Advanced Health Care Of Overland Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Overland Park, Kansas.
- Location
- 4700 Indian Creek Parkway, Overland Park, Kansas 66207
- CMS Provider Number
- 175542
- Inspections on file
- 16
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Advanced Health Care Of Overland Park during CMS and state inspections, most recent first.
The facility failed to submit completed abuse/neglect investigations to the State Agency (SA) within the required five working days for two residents. In one case, a resident’s representative reported that the resident used the call light for urgent medical assistance during the night, staff did not respond in a timely manner, and the resident remained unattended while in acute physical distress. In another case, a resident with a clogged catheter was reportedly pushed into the lobby for discharge so a new admission could use the room, and the resident was instead sent to the hospital at the representative’s request. Although both allegations were reported to the SA, the completed investigations were not submitted on time due to miscommunication and assumptions between administrative staff, and the facility’s abuse policy did not specify the required timeframe for submission to the SA.
The facility failed to complete and submit required abuse/neglect investigations after allegations from two residents’ representatives. In one case, a resident’s representative reported that the resident used the call light for urgent help during the night, was left unattended while in acute distress, and vomited without timely staff response. In the other case, a resident’s representative alleged the resident had a clogged catheter and was pushed into the lobby for discharge so a new admission could take the room, leading the representative to cancel the discharge and request hospital transfer. Although staff obtained witness statements, reviewed the chart, and in one case reviewed video footage, the facility did not produce the written investigative summaries and complete documentation required by its abuse policy, and only partial materials were available when requested by the SA and surveyors.
The facility failed to maintain sanitary dietary standards, with multiple instances of improperly labeled and undated food items found in the kitchen's storage areas. Dietary staff acknowledged the requirement for labeling and dating food packaging, as per the facility's policy, but the failure to adhere to these standards placed residents at risk of food-borne illnesses.
The facility failed to implement a policy to prevent employing staff with criminal backgrounds, as evidenced by not conducting a required background check for an LN hired to work weekends. The LN was initially hired for home health and hospice services, and the facility did not perform its own check when the LN transitioned to the facility. This oversight placed residents at risk for abuse and neglect.
The facility failed to secure hazardous materials, such as medicated ointments and bleach wipes, in unlocked treatment carts accessible to eight cognitively impaired residents. Staff interviews confirmed that these items should be locked away, as per the facility's policy, to prevent accidents and injuries.
A resident with a history of fractures and mild cognitive impairment was found without access to her call light, which was on the floor and out of reach. Despite facility policies and staff statements emphasizing the importance of call light accessibility, the resident's call light was not within reach, placing her at risk for unmet care needs.
A facility failed to provide a resident with a CMS Notice of Medicare Non-Coverage (NOMNC) Form upon discharge from Medicare A services. The resident, with intact cognition, was discharged home without receiving the required notice, despite having benefit days remaining. The facility's policy required providing the NOMNC at least two days before service termination, which was not followed.
A resident with pancreatic cancer and at risk for skin breakdown did not receive consistent bathing opportunities as per the care plan. Despite a policy for twice-weekly baths, records showed missed opportunities, and the resident reported poor hygiene conditions. Upon hospital transfer, the resident was found with a pressure injury and poor hygiene, highlighting documentation and care inconsistencies.
A resident with an indwelling urinary catheter was at risk for complications due to improper positioning of the urine collection bag above bladder level, contrary to facility policy. Staff interviews confirmed the requirement for the bag to be below bladder level for proper drainage.
The facility failed to serve meals at appropriate temperatures, affecting two residents who reported receiving cold meals, particularly during breakfast. Temperature tests confirmed the food was below the safe range. Staff interviews revealed concerns about meal delivery times and the need for temperature checks, highlighting a deficiency in maintaining food service standards.
The facility failed to maintain sanitary infection control standards for biliary drains and Foley catheters, placing residents at risk for infections. Observations showed catheter and drainage bags resting on the floor, contrary to policy. Staff interviews confirmed expectations for proper placement, but compliance was lacking.
