Newton Presbyterian Manor

coordinator.

Consultant Nurse GG reviewed R53's documented MDSs in R53's EMR and reported that

left hip.The facility did not provide a policy,

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Newton Presbyterian Manor 1200 E 7th Street Newton, KS 67114

Based on observation,

interventions for R36's right hand positioning device to prevent contractions (abnormal fixations of a joint or muscle) indwelling urinary catheter (a device inserted into the bladder that drains urine into a collection bag).

Findings included:- R36's Electronic Health Record (EMR) recorded the following diagnoses: hemiplegia/hemiplegia affecting the right side (muscular weakness of one half of the body) benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate).R36's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition with no changes in the ADLs.R36's Annual MDS, dated [DATE], documented a BIMS score of 13, indicating intact cognition.

The MDS also documented R36 had right side impairment to upper and lower extremities and was dependent on staff for all Activities of Daily ADL's.R36's Care plan, dated 09/06/24, revealed R36 has an ADL self-care deficit associated with cerebral infarction, R36 is totally dependent on a staff member for personal hygiene and oral care.

The care plan lacked information regarding an indwelling foley catheter or a device for position of the right hand.R36's Physician Orders, dated 2/19/26, directed to change the indwelling catheter every four weeks or as needed.Observation on 02/14/26 at 08:12 AM, R36 sat in his recliner in his room. A carrot positioning device laid on the bedside table.

During an interview on 02/25/26 at 08:30 AM, Licensed Nurse (LN) G stated any of the staff can update the care plans with interventions such as the carrot positioning device and the indwelling catheter.

She said she was unaware R36's Care Plan lacked the information.

During an interview on 02/25/26 at 11:33 AM, Administrative Nurse D stated she expected all nursing staff to update the care plans.The facilities policy Care Plan, revised 2/3/25, the person-centered plan of care is developed in conjunction with the resident and or legal representative. To identify the individual's needs, strength, preferences, health status, life history and establish obtainable goals. An appropriate plan of care with services and items the resident is to receive is developed to ensure the highest level of functioning the resident may be expected to obtain.

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Newton Presbyterian Manor 1200 E 7th Street Newton, KS 67114

provide a mechanical lift transfer for Resident (R) 53 which resulted in an injury.

Findings included:-

disorder characterized by failing memory and confusion), displaced fracture (traumatic bone break where two ends of the bone separate out of their normal positions) intertrochanteric (the area of the hip/thigh bone located between the greater and lesser trochanters) left femur (thigh bone), and muscle weakness. R53's 07/15/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition. R53's MDS documented she had behaviors, wandered, rejected care, had verbal behavioral symptoms directed towards others, and physical behavioral symptoms directed towards others for 1-3 days in the lookback period. R53's MDS documented she required moderate assistance with activities of daily living (ADL) including transfers.R53's Pressure Ulcer/Injury Care Area Assessment (CAA) triggered related to potential for pressure injuries.

The contributing factors included incontinence and impaired mobility, and the risk factors included skin breakdown and pressure injuries.

The CAA noted the care plan was reviewed to reduce the risk of pressure injuries and weekly skin assessment would be completed by a licensed nurse. R53's 10/21/25 Quarterly MDS documented a BIMS score of three and documented the resident required total assistance with ADL, bed mobility, toileting hygiene, and transfers. R53's MDS documented she was at risk of developing pressure ulcers, and she had one unhealed, unstageable (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus) pressure injury that was not present on admission. R53's MDS documented no pressure reducing device on her bed and she was not on a turn and repositioning program.R53's Care Plan, dated 09/25/24, revealed R53 required total assistance of two staff with a mechanical lift for transfers.R53's Incident Progress Note, dated 11/04/25 at 09:25 AM, documented staff reported R53 had a large bruise to the left side of her chest, under her left arm.

The note documented R53 said she did not know how she received the bruise.

The note included the area was assessed and measured 22.5 centimeters (cm) by 9.5 cm, was purple in color with hints of red scattered throughout, and R53 complained of pain when the area was touched.Review of facility's risk management documentation, dated 11/17/25, revealed the facilty found staff transferring R53 with two staff assistance and a gait belt.

The documentation noted R53 was care-planned for two staff assistance and a mechanical lift (for transfers).

