobility devices. The resident's care plan directed staff to ensure these items were within reach, but this was not followed, leading to falls and injury.
A facility failed to implement a physician-ordered fluid restriction for a resident with heart failure, hypertension, atrial fibrillation, and anxiety. Staff were unaware of the restriction, and the resident's records lacked documentation of fluid intake, placing the resident at risk for dehydration or fluid overload.
The facility failed to complete a trauma-informed care assessment and develop a comprehensive care plan for a resident with PTSD, depression, and anxiety. Staff were unaware of the resident's PTSD diagnosis and triggers, and the required assessment was not conducted, placing the resident at risk for unmet behavioral and mental health needs.
Failure to Implement Timely Pressure Ulcer Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to identify and implement pressure ulcer prevention measures for a resident following readmission from the hospital after surgical repair of a left hip fracture. The resident had dementia with severely impaired cognition, behavioral symptoms including wandering and rejection of care, and required increasing assistance with ADLs, progressing from moderate assistance to total assistance with bed mobility, transfers, and toileting. The resident was documented as at risk for pressure ulcers on multiple MDS assessments, with contributing factors including incontinence and impaired mobility. Despite this identified risk, the resident initially had no pressure-reducing device on the bed or wheelchair and was not on a turning and repositioning program. After the resident returned from the hospital, an admission skin and wound assessment documented no wounds to the back, bottom, feet, or heels, and a Braden Scale score of 13 indicated moderate risk for pressure injury. A subsequent dietary note also documented no open skin issues. However, the EMR lacked evidence of a significant change in condition MDS following the resident’s decline in functional status and the development of an open lesion on the foot. A CNA later reported that upon the resident’s readmission, the resident did not have an air mattress or heel booties, was not on a turn and reposition schedule, and that the CNA had informed a nurse that the resident’s heels were red. Preventive interventions such as an air mattress and heel offloading were reported as being implemented only after a wound developed on the left heel. The resident’s left heel wound was first documented as an open blister that had opened, with a pink wound bed and dark center, and minimal drainage. A progress note described staff finding dry red streaks of blood on the fitted sheet and locating an open blister on the left heel, with a flap of skin hanging, and staff assumed the resident had rubbed the heel against the bed or sheet. Over time, the wound was measured repeatedly and treated with various dressings and topical agents, and later documented as an in-house acquired Stage 3 pressure ulcer to the left heel, present for greater than three months and staged by a wound clinic. The facility’s own policy stated that all residents are considered at potential risk for pressure ulcers and that nursing staff would evaluate skin integrity and implement preventive measures to maintain intact skin, but the resident’s care plan and staff interviews showed that preventive skin interventions were not in place until after the pressure ulcer had developed. The EMR documented that the resident’s care plan for pressure relief, including a pressure-reducing mattress and floating both heels while in bed, was dated after the wound had already been identified. Physician’s orders for heel protection and low air loss mattress were also dated after the wound was present. The EMR lacked wound clinic notes, despite documentation that the resident was to be followed by a wound clinic. Administrative and consultant nursing staff acknowledged that they expected preventive skin interventions to be in place to avoid pressure ulcers and that the resident’s preventive interventions were not provided until after the pressure ulcer occurred. This sequence of documented risk, absence of early preventive measures, staff reports of red heels without timely intervention, and subsequent development and progression of a left heel wound to a Stage 3 pressure ulcer formed the basis of the cited deficiency.
Failure to Prevent Falls and Ensure Safe Transfers for Residents at Risk
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision and assistance to prevent falls for two residents with dementia and documented fall risks. One resident had severe cognitive impairment, a history of falls, and was assessed as high risk for falls over multiple months. Her MDS and care plans showed a progression from independence with transfers and ambulation to requiring staff assistance with transfers, limited ambulation, and use of a wheelchair, with specific care plan directions that staff should provide assistance with transfers, offer a wheelchair, ensure non-skid footwear, provide non-slip strips in front of her recliner, and keep staff close when she was alone. Despite these identified risks and interventions, she continued to ambulate with heavy bags and purses, and staff reported she was very unsteady, could not walk long distances, and required a staff member to walk with her. This resident experienced multiple falls. In one incident, she was found on the floor in a hallway with two full purses and a book next to her, with a large hematoma on her forehead and hand, and was later diagnosed with a left wrist fracture. A post-fall root cause analysis identified that she had been carrying extremely heavy bags, which contributed to her loss of balance and fall. In a later incident, she fell in a living room area described as highly congested, with furniture and other residents present. Staff reported she lost her balance and fell on her left side, and she was later admitted to the hospital with a left hip fracture. Facility documentation of this fall was inconsistent: the facility’s reportable incident form stated she tripped on another resident’s foot while walking between furniture and other residents, while witness statements from a nurse and a CNA indicated they heard or saw her fall but did not clearly document a witnessed fall. The facility’s investigation also lacked documentation that available video footage was reviewed, even though an administrative staff member later stated she had watched the video and determined the resident tripped over another resident’s foot. The second resident involved in the deficiency had dementia, abnormal gait and mobility, and a history of multiple falls since admission. Her care plan identified her as at moderate risk for falls related to safety awareness and dementia, but it initially lacked specific direction to staff regarding transfer technique. During a one-person pivot transfer from a recliner to a wheelchair, her knees buckled and she fell to the floor, landing on her right knee and left cheek. Subsequent nursing documentation reviewing the fall stated that the staff member performing the transfer was not using a gait belt at the time of the incident. Only after this fall was an intervention added to the care plan specifying that she should be transferred with a two-person assist and a gait belt. Administrative nursing staff later confirmed that the resident had been transferred without a gait belt, which caused her to fall, despite the facility’s falls policy stating that residents at risk for falls would have interventions implemented and documented on the comprehensive plan of care.