Failure to Submit Completed Abuse/Neglect Investigations Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to submit completed abuse/neglect investigations to the State Agency (SA) within the required five working-day timeframe for two residents. For one resident, the facility reported an allegation to the SA that the resident’s representative had emailed the facility stating that, between 2:00 AM and 3:00 AM, the resident activated the call light for urgent medical assistance, staff did not respond in a timely manner, and the resident remained unattended while in acute physical distress. The intake was documented at 3:00 PM the same day, and the facility spoke with the resident, who did not remember what time she vomited. Although the allegation was reported to the SA, the facility did not submit the completed investigation within five working days as required. For the second resident, the facility reported an allegation to the SA that the resident had a clogged catheter and staff pushed him into the lobby for discharge so a new admission could have his room. The resident’s representative canceled transportation for the discharge, and the resident went to the hospital at the representative’s request. This allegation was also reported to the SA, but the completed investigation was not submitted within five working days. During interviews, an administrative nurse stated she did not submit the completed investigations for either resident to the SA, and an administrative staff member stated he assumed the nurse had submitted one investigation and did not submit the other because he thought she had done so. The facility’s abuse policy required the Administrator or DON to complete a written investigation summary within five working days of the reported occurrence but did not address the timeframe for submitting completed investigations to the SA.
Failure to Complete and Submit Abuse/Neglect Investigations for Two Residents
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to complete and submit thorough abuse/neglect investigations for two residents after receiving allegations from their representatives. For the first resident, who had been admitted and later discharged home, the State Agency (SA) received an intake alleging that between 2:00 AM and 3:00 AM the resident activated the call light for urgent medical assistance, staff did not respond in a timely manner, and the resident remained unattended while in acute physical distress, including vomiting, which she later reported to her representative. The facility interviewed the resident, who did not recall the time she vomited, and staff were interviewed about events on and around the alleged date. However, when surveyors and the SA requested a completed investigation, the facility only produced staff witness statements and did not provide a written investigative summary or other required documentation. For the second resident, who had been admitted and later transferred to the hospital, the SA received an intake alleging that the resident’s catheter was clogged and that staff pushed the resident into the lobby for discharge so a new admission could use the room; the representative canceled the discharge and arranged for hospital transfer. Facility staff reported that the DON/designee reviewed catheter care notes and that an administrator reviewed video footage of the discharge and documented a brief note, and two nurses were contacted for their recollection of events. Despite these steps, the facility again failed to provide a completed investigation to the SA or onsite surveyors, supplying only staff witness statements. Interviews with the Administrative Nurse and Administrative Staff revealed that each assumed the other had submitted the completed investigations, and no written summary consistent with the facility’s abuse policy—requiring a completed investigation with a written summary of findings within five working days—was produced for either allegation.
Deficient Food Storage Practices
Penalty
Summary
The facility failed to maintain sanitary dietary standards related to food storage, as observed during a survey. Multiple instances of improperly labeled and undated food items were found in the kitchen's dry food storage room, main kitchen area, and walk-in freezer. These included containers of pistachios, puree pasta mix, honey wheat flavoring, potato pearls mashed potatoes, white rice, browning and seasoning sauce, bran flakes, brown powder, pie filling mix, yellow cake mix, pretzels, carrots, green beans, hashbrowns, and steaks. The lack of labeling and dating on these items was noted during observations conducted on specific dates and times. Dietary staff acknowledged the requirement for food packaging to be labeled and dated when opened, as per the facility's Food Storage policy. This policy, created in January 2021, mandates that all high-risk foods be visibly date-marked to indicate their safe use-by dates. The policy also requires that all containers be legibly and accurately labeled and dated, and that frozen foods be covered, labeled, and dated. Despite these guidelines, the facility's failure to adhere to these standards placed residents at risk of food-borne illnesses and food safety concerns.
Failure to Conduct Timely Background Checks for Staff
Penalty
Summary
The facility failed to develop and implement a policy that effectively prohibited and prevented the employment of staff with criminal backgrounds. This deficiency was identified when the facility did not conduct a required criminal background check for a Licensed Nurse (LN) who was hired to work weekends. The LN was initially hired for home health and hospice services under the same company, which had completed a background check. However, when the LN transitioned to work at the facility, the facility did not perform its own background check, as required. The facility's policy allowed for a 10-day period after employment to conduct background checks, which contributed to the oversight. The facility's undated Abuse Policy and Procedure stated that it would not knowingly employ individuals with a history of abuse, neglect, or other misconduct. Despite this, the facility's failure to conduct a timely background check for the LN placed all residents at risk for abuse, neglect, misappropriation, or mistreatment. The administrative staff acknowledged the oversight and the lack of documentation for the LN's background check, highlighting a gap in the facility's hiring and documentation processes.
