Attica Long Term Care Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Attica, Kansas.
- Location
- 302 N Botkin, Attica, Kansas 67009
- CMS Provider Number
- 17E534
- Inspections on file
- 16
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Attica Long Term Care Facility during CMS and state inspections, most recent first.
A resident with dementia experienced significant unintended weight loss after staff failed to provide adequate nutritional care, did not consistently implement or document nutritional supplements, and did not follow the Registered Dietician's recommendations or notify the physician as required. The resident's meal intake was low, and staff interviews revealed gaps in communication and documentation regarding nutritional interventions.
Staff failed to follow infection control protocols, including proper hand hygiene when delivering clean laundry and during resident care, and did not maintain a sanitary environment in the laundry area. Observations included staff not sanitizing hands before or after entering rooms, using dirty gloves to handle clean briefs, and improper storage of clean and dirty linens, with no facility policy provided for laundry processing.
Several residents with mental health diagnoses were prescribed psychotropic medications, including antianxiety, antidepressant, and antipsychotic agents, without documented informed consent or education about the medications' benefits, risks, and alternatives. Facility staff confirmed that consent was not obtained, citing a misunderstanding of policy requirements.
A resident with dementia and severely impaired cognition experienced significant weight loss over several months, with documented weights declining from 135 to 120 pounds. Despite care plan interventions and facility policy requiring physician notification for significant weight loss, there was no evidence that the physician was informed in a timely manner. The RD noted poor meal intake and recommended an appetite stimulant, but staff interviews revealed confusion about the notification process, and the physician was not notified until much later.
A resident with dementia and physical weakness, who was fully dependent on staff for ADLs, was observed over two days with long, jagged, and dirty fingernails. Staff confirmed the resident relied on them for nail care, which was only performed on shower days, and the facility could not provide a nail care policy.
A resident with dementia and moderately impaired cognition, who was able to ambulate independently, did not receive an ongoing, individualized activity program based on his preferences for reading, music, and religious practices. Documentation showed only two activity events in a month, and staff were unclear about his interests, resulting in a lack of engagement and failure to meet his assessed needs.
Multiple residents with cognitive impairment and mobility needs were not consistently provided with safe wheelchair transport, as staff failed to ensure the use of foot pedals during assisted mobility. One resident with a history of falls did not receive individualized fall prevention interventions after a fall, and another was observed being pushed in a wheelchair without foot pedals. Staff interviews confirmed inconsistent practices and the absence of a facility policy regarding wheelchair positioning and foot pedal use.
The facility did not ensure the laundry folding counter and linen storage closet were maintained in good repair, as evidenced by a patched hole in the counter and broken ceiling tiles with exposed gaps. Staff interviews confirmed that maintenance requests and routine inspections were not effectively carried out, leading to an unsanitary environment.
Failure to Provide Adequate Nutrition and Follow RD Recommendations
Penalty
Summary
A resident with dementia and severely impaired cognition experienced significant unintended weight loss of 11.48% over three months due to the facility's failure to provide adequate nutritional care and follow the Registered Dietician's (RD) recommendations. The resident was admitted with a weight of 135 pounds and was on a liberalized geriatric diet, with care plans indicating she made her own food choices and required staff to offer snacks and fluids throughout the day. Despite these interventions being documented, the resident's electronic medical record (EMR) showed a steady decline in weight, with no evidence of additional nutritional orders or consistent documentation of supplement intake. The RD noted limited meal intake, with most meals consumed at less than 26% and staff reporting the resident often preferred to sleep and declined food, stating she was not hungry. The RD recommended a trial of an appetite stimulant and nutritional shakes, but the clinical record lacked evidence that these recommendations were implemented or that the physician was notified of the significant weight loss. Staff interviews confirmed that while attempts were made to offer protein shakes, these were not documented, and there was uncertainty about whether RD recommendations were communicated to the provider or followed up with appropriate orders. Facility policy required staff to notify the physician of significant weight loss and document decisions for supplements, but the record showed these steps were not consistently taken. The resident's weight continued to decline, and staff and consultants acknowledged gaps in communication and documentation regarding nutritional interventions and physician notification. The failure to implement and document appropriate nutritional interventions and to follow RD recommendations contributed directly to the resident's ongoing weight loss.
