Delmar Gardens Of Lenexa
Inspection history, citations, penalties and survey trends for this long-term care facility in Lenexa, Kansas.
- Location
- 9701 Monrovia Street, Lenexa, Kansas 66215
- CMS Provider Number
- 175122
- Inspections on file
- 16
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Delmar Gardens Of Lenexa during CMS and state inspections, most recent first.
Surveyors found that medication carts containing insulins and treatment supplies were left unlocked and unattended on two hallways, with carts observed open for several minutes while an LPN or a CMA was inside resident rooms or otherwise away from the carts. Staff acknowledged that carts are expected to be locked when not in use or out of direct eyesight, and facility policy requires carts to be kept in visible range or locked before entering a resident’s room.
A resident with Alzheimer’s disease, severely impaired cognition (BIMS 0), and total dependence for ADLs had a history of falls and a care plan requiring the call light to be kept within reach due to fall risk and poor safety awareness. During observation, the resident was in bed, awake and yelling out, while the call light was located behind the bed’s headboard and not accessible. Staff, including a CMA, an LN, and an administrative nurse, acknowledged that call lights should be within residents’ reach, and facility policy required staff to ensure call lights were reachable and answered promptly, but this was not done for this resident.
Surveyors found that when a resident’s Medicare Part A coverage ended and the resident remained in the facility, staff issued an outdated or incorrect ABN form instead of the required CMS-10055 notice. Record review confirmed the last covered day under Medicare Part A and showed that the wrong form (CMS-20052) was used. In interviews, administrative and social services staff acknowledged that the correct SNF ABN form was not provided, despite the facility having a policy referencing the proper CMS-10055 form.
Surveyors found that staff failed to protect resident PHI when two unattended medication carts were left in hallways with open computer screens displaying residents’ MAR and treatment orders. In each instance, the cart was left alone for several minutes with identifiable medical information visible, and the CMA and LN involved later acknowledged they should have closed the screens to maintain confidentiality, contrary to the facility’s stated residents’ rights policy.
A resident with dementia, Alzheimer's disease, and documented aggressive behaviors was involved in a resident-to-resident altercation in which she grabbed another resident and required redirection and removal from the area. Nursing documentation described the physical altercation and subsequent 1:1 interaction for calming, but staff did not recognize or treat the event as potential abuse. The incident was not reported to administration or the State Survey Agency, and no investigation, incident report, or witness statements were initiated, despite a facility abuse policy requiring immediate reporting and investigation of suspected abuse, including abuse by other residents.
A resident with dementia, Alzheimer’s disease, depression, and anxiety, who was care planned for disruptive and potentially aggressive behaviors, was documented as grabbing another resident’s arm and covering the resident’s mouth during an altercation that required redirection and removal from the area. Although the facility’s abuse policy required immediate reporting of suspected abuse, assessment, incident reporting, and interviews of involved parties, staff did not report the event to administration at the time, and the facility could not provide evidence that any formal investigation or required follow-up steps were completed.
A resident on hospice with DM, dysphagia, and a G-tube had physician orders and a care plan requiring continuous head-of-bed (HOB) elevation of at least 30 degrees during enteral feeding and Glucerna 1.5 at 50 ml/hr with a daily two-hour interruption. Surveyors observed the resident lying flat in bed while tube feeding was running, and at other times with the HOB at only 3–10 degrees, as well as periods when the feeding was off and disconnected outside the ordered schedule. Staff interviews showed an LPN was unsure of the required HOB elevation, CNAs gave conflicting and incorrect descriptions of the required HOB angle, and another LPN was unclear about when the feeding had been stopped and initially could not find the order for the scheduled gut rest. The G-tube care policy lacked HOB elevation guidance, despite a policy requiring staff to follow physician orders.
A resident had a PRN order for diphenhydramine 50 mg by mouth three times daily without any documented diagnosis or indication, despite having documented insomnia and anxiety, intact cognition, no skin issues, and independence with ADLs. The medication was not reflected in the care plan or in any progress, provider, dermatology, pharmacy, or psych notes. A consultant pharmacist later confirmed the absence of an indication and acknowledged missing it during a prior review, while a CMA, an LN, and an administrative nurse all stated that PRN and other medications are required to have a diagnosis or reason for use. The facility did not provide a policy governing PRN medication orders.