The documentation included the facility provided education, instructed staff to follow the care plan, and provided instructions on how to locate the care plan and Kardex.On 02/24/2026 at 03:12 PM, Certified Medication Aide (CMA) T reported the staff looked in the EMR in the Kardex to know what skin interventions a resident required.On 02/25/2026 at 09:27 AM, Licensed Nurse (LN) G reported the Certified Nurse Aides (CNA) and CMAs were educated to update the nurse when a resident had a skin concern. LN G stated when a resident had a bruise or skin tear and could not say how that happened or it was not witnessed, the staff completed an incident report. LN G said Administrative Nurse D would complete an investigation. LN G said the CNAs should follow the residents care plan interventions for resident safety.On 02/25/26 at 11:53 AM, Administrative Nurse D said she expected all the staff to follow the care plan to keep residents safe and prevent injuries.

The facility's policy Care Management, dated 02/03/25, documented management of resident care is conducted systematically and comprehensively by interdisciplinary team knowledgeable in current concepts of geriatric care.

Resident care is designed to meet a resident's individual needs.

Coordination of the plan of care is the responsibility of nursing; however, planning, implementation and evaluation require joint participation by each discipline rendering service.

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Newton Presbyterian Manor 1200 E 7th Street Newton, KS 67114

natural, weak acid produced by human white blood cells to fight infections and inflammation) and pat

the wound bed, cut calcium alginate to fit the size of the wound bed and fill the deepest part, cut an

wound, and cover the wound with an Aquacel foam dressing.

The staff were to change the dressing daily and as needed.R53's Nutritional Note dated 10/13/25 at 11:02 AM documented the following:On 10/03/25, the left heel open area measured 6.33 cm by 3.38 cm by 2.45 cm.On 10/10/25, the left heel open area measured 2.75 cm by 2.15 cm by 1.78 cm.R53's Skin Issue Note, dated 11/14/25 at 02:49 PM, documented that the wound characteristics had improved and documented the wound as a Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) pressure ulcer wound, acquired in-house.

The wound was noted as greater than three months and staged by the wound clinic.

The left heel wound measured 1.7 cm by 1.2 cm by 0.2 cm with 1.5 cm undermining (a serious complication where tissue destruction occurs under the skin edges, creating a hidden pocket or shelf beneath intact skin, often making the wound much larger than appears on the surface).R53's 01/05/26 Physician's Orders included that the resident had a wound to her left heel, and staff were to cleanse with hypochlorous acid, apply a collagen pad, and cover with bordered foam dressing.

Change every three days and as needed for wound healing.R53's EMR lacked documentation of wound clinic notes.On 02/24/26 at 04:32 PM, Certified Nurse Aide (CNA) Q reported that when R53 readmitted from the hospital on [DATE], R53 did not have an air mattress on her bed or heel booties. CNA Q reported R53 was not on a turn and reposition schedule and reported she had told the nurse that R53's heels were red. CNA Q reported that R53 received an air mattress and a float for heels after her left heel had a wound.On 02/25/26 at 11:53 AM, Administrative Nurse D and Consultant Nurse GG (Regional RN) reported they expected preventative skin interventions to be in place to avoid a pressure ulcer.

Consultant Nurse GG reviewed R53's care plan in EMR and revealed that R53's preventative skin interventions were not provided until after R53 had a pressure ulcer.The facility policy Skin Integrity: Pressure Ulcer/Injury Prevention, Nursing Intervention and Wound Treatment, dated 10/14/24, documented that all residents are considered to have a potential risk for the development of pressure ulcers.

Nursing staff would evaluate skin integrity, implement preventative measures as indicated and treat skin breakdown.

Implement pressure ulcer/ injury preventative measures to maintain intact skin.

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Newton Presbyterian Manor 1200 E 7th Street Newton, KS 67114

Observation on 02/24/26 at 09:09 AM, R23 was up in her recliner, drinking her coffee.

During an interview on 02/24/26 at 10:29 AM, Certified Nurse Aide (CNA) KK revealed R23 now required a two-person transfer.

During an interview on 02/25/26 at 11:35 AM, Administrative Nurse D stated that a staff member had transferred R23 without a gait belt, which caused her to fall.

Administrative Nurse D said the facility did a teachable moment with the staff member, and she expected the staff to use a gait belt with proper technique on transfer.

The facilities policy Falls, revised 11/1/24, documents that residents will be identified for risk of falls and interventions implemented to reduce risk.

The resident's high-risk status will be documented on the comprehensive plan of care or service plan.

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Newton Presbyterian Manor 1200 E 7th Street Newton, KS 67114

Based on observation, interview and record review the facility failed to ensure the posted daily nurse staffing sheets were posted daily as required.

Findings

Ute did not have an accurate staffing sheet posted.

The last date noted was 01/13/26.On 02/25/26 at 12:30 PM, Administrative Staff A stated the staffing sheets should be posted daily with each shift's information completed.The facilities policy Daily Nurse Staffing Report, reviewed 08/18/25, documented that nursing service is to provide each resident admitted to health care center with the appropriate level of care to attain his/her optimum level of functioning.

