Access Mental Health
Inspection history, citations, penalties and survey trends for this long-term care facility in Peabody, Kansas.
- Location
- 500 Peabody, Peabody, Kansas 66866
- CMS Provider Number
- 17E210
- Inspections on file
- 36
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 22 (1 serious)
Citation history
Health deficiencies cited at Access Mental Health during CMS and state inspections, most recent first.
Surveyors found multiple food items in the kitchen and storage areas left open to air, including shredded potatoes, sausage patties, pudding mix, chocolate chips, dressing mix, and shredded cheese. Dented cans of apples and mushrooms were also present. Dietary staff were unaware of the requirement to keep food containers closed, and administrative staff confirmed that all food should be properly stored and dented cans returned or discarded, as per facility policy.
Staff transported soiled laundry in uncovered and overflowing containers through hallways, and clean laundry was processed on a damaged, unsanitizable table. Both CNA and laundry staff confirmed these practices, which did not comply with the facility's infection control policy for handling and processing linens.
The facility did not complete required Care Area Assessments (CAAs) with analysis of findings for several residents who triggered areas such as psychotropic drug use, dental care, behavioral symptoms, and cognitive loss/dementia. Staff interviews confirmed that the responsible nurse lacked education on proper CAA documentation, resulting in incomplete assessments and missing analysis of underlying causes and risk factors.
Several residents had inaccuracies in their MDS assessments, including incorrect documentation of hypoglycemic medications, misclassification of a bed positioning device as a restraint, and failure to record the use of WanderGuard alarms. These errors were acknowledged by the MDS nurse, who cited limited time and infrequent facility presence as contributing factors, and were identified through interviews, observations, and record reviews.
A medication error rate above five percent was identified when a nurse failed to prime insulin pens, did not verify orders with the MAR, and did not follow manufacturer instructions for injection duration while administering insulin to a resident with diabetes. The nurse was unsure of the correct technique, and facility policy requiring verification and proper administration was not followed.
Staff prepared and served a water-thin mixture described as broth instead of gravy over turkey and dressing, without following a written recipe or menu guidelines. Administrative staff confirmed the mixture was not appealing and did not meet expectations for palatability. The facility could not provide a policy on food palatability when requested.
Two residents and/or their representatives were not properly informed or provided with documented consent for the use of psychotropic medications, as required. Consent forms for several medications lacked the necessary signatures, and electronic medical records did not contain evidence of informed consent. Staff interviews revealed confusion about the consent process and responsibilities, leading to incomplete documentation.
A resident was admitted and did not have a complete person-centered baseline care plan developed within the required 48-hour timeframe. Key components of the care plan, including General Information and Initial Goals and Health Conditions, remained incomplete for an extended period. Staff interviews indicated a lack of awareness regarding the 48-hour requirement for baseline care plan completion.
Three residents were not offered the pneumococcal vaccine, and there was no documentation in their EMRs to show that the vaccine was provided or that informed declination was obtained. An administrative nurse confirmed the lack of documentation and cited insurance coverage issues as a barrier.
A resident experienced significant weight loss due to the facility's failure to implement timely nutritional interventions. Despite the resident's medical history and cognitive impairments, the facility did not provide adequate dietary support or communicate effectively with the registered dietician. The resident's care plan was only updated months after the initial weight loss, and the facility lacked a certified dietary manager, leading to continued weight decline and risk of malnourishment.
The facility did not ensure the director of food and nutrition services had the required CDM qualifications. Dietary BB, who lacked CDM certification, was unaware of the requirement, and the registered dietician was only available monthly. Administrative Staff A mistakenly believed that a registered dietician's presence sufficed. The facility failed to provide a policy on CDM qualifications, risking residents' dietary and nutritional needs.
The facility failed to adhere to proper meat thawing procedures, as a pork loin was observed thawing in a sink without running water. This practice, confirmed by dietary staff as incorrect, placed residents at risk for food-borne illnesses.
The facility failed to document and offer influenza and pneumococcal vaccinations to several residents, lacking informed declinations, consent, or physician-documented contraindications. This oversight increased the risk of influenza and pneumonia. Staff interviews revealed inconsistencies in offering vaccinations due to concerns about upsetting legal guardians and Medicaid coverage issues.
A resident with a history of mental health disorders was transferred to a psychiatric hospital without proper documentation, placing them at risk for uninformed care choices. The facility was unaware of the transfer until contacted by the hospital, revealing a deficiency in managing resident transfers and discharges.
The facility failed to provide written notification of transfers for two residents with mental health disorders, leading to uninformed care choices. One resident was transferred to a psychiatric hospital without documentation, while another was transferred to the hospital multiple times without written notice. The facility relied on phone notifications, lacking a policy for written transfer notifications.