Failure to Secure Hazardous Materials in LTC Facility
Penalty
Summary
The facility failed to ensure a safe environment free from hazardous chemicals and materials for eight cognitively impaired independently mobile residents. During a walkthrough of the facility's Two Hall, an unlocked wound treatment cart was found containing medicated ointments and Sani-Cloth bleach wipes, both labeled with warnings to keep out of reach of children. A similar unsecured cart was found in One Hall, containing bottles of diclofenac, disposable medical scalpels, and bleach wipes. These items were accessible to residents, which was against the facility's policy. Interviews with staff, including a CNA, a licensed nurse, and administrative staff, confirmed that treatment carts should be locked when not in use, and chemical cleaning products should always be secured. The facility's Accident and Incident policy, revised in June 2024, stated that the environment should be free from potential hazards, including chemicals. The failure to secure these items placed the residents at risk for preventable accidents and injuries.
Failure to Ensure Resident's Call Light Accessibility
Penalty
Summary
The facility failed to ensure that a resident, identified as R75, had access to her call light to communicate her needs or call for help. R75's medical records indicated she had a history of fractures, insomnia, and repeated falls, with a mild cognitive impairment. Her care plan required that her call light be within reach due to her limited mobility and risk of falls. However, during an observation, it was noted that R75's call light was on the floor and out of her reach, which she confirmed she could not safely access. A CNA later entered the room and corrected the situation by placing the call light back on the bed. Interviews with staff, including a CNA and a licensed nurse, confirmed that call lights should always be within reach of residents, either clipped to their clothing or on the bed. The facility's policy also stated that call lights should be accessible. Despite these guidelines, the facility did not ensure R75's call light was within reach, placing her at risk for unmet care needs.
Failure to Provide NOMNC Form to Resident
Penalty
Summary
The facility failed to provide a resident, identified as R82, with a Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) Form CMS-10095 upon discharge from Medicare A services. R82 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition, and was discharged home without anticipation of returning to the facility. The Beneficiary Protection Notification Review showed that R82 began Medicare Part A skilled services on 07/08/24, with the last covered day being 08/29/24. Despite having benefit days remaining, the facility initiated her discharge from skilled services. Upon request on 09/24/24, the facility was unable to provide a completed NOMNC for R82. An administrative nurse acknowledged the missing documentation and stated that the facility was working to address the issue. The facility's policy, revised in 09/2022, required providing the NOMNC at least two days prior to termination of services, which was not adhered to in this case.
Inconsistent Bathing Opportunities for Resident
Penalty
Summary
The facility failed to provide consistent bathing opportunities for a resident, identified as R18, who was at risk for skin breakdown and pressure injuries due to immobility and other medical conditions. R18's medical records indicated a need for supervision and assistance with activities of daily living, including bathing. Despite the care plan specifying twice-weekly showers, the Treatment Administration Report (TAR) showed missed bathing opportunities on several occasions, with only one bath documented since admission. R18 reported feeling unwell and noted that her drainage bag often fell on the floor, contributing to her discomfort. Observations revealed poor hygiene, with greasy hair, untrimmed nails, and a strong odor of urine and body odor in her room. Upon transfer to an acute care facility, R18 was found to have a pressure injury and poor hygiene, as reported by a consultant. Interviews with facility staff, including a CNA and a licensed nurse, confirmed that bathing schedules were in place, but documentation of refusals or missed baths was inconsistent. The facility's policy required documentation of completed, missed, or refused bathing opportunities, which was not adhered to in R18's case. This lack of consistent care and documentation placed R18 at risk for decreased psychosocial well-being and other complications.
Inadequate Foley Catheter Care for a Resident
Penalty
Summary
The facility failed to provide appropriate Foley catheter care for a resident, identified as R16, by not maintaining the urine collection bag below the level of the bladder, which is necessary for proper drainage. R16's medical history includes chronic kidney disease, spinal stenosis, hemiplegia, hemiparesis, and anxiety disorder. The resident was dependent on staff for various activities of daily living and had an indwelling urinary catheter. Observations revealed that the urine collection bag was positioned on the center of the footboard, higher than the bladder, with foamy yellow urine pooled in the drainage tubing towards the body. Interviews with facility staff, including a CNA, LN, and an administrative nurse, confirmed that urinary catheters should be positioned below the bladder level to ensure proper drainage and prevent contamination. The facility's policy on indwelling urinary catheter care, revised in July 2023, also stipulated that the drainage bag should remain below the bladder level, off the floor, and in a privacy bag. The failure to adhere to these guidelines placed R16 at risk for catheter-related complications, including urinary tract infections.