Daily at the beginning of each shift identify the [NAME] number of staff and actual hours worked for the following licensed and unlicensed staff directly responsible for resident care.

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Newton Presbyterian Manor 1200 E 7th Street Newton, KS 67114

Findings included:- The Electronic Medical Record (EMR) for R1 documented a diagnosis of diabetes mellitus.R1's 07/29/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 10, which indicated intact moderately impaired cognition. R1's MDS revealed she received seven days of insulin injections and also received hypoglycemic medications.R1's 08/05/25 Cognitive Loss/Dementia Care Area Assessment (CAA) documented that R1 had impaired judgment and had memory deficits noted.

Needed staff support.R1's Care Plan, 08/26/2024, revealed an altered endocrine status related to hyperglycemia (greater than normal amount of glucose in the blood) and hypoglycemia (less than normal amount of sugar in the blood) due to the diagnosis of diabetes mellitus.R1's 02/23/26 Care Plan lacked monitoring of laboratory for diabetes mellitus.R1's 09/04/24 Physician Orders documented Jardiance (medicine used to lower blood sugar), give 25 milligrams (mg), by mouth one time a day for diabetes.R1's 09/04/24 Physician Orders documented glargine (long-acting insulin), give 10 units subcutaneously (beneath the skin) at bedtime for diabetes.R1's 09/08/24 Physician Orders documented Januvia (used to improve blood sugar control), give 100 mg, by mouth one time a day for diabetes.R1's 10/03/24 Physician Orders documented Humalog (rapid-acting insulin), give 10 units subcutaneously (beneath the skin) once a day for hyperglycemia.R1's 10/04/24 Physician Orders documented Humalog insulin, give 8 units subcutaneously once a day for hyperglycemia.R1's 07/01/25 Physician Orders documented a complete blood count (CBC- laboratory blood test), complete metabolic panel (CMP-laboratory blood test), and hemoglobin A1c (HbA1c-blood test used to evaluate the level of glucose control over the past 90 days) every six months for an old myocardial infarction (heart attack).R1's EMR revealed HbA1c was completed on 07/01/25.R1's EMR revealed that a CBC was completed on 08/01/25.R1's EMR revealed a CMP completed on 01/02/26.R1's EMR lacked evidence that a CBC and HbA1c were completed on 01/02/26.On 02/24/26 at 03:00 PM, R1 lay in bed with eyes closed.On 02/25/2026 at 08:03 AM, Administrative Nurse E reported that R1's CBC and HbA1c were not completed.

Administrative Nurse E reported R1's January medication administration record had the CBC, CMP, and HbA1c, but there was no note documenting why they were not completed or rescheduled.

Administrative Nurse E reported she expected the physician orders to be followed.On 02/25/2026 10:20 AM, Administrative Nurse E reported that the routine laboratory blood drawings would be completed every Tuesday by the outside laboratory staff on the day shift, and the charge nurse was responsible for having blood drawings completed.

The facility's Drug Regimen Review, dated 08/2024, documented that a resident's medication regimen would be reviewed monthly and as needed by a licensed pharmacist to monitor current or potential impact as indicated by laboratory values.

The community would ensure that the pharmacist had access to residents' laboratory tests.

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Newton Presbyterian Manor 1200 E 7th Street Newton, KS 67114

minimal harm to maintain and or dispose of kitchen garbage refuse properly.

Findings included:- During the initial tour of the kitchen on 02/23/26 at 08:50 AM, observation of the outside garbage bins with Certified

on 02/24/26 at 6:00 PM, the facility has a garbage bin across the street from the facility with a bag of trash on top of the bin.During an observation on 2/25/26 at 7:55 AM, the facility's garbage bin across the street from the facility the lids to the bins were not closed.

During an interview on 02/25 at 10:20 AM, CDM BB stated he expected the trash to be inside the bins, not on top, and the lids should be closed.

The facility policy Dumpster and Trash Compactor, undated, documents to ensure lids are correctly closed after use.

into her room.

After getting the resident to bed, CMA S and CNA P pulled R4's pants down and opened

to wear the gloves she used during peri-care, CNA P opened the drawer again and removed a bottle of

pants, removed their gloves, and transferred R4 back to her wheelchair without performing hand hygiene after removing their gloves.On 02/24/26 at 11:08 AM, Housekeeping Staff V carried a resident's clean personal clothing on hangers, uncovered, in the hallway.

Housekeeping Staff V reported she did not cover the resident's personal clothing when she delivered it.On 02/24/26 at 01:01 PM, LN G entered R15's room, washed her hands, put on gloves, put on a gown, and tied her gown.

