Diversicare Of Chanute
Inspection history, citations, penalties and survey trends for this long-term care facility in Chanute, Kansas.
- Location
- 530 W 14th Street, Chanute, Kansas 66720
- CMS Provider Number
- 175214
- Inspections on file
- 24
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Diversicare Of Chanute during CMS and state inspections, most recent first.
A hospice resident with a history of stroke, depression, anxiety, psychosis, insomnia, and impaired mobility had an established psychotropic regimen including clonazepam, lorazepam (Ativan), and Seroquel to manage terminal agitation and behavioral symptoms. After admission to hospice, an administrative nurse insisted the resident could not receive both clonazepam and Ativan, pressured staff to contact the PCP, and clonazepam was abruptly discontinued without hospice being notified, despite the PCP’s original plan to taper it gradually. Following this change, documentation showed the resident became increasingly agitated, paranoid, confused, and tearful, refused care and medications, attempted unsafe activities such as trying to leave his room and facility, and sustained an unwitnessed fall with a skin tear and low back discomfort, requiring more frequent narcotic pain medication. The resident’s DPOA and hospice staff reported that the resident’s behaviors and anxiety worsened after clonazepam was stopped and that they felt pressured by facility leadership to alter the medication regimen that had previously kept the resident more comfortable.
Failure to Report Resident-to-Resident Abuse Allegation: A resident with dementia, Alzheimer’s disease, and significant cognitive impairment pinched another resident, who also had severe cognitive impairment. The event was documented in the chart, but the incident was not immediately reported to the Administrator or the SA, and the investigation record showed the residents’ representatives and key facility leaders were not notified. The injured resident had no visible bruising or redness on follow-up, but the record lacked further documentation of psychosocial follow-up related to the event.
Surveyors observed that food and drink served to residents was not palatable, attractive, or at a safe and appetizing temperature, resulting in a deficiency related to meal quality and service standards.
Several residents reported not receiving their mail on weekends due to the absence of staff responsible for mail delivery on Saturdays. Staff interviews confirmed that mail was only checked and delivered Monday through Friday, with no clear process for weekend delivery, resulting in delayed access to mail for residents.
A resident with lymphedema and cellulitis had maggots found in his leg dressings due to the facility's failure to maintain clean and dry dressings. Despite the resident's concerns, staff did not change the soiled dressings for several days, and there was no protocol for handling such situations. Observations showed unsanitary conditions in the resident's room and improper hygiene practices by staff during wound care.
A resident with a history of muscle weakness and incontinence did not receive the prescribed wound care treatment due to staff failing to apply Dermafoam as ordered by the physician. Instead, an ointment was used, and the staff was unaware of the correct treatment protocol. The facility lacked a policy for following physician orders, leading to a deficiency in care.
A resident with a fractured right fibula and on medications contributing to constipation did not have a bowel movement for five days. The facility failed to monitor and address this issue, as the care plan lacked information on bowel function, and no medication for constipation was administered. Despite the resident's complaints and the facility's process for bowel monitoring, the physician was not notified, leading to a deficiency in care.
A resident with lymphedema and cellulitis received improper wound care, with staff failing to maintain a clean environment and perform appropriate hand hygiene. Dressings were not clean or intact, and supplies were placed on unclean surfaces. The facility's policies for hand hygiene and clean dressing changes were not followed, leading to an unsanitary environment.
A resident at the facility was found to have maggots on their skin during a wound clinic visit, indicating a failure in the facility's pest control program. Observations revealed flies in the resident's room and soaked bandages, with staff interviews highlighting a lack of awareness and communication regarding the pest issue. The facility's pest control policy was not effectively implemented, leading to this deficiency.
The facility failed to administer the physician-ordered amount of oxygen to a resident with COPD and ensure another resident with respiratory failure received oxygen as prescribed. Observations and staff interviews revealed deviations from prescribed oxygen levels and issues with empty oxygen bottles, highlighting a significant lapse in following physician orders.
