Great Plains Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Wichita, Kansas.
- Location
- 7101 E 21st Street North, Wichita, Kansas 67206
- CMS Provider Number
- 175168
- Inspections on file
- 28
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Great Plains Post Acute during CMS and state inspections, most recent first.
The facility did not employ a certified dietary manager to oversee food and nutrition services, despite having residents who required pureed and mechanical soft diets. During observation of a breakfast meal, dietary staff prepared meals while the person acting as dietary manager was confirmed by both dietary and administrative staff to be uncertified. When surveyors requested documentation, the facility was unable to provide a policy regarding the requirement for a certified dietary manager.
Surveyors found that the kitchen environment used to prepare and serve meals for 106 residents was not maintained in a sanitary condition. Air vents and a ceiling-mounted air conditioner above the sink and stove areas were coated with brownish grease and gray fuzzy buildup blowing directly over cleaning and food-preparation areas. Walls and baseboards behind the stove were splattered with brownish residue and covered in greasy buildup, and plaster was falling from walls behind the wash and tri-compartment sinks onto the floor. Dietary staff and administrative staff confirmed these conditions, and dietary staff reported uncertainty about who was responsible for cleaning the vents, despite policies assigning maintenance and sanitation responsibilities for building and food service areas.
Over an extended period, Resident Council meeting minutes repeatedly documented residents’ concerns that call lights were not being answered in a timely manner, despite notes that nursing administration would address the issue. A resident council leader later reported call light wait times of 30–60 minutes, especially when agency staff worked second and night shifts, and stated that staff often said they would return but did not do so promptly. Residents also lacked information on where state agency reports and Ombudsman information were kept, and reported that staff addressed them with terms like “Momma” and “Grandma” instead of using their names, contrary to expectations confirmed by facility staff. The facility’s grievance policy requires prompt resolution of grievances and written responses with rationale, but the same concerns continued to recur in council minutes.
A resident with dementia, pain, anxiety, and severely impaired cognition, who primarily spoke Bengali and depended on staff for most ADLs, had a care plan requiring use of a Bengali translator and adaptive communication equipment, as well as staff anticipation of her needs. Staff reported that communication with the resident was inconsistent and relied on a therapy staff member’s phone translator when available or on the resident pointing to items, which did not always allow them to understand her needs. Observation showed the resident speaking in her native language and then hitting CNAs during care, and a sign with translator phone numbers in her room was placed where it was not visible to staff, despite facility policy requiring adequate provisions for communication with persons with communication impairments.
Two residents with documented PTSD and other behavioral health diagnoses did not receive trauma‑informed care because the facility failed to complete trauma assessments, identify PTSD triggers, or develop individualized interventions. One resident with PTSD, dementia, anxiety, bipolar and mood disorder had a care plan listing behaviors such as yelling, hitting, refusals, and sexually inappropriate conduct, but the plan lacked any PTSD triggers or specific strategies to manage them, and her EMR contained no trauma‑informed assessment. Another resident with PTSD, depressive disorder, TBI, and panic disorder received multiple psychotropic medications, yet had no documented trauma assessment or triggers, and staff from nursing, social services, and CMA roles all reported they did not know his PTSD triggers and confirmed they were not on the care plan, contrary to the facility’s behavioral health policy.
Surveyors found that insulin pens for two residents on a medication cart were not properly labeled, with one Lantus pen having an unreadable opened date and one Novolog pen lacking any opened or discard date, despite facility expectations that nurses label insulin with the date opened and expiration. In a medication room, a multidose vial of tuberculin solution was also found in use without an open date, even though staff acknowledged it should be dated and discarded within 30 days, contrary to the facility’s Storage of Medication policy requiring complete and accurate labeling of all drug containers.