The facility failed to accurately code the MDS for two residents, leading to potential risks for inappropriate care. One resident's MDS included incorrect treatments not received, while another's omitted a PTSD diagnosis due to documentation issues. These inaccuracies risked inadequate care planning.
The facility failed to develop individualized trauma-based care plans for two residents with PTSD, placing them at risk for impaired care. R30's care plan lacked specific interventions to address her PTSD, while R39's care plan did not include strategies to mitigate triggers or prevent re-traumatization. Staff interviews revealed a lack of awareness and training regarding trauma-based care, and the facility was unable to provide a policy for person-centered care plans.
A facility failed to update a resident's care plan to address incontinence and behavioral needs. Despite a comprehensive assessment, the plan lacked specific interventions for managing the resident's incontinence and resistance to care, influenced by a history of homelessness. Staff acknowledged the need for individualized interventions, but the facility lacked a policy for developing person-centered care plans.
A resident with limited ROM and a history of cerebral infarction and hemiplegia did not receive a ROM program to maintain mobility. Despite the resident's desire to remain independent, the administrative nurse had not evaluated the resident for a restorative program due to time constraints. Facility policy required such evaluations, but this was not conducted, resulting in a deficiency.
A facility failed to implement individualized toileting interventions for a resident with bowel and bladder incontinence. Despite being a good candidate for retraining, the resident's care plan lacked specific instructions for a toileting program and did not address behaviors linked to previous homelessness. Staff were expected to provide reminders, but no structured retraining program was in place, placing the resident at risk for complications.
The facility failed to provide trauma-informed care for three residents with PTSD, as it did not identify trauma-based triggers or implement individualized interventions to prevent re-traumatization. Despite having policies in place, the facility's staff were unaware of the residents' PTSD diagnoses and did not perform necessary assessments or create care plans with specific interventions. This placed the residents at risk for decreased psychosocial well-being and ineffective treatment.
The facility failed to provide individualized behavioral care interventions for three residents with mental health diagnoses, including schizophrenia, PTSD, and bipolar disorder. The care plans lacked specific interventions for managing behaviors such as resistance to care, inappropriate toileting, and verbal outbursts. Staff interviews revealed a lack of awareness of individualized interventions, and the facility's policy on behavioral health services was not effectively implemented, placing residents at risk for continued behavioral episodes and unmet care needs.
The facility's Consultant Pharmacist failed to identify and report deficiencies in medication orders for two residents. One resident's diclofenac order lacked a specified dosage, while another resident's heart rate was outside physician-ordered parameters, and required lab tests were missing. These oversights placed the residents at risk for unnecessary medications and complications.
The facility failed to follow physician orders for lab tests and vital sign monitoring for a resident with diabetes and hypertension, and did not ensure proper dosing instructions for Voltaren gel for two residents. This led to risks of unnecessary medication use and potential side effects. The facility lacked policies related to physician orders and medication dosing.
The facility failed to ensure that PRN psychotropic medications for two residents had a 14-day stop date or specified duration, placing them at risk for unnecessary medication administration. One resident had PRN orders for hydroxyzine, Seroquel, and Haloperidol without proper documentation, while another had a PRN order for Trazodone lacking a stop date. Staff interviews revealed uncertainty about medication order requirements, and the facility lacked a policy for monitoring psychotropic medications.
The facility failed to document the COVID-19 vaccination status for two residents, lacking records of offers, declinations, or contraindications. Interviews indicated that the responsibility for tracking immunizations was with the Infection Preventionist, but the facility could not provide a policy or signed consents. This oversight increased the residents' risk for COVID-19.
A resident with a history of self-harm and aggressive behaviors was physically and chemically restrained by facility staff without proper physician orders or documentation. The resident, diagnosed with multiple mental health disorders, became combative and attempted self-harm, leading staff to use restraints without adequate assessment or care planning.
A resident with multiple mental health diagnoses exhibited severe aggressive and self-harming behaviors, leading to the use of unauthorized chemical and physical restraints by the facility. The facility failed to effectively implement the resident's care plan and lacked a policy for restraint use, resulting in inadequate management of the resident's agitation and placing him in immediate jeopardy.
Improper Food Storage and Handling in Dietary Department
Penalty
Summary
Surveyors observed multiple instances of improper food storage during a tour of the facility's kitchen and storage areas. In the standing freezer, a package of shredded potatoes was found open to air, and in a chest freezer, a box of pork sausage patties was also open to air. In the dry storage area, a package of lemon pudding mix, a large package of butterscotch chocolate chips, and a large package of Italian dressing mix were all found open to air. Additionally, a large can of sliced apples and a small can of sliced mushrooms were noted to be dented. In the standing refrigerator, a large package of yellow/white shredded cheese mixture was open to air. During interviews, dietary staff indicated they were not aware that food containers should be closed, and administrative staff confirmed that all food items should be closed and dented cans should be returned or discarded. The facility's policy required food and non-food supplies to be stored under sanitary and safe conditions, with dented cans to be returned or destroyed. The facility had a census of 42 residents, with one central kitchen and one dining area at the time of the survey.