A resident with atrial fibrillation and dependence on renal dialysis did not receive a physician-ordered anticoagulant medication for 22 days after a fistula placement procedure. The facility failed to document and administer the medication, and did not notify the cardiologist about the procedure. The administrative nurse was unaware of the error until 23 days later, and the facility lacked a policy for following physician orders.
Failure to Follow Hospice-Directed Psychotropic Regimen Resulting in Agitation and Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure a hospice resident received necessary care and his personalized, physician‑ordered medication regimen to manage terminal agitation and promote comfort. The resident had a history of cerebral infarction, depression, anxiety, psychosis, insomnia, impaired balance, lower extremity impairment with a prosthesis, and functional dependence in multiple ADLs. Care Area Assessments identified risks for further ADL decline, falls, incontinence, skin breakdown, pain, increased falls, impaired balance, and worsening depression and anxiety. The resident’s care plan documented he was on hospice for end‑of‑life care related to a terminal cerebral infarction and that staff were to coordinate care with hospice, notify hospice of any change in condition or medication changes, and provide medications as ordered while monitoring for effectiveness and side effects. The resident’s EMR showed he was receiving clonazepam 0.5 mg twice daily for anxiety related to altered mental status and Seroquel for dementia with distressing psychotic features. A provider order then added scheduled lorazepam (Ativan) 0.5 mg three times daily for agitation and irritability and admitted the resident to hospice. On hospice admission, most medications were discontinued, but clonazepam, lorazepam, Seroquel, Tylenol, Lantus, and PRN Tramadol were continued. Shortly afterward, an administrative nurse questioned why the resident had both scheduled Ativan and clonazepam, asserted the resident could not be on both, and required that the primary care provider be called to choose one or the other. A subsequent provider order discontinued clonazepam and continued lorazepam and Seroquel. Hospice was not informed of the discontinuation, and hospice staff later confirmed they had not received an order to stop clonazepam and only learned from facility staff that it had been stopped. Following the abrupt discontinuation of clonazepam, documentation showed the resident became increasingly agitated, confused, and distressed. Nursing notes described the resident becoming upset, refusing medications, expressing paranoid thoughts that staff were trying to poison him, picking up a folding table, threatening to throw it through a door, and requiring repeated staff interventions before eventually taking medications. Additional notes recorded the resident yelling for help, attempting to put on his prosthetic leg to “get some things out of the truck,” refusing care, being visibly upset and tearful, expressing confusion about his location and his daughter’s whereabouts, and having delusions about the Air Force being in the facility. The resident experienced an unwitnessed fall while trying to go downstairs, resulting in a skin tear and apparent discomfort, and he required increased use of narcotic pain medication after clonazepam was stopped. Hospice and the primary care provider later noted that the resident’s agitation and confusion increased around the time clonazepam was discontinued and that the original plan had been to taper clonazepam gradually while adjusting lorazepam, rather than stopping clonazepam abruptly. Interviews further documented that the administrative nurse told hospice and the resident’s DPOA that the resident could not be on both clonazepam and Ativan and indicated that if the DPOA did not agree, the resident could be taken home or the facility’s medical director would be used to discontinue medications. The DPOA reported feeling harassed, bullied, and pressured to have one of the medications discontinued, despite believing the combined regimen of lower‑dose Seroquel, clonazepam, and Ativan best controlled the resident’s behaviors and anxiety. The primary care provider confirmed she had intended to wean clonazepam over one to two weeks while adjusting Ativan but felt pressured by the situation at the facility to discontinue one of the medications sooner than planned. Facility administration later stated that the administrative nurse did not have authority to dictate what medications residents were allowed to take and that it would have been more appropriate to clarify concerns with the prescriber rather than stating the resident could not have the medication. The facility’s psychotropic medication policy stated that psychotropics are to be used only when a practitioner determines they are appropriate for a diagnosed condition and beneficial to the resident, with monitoring and documentation of response, underscoring that the resident’s ordered hospice comfort regimen was not followed as intended.