Failure to Implement Enhanced Barrier Precautions and Basic Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, including Enhanced Barrier Precautions (EBP), hand hygiene, peri-care practices, medication administration, nebulizer cleaning, and handling of clean clothing. Surveyors observed that a resident with EBP signage requiring gown and glove use for direct care, including catheter and wound care, was assisted back to bed by multiple staff who only donned gloves and did not wear gowns as required. During this care, one aide emptied the resident’s urinary catheter without a gown, another aide placed gloved hands in pockets, and one aide removed gloves and handled linens and exited the room without performing hand hygiene. Later, wound care consultants and an administrative nurse provided wound care to the same resident’s coccyx and lower extremity wounds without wearing gowns, despite the posted EBP requirements and the presence of open wounds. Additional observations showed repeated failures in hand hygiene and aseptic technique during medication administration and personal care. A licensed nurse adjusted a resident’s feet on wheelchair pedals, then applied gloves without prior hand hygiene, checked blood sugar, administered insulin, and handled the medication cart and keys after glove removal without sanitizing hands. For another resident, the same nurse found a nebulizer mask and chamber lying directly on a nightstand with unidentified liquid remaining from a prior treatment; she added new medication to the chamber without disassembling, rinsing, or air-drying the equipment as required by facility policy, and only performed hand hygiene after removing gloves worn throughout the process. The nurse acknowledged the nebulizer should have been rinsed and stored properly. Surveyors also observed improper glove use and lack of hand hygiene during peri-care and wound care, as well as improper handling of clean clothing. Two staff members provided peri-care to a resident, opening a wet brief, cleansing the peri-area and buttocks, then using the same contaminated gloves to open a drawer, retrieve powder, and apply it to the resident’s groin before applying a clean brief and transferring the resident without performing hand hygiene after glove removal. In another case, a nurse performing wound care on a resident’s feet donned gloves and a gown but used the same gloves to move the wheelchair, reposition the resident, open wound supplies, remove soiled dressings, cleanse wounds, apply ointment, and place dressings without changing gloves or performing hand hygiene between dirty and clean tasks. Housekeeping staff were seen carrying a resident’s clean personal clothing on hangers, uncovered, through the hallway. Facility policies in place required EBP with gowns and gloves for high-contact care, specific hand hygiene indications, and detailed nebulizer cleaning and drying procedures, which were not followed in these instances.
Failure to Monitor and Appropriately Steward Antibiotic Use
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain an effective antibiotic stewardship program and to monitor antibiotic use. For the period from 02/01/26 through 02/24/26, the facility could not provide antibiotic and infection surveillance logs, demonstrating that infections and antibiotic use were not tracked during that month. As a result, there was no evidence that staff identified commonalities, patterns, or trends in infections or antibiotic usage, nor documentation of how determinations were made regarding the appropriateness of prescribed antibiotics. An administrative nurse stated that the facility used McGeer’s Criteria to determine appropriate antibiotic use but verified there was no evidence of antibiotic tracking, trending, or documentation supporting decisions about antibiotic prescriptions. The deficiency also includes an individual case in which a resident received an antibiotic for a urinary tract infection (UTI) without confirmation of infection by culture. An incident note showed that the resident’s physician ordered a urinalysis (UA) with culture and sensitivity, and a progress note documented preliminary positive UA results with culture and sensitivity pending. A subsequent progress note recorded that the UA results led to an order for Nitrofurantoin 100 mg by mouth twice daily for five days for UTI. A licensed nurse reported that providers generally would not start an antibiotic without a culture and sensitivity report and that the facility used McGeer’s Criteria and opened an Antibiotic Stewardship Assessment. The nurse contacted the lab and obtained the final culture and sensitivity report, which was negative for UTI, even though the resident had already been started on antibiotics two days earlier. An administrative nurse confirmed that the resident should not have received antibiotics for a UTI when the final culture report was negative and acknowledged that antibiotic stewardship should be tracked and monitored for trends, patterns, and appropriate use, consistent with the facility’s Antibiotic Stewardship policy dated 02/04/25.
Failure to Maintain Resident Dignity During Insulin Administration
Penalty
Summary
The facility failed to provide dignified care during medication administration to a resident with a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. During breakfast, a licensed nurse moved the resident away from the dining room table where she was eating and propelled her approximately 10 feet toward a lounge area that remained visible to residents in the dining room. In this lounge area, the nurse donned gloves, performed a fingerstick blood glucose test, lifted the resident’s shirt, exposed her abdomen, and administered an insulin injection, all in a location observable to others. The nurse stated that she always completed the resident’s blood sugar checks and insulin injections in this lounge area, and acknowledged that residents seated in the dining room could see this. The facility’s dignity policy, dated 02/2015, documented that the community would promote care in a manner and environment that maintains or enhances each resident’s dignity and respect in recognition of individuality. This practice of performing blood glucose testing and insulin injections in a visible lounge area, rather than in a private location, constituted a failure to honor the resident’s right to dignity and privacy during care.