A resident with COPD, moderate cognitive impairment, and limited mobility was receiving hospice services, but the facility failed to ensure proper communication and coordination with the hospice provider. Although the resident’s care plan noted hospice admission and general interventions such as assistance with ADLs, monitoring weakness, and observing pain medication effectiveness, it lacked essential hospice-related details, including hospice contact information, visit frequency, and what supplies, equipment, medications, and care hospice would provide. This omission occurred despite a hospice agreement requiring a coordinated plan of care and a facility policy assigning social services to coordinate care between facility and hospice staff.
Staff failed to follow Enhanced Barrier Precautions (EBP) for a resident with MDRO when CNAs and an LN performed high-contact personal care, including incontinence care and treatment of an open area under the abdomen, wearing only gloves and no gowns despite EBP signage on the room. The EBP sign was removed during this episode of care, and staff stated they believed EBP was no longer required because the resident no longer had a catheter, contrary to facility policy that requires gown and glove use for high-contact care activities for residents with MDRO.
Surveyors found that the facility did not maintain a safe, functional, and sanitary environment in the laundry room, noting missing floor tiles in front of and behind front-loading washers and under a sink in the clean area, floor grates with a grayish-black fuzzy substance, and a washer with multiple streaks of dried white residue on its exterior. A laundry supervisor and a maintenance supervisor both confirmed these conditions and acknowledged that maintenance was responsible for cleaning and upkeep, consistent with the facility’s maintenance policy assigning responsibility for keeping buildings, grounds, and equipment safe and operable.
A resident with anxiety, DM, obesity, and dependence on staff for ADLs did not receive consistent bathing services as outlined in the care plan, which specified preferred shower days and times without any documented refusals for those scheduled showers. MDS assessments and monthly bathing records showed multiple extended periods with no baths or showers, while the EMR reflected only a few specific refusals that did not explain all missed bathing days. Staff reported the resident often refused baths and was offered washcloths and alternatives, but this was not consistently documented. During observed incontinence and personal care under Enhanced Barrier Precautions, staff noted a small open area under the resident’s abdominal pannus, and facility policy required provision of ADL care and documentation of refusals with alternative interventions, which was not consistently followed.
Two residents at high risk for falls experienced multiple falls without the facility adequately evaluating or adjusting their fall-prevention interventions. One resident with cerebellar ataxia, autism, severe cognitive impairment, and total dependence for ADLs had repeated falls from bed and wheelchair areas, including an unwitnessed fall with injury and an uninvestigated incident where he came out of a mechanical lift sling while thrashing. Despite numerous care-plan interventions and frequent fall risk assessments, the EMR lacked evidence of systematic evaluation of intervention effectiveness. Another resident with weakness, unsteadiness, hypertension, and impaired cognition had several falls from her room and wheelchair, with incomplete follow-through on ordered monitoring (such as a 3-night sleep diary) and missing documentation of new interventions. Observation showed a CNA encouraging this resident to transfer independently during toileting and bed transfers despite her unsteadiness and repeated requests for help, contrary to her need for supervised or stand-by assist. These actions and omissions failed to ensure adequate supervision and effective fall-prevention measures for both residents.
A LTC facility failed to ensure proper medication administration for two residents. One resident received Trazodone at the wrong time, causing increased exhaustion, while another resident was left with medication in her room without supervision, leading to an accumulation of pills. The facility's policy requires safe and timely administration with verification, which was not followed, resulting in deficiencies in care.
A resident with severe cognitive impairment and constipation required surgery to remove a fecal impaction due to the facility's inadequate system for identifying signs and symptoms of fecal impaction. The facility lacked clear protocols and training for bowel management, leading to inconsistent documentation and failure to administer necessary medications. This placed all residents at risk in immediate jeopardy.
A resident was left with a tourniquet on their arm for five days after a blood draw, leading to discoloration and requiring further medical assessment. The oversight was discovered when a nurse assessed the resident's arm, and it was confirmed that the lab vendor did not collect all ordered labs. The facility's policy on neglect was not upheld, as the resident was not adequately supervised.
A resident at a facility developed stage 3 pressure ulcers due to the facility's failure to implement care plan interventions. Despite being at risk, the resident was often left on their buttocks without repositioning or pressure-relieving devices. The facility did not promptly measure or document the ulcers, and an air mattress was delayed. Staff interviews revealed communication issues and a lack of coordination in the resident's care.