Deficiency in Serving Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at a palatable, safe, and appetizing temperature for two residents, R75 and R76. Observations and interviews revealed that residents frequently received cold meals, particularly during breakfast. R75 reported that the food was often cold in the mornings, and although staff were available to reheat the food upon request, she did not want her food reheated. Similarly, R76 stated that breakfast was often cold by the time it reached her room. Temperature tests conducted on their breakfast trays confirmed that the food items, including scrambled eggs, oatmeal, and cherry crumble, were served at temperatures significantly below the appropriate range. Interviews with staff members further highlighted the issue. A Certified Nurse's Aide (CNA) acknowledged that residents had concerns about the temperature of food delivered to their rooms and suggested that staff should test food temperatures before serving. Dietary Staff BB mentioned that a recent mock survey had identified concerns with meal service, and the facility should be using heaters and testing trays to maintain appropriate food temperatures. The facility's Food Service policy indicated that meals should be served within appropriate temperature ranges, but the practice of delivering meals to rooms without maintaining these standards led to the deficiency.
Infection Control Deficiency in Catheter and Drain Maintenance
Penalty
Summary
The facility failed to adhere to sanitary infection control standards concerning the maintenance of biliary drains and Foley catheters, which placed residents at risk for infectious diseases. During observations, it was noted that a resident's urinary catheter collection bag was resting flat on the floor beside her bed, and another resident's biliary drain tubing was running over her bed covers with the drainage collection bag also on the floor. These practices were contrary to the facility's policy, which mandates that drainage bags should remain below the level of the bladder, off the floor, and within a privacy bag. Interviews with staff revealed a lack of compliance with the facility's infection control policies. A CNA acknowledged that medical drains and catheter bags should never touch the floor and should be positioned below the bladder level to prevent backflow. A licensed nurse and an administrative nurse both confirmed that staff were expected to check the placement of catheter bags during each interaction with residents, ensuring they were off the floor and properly positioned. Despite these expectations, the facility's failure to maintain sanitary conditions for medical drains and catheters was evident, as observed by the surveyors.
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Surveyors identified unsanitary food storage and preparation conditions, including food debris in a reach-in freezer, an unknown spilled liquid in a reach-in refrigerator, missing two-inch air gap on an ice machine drain, dirty carts used for clean dishes, and a steamtable shelf with built-up food debris. A dietary staff member acknowledged these areas needed cleaning, and it was determined the facility lacked a cleaning schedule or policy for kitchen cleanliness.
The facility failed to complete and analyze Care Area Assessments (CAAs) for multiple residents after Admission, Annual, and Significant Change MDS assessments triggered areas such as cognition, mood/behavior, functional status, urinary incontinence/indwelling catheter, nutrition, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, and visual function. Instead of documenting individualized analysis of underlying causes and contributing factors, an LPN reported she had stopped writing CAA notes and relied mainly on check-off worksheets and the fact that triggers appeared in the MDS CAA section. No facility policy on CAAs was provided to surveyors, and the CAAs consistently lacked required analytical documentation for residents with diverse and significant clinical needs.
A resident with dementia, severe cognitive impairment, and an indwelling urinary catheter was repeatedly observed sitting in common areas with his catheter drainage bag resting on his lower leg, visibly filled with dark amber urine and lacking a privacy cover, despite a care plan directing staff to cover the drainage bag. CNAs reported that the bag often slid down from the resident’s thigh, that they did not use catheter dignity bags on their hall, and that they simply moved the bag back up when it slid down. An administrative nurse stated she had not considered the use of dignity bags on the memory care unit, even though the facility’s resident rights policy affirms each resident’s right to a dignified existence, privacy, and confidentiality.
Two residents with documented cognitive ability to participate in care planning were not invited to any care plan meetings, and their EMRs lacked evidence of care plan conferences, invitations, or Interdisciplinary Care Conference assessments. Administrative staff stated that invitations should be mailed or hand-delivered and uploaded to the EMR, and that an Interdisciplinary Care Conference note should be completed, but none of this documentation existed for these residents, contrary to facility policy and federal requirements for resident and/or representative participation in care planning.
A resident with C-diff and CHF, newly admitted and with a baseline care plan that did not address call light use, was repeatedly found without access to a call light. Surveyors observed the resident yelling for help with her room door closed and later noted the call light on the floor under the bed and again on the floor while the resident sat in a recliner and stated she wanted to return to bed but could not do so independently. Staff reported using a binder clip to attach the call light to the resident’s clothing because the cord lacked a clip, acknowledged the resident sometimes threw the call light to the floor, and stated that call lights should be kept within residents’ reach. An administrative nurse confirmed the expectation that call lights be accessible at all times and was unsure about the use of a binder clip, and no facility policy on call lights was provided.