Failure to Complete Significant Change MDS After Resident’s Functional Decline
Penalty
Summary
The deficiency involves the facility’s failure to identify a significant change in condition and complete a corresponding significant change MDS assessment for one resident following a left hip fracture. The resident had dementia with severely impaired cognition, a displaced intertrochanteric fracture of the left femur, and muscle weakness. A 07/15/25 significant change MDS documented a BIMS score of four and indicated the resident required moderate assistance with transfers, maximal assistance with toileting hygiene, and was independent with bed and wheelchair mobility, with ambulation not attempted due to medical or safety concerns. A 07/21/25 Cognitive Loss/Dementia CAA documented impaired judgment and safety and the need for 24-hour nursing care in a secure setting, while the ADL Functional/Rehabilitation Potential CAA did not trigger. Subsequent MDS assessments on 09/16/25 and 10/21/25 continued to show severely impaired cognition and documented that the resident required total assistance with bed mobility, toileting hygiene, and transfers, with ambulation not attempted due to medical or safety concerns. Despite this clear decline in functional status, the EMR lacked evidence of a required significant change in condition MDS after the resident fractured her left hip on 09/02/25. Care plans dated 01/30/25, 07/24/25, and 10/31/24 were revised on 09/25/25 to reflect that the resident, who previously could make major position changes in bed, ambulate very short distances, and required only moderate or maximal assistance for transfers and toileting, now required total assistance with two staff and a mechanical lift for transfers, total assistance for toileting, and maximal assistance for repositioning in bed. A Discharge GG Evaluation on 09/04/25 showed the resident had been independent or required only supervision/touching assistance for bed mobility, transfers, and walking prior to the decline, while a Restorative Nursing Screener/GG Evaluation on 09/17/25 documented total assistance for bed mobility, transfers, and toileting, with walking not attempted due to medical or safety concerns. A 09/25/25 health status note confirmed the resident was now a mechanical lift transfer with two staff, used incontinence products, and was dependent on a wheelchair. CNAs reported the resident required total assistance with ADLs after the hip fracture, and the Regional RN confirmed that a significant change MDS should have been completed, but none was present in the record.
Failure to Update Care Plan for Positioning Device and Indwelling Catheter
Penalty
Summary
The facility failed to update a resident’s comprehensive care plan to include interventions for a right hand positioning device and an indwelling urinary catheter. The resident had diagnoses including right-sided hemiplegia and benign prostatic hyperplasia, and the Annual MDS documented intact cognition with a BIMS score of 13, right-sided impairment of upper and lower extremities, and total dependence on staff for all ADLs. The existing care plan, dated 09/06/24, addressed an ADL self-care deficit associated with cerebral infarction and total dependence for personal hygiene and oral care, but did not include any information or interventions related to the indwelling Foley catheter or the right hand positioning device. Physician orders dated 2/19/26 directed that the resident’s indwelling catheter be changed every four weeks or as needed, and observation showed the resident seated in a recliner with a carrot positioning device lying on the bedside table, indicating the device was in use but not reflected in the care plan. During interviews, a licensed nurse stated that any staff member could update care plans with interventions such as the positioning device and catheter, but she was unaware that this resident’s care plan lacked that information. An administrative nurse stated she expected all nursing staff to update care plans. The facility’s care plan policy, revised 2/3/25, required development of a person-centered plan of care that identifies needs, strengths, preferences, health status, and establishes goals and services to ensure the highest level of functioning, which was not fully implemented for this resident regarding the catheter and hand positioning device.
Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Injury
Penalty
Summary
The facility failed to follow a resident’s care plan requiring use of a mechanical lift with two staff for transfers, instead transferring the resident with two staff and a gait belt. The resident had dementia with severely impaired cognition, a history of an intertrochanteric left femur fracture, muscle weakness, behaviors including wandering and rejection of care, and required increasing assistance with ADLs over time. Earlier assessments documented moderate assistance with transfers, but a later MDS showed the resident required total assistance with bed mobility, toileting hygiene, and transfers, and was at risk for pressure ulcers with one unhealed, unstageable pressure injury not present on admission. The care plan dated 09/25/24 specifically identified the need for total assistance of two staff with a mechanical lift for transfers. On 11/04/25, staff identified a large bruise on the resident’s left chest under the arm, measuring 22.5 cm by 9.5 cm, purple with red areas, and painful to touch; the resident could not state how the bruise occurred. Subsequent facility risk management documentation dated 11/17/25 revealed staff had been transferring the resident with two staff and a gait belt, contrary to the care-planned requirement for a mechanical lift. Staff interviews confirmed that CNAs and CMAs were expected to follow the care plan and use the EMR Kardex to determine required interventions, and that nursing was responsible for coordinating resident care. Despite these expectations and policies, the resident’s transfer was performed without the ordered mechanical lift, resulting in an injury.