Deficient Infection Control in Laundry Handling and Processing
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding the handling and processing of laundry. Observations revealed that a CNA transported soiled laundry in an uncovered bin down the hallway, with laundry overflowing from the container. On another occasion, the same CNA transported a closed dirty laundry bin with an open basket of soiled laundry placed on top, also overflowing. The CNA confirmed she was unaware that soiled laundry needed to be covered during transport. Administrative nursing staff confirmed that all laundry should be covered during transport to prevent cross-contamination and the spread of infection. Further observation in the laundry area, with laundry staff present, identified a wood table used for folding and processing clean laundry that had chipped laminate and exposed bare wood, creating a surface that could not be properly sanitized. Laundry staff acknowledged the unsanitizable condition of the table and agreed it required repair. The facility's infection surveillance policy requires proper cleansing and disinfection of surfaces and equipment used for handling, processing, and transporting linens, which was not followed in these instances.
Incomplete Care Area Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete Care Area Assessments (CAAs) that addressed the individual underlying causes, contributing factors, and risk factors for five residents. For these residents, the CAAs triggered by the Minimum Data Set (MDS) assessments, such as those related to psychotropic drug use, dental care, behavioral symptoms, and cognitive loss/dementia, lacked required analysis of findings. The documentation did not include an analysis of the residents' conditions or the factors contributing to their care needs, as required by facility policy and federal guidelines. Staff interviews revealed that the MDS nurse responsible for completing the CAAs was not adequately educated on how to complete the CAA notes, resulting in incomplete documentation. Administrative staff confirmed that the CAAs were not completed as they should have been and lacked necessary analysis and risk findings. The facility's policy required that each triggered CAA be fully assessed and documented, but this was not done for the identified residents, placing them at risk for inadequate care due to unidentified care needs.
Inaccurate MDS Documentation for Medications, Restraints, and WanderGuard Alarms
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for seven residents, resulting in documentation errors related to medication administration, use of physical restraints, and the presence of WanderGuard alarms. Specifically, two residents had their non-insulin hypoglycemic medications (Ozempic, Metformin, and Trulicity) incorrectly coded as insulin, and these medications were not properly documented in the MDS. One resident was incorrectly coded as having a physical restraint due to the use of a bed positioning device, despite using it for mobility and independence rather than restraint. Four residents with physician orders for WanderGuard alarms were not accurately documented as having these devices in their MDS assessments. These inaccuracies were identified through observation, interviews, and record reviews. The MDS nurse responsible for completing the assessments acknowledged making errors in coding medications and WanderGuard alarms, attributing some mistakes to limited time and infrequent presence in the facility. Another administrative nurse reported that she expected the MDS to be accurate and that she reviewed and signed off on the assessments, but errors still occurred. The facility's policy requires that assessments accurately reflect the resident's status at the time of assessment, which was not met in these cases.
Medication Error Rate Exceeds Five Percent Due to Insulin Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, when two insulin administration errors were observed out of 25 medication opportunities, resulting in an eight percent error rate. Specifically, a licensed nurse administered insulin to a resident with diabetes mellitus without priming either the insulin lispro or insulin glargine pens, did not verify the insulin orders against the medication administration record at the time of preparation, and did not follow manufacturer instructions for the duration the pen button should be depressed during injection. The nurse kept the insulin pen button pressed for only two seconds for both types of insulin, despite manufacturer instructions specifying five seconds for insulin lispro and ten seconds for insulin glargine to ensure full dose delivery. Interviews revealed that the nurse was unsure of the required duration for keeping the insulin needle in the skin and did not follow the facility's policy, which mandates verification of medication orders and adherence to proper administration technique. The administrative nurse confirmed the expectation that all medication orders be verified with the medication administration record prior to administration. The facility's policy also requires that the medication be administered at the proper time, in the prescribed dose, and by the correct route, with specific instructions for insulin pen use that were not followed in this instance.