Surveyors observed that nurses crushed and administered multiple medications that should not have been crushed, resulting in a medication error rate of 19.23%. One resident with anemia and a G-tube received crushed ferrous sulfate and sennosides-docusate, while tamsulosin was withheld due to a discrepancy between the order and the medication card. Another resident with constipation and a psychotic disorder received crushed docusate sodium capsules and trazodone mixed in pudding. These practices conflicted with facility policy prohibiting crushing medications when contraindicated, contributing to the high observed error rate.
Staff failed to consistently implement Enhanced Barrier Precautions (EBP) and basic infection control practices, including not sanitizing a mechanical lift between residents, not using required gowns when providing high-contact care to a resident with an indwelling catheter, and allowing a urine drainage bag and tubing to rest on and drag along the floor. CNAs conducting an ice pass left the ice scoop in the cooler, kept the lid open, and moved between multiple residents without performing hand hygiene. For a resident on EBP, staff used appropriate PPE during incontinence care but later transferred the resident without gowns, despite acknowledging EBP requirements. Another resident with numerous open and scabbed wounds, active bleeding onto clothing and linens, and a widespread rash had no EBP signage or PPE setup, and the EMR lacked a detailed skin assessment, contrary to facility policy requiring covered skin lesions and hand hygiene.
The facility failed to properly label and discard insulin medications for several residents and expired stock medications. This included unlabeled and outdated insulin pens and vials, as well as expired Tussin DM. These deficiencies were confirmed through observations and interviews with the administrative nurse.
A resident was not treated with dignity during the noon meal as a CNA stood over him while assisting with eating and left the table multiple times to perform other tasks. Facility policy requires staff to sit next to residents and engage in conversation during meals.
The facility failed to provide written notice for hospital transfers for three residents, placing them at risk for uninformed care choices. The facility also lacked documentation and policies regarding these transfers.
The facility failed to provide three residents or their representatives with written information regarding the bed hold policy when they were transferred to the hospital. Administrative staff confirmed the absence of documentation and acknowledged that nursing staff were responsible for sending the bed hold policy with transfer papers but did not follow up on obtaining the signed notice.
The facility failed to ensure that three residents received a PASRR to identify potential care needs related to mental disorders or intellectual disabilities. The residents were admitted from the VA without the required assessments, placing them at risk for unidentified needs and inadequate care.
The facility failed to revise the care plan for a resident with PTSD, leading to uncommunicated care needs. Despite multiple diagnoses, including dementia and PTSD, the care plan did not address trauma triggers or coping strategies. Staff admitted to not assessing trauma triggers, and the facility's policy on Trauma Informed Care was not followed.
A resident with diabetes, osteoarthritis, and COPD did not receive the required restorative services to maintain mobility and ambulation. Despite a plan directing ambulation activities, the facility failed to document and follow through, placing the resident at risk for a decline in mobility and independence.
Unlocked and Unattended Medication Carts on Multiple Hallways
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medication carts containing drugs and biologicals were locked when unattended, as required by facility policy and professional standards. Surveyors observed three of six medication carts on the 500 and 600 hallways left unlocked and unattended for several minutes. On one occasion, an unlocked and unattended cart was observed on the 600 hallway for three minutes until a licensed nurse walked by, locked it, and left. On another occasion on the 600 hallway, a certified medication aide returned to an already unlocked cart, used the computer, then walked away into a resident’s room, leaving the cart unlocked and unattended for two minutes before returning to prepare medications. A further observation on the 500 hallway showed an unlocked and unattended medication cart for three minutes while a licensed nurse was in a resident’s room; during this time, a cart drawer was opened without the nurse noticing. Staff interviews confirmed that the medication carts stored residents’ insulins and treatment supplies and that staff understood the expectation that carts must be locked when not in use or out of direct eyesight. The administrative nurse also stated that all medication carts were expected to be locked when unattended. The facility’s Medication Administration policy dated January 2021 documented that staff were to keep the cart in visible range or lock all items prior to going into a resident’s room.