Failure to Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure staff immediately reported a resident-to-resident abuse allegation to the Administrator and failed to report the incident to the State Agency. The record showed one resident had diagnoses of dementia, Alzheimer’s disease, and gait and mobility abnormalities, with a BIMS score of 3 indicating significantly impaired cognition. He was dependent on staff for several activities of daily living, used a manual wheelchair, and had a behavioral care area assessment that triggered for physical and verbal abusive behaviors toward staff and other residents, resistance to care, wandering, yelling, and cursing. His care plan addressed limited awareness of safety and personal space but did not include interventions related to physical or verbal behaviors toward other residents. The incident record documented that the resident approached another resident and pinched her on the arm, after which he attempted to hit staff and used expletives. The other resident had severe cognitive impairment with a BIMS score of 4. Her record documented that she was pinched by another resident, and the next day staff examined her arm and found no bruising or redness and no verbal complaints of pain. Her record did not include further documentation of follow-up related to psychosocial impact from the event. The investigation template showed the incident was not reported to the residents’ representatives and that the nurse did not notify the provider, family, Administrative Nurse D, or Administrative Staff A. The facility could not provide witness statements or corrective actions associated with the incident. During interviews, one nurse stated she immediately separated the residents and checked the injured resident’s arm, while Administrative Nurse D initially stated such an event would only be reported if there was an actual injury and that she was not aware the pinching had occurred. Administrative Staff A stated the incident was not reported to the State Agency because he did not think the resident had actually pinched the other resident and, if it did happen, there was no physical injury.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. Surveyors observed that the food and beverages did not meet these standards during their review. The deficiency was identified based on direct observation of the meals served to residents, noting issues with the quality, presentation, and temperature of the food and drink.
Failure to Ensure Timely Delivery of Resident Mail on Weekends
Penalty
Summary
The facility failed to provide residents with reasonable access to receive their mail, specifically on Saturdays. Multiple residents reported that while they received mail Monday through Friday, mail was not delivered to them on Saturdays because the staff responsible for mail delivery did not work weekends. One resident noted that he received mail at his nearby house on Saturdays and expected the same at the facility. Staff interviews confirmed that the mail was checked and delivered only on weekdays, and there was confusion among staff regarding who was responsible for mail delivery on weekends. Activity staff and administrative staff both stated they did not work on Saturdays, and mail accumulated over the weekend was delivered on Mondays. Facility policy affirms residents' rights to send and receive mail, but the policy did not address timely delivery of mail received on Saturdays. Observations and staff interviews indicated that no system was in place to ensure mail was delivered to residents on Saturdays, resulting in delayed access to their correspondence. The deficiency was identified through direct observation, resident interviews, and staff statements, all confirming the lack of weekend mail delivery.