Infection Control Deficiencies in Hand Hygiene and Laundry Services
Penalty
Summary
Facility staff failed to implement adequate infection control practices, specifically regarding hand hygiene and laundry services. Observations revealed that dietary staff delivering clean laundry to resident rooms did not sanitize their hands before or after each delivery. Additionally, a CNA was observed wiping a resident's buttock with gloved hands and, without changing gloves or performing hand hygiene, proceeded to place a clean brief on the resident. Multiple staff interviews confirmed that hand hygiene was expected before and after entering resident rooms and when handling laundry, but these practices were not consistently followed. The facility's own hand hygiene policy, which aligns with CDC guidelines, was not adhered to during these observed events. Further observations in the laundry area showed improper separation of clean and dirty items, with a dirty linen cart placed against the clean linen folding counter and non-linen items stored on the clean linen processing area. The environment was also found to be unsanitary, with a dusty bar of soap hanging from the ceiling and dirty air conditioning vents blowing towards the clean linen counter. Staff interviews indicated that each department was responsible for cleaning its own area, but there was no facility policy provided regarding laundry processing or maintaining the cleanliness of the laundry area.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were fully informed and provided informed consent regarding the use of psychotropic medications, as required by facility policy. Multiple residents with diagnoses such as PTSD, anxiety, depression, panic disorder, bipolar disorder, and dementia were prescribed various psychotropic medications, including antianxiety agents, antidepressants, and antipsychotics. Despite these prescriptions, the electronic medical records (EMRs) and electronic health records (EHRs) for these residents lacked documentation that informed consent was obtained or that education was provided about the medications' benefits, risks, and alternatives. For example, one resident with PTSD, anxiety, and depression was prescribed lorazepam, mirtazapine, and sertraline, but there was no evidence in the EMR of informed consent for these medications. Another resident with panic disorder, major depressive disorder, and bipolar disorder was prescribed buspirone, desvenlafaxine, lorazepam, and olanzapine, again without documentation of informed consent. Additional residents with depression, adjustment disorder, insomnia, and dementia were also prescribed psychotropic medications such as bupropion, citalopram, and duloxetine, with no evidence that they or their representatives were informed about the medications or provided consent. Interviews with facility staff confirmed that informed consent for psychotropic medications had not been completed for these residents. The administrative nurse indicated a misunderstanding of the facility's policy, believing that consent was only necessary for new medications started at the facility, not for those continued upon admission. The facility's policy, however, clearly required informing residents, families, or representatives of the benefits, risks, and alternatives for each psychotropic medication prior to adding, discontinuing, or changing any such medication.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of significant weight changes in a resident with dementia and severely impaired cognition. The resident was admitted with a weight of 135-136 pounds and was noted to have no known weight loss at admission. Over the course of several months, the resident experienced a significant weight loss, dropping to 120 pounds as documented in the quarterly Minimum Data Set. The care plan indicated that the resident made her own food choices, was on a liberalized geriatric diet, and required staff to cue her for meals and encourage fluid and snack intake. Weights were to be recorded weekly, and the facility policy required the nursing director to notify the physician of significant weight loss. Despite these interventions and policies, the electronic medical record showed a progressive decline in the resident's weight, with no evidence that the physician was notified after weights of 127.5 pounds and 119.5 pounds were recorded. The registered dietician documented limited meal intake, with most meals consumed at less than 26% and only 14 meals charted over two weeks. Staff reported the resident often preferred to stay in her room, slept late, and declined meal and snack offers, stating she was not hungry. The dietician recommended considering an appetite stimulant due to the ongoing weight loss and poor intake, but there was no documentation that these recommendations or the significant weight loss were communicated to the physician in a timely manner. Interviews with staff revealed a lack of clarity regarding the process for notifying the physician about weight loss and following up on the dietician's recommendations. The administrative nurse stated that the dietician provided a weekly list of residents with weight loss and that nurses were responsible for discussing recommendations with the physician. However, the consultant physician confirmed she was not notified of the resident's weight loss until much later, at which point she ordered nutritional supplements. The facility's failure to promptly notify the physician of the resident's significant weight loss constituted the identified deficiency.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
A resident with diagnoses of dementia and weakness, who was assessed as having moderately impaired cognition and being dependent on staff for all activities of daily living (ADLs), did not receive appropriate nail care. The resident's care plan and assessments indicated a need for staff assistance with personal hygiene, including nail care. Despite these documented needs, observations over two consecutive days showed that the resident's fingernails were long, jagged, and dirty. Interviews with certified nurse aides confirmed that the resident was dependent on staff for all ADLs, including fingernail care, and that nail care was typically performed on shower days. An administrative nurse stated that staff were expected to ensure the resident's fingernails were smooth and clean. The facility was unable to provide a policy for nail care.