Surveyors found that a resident’s bathroom and handwashing area were not maintained in a safe, sanitary, and comfortable condition, including a loose baseboard with black substance behind it, a cracked toilet seat, and an empty, improperly mounted hand soap dispenser. Maintenance staff confirmed these conditions, noted that the soap dispenser was nonfunctional, and reported that although a QR code system existed for reporting maintenance issues, these problems had not been reported. Maintenance staff also stated there were no facility policies for maintenance repair in resident rooms and no policy provided for ensuring a safe, homelike environment.
Multiple residents were affected by inaccurate MDS assessments, including a resident with dementia and an indwelling catheter who was miscoded as always incontinent of urine and independent in ADLs despite staff and EMR documentation showing long-term catheter use and total dependence for dressing and wheelchair positioning. Another resident with a history of stroke was incorrectly coded as having a restraint, even though bed grab bars were used as enablers to assist with repositioning and did not limit voluntary movement. A resident with diabetes and unsteadiness experienced two documented falls that were not captured on the MDS, and another resident with diabetes, depression, CAD, and CKD was actively receiving hospice services per EMR, social services, and staff interviews, yet hospice was not coded on the MDS. The consultant MDS nurse confirmed these were significant coding errors not in accordance with the RAI User’s Manual.
A resident with C. diff and CHF was admitted, and while a baseline care plan documenting contact precautions was created, the resident later reported not knowing what a baseline care plan was. The resident was also found yelling for help with her call light on the floor under the bed. Nursing staff stated that baseline care plans are started on the day of admission and reviewed with residents, but also indicated that residents and families are not given written copies. An administrative nurse claimed a 48-hour interdisciplinary care conference had been completed, yet no corresponding documentation existed in the EMR, and explanations about who was responsible and why it was missing were inconsistent. No facility policy for baseline care plans was provided.
A resident with dementia and severe cognitive impairment was inaccurately assessed and care planned as needing only setup or independent assistance with dressing, despite actually requiring total staff assistance. The EMR lacked clear ADL documentation, and the ADL CAA did not trigger, leading to inaccurate MDS entries and a care plan that did not match the resident’s functional status. Surveyors observed the resident sitting in a wheelchair wearing dirty, food-stained pants and being taken to the dining room without a clothing change, with the soiled pants not changed until later when two CNAs provided total assistance. Staff, including CNAs, an LN, and an administrative nurse, acknowledged that the resident needed total help with dressing and should always be in clean clothing, revealing a failure to provide appropriate ADL support and maintain clean attire.
A resident with dementia and severe cognitive impairment was transported multiple times in a wheelchair without staff ensuring that his feet remained safely on the foot pedals. Although assessments inaccurately documented that he was independent with walking using a walker and/or wheelchair, his care plan did not instruct staff on proper use of wheelchair foot pedals. During observed transports by CNAs, the resident’s shoed feet repeatedly fell off the pedals and skimmed the floor between them. Staff acknowledged that his feet did not stay on the pedals and that the pedals were not effectively adjusted, and nursing leadership confirmed expectations that feet should remain on the pedals during transport. No wheelchair safety policy was provided.
Unsanitary Kitchen Conditions and Lack of Cleaning Policy
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions when surveyors observed multiple cleanliness and equipment issues in the kitchen. During an initial kitchen tour on 04/27/26 at 08:57 AM, the three-door reach-in freezer was found with food debris on the bottom shelf, and the three-door reach-in refrigerator had an unknown spilled liquid on the bottom shelf. The drain to the ice machine did not have the required two-inch air gap. Two black two-tiered plastic carts used to store clean dishes had food debris on the bottom tier, and the bottom shelf of the steamtable, which was used to store plate covers, had a buildup of food debris. On 04/28/26 at 01:57 PM, a dietary staff member confirmed these areas required cleaning, and it was identified that the facility did not have a cleaning schedule or a policy regarding kitchen cleanliness. No specific residents, medical histories, or clinical conditions were mentioned in the report in relation to this deficiency.