Failure to Complete Ordered Lab Monitoring for Hypoglycemic Regimen
Penalty
Summary
Surveyors identified a deficiency related to failure to monitor the effectiveness of a resident’s hypoglycemic medication regimen. The resident had a diagnosis of diabetes mellitus, impaired judgment, and memory deficits, and required staff support. Her MDS documented that she received insulin injections and hypoglycemic medications, and her care plan noted altered endocrine status related to hyperglycemia and hypoglycemia due to diabetes mellitus. However, the care plan dated 02/23/26 did not include monitoring of laboratory tests for diabetes mellitus. Physician orders included multiple diabetes-related medications (Jardiance, glargine insulin, Januvia, and Humalog insulin) and also ordered a CBC, CMP, and HbA1c every six months. The EMR showed that an HbA1c was completed on 07/01/25, a CBC on 08/01/25, and a CMP on 01/02/26, but there was no evidence that the CBC and HbA1c ordered for 01/02/26 were completed. During interviews, Administrative Nurse E confirmed that the CBC and HbA1c were not completed and that the January medication administration record listed the CBC, CMP, and HbA1c without any documentation explaining why they were not done or rescheduled. Nurse E stated that physician orders were expected to be followed and explained that routine lab draws were performed weekly by an outside laboratory, with the charge nurse responsible for ensuring completion. The facility’s Drug Regimen Review policy indicated that a resident’s medication regimen would be reviewed monthly and as needed by a licensed pharmacist, using laboratory values as indicated, and that the pharmacist would have access to residents’ lab tests. Despite these requirements, the necessary laboratory monitoring for the resident’s diabetes management was not carried out or documented, resulting in a failure to ensure the resident’s drug regimen was monitored for effectiveness.
Failure to Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was accurately posted as required. Surveyor observation on 02/24/26 at 1:38 PM showed that none of the three houses, identified as [NAME], [NAME], and Ute, had an accurate or current staffing sheet posted; the most recent date displayed was 01/13/26, despite the facility reporting a current census of 53 residents. In an interview on 02/25/26 at 12:30 PM, an administrative staff member acknowledged that staffing sheets were supposed to be posted daily with each shift’s information completed. The facility’s policy, “Daily Nurse Staffing Report,” last reviewed on 08/18/25, required nursing services to identify at the beginning of each shift the number of staff and actual hours worked for licensed and unlicensed staff directly responsible for resident care, but this process was not being followed as evidenced by the outdated postings. No specific resident medical histories or conditions were mentioned in relation to this deficiency.
Improper Maintenance and Use of Garbage Bins
Penalty
Summary
The facility failed to properly maintain and dispose of kitchen garbage and refuse as required by its own policy. With a reported census of 53 residents, surveyors observed during an initial kitchen tour that one outside garbage bin had trash placed on top of the bin rather than inside it. On a subsequent observation, a garbage bin located across the street from the facility was noted to have a bag of trash on top of the bin. During another observation, the same garbage bins across the street were found with their lids not closed. In an interview, the Certified Dietary Manager stated that his expectation was that trash should be inside the bins, not on top, and that the lids should be closed, which was consistent with the facility’s undated “Dumpster and Trash Compactor” policy requiring lids to be correctly closed after use. No specific residents, medical histories, or clinical conditions were mentioned in relation to this deficiency.
Failure to Follow Transfer Protocol Results in Resident Injury
Penalty
Summary
The facility failed to prevent an injury to a dependent resident when staff did not adhere to the resident's care plan, which required two staff members to assist with transfers. The resident, who had diagnoses including dementia, hallucination, and osteoarthrosis, required maximum assistance for transfers and was severely cognitively impaired. Despite these needs, a Certified Nurse Aide (CNA) attempted to transfer the resident alone, resulting in the resident sustaining a 2-to-3-centimeter laceration on her left lower extremity. The incident occurred when the CNA assisted the resident to stand using a gait belt, during which the resident complained of leg pain and was immediately seated back in her wheelchair. The CNA observed bleeding from the resident's left lower extremity and reported the incident to a Licensed Nurse (LN). The laceration was treated at the facility before the resident was transported to the Emergency Department, where she received 10 sutures. The resident's care plan clearly documented the need for two staff members during transfers, a requirement that was not followed by the CNA involved in the incident. The facility's policy on lifting and transferring residents emphasized the importance of using safety materials and equipment to prevent injuries, which was not adhered to in this case. This oversight led to the resident's injury and subsequent medical treatment.
Failure to Provide Necessary Equipment Resulting in Falls
Penalty
Summary
The facility failed to ensure Resident 40 remained free from avoidable falls when staff did not provide the necessary equipment to ensure safety, including a call light and mobility devices, on two separate occasions. This resulted in falls on both occasions. Resident 40 had diagnoses of heart failure, hypertension, atrial fibrillation, and anxiety, and required extensive assistance for bed mobility, transfers, ambulation, dressing, and toileting. The resident's care plan directed staff to ensure his walker and wheelchair were within reach and to check on him frequently to ensure safety and call light placement. However, these directives were not followed, leading to the falls. On the first occasion, Resident 40 was found lying on the floor next to his bed with his call light on the floor, which caused him to roll out of bed while trying to retrieve it. This resulted in a laceration to the top of his head. On the second occasion, the resident was found on the floor in his room after attempting to get out of his recliner to use the bathroom without his walker or wheelchair within reach, and his call light was also not accessible. Both incidents highlight the staff's failure to ensure the resident's call light and mobility devices were within reach, as directed by the care plan.
Failure to Implement Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to establish and implement a physician-ordered fluid restriction for a resident diagnosed with heart failure, hypertension, atrial fibrillation, and anxiety. The resident's care plan and physician's order specified a fluid restriction of 1800 ml every 24 hours, with 75% of the fluid to be provided by nutrition and 25% by nursing. However, the resident's Treatment Administration Records (TAR) for several months lacked documentation of the fluid restriction, and staff members, including a Certified Medication Aide, a Licensed Nurse, and a dietary staff member, were unaware of the restriction. Observations revealed that the resident had multiple fluid containers at their bedside, indicating that the fluid restriction was not being followed. Interviews with staff confirmed that they were not informed or aware of the fluid restriction, and the facility's policy on fluid restrictions was not adhered to. The administrative nurse verified that the fluid restriction was never implemented, placing the resident at risk for dehydration or fluid overload.