Failure to Ensure Palatable and Properly Prepared Meals
Penalty
Summary
The facility failed to ensure that meals were prepared in a manner that preserved or promoted palatability for its residents. During the preparation of a noon meal consisting of turkey, stuffing, mixed vegetables, and a dinner roll, a dietary staff member prepared a gravy by combining chicken base, water, and an unspecified amount of corn starch without following a written recipe. The resulting mixture was water-thin and described as a broth rather than a traditional gravy. The dietary staff member was unable to provide a recipe for the gravy, stating that she had memorized it from experience. Administrative staff observed the meal service and confirmed that the mixture served over the turkey and dressing did not resemble gravy and was not appealing. Additionally, the facility was unable to provide a policy related to food palatability when requested. The lack of adherence to standardized recipes and absence of a relevant policy contributed to the deficiency in meal preparation and presentation.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents and/or their representatives were properly informed and provided with documented consent regarding the use of psychotropic medications. Review of the Psychoactive Medication Therapy Informed Consent Form logbook revealed that consent forms for multiple psychotropic medications, including Invega, Haldol, Abilify, lithium, Ativan, trazodone, and Zyprexa, lacked signatures from the appropriate residents or their guardians. Specifically, consent forms for one resident were missing the resident's signature, while consent forms for another resident were missing the guardian's signature. Additionally, the electronic medical records for both residents did not contain documentation of informed consent for these medications. Interviews with facility staff indicated confusion and lack of clarity regarding the process for obtaining and documenting informed consent. Social Services staff reported being newly assigned to the task and were unaware of the requirement for guardian signatures when applicable. Administrative nursing staff acknowledged the missing signatures and described a practice of signing consent forms in advance or delegating the task to others, which resulted in incomplete documentation. The facility's policy required discussion of risks and benefits with residents or responsible parties, but this was not consistently documented or followed.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a person-centered baseline care plan within the required 48-hour timeframe for a newly admitted resident. The resident's electronic health record showed that only some components of the baseline care plan were completed over a period of days, with two essential components—General Information and Initial Goals and Health Conditions—remaining incomplete as of nearly two weeks after admission. Interviews revealed that the nurse responsible for admitting the resident did not complete the baseline care plan as required, and administrative staff were unaware of the 48-hour completion requirement. The facility's policy stated that an initial person-centered care plan should be developed within 48 hours of admission, but this was not followed in the case reviewed.
Failure to Offer and Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer the pneumococcal vaccine to three residents, as evidenced by the absence of documentation in their electronic medical records showing that the vaccine was offered, provided, or that informed declination was obtained. Specifically, the records for these residents did not contain evidence of education regarding the benefits and potential side effects of the immunization, nor any indication that the vaccine was administered or declined. An administrative nurse confirmed these findings and noted that while the facility attempts to vaccinate eligible residents, insurance coverage issues sometimes prevent administration. The facility's immunization policy requires that each resident or their representative receive current education and be offered the influenza and pneumococcal vaccines, but this process was not documented for the affected residents.
Failure to Implement Nutritional Interventions for Resident
Penalty
Summary
The facility failed to identify and implement nutritional interventions for a resident, referred to as R27, who experienced significant weight loss over two separate periods. Initially, between January and June, R27 lost 19.52% of her body weight without any documented intervention or prescribed weight loss program. Despite the resident's medical history, which included schizophrenia, asthma, and a history of fractures, the facility did not provide adequate nutritional support or monitoring during this time. In the subsequent period from August to January, R27 continued to lose weight, amounting to a 16.84% decrease. The facility's records showed a lack of timely dietary supplementation and intervention, as R27's care plan was only updated in November to include one-to-one assistance during meals and supplemental shakes. The facility's failure to act promptly on R27's weight loss and dietary needs was compounded by inadequate communication with the registered dietician, who was not informed of the resident's significant decline and was not included in care plan meetings. Observations and interviews with staff revealed that R27 required constant supervision and assistance during meals due to cognitive impairments and behaviors that affected her eating. Despite these needs, the facility did not have a certified dietary manager, and the registered dietician reported a lack of communication regarding changes in residents' weights and dietary intake. The facility's nutritional services policy, which required monitoring and intervention for residents at risk of significant weight loss, was not effectively implemented, leading to R27's continued weight decline and risk of malnourishment-related complications.
Lack of Certified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the director of food and nutrition services possessed the required qualifications of a Certified Dietary Manager (CDM). During an observation on January 13, 2025, at 07:17 AM, Dietary BB admitted to not having CDM certification, although she had completed her Safe Serv courses. She was unaware of the need to obtain CDM certification. Additionally, the registered dietician was only present at the facility once a month. On January 15, 2025, at 03:42 PM, Administrative Staff A expressed the belief that the presence of a registered dietician negated the necessity for the dietary manager to be certified. The facility was unable to provide a policy regarding the CDM qualifications when requested. This deficiency placed residents at risk for unmet dietary and nutritional needs.
Improper Thawing of Meat in Kitchen
Penalty
Summary
The facility, with a census of 45 residents, was found to have a deficiency in its food handling practices. During an initial tour of the kitchen, a pork loin was observed thawing in a three-bin wash sink without water running over it. This method of thawing meat does not comply with professional standards, which require meat to be thawed on the bottom shelf of the refrigerator or in a tub with running water if thawed in the sink. Dietary staff confirmed the correct procedures for thawing meat, indicating a failure to adhere to these standards. This oversight placed residents at risk for food-borne illnesses due to potential bacterial growth.