Failure to Complete and Analyze Care Area Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive Care Area Assessments (CAAs) with analysis of underlying causes, contributing factors, and risk factors for multiple residents following MDS assessments. Record review showed that numerous residents had Admission, Annual, or Significant Change MDS assessments that triggered CAAs in areas such as mood/behavior, cognitive loss/dementia, functional abilities, communication, urinary incontinence/indwelling catheter, nutritional status, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, visual function, and psychosocial well-being. For each of these triggered areas, the corresponding CAAs lacked analysis of the findings. This pattern was identified for residents with a wide range of clinical issues, including dementia, incontinence, falls, pressure ulcers, nutritional concerns, psychotropic medication use, pain, and functional decline. During an interview, a licensed nurse reported that she had stopped writing CAA notes the previous year after being told to do so by someone she could not identify. She stated that she did not write anything on the triggered CAAs and that, at times, she would document risk concerns only on a main check-off worksheet, relying on the fact that the triggers were already reflected in the MDS CAA section. The facility did not provide a policy regarding CAAs when requested. These findings demonstrate that the facility did not ensure that comprehensive assessments were fully completed as required when residents were first admitted and periodically thereafter.
Failure to Maintain Dignity and Privacy for Resident with Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to a dignified existence by not maintaining privacy for his urinary catheter drainage bag as directed in his care plan. The resident had diagnoses including bladder calculus and dementia, with a BIMS score of one indicating severe cognitive impairment, and was dependent on staff for toileting hygiene with an indwelling urinary catheter and constant urinary incontinence. His care plan, revised 03/23/26, instructed staff to cover his drainage bag with a privacy cover. However, during observations on 04/27/26, the resident was seen sitting in his wheelchair at his room doorway and later in the dining room with his catheter drainage bag resting on his lower left leg, supported by his shoe, containing dark amber urine and visible to visitors and other residents, without a privacy cover. Staff interviews confirmed that the catheter drainage bag frequently slid from the resident’s left thigh down to his lower leg and that staff did not consistently reposition it or use dignity/privacy bags. One CNA stated he had never placed a dignity bag on the resident’s drainage bag, and another CNA reported that staff on their hall did not utilize catheter dignity bags, instead just moving the bag back up when it slid down. An administrative nurse acknowledged she had not considered staff use of dignity bags for urinary catheters on the memory care unit. The facility’s Resident Rights policy, approved 12/2024, stated that each resident has the right to a dignified existence including privacy and confidentiality, which was not followed in this case.
Failure to Involve Cognitively Able Residents in Care Plan Meetings
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were given the opportunity to participate in the development and implementation of their person-centered plans of care. For one resident with a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognition, the electronic medical record showed an admission MDS and a Significant Change MDS, but there was no documentation of any care plan meeting in the prior four months. This resident reported not being invited to any care plan meeting. For a second resident with a BIMS score of 14, indicating intact cognition, the electronic medical record contained an admission MDS and a Quarterly MDS, but there was no documentation of a care plan meeting in the prior two months. This resident also reported not being invited to any care plan meeting. Administrative staff reported that residents and/or family members were supposed to be mailed or hand-delivered invitations to attend care planning meetings and that a copy of the invitation should be uploaded into the EMR. They further stated that an Interdisciplinary Care Conference assessment should be completed in the EMR during the care plan meeting. However, the administrative nurse confirmed that there was no documentation of invitations, Interdisciplinary Care Conference assessments, or completed care plan meetings for the two residents. The facility’s care planning policy stated that social services should attend care plan meetings and that the team presents information to the resident and/or representative about progress toward care plan goals, and referenced federal law requiring resident and/or representative participation in care plan meetings to the extent possible, but this process was not carried out or documented for the two residents identified.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach and to reasonably accommodate the resident’s needs and preferences. The resident had documented diagnoses of C-diff and CHF, and her baseline care plan dated 04/23/26 directed staff to evaluate for changes in level of consciousness but did not include any direction regarding call light use or accessibility. On 04/28/26 at 08:06 AM, surveyors observed the resident’s room door closed while she yelled loudly for help several times. When a licensed nurse entered the room, the resident was lying on her left side in bed, stated she wanted to get up, and reported she could not find her call light. The call light was observed on the floor under her bed. Later that morning, a CNA attached the call light to the resident’s shirt using a black and silver binder clip because the call light cord did not have its own clip. On 04/29/26 at 12:15 PM, the resident was seated in a recliner with the call light again lying on the floor out of her reach; she reported she wanted to go to bed and could not get herself back into bed. Staff interviews revealed that the CNA used the binder clip to keep the call light attached to the resident, and the licensed nurse stated staff should make sure the call light is clipped to the resident’s clothes and reported that the resident would throw her call light on the floor. An administrative nurse stated she expected staff to ensure all residents always have their call lights in reach and was unsure about using a binder clip to hold a call light in place. The facility did not provide a policy regarding call lights.