Failure to Complete Trauma-Informed Care Assessment for Resident with PTSD
Penalty
Summary
The facility failed to complete a trauma-informed care assessment and develop a comprehensive trauma-informed care plan for a resident diagnosed with PTSD, depression, and anxiety. The resident's electronic medical record documented these diagnoses, and the admission Minimum Data Set indicated the resident had intact cognition and required supervision with certain activities. Despite these documented needs, the care plan lacked direction for staff on the resident's trauma triggers and coping strategies. Additionally, the resident's electronic medical record did not show evidence of a trauma-informed assessment being completed after admission. Interviews with staff revealed a lack of awareness regarding the resident's PTSD diagnosis and associated triggers. A Certified Nurse Aide and a Licensed Nurse both stated they were not informed of the resident's PTSD or any specific triggers. Social Services admitted to not completing a trauma-informed care assessment for the resident's most recent admission and had not communicated with staff about the resident's PTSD triggers. The facility's Trauma Informed Care policy required such an assessment within 72 hours of admission, but this was not adhered to, placing the resident at risk for unmet behavioral and mental health needs and retraumatization.
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Surveyors identified unsanitary food storage and preparation conditions, including food debris in a reach-in freezer, an unknown spilled liquid in a reach-in refrigerator, missing two-inch air gap on an ice machine drain, dirty carts used for clean dishes, and a steamtable shelf with built-up food debris. A dietary staff member acknowledged these areas needed cleaning, and it was determined the facility lacked a cleaning schedule or policy for kitchen cleanliness.
The facility failed to complete and analyze Care Area Assessments (CAAs) for multiple residents after Admission, Annual, and Significant Change MDS assessments triggered areas such as cognition, mood/behavior, functional status, urinary incontinence/indwelling catheter, nutrition, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, and visual function. Instead of documenting individualized analysis of underlying causes and contributing factors, an LPN reported she had stopped writing CAA notes and relied mainly on check-off worksheets and the fact that triggers appeared in the MDS CAA section. No facility policy on CAAs was provided to surveyors, and the CAAs consistently lacked required analytical documentation for residents with diverse and significant clinical needs.
A resident with dementia, severe cognitive impairment, and an indwelling urinary catheter was repeatedly observed sitting in common areas with his catheter drainage bag resting on his lower leg, visibly filled with dark amber urine and lacking a privacy cover, despite a care plan directing staff to cover the drainage bag. CNAs reported that the bag often slid down from the resident’s thigh, that they did not use catheter dignity bags on their hall, and that they simply moved the bag back up when it slid down. An administrative nurse stated she had not considered the use of dignity bags on the memory care unit, even though the facility’s resident rights policy affirms each resident’s right to a dignified existence, privacy, and confidentiality.
Two residents with documented cognitive ability to participate in care planning were not invited to any care plan meetings, and their EMRs lacked evidence of care plan conferences, invitations, or Interdisciplinary Care Conference assessments. Administrative staff stated that invitations should be mailed or hand-delivered and uploaded to the EMR, and that an Interdisciplinary Care Conference note should be completed, but none of this documentation existed for these residents, contrary to facility policy and federal requirements for resident and/or representative participation in care planning.
A resident with C-diff and CHF, newly admitted and with a baseline care plan that did not address call light use, was repeatedly found without access to a call light. Surveyors observed the resident yelling for help with her room door closed and later noted the call light on the floor under the bed and again on the floor while the resident sat in a recliner and stated she wanted to return to bed but could not do so independently. Staff reported using a binder clip to attach the call light to the resident’s clothing because the cord lacked a clip, acknowledged the resident sometimes threw the call light to the floor, and stated that call lights should be kept within residents’ reach. An administrative nurse confirmed the expectation that call lights be accessible at all times and was unsure about the use of a binder clip, and no facility policy on call lights was provided.
Surveyors found that a resident’s bathroom and handwashing area were not maintained in a safe, sanitary, and comfortable condition, including a loose baseboard with black substance behind it, a cracked toilet seat, and an empty, improperly mounted hand soap dispenser. Maintenance staff confirmed these conditions, noted that the soap dispenser was nonfunctional, and reported that although a QR code system existed for reporting maintenance issues, these problems had not been reported. Maintenance staff also stated there were no facility policies for maintenance repair in resident rooms and no policy provided for ensuring a safe, homelike environment.
Multiple residents were affected by inaccurate MDS assessments, including a resident with dementia and an indwelling catheter who was miscoded as always incontinent of urine and independent in ADLs despite staff and EMR documentation showing long-term catheter use and total dependence for dressing and wheelchair positioning. Another resident with a history of stroke was incorrectly coded as having a restraint, even though bed grab bars were used as enablers to assist with repositioning and did not limit voluntary movement. A resident with diabetes and unsteadiness experienced two documented falls that were not captured on the MDS, and another resident with diabetes, depression, CAD, and CKD was actively receiving hospice services per EMR, social services, and staff interviews, yet hospice was not coded on the MDS. The consultant MDS nurse confirmed these were significant coding errors not in accordance with the RAI User’s Manual.