Failure to Document and Offer Vaccinations
Penalty
Summary
The facility failed to offer or obtain informed declinations, consent, or a physician-documented contraindication for influenza and pneumococcal vaccinations for several residents, including R5, R16, R19, R27, and R30. The clinical records of these residents lacked documentation indicating whether the influenza and PCV20 vaccinations were offered, declined, or administered, and there was no physician-documented contraindication. This oversight placed the residents at an increased risk for influenza, pneumonia, and related complications. Interviews with facility staff revealed that the pharmacy administered immunizations annually, and residents were typically offered vaccinations upon admission. However, it was noted that some residents or their legal guardians reported prior immunizations, and in some cases, the facility did not offer vaccinations due to concerns about upsetting legal guardians. Additionally, the facility did not offer the PCV20 vaccine to residents at risk of pneumonia because Medicaid did not cover the cost. The facility's immunization policy emphasized the importance of offering vaccines unless contraindicated or refused after appropriate education, but this policy was not consistently followed, leading to the identified deficiencies.
Failure to Document Resident Transfer to Hospital
Penalty
Summary
The facility failed to document the transfer of a resident, identified as R39, to an acute hospital, which placed the resident at risk for uninformed care choices. R39 had a history of mental health disorders, including PTSD, major depressive disorder, suicidal ideations, bipolar disorder, anxiety, and borderline personality disorder. Despite having intact cognition and being independent with her functional abilities, R39 was transferred to a psychiatric hospital without proper documentation of when, where, and why the transfer occurred. The facility's records, including the Electronic Medical Record (EMR) and Progress Notes, lacked documentation regarding the transfer, and the facility did not provide a policy on transfer and discharge when requested. Interviews with facility staff revealed that R39 was on therapeutic leave with her mother when she attempted suicide and was subsequently taken to a psychiatric hospital by her mother. The facility was unaware of R39's admission to the hospital until they received a call from the hospital stating that R39 had been discharged and needed to be transported back to the facility. The lack of documentation and communication regarding R39's transfer to the psychiatric hospital highlights a deficiency in the facility's procedures for managing resident transfers and discharges.
Failure to Provide Written Notification of Transfers
Penalty
Summary
The facility failed to provide written notification of transfer for two residents, R39 and R20, during facility-initiated transfers. R39, who had a history of mental health disorders including PTSD, major depressive disorder, and bipolar disorder, was transferred to a psychiatric hospital without written notification. The facility did not document the transfer in R39's progress notes, and staff stated that since R39 was on leave with her mother at the time of the transfer, they did not issue a written notification. This oversight placed R39 at risk for uninformed care choices. R20, who had diagnoses of bipolar disorder, epilepsy, and anxiety, was transferred to the hospital on multiple occasions without receiving written notification of the transfers. The facility's records showed that R20 was transferred and admitted to the hospital on several dates, but there was no evidence of written notice provided to R20 or his legal representative. The facility relied on phone notifications to the resident's legal guardian or family representatives, which did not meet the requirement for written notification. The facility was unable to provide a policy related to facility-initiated transfers for both residents. This lack of documentation and failure to provide written notifications for transfers placed both residents at risk of uninformed choices and miscommunication regarding their care needs.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for two residents, leading to potential risks for inappropriate comprehensive care. Resident 28's MDS was incorrectly coded to include treatments and services such as dialysis, hospice care, and mechanical ventilation, which the resident did not receive. This error was acknowledged by the administrative nurse responsible for completing the MDS, who admitted to making a mistake. The facility was unable to provide an MDS Accuracy policy upon request, highlighting a lack of procedural guidance. Resident 39's MDS assessments failed to include a diagnosis of post-traumatic stress disorder (PTSD), despite the resident having a documented history of PTSD. The omission was attributed to difficulties in obtaining documentation from the resident's previous facility, resulting in the PTSD diagnosis being excluded from the MDS. This oversight meant that the resident's care plan did not address PTSD-related triggers or interventions, potentially impacting the resident's care and well-being. Both cases demonstrate a failure in the facility's processes for accurately completing MDS assessments, which are crucial for developing appropriate care plans. The inaccuracies in the MDS coding for these residents placed them at risk for receiving care that did not fully address their needs. The facility's inability to provide relevant policies further underscores the deficiencies in their assessment and documentation procedures.
Failure to Develop Individualized Trauma-Based Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, R30 and R39, which included individualized person-centered interventions for their trauma-based care. R30's care plan lacked specific interventions to address her PTSD, despite her diagnoses of PTSD, tardive dyskinesia, schizoaffective disorder, and anxiety. The care plan did not identify ways to decrease exposure to triggers that could re-traumatize her. Staff interviews revealed a lack of awareness and training regarding trauma-based care plans, with some staff unaware of which residents had PTSD or how to prevent re-traumatization. R39's care plan also failed to address her PTSD, despite her diagnoses of PTSD, major depressive disorder, suicidal ideations, anxiety, bipolar disorder, and borderline personality disorder. The care plan included general interventions for aggressive behaviors but did not include specific strategies to mitigate triggers or prevent re-traumatization related to her PTSD. Interviews with administrative nurses confirmed that R39's care plan was not individualized to her specific needs and behaviors. The facility was unable to provide a policy related to the development of person-centered care plans, and staff interviews indicated a lack of trauma-based assessments and individualized interventions. The absence of a social service staff member further contributed to the deficiency in addressing the residents' trauma-based care needs. This lack of comprehensive care planning placed both residents at risk for impaired care and re-traumatization due to uncommunicated care needs.