Failure to Maintain Safe and Sanitary Resident Bathroom Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, functional, sanitary, and comfortable environment in Resident 87’s bathroom and handwashing area. During an environmental tour with Maintenance Staff UU, surveyors observed an approximately four-foot section of loose baseboard to the left of and behind the toilet, with a black substance present on the wall and floor behind the loose baseboard. They also noted an approximately three-inch crack in the toilet seat and an empty hand soap dispenser hanging above the handwashing sink, mounted with exposed lag bolt fasteners. Maintenance Staff UU confirmed these conditions, acknowledged that the soap dispenser did not work, and stated that the toilet seat should be replaced, the bathroom baseboard removed, the black substance tested for mold, and the sheetrock removed and replaced. Further interview with Maintenance Staff UU revealed that the facility had implemented a QR code system for staff and visitors to report maintenance items, but the issues in this resident’s bathroom had not been reported through that system. He also reported that there had been a leak behind the handwashing sink that had flowed into the bathroom area, leading to the sink’s replacement, but he had received no report of the specific deficiencies observed in the bathroom. Additionally, Maintenance Staff UU stated that the facility did not have policies for maintenance repair in residents’ rooms, and the facility did not provide a policy for ensuring a safe, homelike environment.
Inaccurate MDS Coding for ADLs, Restraints, Falls, and Hospice Services
Penalty
Summary
The deficiency involves the facility’s failure to complete accurate Minimum Data Set (MDS) assessments in accordance with the Resident Assessment Instrument (RAI) User’s Manual, resulting in multiple residents’ clinical status not being correctly reflected. For one resident with dementia and severe cognitive impairment, the Significant Change and subsequent Quarterly MDS assessments coded him as always incontinent of bladder and independent with eating and upper body dressing, with use of a walker and wheelchair. However, the electronic medical record showed ongoing indwelling catheter care each shift and no documentation of walker use, wheelchair mobility, or dressing requirements during the review period. Staff interviews revealed that this resident had an indwelling catheter for more than a year, had not walked for several years, and was dependent on staff for all ADLs, including dressing and wheelchair positioning, contradicting the MDS coding. Observations showed the resident slumped in a wheelchair, wearing a hospital gown over clothing, with a visible catheter bag on his lower leg and feet frequently skimming the floor despite foot pedals being present, further indicating dependence and catheter use not accurately captured on the MDS. Another deficiency involved a resident with a history of stroke, hemiplegia, and hemiparesis whose Significant Change MDS coded the use of “other restraint.” During observation, the resident was seen in bed with bilateral grab bars at the head of the bed and her right arm positioned on a pillow. The resident reported using the grab bars to help move and reposition herself in bed. CNAs and administrative nursing staff confirmed that the facility did not use restraints and that the grab bars were used as enablers to assist residents with repositioning and to increase independence. Administrative staff acknowledged that the MDS coding for restraints was inaccurate because the grab bars did not limit the resident’s voluntary movement or access to her body. A further inaccuracy was identified for a resident with diabetes, atrial fibrillation, unsteadiness of feet, and a toe fracture. Both a Significant Change and a Quarterly MDS documented intact cognition, partial/moderate assistance with transfers, no ambulation, and no falls. However, progress notes in the EMR documented two unwitnessed falls during the look-back period, including one where the resident was found on the floor next to the bed with a forehead skin tear and another where the resident was found sitting on a fall mat on the floor with a scratch on the ankle. These documented falls were not reflected on the MDS. In addition, another resident with diabetes, depression, CAD, and chronic kidney disease had a Significant Change MDS that coded no hospice services, while the EMR contained a hospice certification and physician orders initiating hospice services, and social service notes and staff interviews confirmed that hospice services, including bathing by a hospice aide, were being provided during the look-back period. The consultant MDS nurse confirmed that these assessments were inaccurate and not completed in accordance with the RAI User’s Manual, constituting significant errors in coding for urinary status, ADL dependence, restraints, falls, and hospice services. The consultant MDS nurse stated that the resident with the indwelling catheter should have been coded as not rated for urinary continence due to catheter placement rather than as always incontinent, and that his ADL status should not have been coded as independent given his dependence on staff for dressing and wheelchair positioning. For the resident with grab bars, the nurse confirmed that the grab bars were used as enablers and not as restraints, making the restraint coding inaccurate. For the resident with documented falls, the MDS failed to capture falls that occurred within the look-back period, and for the resident receiving hospice services, the MDS did not reflect hospice care that was active during the look-back period. These miscodings met the RAI Manual’s definition of significant error, in which the resident’s overall clinical status is not accurately represented on the assessment and the error has not been corrected by a more recent assessment.