A resident with C. diff and CHF was admitted, and while a baseline care plan documenting contact precautions was created, the resident later reported not knowing what a baseline care plan was. The resident was also found yelling for help with her call light on the floor under the bed. Nursing staff stated that baseline care plans are started on the day of admission and reviewed with residents, but also indicated that residents and families are not given written copies. An administrative nurse claimed a 48-hour interdisciplinary care conference had been completed, yet no corresponding documentation existed in the EMR, and explanations about who was responsible and why it was missing were inconsistent. No facility policy for baseline care plans was provided.
A resident with dementia and severe cognitive impairment was inaccurately assessed and care planned as needing only setup or independent assistance with dressing, despite actually requiring total staff assistance. The EMR lacked clear ADL documentation, and the ADL CAA did not trigger, leading to inaccurate MDS entries and a care plan that did not match the resident’s functional status. Surveyors observed the resident sitting in a wheelchair wearing dirty, food-stained pants and being taken to the dining room without a clothing change, with the soiled pants not changed until later when two CNAs provided total assistance. Staff, including CNAs, an LN, and an administrative nurse, acknowledged that the resident needed total help with dressing and should always be in clean clothing, revealing a failure to provide appropriate ADL support and maintain clean attire.
A resident with dementia and severe cognitive impairment was transported multiple times in a wheelchair without staff ensuring that his feet remained safely on the foot pedals. Although assessments inaccurately documented that he was independent with walking using a walker and/or wheelchair, his care plan did not instruct staff on proper use of wheelchair foot pedals. During observed transports by CNAs, the resident’s shoed feet repeatedly fell off the pedals and skimmed the floor between them. Staff acknowledged that his feet did not stay on the pedals and that the pedals were not effectively adjusted, and nursing leadership confirmed expectations that feet should remain on the pedals during transport. No wheelchair safety policy was provided.
Unsanitary Kitchen Conditions and Lack of Cleaning Policy
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions when surveyors observed multiple cleanliness and equipment issues in the kitchen. During an initial kitchen tour on 04/27/26 at 08:57 AM, the three-door reach-in freezer was found with food debris on the bottom shelf, and the three-door reach-in refrigerator had an unknown spilled liquid on the bottom shelf. The drain to the ice machine did not have the required two-inch air gap. Two black two-tiered plastic carts used to store clean dishes had food debris on the bottom tier, and the bottom shelf of the steamtable, which was used to store plate covers, had a buildup of food debris. On 04/28/26 at 01:57 PM, a dietary staff member confirmed these areas required cleaning, and it was identified that the facility did not have a cleaning schedule or a policy regarding kitchen cleanliness. No specific residents, medical histories, or clinical conditions were mentioned in the report in relation to this deficiency.
Failure to Complete and Analyze Care Area Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive Care Area Assessments (CAAs) with analysis of underlying causes, contributing factors, and risk factors for multiple residents following MDS assessments. Record review showed that numerous residents had Admission, Annual, or Significant Change MDS assessments that triggered CAAs in areas such as mood/behavior, cognitive loss/dementia, functional abilities, communication, urinary incontinence/indwelling catheter, nutritional status, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, visual function, and psychosocial well-being. For each of these triggered areas, the corresponding CAAs lacked analysis of the findings. This pattern was identified for residents with a wide range of clinical issues, including dementia, incontinence, falls, pressure ulcers, nutritional concerns, psychotropic medication use, pain, and functional decline. During an interview, a licensed nurse reported that she had stopped writing CAA notes the previous year after being told to do so by someone she could not identify. She stated that she did not write anything on the triggered CAAs and that, at times, she would document risk concerns only on a main check-off worksheet, relying on the fact that the triggers were already reflected in the MDS CAA section. The facility did not provide a policy regarding CAAs when requested. These findings demonstrate that the facility did not ensure that comprehensive assessments were fully completed as required when residents were first admitted and periodically thereafter.
Failure to Maintain Dignity and Privacy for Resident with Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to a dignified existence by not maintaining privacy for his urinary catheter drainage bag as directed in his care plan. The resident had diagnoses including bladder calculus and dementia, with a BIMS score of one indicating severe cognitive impairment, and was dependent on staff for toileting hygiene with an indwelling urinary catheter and constant urinary incontinence. His care plan, revised 03/23/26, instructed staff to cover his drainage bag with a privacy cover. However, during observations on 04/27/26, the resident was seen sitting in his wheelchair at his room doorway and later in the dining room with his catheter drainage bag resting on his lower left leg, supported by his shoe, containing dark amber urine and visible to visitors and other residents, without a privacy cover. Staff interviews confirmed that the catheter drainage bag frequently slid from the resident’s left thigh down to his lower leg and that staff did not consistently reposition it or use dignity/privacy bags. One CNA stated he had never placed a dignity bag on the resident’s drainage bag, and another CNA reported that staff on their hall did not utilize catheter dignity bags, instead just moving the bag back up when it slid down. An administrative nurse acknowledged she had not considered staff use of dignity bags for urinary catheters on the memory care unit. The facility’s Resident Rights policy, approved 12/2024, stated that each resident has the right to a dignified existence including privacy and confidentiality, which was not followed in this case.