Failure to Maintain Clean Dressings and Proper Hygiene
Penalty
Summary
The facility failed to ensure that a resident, who was diagnosed with lymphedema, venous insufficiency, and cellulitis, had clean and dry dressings on his lower extremities. On a scheduled appointment, it was discovered that the resident's dressings were soaked with urine and fluid, and maggots were found on his right lower extremity. The dressings had not been changed since they were applied four days prior, despite the resident voicing concerns about the condition of his wraps to a licensed nurse the night before his appointment. The facility lacked additional orders to guide staff on actions to take if the dressings became soiled, wet, or loose. The resident's care plan and physician orders required that his lymphedema wraps be kept clean, dry, and intact, with outpatient therapy scheduled to change the dressings on specific days. However, the facility staff failed to monitor and address the condition of the wraps adequately. Documentation indicated that the wraps were not clean, dry, or intact on several occasions, yet no action was taken to rectify the situation or notify the physician for further instructions. The resident's condition was further compromised by the lack of a clear protocol for staff to follow when the dressings were not maintained as required. Observations revealed that the resident's room was unsanitary, with soiled dressings and gauze on the floor, and flies present, contributing to a foul odor. Staff members were observed handling the resident's dressings and performing wound care without adhering to proper hygiene protocols, such as changing gloves and performing hand hygiene. The facility's failure to maintain the resident's dressings and follow appropriate hygiene practices placed the resident at risk for further skin impairment and the presence of maggots in the wound areas.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to provide appropriate wound treatment for a resident, identified as R4, who had a medical history of muscle weakness, edema, and frequent incontinence leading to moisture-associated skin damage (MASD). Despite physician orders to apply Dermafoam to R4's bilateral upper back thigh wounds, the facility staff did not follow these orders. On a specific date, a Licensed Nurse (LN) applied Dermaseptin ointment instead of the prescribed foam dressing, indicating a failure to adhere to the treatment plan. The LN admitted to never having applied foam to those wounds before and was unaware of the correct treatment protocol. Further investigation revealed that the facility lacked a policy regarding adherence to physician orders, contributing to the oversight. Administrative staff confirmed that the Dermafoam should have been in place at all times and not treated as a PRN dressing. Additionally, another LN who worked the night shift was unaware of the treatment required for R4's thigh wounds, highlighting a communication gap among the staff. The resident, R4, reported that the foam dressing had been off since the previous night, and she was unsure if the nursing staff was aware of this. This series of actions and inactions led to the deficiency in providing the necessary wound care as per the physician's orders.
Failure to Monitor and Address Constipation in Resident
Penalty
Summary
The facility failed to monitor and address the bowel functioning of Resident 3, who had a medical history of a fractured right fibula and required assistance with personal care. Despite receiving medications such as Ultram and Bumex, which can contribute to constipation, there was no documentation of bowel movements for five days from June 20 to June 24, 2024. The facility's records, including the Baseline Care Plan and Care Plan, lacked information regarding bowel function, and there was no medication administered for constipation during this period. The facility's process for bowel monitoring involved CNAs reporting bowel movements daily, with alerts generated if a resident had not had a bowel movement in three days. However, this process was not effectively followed for Resident 3. Interviews with staff revealed that the facility had standing physician orders for constipation that could be activated if needed, but these were not utilized for Resident 3. The Licensed Nurse and Administrative Nurse were unaware of any actions taken to address the lack of bowel movements, and the physician was not notified as required by the facility's policy. Resident 3 expressed experiencing significant constipation and stated that at home, she took Miralax to manage her condition. Despite complaints of constipation reported by the CNA to the Licensed Nurse, no action was taken to address the issue, resulting in a deficiency in the facility's care for Resident 3.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper handling of a resident's wound care. The resident, who had a medical history of lymphedema, venous insufficiency, and cellulitis, was observed with dressings that were not clean, dry, or intact. The resident's room was unsanitary, with dressings and gauze on the floor, and flies present, contributing to a foul odor. The staff did not follow proper procedures for maintaining a clean environment, as evidenced by the presence of a tied-up plastic bag and a pile of wraps and gauze on the floor. During the dressing change, the licensed nurse (LN) failed to perform appropriate hand hygiene and did not use a clean dressing change procedure. The LN used the same contaminated gloves to clean the resident's legs after removing soiled dressings and did not perform hand hygiene before applying new gloves. Additionally, the LN placed treatment supplies directly on surfaces without a barrier and used a trash can to prop the resident's foot during the dressing change, which is against the facility's policy. The LN also failed to address the leaking dressings promptly and did not have an order for what to do if the wraps were not clean, dry, or intact. The facility's policies for hand hygiene and clean dressing changes were not followed, as the LN did not wash hands after removing gloves, did not use a barrier for dressing supplies, and did not dispose of dressings that touched unclean surfaces. The administrative nurse confirmed that hand hygiene should be performed during dressing changes, and a barrier should be used for dressing supplies. The failure to adhere to these policies resulted in an unsafe and unsanitary environment, increasing the risk of infection transmission.