Failure to Keep Resident Call Light Within Reach
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was kept within reach as required by the resident’s care plan and facility policy. The resident had diagnoses including Alzheimer’s disease, hypertension, depression, and anxiety, with a BIMS score of zero indicating severely impaired cognition, and was dependent on staff for all ADLs. The Falls CAA documented a prior minor-injury fall and that fall precautions were in place with close monitoring. The care plan included an intervention, initiated in December 2022, to keep the resident’s call light within reach and answer it promptly, along with multiple fall-related interventions following falls in August 2025 and September 2025, and documentation in May 2026 that the resident was at risk for falls due to poor safety awareness and impulsiveness. On the survey date, the resident was observed lying in bed on her back with eyes open, covered with blankets, and yelling out, while the call light was found behind the headboard of the bed and not within reach. A CMA stated that residents should always have their call lights within reach and moved the resident’s pancake light onto her abdomen. Subsequent interviews with a licensed nurse and an administrative nurse confirmed that residents’ call lights should be placed where they are reachable by the resident. The facility’s Call Light Answering policy required staff to answer call lights within 15 minutes, respond to emergency lights immediately, and check to ensure the call light was within the resident’s reach, which was not followed in this instance.
Failure to Use Correct ABN Form When Medicare Part A Coverage Ended
Penalty
Summary
The facility failed to provide the correct Medicare Advance Beneficiary Notice of Non-Coverage (ABN) to a resident whose Medicare Part A skilled coverage ended while the resident remained in the facility. The facility census was 162 residents, with three residents reviewed for beneficiary notifications, and documentation showed that one resident’s Medicare Part A last covered day was 10/31/25. Instead of using the required ABN Form CMS-10055, the facility issued Form CMS-20052 (11/2017). During interviews, an administrative staff member and a social services staff member both confirmed that the correct ABN Form CMS-10055 was not provided to this resident. The facility had an undated policy titled “Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) Form CMS-10055 (2024),” but it was not followed in this case. This deficiency was identified through record review and staff interviews, which established that the resident did not receive the appropriate standardized notice of Medicare non-coverage at the time their Part A coverage ended, despite the facility having a policy referencing the correct ABN form.
Failure to Protect Resident PHI on Unattended Medication Carts
Penalty
Summary
Surveyors identified a failure to maintain the privacy and confidentiality of residents’ personal and medical records when unattended medication carts were left with open computer screens displaying protected health information (PHI). On 03/16/26 at 8:53 AM, a medication cart in the 600 hallway was observed unattended for four minutes with the electronic medication administration record for Resident 10 visible on the screen. Later that morning at 11:37 AM, another medication cart in the 500 hallway was observed unattended for over three minutes with treatment orders for Resident 96 displayed on the computer screen. The certified medication aide responsible for the first cart acknowledged he should have closed the computer screen so that Resident 10’s information could not be seen, and the licensed nurse responsible for the second cart similarly acknowledged she should have closed the screen to maintain confidentiality of residents’ medical information. On 03/17/26 at 1:38 PM, an administrative nurse stated the expectation that all resident information on computers should be protected by closing the computer screen when the cart is unattended. The facility’s undated Residents’ Rights policy documented that residents have the right to privacy and confidentiality for their personal and clinical records, and that confidentiality of personal and clinical records is a resident right.
Failure to Report and Investigate Resident-to-Resident Altercation as Potential Abuse
Penalty
Summary
Facility staff failed to identify and report a resident-to-resident altercation as potential abuse in accordance with facility policy and regulatory requirements. One resident involved, R62, had diagnoses including dementia with behaviors, Alzheimer's disease, major depressive disorder, and anxiety, with a Quarterly MDS indicating severely impaired cognitive function and dependence on staff for most ADLs. Her care plan documented a history of disruptive and combative behaviors, including potential physical aggression toward other residents and staff, and directed staff to use non-pharmacological interventions and assess for unmet needs when behaviors occurred. Nurse's notes dated 09/04/25 at 2:26 PM documented that R62 was involved in a resident-to-resident altercation in which she was observed grabbing another resident's arm and covering the other resident's mouth. The note indicated that R62 required redirection and physical removal of her hands, after which she was removed from the area and provided 1:1 interaction with a nurse to calm her, with staff to continue monitoring for safety due to poor safety awareness. Despite this documentation of physical contact and an altercation between residents, the facility did not initiate an investigation into the incident. The facility was unable to provide evidence that the incident was reported to the Administrator or to the State Survey Agency as required by its Abuse, Neglect, and Exploitation policy. That policy requires all individuals to immediately report allegations or suspicions of abuse, including abuse by other residents, to the Administrator or supervisor, and requires the Administrator or designee to assess the resident, complete an incident report, gather witness statements, and report to the State agency and law enforcement as indicated. Interviews with administrative nursing staff revealed that the nurse who documented the incident was new, and the training nurse did not consider the event to be abuse and therefore did not report it to administration, resulting in no timely reporting or investigation of the altercation as potential abuse.