A resident with a history of falls and fractures fell from an unlocked wheelchair, resulting in a pelvic fracture. The facility failed to assess and document the fall, and the incident was not recorded in the nurse's notes. Staff interviews confirmed the fall was reported, but the resident was moved before an assessment was completed, violating the facility's fall management policy.
A resident with severe cognitive impairment experienced a 20.54% weight loss in one month due to the facility's failure to monitor and address the issue. Despite being on an NPO diet and receiving tube feedings, the resident's care plan was not effectively implemented, and a speech therapy evaluation was not documented. Staff interviews revealed inconsistencies in weight monitoring and communication, contributing to the deficiency.
The facility did not provide quarterly statements for the trust accounts of 57 residents. Administrative Staff PP indicated that statements were either hand-delivered or mailed, but no documentation was available to confirm this. Additionally, the facility lacked a policy for managing trust funds, leading to the deficiency.
A facility failed to ensure competent nursing care when a LN did not apply a pressure dressing to a resident's bleeding hematoma, leading to the resident being sent to the emergency room. Additionally, the facility did not assess or document a fall for another resident, who was later diagnosed with a pelvic fracture. The lack of appropriate response and documentation contributed to the deficiencies.
The facility did not conduct annual performance reviews for five direct care staff members, including CMAs and CNAs, who had been employed for over a year. This deficiency was confirmed by Administrative Staff A and highlighted the absence of a policy to ensure these evaluations, which are crucial for identifying staff weaknesses and improving performance to provide adequate resident care.
The facility's call system only activated a light above the door without an audible indicator or centralized console, requiring staff to walk the halls to identify activated call lights. Resident council minutes documented ongoing complaints about delayed responses, with wait times of up to three hours. Staff interviews confirmed the lack of visibility from the nurse station, and no effective policy was produced to address the issue.
The facility failed to provide annual mandatory training on abuse, neglect, and exploitation (ANE) for its nurse aides, as required by its policy. A review of employment files for five CMAs/CNAs employed for over a year showed they lacked the necessary continuing education on ANE. Administrative Staff A confirmed the deficiency, acknowledging the absence of assurance that the mandatory in-services had been provided.
The facility failed to ensure nurse aides received the required 12 hours of continuing education, including training on abuse prevention and dementia management. A review of five CMAs/CNAs employed for over a year showed they lacked this mandatory training. Administrative Staff A confirmed the absence of a system to ensure all staff received necessary in-services, as outlined in the facility's Abuse Prevention Program.
The facility failed to document the bathing preferences of three residents and the tube feeding needs of another, despite clear expectations and policies. This oversight involved residents with varying cognitive abilities and care needs, leading to potential negative impacts on their well-being.
The facility failed to provide necessary bathing services to six residents dependent on staff for ADL care due to a lack of hot water. Despite the facility's policy requiring support for residents unable to perform ADLs independently, the residents did not receive regular baths or showers. Staff interviews confirmed the absence of hot water and alternative bathing solutions, leading to inadequate personal hygiene care.
The facility failed to serve food at appropriate temperatures, with multiple residents reporting cold and unappetizing meals. Observations confirmed food items were below required temperatures, and improper thermometer cleaning practices were noted. Despite ongoing grievances and staff awareness, the facility did not adhere to its food preparation policy.
The facility failed to store, prepare, and serve food in a sanitary manner, risking food-borne illnesses. Observations revealed improperly sealed and unlabeled food items, dirty ice maker drains, and a lack of awareness among staff regarding food labeling requirements. These deficiencies violated the facility's food handling policy, potentially affecting resident safety.
The facility failed to maintain the dignity and privacy of two residents by not addressing their grooming needs and privacy during care. One resident was observed with unwanted facial hair and reported staff entering without knocking, while another had long facial hair and fingernails, expressing shame and lack of assistance. Additionally, staff did not close blinds during care, exposing a resident to public view. Interviews confirmed these practices, and grievances were filed regarding nail care.