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a resident having maggots identified on their skin. On a visit to a wound clinic, two maggots were discovered on the resident's right lower extremity by Consultant Staff GG while removing urine and fluid-soaked dressings. The dressings had been in place since 06/13/24, and the maggots were found on 06/17/24. The facility's progress notes did not document the presence of maggots upon the resident's return from the clinic. Observations on 06/24/24 revealed flies in the resident's room, a foul odor, and soaked bandages, indicating a lack of effective pest control measures. Interviews with staff revealed a lack of awareness and communication regarding the pest issue. Housekeeping Staff U noted flies in the resident's room but did not take action due to a lack of resources. Maintenance Staff V was unaware of any fly issues or maggots and stated that concerns should be communicated through the TELS system. Administrative Staff A was not informed of the maggot issue until the surveyor's arrival. The facility's pest control policy, dated 09/01/14, was not effectively implemented, as evidenced by the presence of flies and maggots in the resident's environment.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to administer the physician-ordered amount of oxygen to Resident 5 (R5) and ensure Resident 1 (R1) received oxygen as prescribed. R5, diagnosed with chronic obstructive pulmonary disease (COPD), had a physician order for oxygen at three liters per minute via nasal cannula. However, observations on multiple occasions showed the oxygen concentrator set between 3.5 to 4.0 liters. Licensed Nurse H admitted to increasing the oxygen flow without verifying the current physician order, which was still set at three liters per minute. This discrepancy was confirmed by Administrative Nurse D, who emphasized the importance of following physician orders for oxygen administration. Resident 1 (R1), diagnosed with acute respiratory failure with hypoxia and heart failure, had a physician order for oxygen at two liters per minute via nasal cannula as needed to maintain oxygen saturation above 90 percent. However, during a physician visit, R1's oxygen tank was found empty, resulting in an oxygen saturation level of 80 percent. Observations and interviews revealed that R1 frequently experienced issues with empty oxygen bottles, both in the facility and during transportation to appointments. Staff members, including a Certified Medication Aide and Maintenance Staff, confirmed that R1 often returned from dialysis with an empty or improperly set oxygen bottle. Administrative Staff A and Nurse G acknowledged the issue and noted that the facility's policy required ensuring residents had enough oxygen before leaving the building. The facility's policy on oxygen guidelines, dated 01/01/22, stated that oxygen should be provided according to a physician's order, including the dose and rate of administration. The facility failed to adhere to this policy for both R5 and R1, resulting in deviations from the prescribed oxygen levels. This failure was corroborated by multiple staff members and documented observations, highlighting a significant lapse in following physician orders and ensuring proper oxygen administration for residents with respiratory needs.
Failure to Administer Physician-Ordered Medication
Penalty
Summary
The facility failed to start a physician-ordered medication for a resident (R1) with diagnoses of atrial fibrillation and dependence on renal dialysis, resulting in 22 days without the ordered medication. The resident was supposed to start taking apixaban (Eliquis), an anticoagulant, after a fistula placement procedure. However, the facility did not document or administer the medication until 23 days after the initial order. The Medication Administration Record (MAR) for February and March 2024 lacked instructions for administering apixaban until March 15, 2024, and the medication was only administered starting March 16, 2024. The facility also failed to notify the cardiologist about the fistula placement and the need to restart the medication. Interviews and record reviews revealed that the facility's administrative nurse was unaware of the medication error until March 18, 2024. The facility lacked a policy for following physician orders, and the process for handling new orders upon a resident's return from an appointment was not followed. The charge nurse and medical records staff were responsible for ensuring new orders were noted and brought to the morning meeting, but this did not occur in R1's case. The family member of R1 also reported multiple calls questioning whether the medication had been restarted, indicating a communication breakdown within the facility.
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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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