Failure to Investigate Resident-to-Resident Altercation as Potential Abuse
Penalty
Summary
The deficiency involves the facility’s failure to identify a resident-to-resident altercation as potential abuse and to initiate an investigation as required by its abuse, neglect, and exploitation policy. One resident, who had diagnoses of dementia with behaviors, Alzheimer’s disease, major depressive disorder, and anxiety, was care planned for disruptive and potentially physically aggressive behaviors toward other residents and staff. Her care plan directed staff to use non-pharmacological interventions, assess for unmet needs, and review behaviors regularly. Despite this, nursing documentation on one occasion recorded that she was involved in a resident-to-resident altercation in which she grabbed another resident’s arm and covered the other resident’s mouth, requiring redirection and physical removal of her hands. The nurse’s note from that incident stated that the resident was removed from the area and provided one-on-one interaction to calm her, and that staff would continue to monitor for safety due to poor safety awareness. However, the facility was unable to provide evidence that a thorough investigation of this altercation was conducted. There was no documentation of an incident report, no documented assessment of injuries, and no collected witness statements related to the event, despite the description of physical contact between residents. Administrative staff later reported that the documenting nurse was new and had been trained by another nurse, and that the incident was not reported to administration at the time because the training nurse did not feel it was abuse. The facility’s written Abuse, Neglect, and Exploitation policy required that all individuals report allegations or suspicions of abuse, including abuse by other residents, immediately to the Administrator or supervisor. The policy further required the Administrator or designee to assess the resident, document injuries, complete an incident report, notify the physician and family, interview involved parties and witnesses, and report to the State agency and law enforcement within specified time frames when there is reasonable suspicion of a crime. In this case, despite a documented resident-to-resident altercation involving physical contact, these required reporting and investigative steps were not initiated or carried out, resulting in the failure to recognize and treat the event as a potential abuse incident in accordance with facility policy and regulatory expectations.
Failure to Maintain Ordered Head-of-Bed Elevation and Tube Feeding Regimen
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident receiving enteral nutrition via a gastrostomy tube (G-tube) had the head of bed (HOB) elevated as ordered and that tube feedings were administered according to physician orders. The resident had diagnoses including diabetes mellitus and dysphagia, a severely impaired BIMS score, required total assistance with ADLs, and was on hospice with a low BMI. The care plan and physician orders directed that the HOB be elevated 30 degrees continuously during enteral feeding and that Glucerna 1.5 be administered at 50 ml/hr with a scheduled daily two-hour “gut rest” period when the feeding was to be stopped. Surveyors observed multiple instances where these orders were not followed. On one day, the resident was found in bed lying flat while the enteral feeding pump was running at 50 ml/hr; the feeding bag label lacked the type of formula. On the following day, the resident was observed with the HOB at 30 degrees but the feeding pump was off and not connected, and later the same morning the resident remained with the HOB at 3 degrees and the tube feeding still off and disconnected. After medications were given, an LPN turned the pump on and connected the G-tube, then positioned the resident on the left side with the HOB at 30 degrees; later that morning, the resident was observed on the right side with the HOB at 10 degrees while the feeding was running at 50 ml/hr. Staff interviews further demonstrated lack of adherence to and understanding of the orders. One LPN did not notice the resident’s bed was flat while the feeding was running until prompted, and she was unsure how high the HOB should be elevated. CNAs gave inconsistent responses about who had provided care and what HOB elevation was required, with one CNA incorrectly stating the HOB should be elevated to 180 degrees. Another LPN reported that the tube feeding had not been turned back on until mid-morning and was unsure when it had been shut off, and initially could not locate the order for the scheduled two-hour morning interruption of feeding, despite the dietitian’s documented recommendation and the presence of the order in the EMR. The facility’s gastrostomy tube care policy did not address HOB elevation for enteral feedings, while the physician order-following policy required licensed staff to follow physician orders.