A facility failed to honor a resident's bathing preferences, offering her preferred shower only once in 25 days due to hot water issues. The resident, who had intact cognition and was partially dependent on staff, reported feeling unclean with the alternative methods provided. Despite reporting grievances, there was no follow-up or resolution, and the care plan lacked documentation of her preferences.
A facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage Form (CMS-10055) to a resident, as confirmed by administrative staff. This form is necessary when terminating services expected to be non-covered by Medicare, as per the facility's policy.
A resident with a history of edema, pain, and anxiety did not receive the ordered Replens vaginal gel for dryness due to repeated delays in delivery. Despite being ordered, the gel was not administered, leading to the resident experiencing vaginal itching and being diagnosed with candidiasis. Staff interviews revealed the gel was not found in the treatment cart, and the pharmacy had not delivered it until later. The facility could not provide a policy on medication order and delivery.
A resident receiving tube feedings for dysphagia and malnutrition did not have tube placement or gastric residuals checked prior to a bolus feeding, and staff failed to maintain the head of bed at the required elevation for 60 minutes after feeding. These actions were not consistent with facility policy and could negatively impact the resident's physical well-being.
A resident with end stage renal disease requiring regular dialysis did not have consistent pre- and post-dialysis assessments or communication forms completed as required by physician orders and facility policy. Staff interviews and record review confirmed that documentation was missing for numerous dialysis sessions, and the resident reported that vital signs, weights, and access site checks were not always performed before and after dialysis.
A resident in an LTC facility experienced misappropriation of medications when two Percocet tablets were unaccounted for. The discrepancy was discovered during a shift change by a CMA and an LN, who attempted to correct the count but remained short. Despite an investigation, the facility could not substantiate theft or identify the responsible party, highlighting a lapse in medication accountability and resident protection policies.
A resident at risk for falls due to severe cognitive impairment and physical limitations did not receive the necessary fall prevention interventions as outlined in their care plan. Observations revealed that the resident's bed was not in the lowest position, the call light was out of reach, and no fall mats were present, contrary to the facility's Fall Prevention Program. An incident occurred where the resident fell during a bed bath, underscoring the failure to implement these safety measures.
Lack of Certified Dietary Manager Oversight for Specialized Diets
Penalty
Summary
The facility failed to provide the services of a full-time certified dietary manager to oversee the food and nutrition services for residents receiving meals from the kitchen. During a breakfast meal observation, dietary staff were seen preparing the meal, and subsequent interviews confirmed that the individual functioning as the dietary manager was not certified. Dietary staff reported that two residents were on a pureed diet and eight residents required a mechanical soft diet, indicating the presence of residents with specialized dietary needs. Administrative staff also verified that the dietary manager lacked certification, and when requested, the facility was unable to provide a policy regarding the requirement for a certified dietary manager. These findings demonstrate that the facility did not employ a certified dietary manager as required and did not have a related policy available when requested by surveyors, despite having residents who required modified diets such as pureed and mechanical soft diets.
Unsanitary Kitchen Vents, Walls, and Surfaces in Food Service Area
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to prepare, store, distribute, and serve food under sanitary conditions for all 106 residents receiving meals from the kitchen. During an initial kitchen tour, one air vent grill above the tri-compartment sink was observed to be covered with a brownish greasy/sticky substance and gray fuzzy material on all four edges, blowing directly onto the cleaning area. Two return air vent grills above the cooking stove area were also covered with brownish grease/sticky substance and gray fuzzy material, blowing directly over the food preparation and stove cooking area. Brownish splatter was present on the wall behind the cooking stove approximately four feet from the baseboard, and the baseboard itself was covered with a brownish greasy substance along the floor area. Additionally, a ceiling-mounted air conditioner had a metal grill covered with a brownish gray fuzzy substance. The wall behind the wash sink and the wall behind the tri-compartment sink each had sections of plaster, approximately 12 inches by 12 inches, falling off the wall, with plaster debris on the floor. Dietary staff confirmed the presence of the dirty vent grills, splatters and stains behind the stove, and the deteriorating plaster, and stated uncertainty about who was responsible for cleaning the vents, indicating that plaster repair would be a maintenance responsibility. Administrative staff later verified the same unsanitary conditions. These observations occurred despite existing facility policies stating that maintenance is responsible for maintaining building and equipment in a safe and operable manner and that food service areas must be kept clean and sanitary, with kitchen areas free from litter and maintained by trained food service staff.