Failure to Revise Care Plan for Resident's Incontinence and Behavioral Needs
Penalty
Summary
The facility failed to revise the care plan for Resident 3 to accurately reflect his care needs related to incontinence, activities of daily living (ADLs), and behaviors. Despite having a comprehensive assessment that identified his needs, the care plan lacked specific interventions and instructions for managing his incontinence and behavioral issues. The resident, who has a history of schizophrenia, diabetes mellitus, and asthma, was noted to be occasionally incontinent of his bladder and required supervision during ADLs. However, the care plan did not include a toileting program or strategies to address his resistance to care, which was influenced by his previous lifestyle of homelessness. Observations and interviews revealed that the care plan did not provide individualized interventions for the resident's behaviors, such as defecating in inappropriate places due to his past experiences. Staff members, including a Certified Medication Aide and an Administrative Nurse, acknowledged the resident's history of rejecting care and the need for a care plan that includes specific behaviors and interventions. The facility was unable to provide a policy related to the development of a person-centered care plan, which contributed to the deficiency in addressing the resident's care needs effectively.
Failure to Implement ROM Program for Resident
Penalty
Summary
The facility failed to implement a range of motion (ROM) program for Resident 16, who was at risk of decreased mobility and potential development of contractures. Resident 16's medical history included schizophrenia, cerebral infarction, hemiplegia, chronic pain, insomnia, and PTSD. The resident had limited ROM on one side of the body and required partial to moderate assistance with dressing. Despite these needs, there was no evidence in the electronic medical record (EMR) that ROM or restorative care was provided to the resident. Observations and interviews revealed that Resident 16 expressed a desire to maintain mobility and independence. However, the administrative nurse responsible for evaluating residents for restorative programs had not assessed Resident 16 due to time constraints. Both the certified medication aide and a licensed nurse acknowledged that the resident would benefit from a ROM program. The facility's policy stated that residents should be evaluated for restorative programs upon admission and after significant changes in condition, but this was not done for Resident 16, leading to the deficiency.
Failure to Implement Individualized Toileting Interventions
Penalty
Summary
The facility failed to implement individualized toileting interventions for a resident, identified as R3, who was occasionally incontinent of bowel and bladder. Despite being noted as a good candidate for retraining in multiple assessments, R3's care plan lacked specific instructions for a toileting program or the use of incontinence products. The care plan also failed to address R3's history of defecating and urinating in his room, a behavior linked to his previous homelessness. Staff were expected to provide reminders for toileting every two hours, but there was no evidence of a structured retraining program being in place. R3's medical history included schizophrenia, diabetes mellitus, and asthma, with a BIMS score indicating intact cognition. The resident was independent in most activities of daily living but required supervision and encouragement due to resistive behavior. Interviews with staff revealed that R3's incontinence and behavioral needs were not adequately documented in the care plan, and the facility did not have a retraining program for incontinence. This oversight placed R3 at risk for complications related to incontinence, as the facility's policy required individualized continence management programs based on pattern evaluations.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for three residents diagnosed with posttraumatic stress disorder (PTSD), namely R30, R16, and R39. The facility did not identify trauma-based triggers or implement individualized interventions to prevent re-traumatization. For R30, the care plan lacked specific interventions to decrease exposure to triggers, despite her intact cognition and history of verbal behaviors. Staff members, including a Certified Medication Aide and a Licensed Nurse, were unaware of which residents had PTSD or required trauma-based care plans. R16, who had moderately impaired cognition and a history of schizophrenia and PTSD, also did not have a care plan with individualized interventions to prevent re-traumatization. The facility's staff, including the MDS coordinator and an administrative nurse, acknowledged the absence of trauma-based assessments and interventions, citing the facility's small size and lack of social service staff as reasons for not having individualized care plans. R39's care plan did not address her PTSD, despite her intact cognition and history of major depressive disorder and bipolar disorder. The facility failed to perform a trauma-informed care assessment upon her admission, and staff were unaware of her PTSD diagnosis until a month after her admission. The facility's Behavioral Health Services policy stated that residents with a history of trauma should receive appropriate treatment, but this was not implemented for R39, placing her at risk for decreased psychosocial well-being and ineffective treatment.