PRN Diphenhydramine Order Lacked Indication for Use
Penalty
Summary
Surveyors identified a deficiency related to unnecessary medications when a resident had a PRN diphenhydramine order without an associated diagnosis or documented reason for use. The resident’s EMR showed diagnoses of insomnia and anxiety, an Annual MDS with a BIMS score of 15 indicating intact cognition, no skin issues, and independence with ADLs. The Psychotropic Drug Use CAA noted the resident was prescribed psychotropic medications for anxiety and would be closely monitored. However, the care plan dated 03/16/26 did not include diphenhydramine, and a physician order dated 11/12/25 directed administration of diphenhydramine 50 mg by mouth three times a day as needed, without specifying an indication. Review of the EMR from 11/12/25 through 03/17/26 showed no documentation of this PRN diphenhydramine order in progress notes, provider notes, dermatology notes, pharmacy notes, or psychiatric notes. During observations, the resident was seen independently ambulating, participating in activities, and reporting that she did not know all of her medications but would ask the nurse if she needed something, stating she had many options to choose from. The consultant pharmacist confirmed on 03/17/26 that the PRN diphenhydramine order lacked a reason or diagnosis and acknowledged missing this issue during the last medication review. A CMA, a licensed nurse, and an administrative nurse each stated that all medications, including PRNs, were required to have a diagnosis or reason for administration, and the administrative nurse acknowledged that the diphenhydramine order should have included a reason since its initiation on 11/12/25. The facility did not provide a policy on PRN medication orders.
Crushing of Contraindicated Medications Leads to Elevated Medication Error Rate
Penalty
Summary
Surveyors identified a failure to maintain a medication error rate below 5 percent when five errors were found among 26 observed medication administrations, resulting in a 19.23 percent error rate. For one resident with anemia and a G-tube, physician orders directed daily administration of ferrous sulfate 325 mg and sennosides-docusate 8.6-50 mg via G-tube, and tamsulosin 0.4 mg via G-tube for malignant neoplasm of the bladder. During a morning medication pass, a licensed nurse noted a discrepancy between the tamsulosin order and the medication card, which was labeled for bedtime administration, and therefore withheld the tamsulosin pending clarification. The same nurse then crushed and administered the ferrous sulfate and sennosides-docusate via the G-tube, despite later confirmation from facility nursing leadership and the consultant pharmacist that these medications should not have been crushed. For another resident with an order for docusate sodium 100 mg capsules (two capsules once daily for constipation) and trazodone 50 mg twice daily for a psychotic disorder, a licensed nurse crushed the trazodone tablet and both docusate capsules and administered them mixed in pudding. Facility nursing leadership later reported that these medications also should not have been crushed. The facility’s medication administration policy stated that medications should not be crushed when contraindicated on a caution label or in the Prescribers’ Digital Reference, but the observed practice of crushing ferrous sulfate, sennosides-docusate, docusate sodium, and trazodone was inconsistent with this policy and contributed to the elevated medication error rate identified during the survey.
Failure to Implement Enhanced Barrier Precautions and Basic Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow Enhanced Barrier Precautions (EBP) and basic infection prevention practices for multiple residents. Surveyors observed that staff did not consistently use required PPE, including gowns and gloves, when providing high-contact care to residents on EBP or with open wounds and indwelling devices. For one resident with an indwelling catheter, CNAs used a sit-to-stand mechanical lift that had not been sanitized between residents, did not wear gowns as required for EBP, and allowed the resident’s urine drainage bag and tubing to rest on and drag along the floor during transfers. One CNA removed gloves and exited the room without performing hand hygiene. Staff acknowledged they should have worn gowns and sanitized the lift but stated they were in a hurry. Surveyors also observed improper hand hygiene and handling of ice during an ice pass. A CNA left the ice scoop in the cooler and the lid open while going in and out of resident rooms, and another CNA repeatedly retrieved resident cups from rooms, filled them from the cooler, and returned them without performing hand hygiene between residents. Both CNAs later confirmed that the scoop should be kept in a holder, the cooler lid should remain closed when not in use, and that hand hygiene should be performed between residents. A licensed nurse confirmed that facility expectations were for the ice coolers to remain closed, the scoop to be stored in a holder, and staff to wash their hands between residents. Additional deficiencies were identified related to EBP implementation and wound management. One resident with EBP signage on the door had PPE available, and a CNA initially used gown and gloves with appropriate hand hygiene during incontinence care, but when two CNAs later returned to transfer the resident with a mechanical lift, they did not wear gowns despite acknowledging the resident was on EBP. Another resident with multiple open and scabbed wounds, bleeding onto clothing and linens, and a widespread rash had no EBP signage or PPE setup at the door, and the electronic medical record lacked a detailed skin assessment despite the presence of at least 13 documented wounds. Facility policy required all skin lesions to be covered with dry dressings and mandated hand hygiene, but staff confirmed that EBP had not been implemented for this resident and that open, bleeding wounds had been present for a couple of months.