Failure to Provide and Communicate Baseline Care Plan to New Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide a summary of the baseline care plan to a newly admitted resident and to ensure that the baseline care plan process was completed and documented as required. The resident’s EMR documented diagnoses of C. difficile and CHF. The Entry MDS was completed on the admission date, and the admission MDS was noted as in progress with no information available. A baseline care plan dated the day after admission documented contact precautions, including staff use of gowns and masks when changing contaminated linens and proper handling and bagging of soiled linens. However, during an interview several days after admission, the resident reported she did not know what a baseline care plan was, indicating that the plan had not been explained or summarized to her. Further observations and interviews showed additional failures in implementing and communicating the baseline care plan. On one occasion, the resident was heard yelling for help with her room door closed; when a nurse entered, the resident stated she wanted to get up but could not find her call light, which was observed on the floor under the bed. A nurse reported that the baseline care plan was started on the day of admission and that nurses would review it with the resident, but also stated that the charge nurse would not provide a written copy of the baseline care plan to the resident or family. An administrative nurse reported she would review the baseline care plan with the resident and/or family and claimed to have completed a 48-hour interdisciplinary care conference, but there was no opened or completed conference note in the EMR. She gave inconsistent explanations regarding who was responsible and why the conference note was missing. The facility did not provide a policy for baseline care plans.
Failure to Provide Accurate ADL Assessment and Timely Clothing Changes
Penalty
Summary
The facility failed to provide appropriate assistance with activities of daily living (ADLs), specifically dressing and clothing changes, for a resident with severe cognitive impairment. The resident had a diagnosis of dementia and repeated Brief Interview for Mental Status (BIMS) scores of one, indicating severe cognitive impairment. Despite this, both a Significant Change MDS and a Quarterly MDS inaccurately documented that the resident required only setup assistance with lower body dressing. The ADL Care Area Assessment did not trigger, and the resident’s care plan, revised on 03/23/26, inaccurately instructed staff that the resident was independent with dressing. The electronic medical record lacked staff documentation of the resident’s ADL needs, resulting in care instructions that did not reflect the resident’s actual functional status. On the day of observation, the resident was seen sitting in a wheelchair wearing black pants with food crumbs on them in the morning, and later was transported by a CNA to the dining room still wearing the same dirty pants. The pants were not changed until early afternoon, at which time two CNAs provided total assistance to change the dirty pants, and the resident was unable to participate in dressing or undressing. During interviews, the CNAs, a licensed nurse, and an administrative nurse all stated that residents should always be dressed in clean clothing and confirmed that this resident required total staff assistance with dressing. These observations and interviews showed that the resident’s actual need for total assistance with dressing and clothing changes was not accurately reflected in the MDS, care plan, or ADL documentation, and that the facility did not ensure the resident was kept in clean clothing as expected by facility policy for ADL care.
Failure to Maintain Safe Wheelchair Foot Positioning During Resident Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision during wheelchair transport for a resident with dementia. The resident’s EMR documented a diagnosis of dementia and a BIMS score of one on both a Significant Change MDS and a Quarterly MDS, indicating severe cognitive impairment. These MDS assessments inaccurately documented that the resident was independent with walking using a walker and/or wheelchair, and the ADL CAA did not trigger. The resident’s care plan, revised 03/23/26, identified cognitive impairment due to dementia but did not include instructions for staff on the use of wheelchair foot pedals while propelling the resident. On multiple observed occasions, staff propelled the resident in a wheelchair without maintaining his feet safely on the foot pedals. During transport from his room to the dining room, the resident’s left shoed foot fell from the foot pedal and skimmed the floor between the pedals, and later, during transport from the dining room to the shower room, both shoed feet skimmed the floor between the pedals. CNAs reported that the resident’s feet never stayed on the foot pedals and described the pedals as useless because he could not keep his feet on them. A licensed nurse confirmed the resident’s feet did not always remain on the foot pedals when staff propelled him and stated the pedals should be adjusted to better fit his needs. An administrative nurse stated it was the expectation that staff ensure the resident’s feet remained on the foot pedals during transport and that pedals should be lowered if needed. The facility did not provide a policy regarding wheelchair safety.
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