Failure to Implement Individualized Behavioral Care Interventions
Penalty
Summary
The facility failed to implement individualized behavioral care interventions for three residents, R3, R30, and R39, who were reviewed for behavioral services. For R3, the facility did not provide adequate interventions for his behavioral symptoms, which included resistance to care, defecating on the floor, and urinating in inappropriate places. Despite having a care plan that identified potential aggressive behaviors, the plan lacked specific interventions for his refusals to complete self-care and his incontinence issues. Progress notes repeatedly documented his resistance to care and inappropriate toileting behaviors, but they did not specify what behavioral interventions were used during these episodes. R30's care plan was also found lacking in individualized interventions for her behavioral symptoms, which included verbal behaviors and refusal to take medications. Although she had a history of PTSD and other mental health diagnoses, her care plan did not include specific interventions to address her triggers or prevent re-traumatization. Staff interviews revealed a lack of awareness of individualized interventions for her behaviors, and the facility's policy on behavioral health services was not adequately implemented to ensure person-centered care. Similarly, R39's care plan did not address her PTSD diagnosis or provide specific interventions for her anxiety, depression, and bipolar disorder. Her care plan included general strategies for managing aggressive behaviors but did not identify triggers or interventions specific to her mental health needs. Interviews with administrative nurses confirmed that her care plan was not individualized, and the facility's policy on behavioral health services was not effectively applied to meet her needs. These deficiencies placed the residents at risk for continued behavioral episodes and unmet care needs.
Consultant Pharmacist Fails to Identify Medication Order Deficiencies
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported deficiencies in medication orders for two residents, R5 and R19. For R5, the CP did not report that the physician's order for diclofenac, a non-steroidal anti-inflammatory medication, lacked a specified dosage. This oversight was noted in the Medication Regimen Review (MRR) for November and December 2024. Interviews with facility staff revealed a lack of awareness regarding the necessity of specifying a dosage for topical medications like diclofenac, which placed R5 at risk for unnecessary medications and related complications. For R19, the CP failed to identify and report that the resident's heart rate was outside the physician-ordered parameters on multiple occasions over a 73-day period. Additionally, the CP did not report the absence of physician-ordered laboratory test results in R19's clinical record. The facility was unable to provide these test results upon request, indicating a lapse in monitoring and documentation. Interviews with staff highlighted a breakdown in communication and responsibility for notifying physicians about out-of-parameter vital signs and ensuring laboratory tests were conducted as ordered. The facility's Drug Regimen Review policy mandates that the CP perform a drug regimen review for each resident at least monthly, including monitoring for irregularities in medication orders and ensuring appropriate documentation and notification of any issues. The failure to adhere to this policy for both R5 and R19 resulted in deficiencies that placed the residents at risk for unnecessary medications and related complications.
Failure to Follow Physician Orders and Ensure Proper Medication Dosing
Penalty
Summary
The facility failed to ensure that the physician's orders were followed for Resident 19's laboratory tests to monitor high-risk medications and did not notify the physician when heart rates were outside the ordered parameters. Resident 19, who had diagnoses of diabetes mellitus and hypertension, was supposed to have regular laboratory tests and monitoring of vital signs as per physician orders. However, the facility's records lacked evidence of these tests being conducted, and there was no documentation of physician notification when the resident's heart rate was outside the specified parameters on multiple occasions. For Resident 16, the facility did not ensure proper dosing instructions for the application of Voltaren gel, a topical pain reliever. Resident 16, who had multiple diagnoses including schizophrenia and chronic pain, was prescribed Voltaren gel to be applied to specific areas. However, the facility staff were unsure about the dosage requirements, and the facility was unable to provide a policy related to physician orders, leading to a risk of unnecessary medication use and potential side effects. Similarly, Resident 5's physician order for diclofenac gel lacked a specified dosage amount. Resident 5, who had a history of schizophrenia and a stress fracture, was at high risk of falls and was prescribed diclofenac gel for knee pain. The facility failed to identify and report the missing dosage information, which could lead to unnecessary medication use and related complications. The facility was unable to provide a policy regarding unnecessary medications, further contributing to the deficiencies observed.
Failure to Ensure PRN Psychotropic Medications Have Stop Dates
Penalty
Summary
The facility failed to ensure that as-needed (PRN) psychotropic medications for two residents, R30 and R16, had a 14-day stop date or a specified duration with supporting physician documentation. This oversight was identified during a review of the residents' electronic medical records (EMR) and interviews with facility staff. The absence of a stop date or specified duration for these medications placed the residents at risk for unnecessary medication administration and potential adverse side effects. Resident R30 had a history of posttraumatic stress disorder, tardive dyskinesia, schizoaffective disorder, and anxiety. The resident's care plan included the administration of psychotropic medications as ordered by the physician. However, the EMR revealed that PRN orders for hydroxyzine, Seroquel, and Haloperidol lacked a 14-day stop date or a physician-ordered specific duration. Additionally, a physician order to discontinue Seroquel was not followed, as it was not discontinued as ordered. Interviews with facility staff indicated a lack of clarity regarding the requirement for a duration in PRN psychotropic medication orders. Resident R16, diagnosed with schizophrenia, cerebral infarction, hemiplegia, chronic pain, insomnia, and PTSD, also had PRN orders for Trazodone without a 14-day stop date or specified duration. The facility was unable to provide a policy related to monitoring psychotropic medications, and staff interviews revealed uncertainty about the requirements for PRN psychotropic medication orders. This deficiency in medication management practices placed both residents at risk for unnecessary medication administration and possible adverse side effects.