Failure to Involve Cognitively Able Residents in Care Plan Meetings
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were given the opportunity to participate in the development and implementation of their person-centered plans of care. For one resident with a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognition, the electronic medical record showed an admission MDS and a Significant Change MDS, but there was no documentation of any care plan meeting in the prior four months. This resident reported not being invited to any care plan meeting. For a second resident with a BIMS score of 14, indicating intact cognition, the electronic medical record contained an admission MDS and a Quarterly MDS, but there was no documentation of a care plan meeting in the prior two months. This resident also reported not being invited to any care plan meeting. Administrative staff reported that residents and/or family members were supposed to be mailed or hand-delivered invitations to attend care planning meetings and that a copy of the invitation should be uploaded into the EMR. They further stated that an Interdisciplinary Care Conference assessment should be completed in the EMR during the care plan meeting. However, the administrative nurse confirmed that there was no documentation of invitations, Interdisciplinary Care Conference assessments, or completed care plan meetings for the two residents. The facility’s care planning policy stated that social services should attend care plan meetings and that the team presents information to the resident and/or representative about progress toward care plan goals, and referenced federal law requiring resident and/or representative participation in care plan meetings to the extent possible, but this process was not carried out or documented for the two residents identified.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach and to reasonably accommodate the resident’s needs and preferences. The resident had documented diagnoses of C-diff and CHF, and her baseline care plan dated 04/23/26 directed staff to evaluate for changes in level of consciousness but did not include any direction regarding call light use or accessibility. On 04/28/26 at 08:06 AM, surveyors observed the resident’s room door closed while she yelled loudly for help several times. When a licensed nurse entered the room, the resident was lying on her left side in bed, stated she wanted to get up, and reported she could not find her call light. The call light was observed on the floor under her bed. Later that morning, a CNA attached the call light to the resident’s shirt using a black and silver binder clip because the call light cord did not have its own clip. On 04/29/26 at 12:15 PM, the resident was seated in a recliner with the call light again lying on the floor out of her reach; she reported she wanted to go to bed and could not get herself back into bed. Staff interviews revealed that the CNA used the binder clip to keep the call light attached to the resident, and the licensed nurse stated staff should make sure the call light is clipped to the resident’s clothes and reported that the resident would throw her call light on the floor. An administrative nurse stated she expected staff to ensure all residents always have their call lights in reach and was unsure about using a binder clip to hold a call light in place. The facility did not provide a policy regarding call lights.
Failure to Maintain Safe and Sanitary Resident Bathroom Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, functional, sanitary, and comfortable environment in Resident 87’s bathroom and handwashing area. During an environmental tour with Maintenance Staff UU, surveyors observed an approximately four-foot section of loose baseboard to the left of and behind the toilet, with a black substance present on the wall and floor behind the loose baseboard. They also noted an approximately three-inch crack in the toilet seat and an empty hand soap dispenser hanging above the handwashing sink, mounted with exposed lag bolt fasteners. Maintenance Staff UU confirmed these conditions, acknowledged that the soap dispenser did not work, and stated that the toilet seat should be replaced, the bathroom baseboard removed, the black substance tested for mold, and the sheetrock removed and replaced. Further interview with Maintenance Staff UU revealed that the facility had implemented a QR code system for staff and visitors to report maintenance items, but the issues in this resident’s bathroom had not been reported through that system. He also reported that there had been a leak behind the handwashing sink that had flowed into the bathroom area, leading to the sink’s replacement, but he had received no report of the specific deficiencies observed in the bathroom. Additionally, Maintenance Staff UU stated that the facility did not have policies for maintenance repair in residents’ rooms, and the facility did not provide a policy for ensuring a safe, homelike environment.
Inaccurate MDS Coding for ADLs, Restraints, Falls, and Hospice Services
Penalty
Summary
The deficiency involves the facility’s failure to complete accurate Minimum Data Set (MDS) assessments in accordance with the Resident Assessment Instrument (RAI) User’s Manual, resulting in multiple residents’ clinical status not being correctly reflected. For one resident with dementia and severe cognitive impairment, the Significant Change and subsequent Quarterly MDS assessments coded him as always incontinent of bladder and independent with eating and upper body dressing, with use of a walker and wheelchair. However, the electronic medical record showed ongoing indwelling catheter care each shift and no documentation of walker use, wheelchair mobility, or dressing requirements during the review period. Staff interviews revealed that this resident had an indwelling catheter for more than a year, had not walked for several years, and was dependent on staff for all ADLs, including dressing and wheelchair positioning, contradicting the MDS coding. Observations showed the resident slumped in a wheelchair, wearing a hospital gown over clothing, with a visible catheter bag on his lower leg and feet frequently skimming the floor despite foot pedals being present, further indicating dependence and catheter use not accurately captured on the MDS. Another deficiency involved a resident with a history of stroke, hemiplegia, and hemiparesis whose Significant Change MDS coded the use of “other restraint.” During observation, the resident was seen in bed with bilateral grab bars at the head of the bed and her right arm positioned on a pillow. The resident reported using the grab bars to help move and reposition herself in bed. CNAs and administrative nursing staff confirmed that the facility did not use restraints and that the grab bars were used as enablers to assist residents with repositioning and to increase independence. Administrative staff acknowledged that the MDS coding for restraints was inaccurate because the grab bars did not limit the resident’s voluntary movement or access to her body. A further inaccuracy was identified for a resident with diabetes, atrial fibrillation, unsteadiness of feet, and a toe fracture. Both a Significant Change and a Quarterly MDS documented intact cognition, partial/moderate assistance with transfers, no ambulation, and no falls. However, progress notes in the EMR documented two unwitnessed falls during the look-back period, including one where the resident was found on the floor next to the bed with a forehead skin tear and another where the resident was found sitting on a fall mat on the floor with a scratch on the ankle. These documented falls were not reflected on the MDS. In addition, another resident with diabetes, depression, CAD, and chronic kidney disease had a Significant Change MDS that coded no hospice services, while the EMR contained a hospice certification and physician orders initiating hospice services, and social service notes and staff interviews confirmed that hospice services, including bathing by a hospice aide, were being provided during the look-back period. The consultant MDS nurse confirmed that these assessments were inaccurate and not completed in accordance with the RAI User’s Manual, constituting significant errors in coding for urinary status, ADL dependence, restraints, falls, and hospice services. The consultant MDS nurse stated that the resident with the indwelling catheter should have been coded as not rated for urinary continence due to catheter placement rather than as always incontinent, and that his ADL status should not have been coded as independent given his dependence on staff for dressing and wheelchair positioning. For the resident with grab bars, the nurse confirmed that the grab bars were used as enablers and not as restraints, making the restraint coding inaccurate. For the resident with documented falls, the MDS failed to capture falls that occurred within the look-back period, and for the resident receiving hospice services, the MDS did not reflect hospice care that was active during the look-back period. These miscodings met the RAI Manual’s definition of significant error, in which the resident’s overall clinical status is not accurately represented on the assessment and the error has not been corrected by a more recent assessment.