She used her gloved hands to touch the resident's wheelchair handles to move the wheelchair away from the bed. LN G touched the resident's feet, repositioned him in the bed, opened the wound dressing packages, placed a date on the bandage, removed the soiled dressing from his right foot, picked up the wound cleanser, placed Santyl (debriding ointment) directly on the open wound, and applied dressing with the same gloves. LN G proceeded to provide the same care to the resident's left foot.

She did not remove her gloves or perform hand hygiene throughout the observation.On 02/24/26 at 01:32 PM, LN G stated she should have placed a barrier before setting up the resident's wound dressing supplies, changed her gloves between dirty and clean tasks, as well as performed hand hygiene when removing her gloves and prior to reapplying gloves to prevent cross-contamination and/or the spread of infection.On 02/25/26 at 11:33 AM, Administrative Nurse D stated she expected staff to follow EBP protocol, which included personal protective equipment (PPE) as outlined on the signage on the resident's door.

She stated gowns and gloves should be worn when providing direct care to residents with catheters, wounds, and anyone with an artificial opening into their body.

Hand hygiene should be performed upon entering a resident's room, prior to applying gloves, in between glove changes, after removing gloves, and anytime going from a dirty task to a clean task to prevent cross-contamination and prevent the spread of infection.The facility policy titled Enhanced Barrier Precautions, dated 02/03/25, included Enhanced Barrier Precautions (EBP), which are an effective infection control intervention used to reduce the transmission of multidrug-resistant organisms in skilled and long-term care nursing facilities. EBP involves the use of PPE, specifically gowns and gloves, during high-contact resident care activities.The facility policy titled Hand Hygiene, dated 02/03/25, included that all staff members will comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines, as effective hand hygiene reduces the incidence of healthcare.

Indications for hand washing include:Before and after removing glovesBefore and after medication administrationBefore and after having direct contact with residents.Before and after contact with residents' intact skin, such as assisting residents with activities of daily living, transfers, and repositioning.Moving from a contaminated body site to a clean body site during resident care.Gloves reduce hand contamination by 70-80%, prevent contamination, and protect elders and healthcare personnel from infection.

However, the use of gloves does not eliminate the need for hand hygiene.

Change gloves during elder care if moving from a contaminated body site to a clean body site during resident care.The policy titled Nebulizer Cleaning Instructions, dated 02/03/25, documented that after each treatment, staff would rinse the resident's nebulizer and mouthpiece/mask with tap water, allow it to air dry, and store it in an open Ziploc bag or container after the nebulizer components dried.

Staff would wipe down the outside of the machine, using a damp cloth.

After the last treatment of the day, staff would completely disassemble the nebulizer, including the mouthpiece/mask.

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Newton Presbyterian Manor 1200 E 7th Street Newton, KS 67114

Review of R 9's Incident Note dated 02/20/26 at 03:30 PM revealed the resident's physician ordered a urinalysis (UA) with culture and sensitivity.The 02/21/26 at 12:23 PM Progress Note included preliminary positive UA results with culture and sensitivity results pending.The 02/23/26 at 09:41 AM Progress Note included the UA results and noted orders were received to start Nitrofurantoin (antibiotic), 100 milligrams (mg), by mouth two times a day for five days for urinary tract infection.On 02/25/26 at 09:27 AM, Licensed Nurse (LN) G reported that the provider generally would not start an antibiotic without a culture and sensitivity report.

The LN reported the facility used McGeer's Criteria and opened an Antibiotic Stewardship Assessment.

The lab did not always send the results back to the facility, and they would have to call the lab to obtain the findings. LN G then called the lab for R9's culture and sensitivity results and obtained the final report.

The LN then reported the results were negative for UTI (although the resident was placed on an antibiotic for UTI, two days prior). LN G stated no further testing was indicated.On 02/25/2026 at 04:22 PM, Administrative Nurse D confirmed the above findings and stated R9 should not have received antibiotics for a UTI when her final culture report was negative for UTI.

Administrative Nurse D confirmed that antibiotic stewardship should be tracked and monitored for trends and patterns, as well as for the appropriate use to prevent the overuse of antibiotics and the risk to residents of developing multidrug-resistant organisms.The facility's policy Antibiotic Stewardship, dated 02/04/25, documented that antibiotic stewardship refers to a set of commitments and actions to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.

This can be accomplished through improved antibiotic prescribing and management practices to reduce inappropriate use and to ensure that residents receive the right antibiotic for the right indication, dose, and duration.

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Newton Presbyterian Manor 1200 E 7th Street Newton, KS 67114