Failure to Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to offer or obtain informed declinations or a physician-documented contraindication for the COVID-19 vaccinations for two residents, identified as R16 and R5. Upon review of their clinical records, it was found that there was no documentation under the Immunization tab indicating that the COVID-19 vaccination was offered, declined, or administered. Additionally, there was no physician-documented contraindication present in their records. This lack of documentation and action placed these residents at an increased risk for COVID-19. Interviews with facility staff revealed that the responsibility for tracking immunizations was with Administrative Nurse D, who also served as the facility's Infection Preventionist. It was noted that the pharmacy visited the facility annually to administer immunizations, and residents were offered vaccinations upon admission. However, the facility was unable to provide a policy related to the administration of COVID-19 vaccinations, nor could they provide signed consents or declinations for the residents in question. This oversight in documentation and procedure led to the identified deficiency.
Failure to Ensure Resident Remained Free from Restraints
Penalty
Summary
The facility failed to ensure that a resident, who had a history of self-harm and aggressive behaviors, remained free from physical and chemical restraints. On multiple occasions, the resident attempted to injure himself and became combative with staff, leading to the use of both chemical and physical restraints. The facility did not have physician orders for the use of these restraints, nor did they document any assessments or person-centered care planning related to the restraint use. The resident had multiple diagnoses, including bipolar disorder with psychotic features, major depressive disorder, ADHD, PTSD, and autistic disorder. Despite these conditions, the facility did not assess the resident's mental status adequately and failed to identify any medical or behavioral symptoms that warranted the use of restraints. The care plan for the resident included monitoring behavior episodes and attempting to determine underlying causes, but it did not include any specific strategies for managing the resident's aggressive behaviors without resorting to restraints. During the incidents, the resident exhibited severe agitation and aggression, including making threats, attempting self-harm, and physically attacking staff. The facility staff responded by physically restraining the resident with the help of multiple staff members and using a bedsheet to further restrain him. The resident was also chemically sedated with medications like Haldol and Ativan. These actions were taken without proper documentation or physician orders, placing the resident in immediate jeopardy.
Removal Plan
- The facility completed a violence risk screening on all current residents.
- The facility revised care plan for residents identified at high risk for assault identified in the screening tool.
- The facility began educating staff on the Federal Guidelines on the use of restraints.
- The facility assigned online training for Handling Aggressive Behaviors, Overview of Abuse and Neglect of Individuals with IDD, Understanding Wandering and Elopement, and the Meaning Behind Behaviors.
Inadequate Response to Resident's Aggressive Behavior
Penalty
Summary
The facility failed to appropriately acknowledge and respond to a resident's behaviors related to his psychosocial disorder and physical aggression. The resident, diagnosed with bipolar disorder, major depressive disorder, ADHD, PTSD, and autistic disorder, exhibited severe aggressive and self-harming behaviors over several days. On multiple occasions, the resident made threats to harm himself and others, engaged in self-injurious actions, and became physically aggressive towards staff, necessitating intervention to prevent harm. The facility's response included the use of chemical and physical restraints without proper physician orders, as evidenced by the lack of documentation in the Electronic Medical Record. The resident's care plan, which was supposed to address his behavior problems, was not effectively implemented. Staff interventions were inadequate, as they failed to de-escalate the resident's agitation and resorted to physical restraint methods that were not authorized or documented. The facility also lacked a policy for the use of restraints, further complicating the situation. The resident's aggressive episodes were exacerbated by anxiety related to legal issues, and the facility's attempts to manage these episodes included calling law enforcement and administering medications like Haldol and Ativan. Despite these efforts, the facility's actions were insufficient to prevent the resident from harming himself and others, leading to the use of unauthorized restraints and placing the resident in immediate jeopardy.
Removal Plan
- The facility completed a violence risk screening on all current residents.
- The facility revised care plan for residents identified at high risk for assault identified in the screening tool.
- The facility began educating staff on the Federal Guidelines on the use of restraints.
- The facility assigned online training for Handling Aggressive Behaviors, Overview of Abuse and Neglect of Individuals with IDD, Understanding Wandering and Elopement, and the Meaning Behind Behaviors.
Latest citations in Kansas
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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