Ongoing Unresolved Resident Council Concerns About Call Light Response and Communication
Penalty
Summary
The deficiency involves the facility’s failure to resolve recurring resident council concerns about delayed call light response times and related communication issues. Review of Resident Council minutes from January 2025 through February 2026 showed that, in multiple monthly meetings with between 14 and 20 residents present, residents repeatedly reported that call lights were not being answered in a timely manner. Each set of minutes documented that the issue would be addressed by nursing administration, but the same concern continued to appear over many months. The facility’s grievance/complaint policy, dated April 2017, states that the administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident or representative, and that all grievances or recommendations from resident or family groups concerning resident care will be considered and responded to in writing, including a rationale for the response. During an interview on April 22, 2026, the Resident Council President reported ongoing concerns with call lights, stating that staff would answer the call light and say they would return shortly, but often did not return promptly, with wait times reported between 30 minutes to an hour. The Resident Council President also reported that longer wait times occurred when agency staff were on duty, particularly on second and night shifts, and confirmed that the Resident Council did not have information on where state agency reports and Ombudsman information were kept. The Resident Council President further stated that staff should address residents by name rather than using terms such as “Momma” and “Grandma.” Activity staff confirmed that council concerns were reported to department directors and verified the lack of documentation informing the Resident Council where to locate state agency reports and Ombudsman information. An administrative nurse confirmed being invited to a Resident Council meeting to address call light response and verified that staff should address residents by name rather than with informal familial terms.
Failure to Implement Effective Communication Methods for Non‑English‑Speaking Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement alternative communication methods for a Bengali‑speaking resident with dementia, pain, and anxiety, resulting in staff being unable to effectively understand and respond to her needs. The resident’s EMR documented severely impaired cognition and dependence on staff for toileting, showers, dressing, personal hygiene, and substantial assistance for mobility and transfers. Her care plan specified that she required a Bengali translator to communicate, that staff should ensure the availability and functioning of adaptive communication equipment, that a translator be provided as necessary, and that staff should anticipate her needs. Despite these documented interventions, staff did not consistently use translation resources when interacting with her. During observation, two CNAs woke the resident for lunch, assisted her to a seated position, and applied a gait belt; the resident spoke in her native language and then began hitting the CNAs, who reported difficulty understanding what she needed. One CNA stated that a therapy staff member had a translator app on her phone but did not work every day, making communication “hit or miss,” and the other CNA said the resident would point at things but staff did not always know what she needed. A nurse stated that there were signs with translator phone numbers in rooms of residents who spoke different languages and that family could assist, but also noted that the resident’s dementia sometimes made her requests unclear. Observation of the resident’s room showed that the sign with translator phone numbers was not visible to staff because it was placed under another sign, contrary to the expectation that it be accessible. This occurred despite a facility policy stating that the facility would provide for communication with persons with impairments in communication and ensure adequate provisions to meet communication needs.