Failure to Properly Label and Discard Insulin and Expired Medications
Penalty
Summary
The facility failed to properly label and discard insulin medications for several residents, as well as expired stock medications. Specifically, Resident 53's Lantus flex pen lacked an open date and discard date, while Resident 15's Lantus flex pen and Resident 346's Levemir flex pen were outdated but not discarded. Additionally, Resident 1's Lantus vial was outdated and not discarded. Expired stock medications, such as a bottle of Tussin DM, were also found in the medication cart. These deficiencies were confirmed through observations and interviews with the facility's administrative nurse, who verified that the nurses were responsible for dating insulin when opened and discarding outdated insulin and expired stock medications. The facility's policies on insulin administration and drug storage were not followed, leading to the risk of residents receiving ineffective medications.
Failure to Maintain Resident Dignity During Assisted Dining
Penalty
Summary
The facility failed to treat Resident 115 with dignity during the noon meal in one of the dining rooms. Certified Nurse Aide M was observed standing over Resident 115 while assisting him to eat, leaving the table multiple times to perform other tasks, and then returning to continue feeding the resident. This behavior was contrary to the facility's expectations, as confirmed by the Certified Dietary Manager and Administrative Nurse, who stated that staff should sit next to the resident and engage in conversation while assisting with eating. The facility's Resident Rights Policy emphasized the importance of treating residents with dignity and respect, which was not upheld in this instance.
Failure to Provide Written Notice for Hospital Transfers
Penalty
Summary
The facility failed to provide written notice for facility-initiated transfers to the hospital for three residents, placing them at risk for uninformed care choices. Resident 68, who had a diagnosis of benign prostatic hyperplasia and an indwelling catheter, was transferred to the hospital without written notice being provided to the resident or their representative. Both Administrative Staff B and Administrative Nurse D confirmed the lack of documentation for the written notice. The facility also failed to provide a policy regarding facility-initiated transfers to the hospital upon request. Similarly, Resident 347, who had a diagnosis of lung disorders and required oxygen therapy, was transferred to the hospital without written notice being provided to the resident or their representative. Observations and interviews with Administrative Staff B and Administrative Nurse D confirmed the absence of documentation for the written notice. The facility again failed to provide a policy for facility-initiated transfers to the hospital upon request. Resident 75, who had diagnoses including diabetes mellitus, heart failure, and hypertension, was also transferred to the hospital without written notice being provided to the resident or their representative. Interviews with Licensed Nurse G and Administrative Nurse D confirmed that the facility did not notify the resident's representative in writing regarding the transfer. The facility's Bed Hold policy indicated that written notice should be provided, but this was not followed in these cases.