Failure to Provide and Communicate Baseline Care Plan to New Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide a summary of the baseline care plan to a newly admitted resident and to ensure that the baseline care plan process was completed and documented as required. The resident’s EMR documented diagnoses of C. difficile and CHF. The Entry MDS was completed on the admission date, and the admission MDS was noted as in progress with no information available. A baseline care plan dated the day after admission documented contact precautions, including staff use of gowns and masks when changing contaminated linens and proper handling and bagging of soiled linens. However, during an interview several days after admission, the resident reported she did not know what a baseline care plan was, indicating that the plan had not been explained or summarized to her. Further observations and interviews showed additional failures in implementing and communicating the baseline care plan. On one occasion, the resident was heard yelling for help with her room door closed; when a nurse entered, the resident stated she wanted to get up but could not find her call light, which was observed on the floor under the bed. A nurse reported that the baseline care plan was started on the day of admission and that nurses would review it with the resident, but also stated that the charge nurse would not provide a written copy of the baseline care plan to the resident or family. An administrative nurse reported she would review the baseline care plan with the resident and/or family and claimed to have completed a 48-hour interdisciplinary care conference, but there was no opened or completed conference note in the EMR. She gave inconsistent explanations regarding who was responsible and why the conference note was missing. The facility did not provide a policy for baseline care plans.
Failure to Provide Accurate ADL Assessment and Timely Clothing Changes
Penalty
Summary
The facility failed to provide appropriate assistance with activities of daily living (ADLs), specifically dressing and clothing changes, for a resident with severe cognitive impairment. The resident had a diagnosis of dementia and repeated Brief Interview for Mental Status (BIMS) scores of one, indicating severe cognitive impairment. Despite this, both a Significant Change MDS and a Quarterly MDS inaccurately documented that the resident required only setup assistance with lower body dressing. The ADL Care Area Assessment did not trigger, and the resident’s care plan, revised on 03/23/26, inaccurately instructed staff that the resident was independent with dressing. The electronic medical record lacked staff documentation of the resident’s ADL needs, resulting in care instructions that did not reflect the resident’s actual functional status. On the day of observation, the resident was seen sitting in a wheelchair wearing black pants with food crumbs on them in the morning, and later was transported by a CNA to the dining room still wearing the same dirty pants. The pants were not changed until early afternoon, at which time two CNAs provided total assistance to change the dirty pants, and the resident was unable to participate in dressing or undressing. During interviews, the CNAs, a licensed nurse, and an administrative nurse all stated that residents should always be dressed in clean clothing and confirmed that this resident required total staff assistance with dressing. These observations and interviews showed that the resident’s actual need for total assistance with dressing and clothing changes was not accurately reflected in the MDS, care plan, or ADL documentation, and that the facility did not ensure the resident was kept in clean clothing as expected by facility policy for ADL care.
Failure to Maintain Safe Wheelchair Foot Positioning During Resident Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision during wheelchair transport for a resident with dementia. The resident’s EMR documented a diagnosis of dementia and a BIMS score of one on both a Significant Change MDS and a Quarterly MDS, indicating severe cognitive impairment. These MDS assessments inaccurately documented that the resident was independent with walking using a walker and/or wheelchair, and the ADL CAA did not trigger. The resident’s care plan, revised 03/23/26, identified cognitive impairment due to dementia but did not include instructions for staff on the use of wheelchair foot pedals while propelling the resident. On multiple observed occasions, staff propelled the resident in a wheelchair without maintaining his feet safely on the foot pedals. During transport from his room to the dining room, the resident’s left shoed foot fell from the foot pedal and skimmed the floor between the pedals, and later, during transport from the dining room to the shower room, both shoed feet skimmed the floor between the pedals. CNAs reported that the resident’s feet never stayed on the foot pedals and described the pedals as useless because he could not keep his feet on them. A licensed nurse confirmed the resident’s feet did not always remain on the foot pedals when staff propelled him and stated the pedals should be adjusted to better fit his needs. An administrative nurse stated it was the expectation that staff ensure the resident’s feet remained on the foot pedals during transport and that pedals should be lowered if needed. The facility did not provide a policy regarding wheelchair safety.
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