Failure to Identify PTSD Triggers and Implement Trauma‑Informed Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide trauma‑informed and culturally competent care by not identifying PTSD triggers or developing individualized interventions for two residents with documented PTSD and other behavioral health diagnoses. One resident had PTSD, dementia, anxiety, bipolar and mood disorder, and was care planned for behavioral symptoms such as yelling at staff, hitting, refusal of medications and treatment, refusal of meals, and sexually inappropriate behavior. Her care plan directed staff to administer medications as ordered, notify the physician of inappropriate behavior, and allow her to express herself, but it did not identify any PTSD triggers or specify how staff should manage those triggers. Her EMR also lacked any trauma‑informed care assessment, despite her intact cognition and dependence in ADLs. For this same resident, physician orders included antipsychotic medication (Latuda) for schizophrenia, and nursing documentation noted a history of mental and behavioral disorders and that she was upset after a care plan meeting where she was told she had schizophrenia and underlying mental health conditions. Administrative nursing staff confirmed that resident‑specific interventions had not been developed to address her PTSD diagnosis upon admission. This was inconsistent with the facility’s Behavioral Health Services policy, which stated that behavioral health services, including trauma‑informed care related to history of trauma and PTSD, would be provided as part of an interdisciplinary, person‑centered approach. The second resident’s EMR documented PTSD, depressive disorder, traumatic brain injury, and panic disorder, with intact cognition and partial assistance needs for certain ADLs. The resident received multiple psychotropic medications, including antipsychotics and an antidepressant, for PTSD, depressive disorder, and TBI‑related PTSD. However, the EMR lacked a trauma‑informed assessment with identified triggers, and the care plan only noted potential for behaviors due to PTSD, depression, and panic disorder, with general interventions such as administering medications, providing positive interactions, explaining procedures, allowing adjustment to changes, and monitoring for behaviors. A CMA, social services staff, and a nurse each stated they were unaware of any PTSD triggers for this resident, and confirmed that no PTSD triggers were listed on the care plan. Administrative nursing staff acknowledged that a trauma assessment had not been completed as expected under the facility’s Behavioral Health Services policy, which required behavioral health and trauma‑informed services in accordance with the comprehensive assessment and plan of care.
Failure to Properly Label Insulin Pens and Tuberculin Vial
Penalty
Summary
Surveyors identified that insulin pens and a multidose tuberculin vial were not properly labeled in accordance with facility policy and accepted professional standards. During observation of the East Hall medication cart, one resident’s Lantus insulin flex pen had an opened date label that was smeared and unreadable, and another resident’s Novolog insulin flex pen had no opened date or discard date. Administrative nursing staff confirmed that nurses are required to label insulin pens with the date opened and the expiration/discard date, and that expired insulin pens are to be discarded. Reference information from Medlineplus.gov noted that open, unrefrigerated Lantus and Humalog can be used within 28 days and must be discarded after that time. In a separate observation of the west medication room, surveyors found a multidose vial of Tuberculin Purified Protein Derivative without an open date. A licensed nurse verified that the vial had been opened and acknowledged it should be discarded within 30 days of opening, and administrative nursing staff confirmed the vial should have been dated when put into use. The facility’s Storage of Medication policy, dated 11/2020, documented that all drugs and biologicals are to be stored in a safe, secure, and orderly manner, and that drug containers with missing, incomplete, improper, or incorrect labels are to be returned to the pharmacy for proper labeling, with discontinued, outdated, or deteriorated drugs or biologicals returned to the dispensing pharmacy or destroyed.
Failure to Coordinate and Document Hospice Services in Resident Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure an effective communication process and coordinated plan of care between the hospice provider and the facility for a resident receiving hospice services. The resident’s EHR showed a diagnosis of COPD and a BIMS score of 11, indicating moderately impaired cognition, with partial to moderate staff assistance required for most ADLs. The MDS documented that the resident was receiving hospice care, and the care plan, revised 02/17/26, noted limited physical mobility due to weakness, hospice admission on 10/31/25, and interventions such as assistance with ADLs, establishing a daily routine, encouraging activities of choice, monitoring and reporting increased weakness or tiredness to the physician, encouraging rest, and observing the effectiveness of pain medication. However, the care plan did not include hospice-specific communication details such as a contact number for hospice, what supplies, equipment, and medications hospice would provide, when hospice staff would be in the building, or what care hospice staff would provide. Record review showed the resident was admitted to hospice care on 10/31/25, and the Hospice Agreement dated 10/31/26 stated that hospice and the facility would jointly develop and agree upon a coordinated plan of care. Despite this agreement, the resident’s care plan lacked the required hospice coordination information. During observation on 04/20/26, the resident was seen sitting in a wheelchair in the hall across from the east nurse’s station without signs or symptoms of pain. On 04/22/26, an administrative nurse confirmed that the care plan did not contain information regarding hospice visits, phone numbers, or medical supplies hospice would provide. The facility’s Hospice Program Policy, revised 07/17, documented that social services would be designated to coordinate care provided by facility staff and hospice staff, but this coordination was not reflected in the resident’s care plan documentation.