Failure to Provide Bed Hold Policy to Residents During Hospital Transfers
Penalty
Summary
The facility failed to provide three residents or their representatives with written information regarding the facility's bed hold policy when they were transferred to the hospital. Resident 68, who had a diagnosis of benign prostatic hyperplasia and required substantial assistance with toileting and personal hygiene, was admitted to the hospital. The facility lacked documentation that Resident 68 or his representative was provided with the bed hold policy at the time of transfer. Administrative staff confirmed the absence of this documentation and acknowledged that nursing staff were responsible for sending the bed hold policy with transfer papers but did not follow up on obtaining the signed notice. Resident 347, who had a diagnosis of lung disorders and required various levels of assistance for daily activities, was also admitted to the hospital. Similar to Resident 68, there was no evidence in Resident 347's clinical record that the bed hold policy was provided to the resident or their representative. Administrative staff verified the lack of documentation and confirmed that the bed hold policy was supposed to be sent with transfer papers but was not followed up on. Resident 75, who had multiple diagnoses including diabetes mellitus and heart failure, was admitted to the hospital. The clinical record for Resident 75 also lacked evidence that the bed hold policy was provided to the resident or their representative. Staff interviews revealed that while the bed hold policy was sent with the resident, there was no written notice provided to the resident's representative. The facility's bed hold policy stated that residents should be informed and given a written copy of the policy upon admission and if transferred to a hospital or during therapeutic leave, but this was not adhered to in these cases.
Failure to Complete PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure that three residents, identified as R87, R68, and R110, received a Preadmission Screening and Resident Review (PASRR) to identify potential care needs related to mental disorders or intellectual disabilities. This deficiency was identified through observation, interview, and record review. R87, who had diagnoses including bipolar disorder, did not have a PASRR completed before admission from the Veteran's Administration (VA). Similarly, R68, who required substantial assistance with activities of daily living and had diagnoses including congestive heart failure, also lacked a PASRR assessment. Both residents' clinical records lacked evidence of the required screening, and the facility did not provide a policy on PASRR completion upon request. Administrative staff confirmed that the VA did not perform PASRR assessments for these residents before admission. R110, who had diagnoses of posttraumatic stress disorder and anxiety disorder, also did not have a PASRR assessment completed as required. The resident's care plan indicated a history of behavioral symptoms and manipulative behavior. Despite this, the facility was unable to provide a PASRR screening for R110 upon request. Administrative staff verified that the VA did not assess for PASRR upon admission. The lack of PASRR assessments for these residents placed them at risk for unidentified needs and inadequate care.
Failure to Address PTSD in Resident Care Plan
Penalty
Summary
The facility failed to revise the care plan for a resident (R50) with PTSD, which placed the resident at risk for impaired care due to uncommunicated care needs. R50's electronic medical record documented multiple diagnoses, including dementia, anxiety, cerebral infarction, aphasia, PTSD, major depressive disorder, and Wernicke's encephalopathy. Despite these diagnoses, the care plan did not address trauma triggers or coping strategies for R50. The resident's quarterly MDS indicated moderate cognitive impairment and episodes of care refusal. The Behavioral Symptoms CAA noted multiple episodes of care refusal, and the care plan directed staff to inform R50 before initiating care and to encourage discussions about her past. However, the care plan did not include specific interventions for PTSD. Observations and interviews revealed that the facility's social services and nursing staff had not assessed or gathered information related to R50's trauma triggers. Social Service X admitted to not assessing R50's trauma triggers or speaking to the family about them. Administrative Nurse D confirmed that PTSD assessments were only conducted when symptoms like depression, flashbacks, or anxiety were observed. The facility's policy on Trauma Informed Care and Behavioral Health Management emphasized early identification of past traumatic events and the development of interventions to manage behaviors, but this was not followed for R50. Consequently, the facility failed to identify and implement necessary interventions for R50's PTSD, leading to uncommunicated care needs.
Failure to Provide Appropriate Restorative Services
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and services to maintain and prevent a decline in mobility and ambulation. The resident, who had diagnoses of diabetes mellitus, osteoarthritis, and chronic obstructive pulmonary disease, required partial to moderate assistance with activities of daily living and supervision to walk 50 to 150 feet. Despite having a restorative therapy plan that directed the resident to walk two to three times a week, the facility did not document any ambulation activities from the time the plan was developed until the resident refused to walk on one occasion. This lack of documentation and follow-through placed the resident at risk for a decline in mobility and impaired independence. Observations and interviews revealed that the resident was often found sitting in a recliner with feet elevated and did not receive the restorative services as directed. The facility's policy required that each resident be assisted to attain and maintain their highest functional level of independence, with restorative services documented in the electronic medical record. However, the facility did not adhere to this policy, as the resident did not receive the necessary restorative services, and the documentation was incomplete. This failure was verified by both the physical therapist and the administrative nurse, confirming that the resident had not received the directed restorative services since the plan was developed.
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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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