Failure to Provide Resident-Centered Activity Program
Penalty
Summary
The facility failed to implement an ongoing, resident-centered activity program for a resident diagnosed with dementia and moderately impaired cognition. The resident's medical record and assessments indicated that it was important for him to have access to reading materials, listen to music, participate in religious practices, keep up with the news, and engage in favorite activities. Despite being able to ambulate independently and having no impairment in range of motion, documentation showed only two activity events over a one-month period, with no further evidence of participation in activities. Observations on multiple occasions revealed the resident sitting in a common area with the television on, but not engaging with it or any other activities. Interviews with staff indicated uncertainty about the resident's activity preferences, with some staff only aware that he enjoyed talking or one-to-one activities. The facility's policy required activities to be based on comprehensive assessment and care plans tailored to resident preferences, with documentation of participation. However, the lack of documented activities and staff awareness demonstrated a failure to provide a resident-centered activity program as required.
Failure to Prevent Accident Hazards and Ensure Safe Wheelchair Use
Penalty
Summary
The facility failed to ensure that areas were free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents. One resident with dementia and weakness, who was dependent on staff for wheelchair mobility and had moderately impaired cognition, was observed being transported in a wheelchair with her feet not consistently on the foot pedals. Staff confirmed that her feet did not always stay on the pedals during transport, and the facility did not have a policy regarding wheelchair positioning or foot pedal use. Another resident with a history of falls, memory impairment, and confusion, who was on hospice services, experienced a fall while attempting to retrieve an item from her bedside table. The care plan for this resident included reminders to use the call light and wait for staff assistance, but lacked further interventions after the fall. Staff interviews indicated that the intervention of re-educating the resident to use the call light was not appropriate given her cognitive status, and that she often got up without waiting for help despite the call light being within reach. A third resident with severe cognitive impairment and peripheral vascular disease was observed being pushed in a wheelchair without foot pedals. Staff acknowledged that foot pedals should be used when assisting residents in wheelchairs, but in this case, the pedals were not available. The facility did not provide a policy for wheelchair positioning, including the use of foot pedals, and staff interviews confirmed inconsistent practices regarding their use.
Failure to Maintain Safe and Sanitary Laundry and Linen Storage Areas
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the laundry and linen storage areas. Observations revealed that the clean clothes folding counter in the laundry area had a large patched hole, measuring three feet long and six inches wide, covered with plain plywood, and several chipped areas. Additionally, the clean linen storage closet had multiple ceiling tiles with broken areas, creating large gaps, and one tile had a large hole inadequately covered with plastic, leaving gaps exposed. Interviews with housekeeping, maintenance, and administrative staff confirmed that there was a repair request system in place and that maintenance items related to residents were prioritized. However, staff acknowledged that a work order should have been submitted to repair or replace the broken counter and that ceiling tiles should be clean and intact. Facility policies required routine inspections and maintenance of fixtures and equipment, including weekly checks of the laundry area, but these procedures were not effectively implemented, resulting in the observed deficiencies.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