Failure to Follow Enhanced Barrier Precautions for Resident With MDRO
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow Enhanced Barrier Precautions (EBP) for a resident on EBP with multiple drug-resistant organisms (MDRO). On the morning of 04/21/26, EBP signage was posted at the entrance to the resident’s room, indicating the need for gown and glove use during high-contact care. Two CNAs entered the room and gloved but did not don gowns before removing the resident’s incontinence brief and performing personal care, including wiping under the resident’s abdominal area. During this care, the resident reported pain, and a small open area was observed under the resident’s belly. The CNAs notified a licensed nurse, who then entered the room without a gown and applied cream to the open area. After completing care and assisting the resident up for breakfast, the EBP signage was no longer hanging by the door. One CNA stated she believed EBP was no longer required because the resident no longer had a catheter, and the licensed nurse similarly stated the resident did not require EBP due to the absence of a catheter. The facility’s EBP policy, dated December 2024, specifies that EBP is used to prevent the spread of MDROs and requires gown and glove use during high-contact resident care activities such as dressing, bathing, providing hygiene, changing briefs, assisting with toileting, and transferring, even when contact precautions do not otherwise apply.
Failure to Maintain Safe and Sanitary Laundry Room Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, functional, sanitary, and comfortable environment in the laundry room. During observation, they noted missing floor tile along the front and behind two front-loading washing machines, covering an area of approximately five feet by eight inches, as well as missing tile underneath a sink in the clean area measuring about two feet by 18 inches. Behind the washing machines, two floor grates measuring approximately two feet by 18 inches each were observed with a grayish-black fuzzy substance on their surfaces. In addition, the right front-loading washing machine had numerous different-sized streaks of dried white substance below the door and on the right side. The Laundry Supervisor confirmed these conditions and stated that maintenance was responsible for cleaning the area and that the tile had been scheduled for replacement about a year earlier. The Maintenance Supervisor also verified the findings, acknowledged responsibility for cleaning the laundry room, and stated he was aware the tile needed replacement. The facility’s Maintenance Service Policy documented that the maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. No specific residents or their medical conditions were mentioned in relation to this deficiency.
Failure to Provide Consistent, Care-Planned Bathing Services
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent bathing services as care planned for one resident who required staff assistance with activities of daily living. The resident had diagnoses including anxiety, diabetes mellitus, and obesity, and MDS assessments documented dependence on staff for toileting hygiene, dressing, mobility, transfers, lower body dressing, and personal hygiene. The resident’s care plan documented a preference for showers on Tuesday, Thursday, and Saturday evenings, and there was no documentation that the resident refused these scheduled showers. MDS assessments over multiple periods documented that the resident did not receive showers, and monthly bathing records showed extended gaps with no bath or shower provided, including 16 consecutive days in February, 13 consecutive days in March, and 12 consecutive days in April. During these gaps, the EMR documented only a limited number of specific bath or shower refusals, which did not account for all of the missed bathing days. Staff interviews indicated that the resident often refused baths and that staff attempted to offer washcloths for partial hygiene and alternatives to baths or showers, but this was not consistently reflected in the care plan or records. On observation, staff provided incontinence and personal care to the resident, who was on Enhanced Barrier Precautions, and a small open area was noted under the resident’s abdominal pannus during care. The facility’s ADL Supporting policy required that residents be provided care and services to maintain or improve their ability to carry out ADLs and that refusals be addressed with risk/benefit information and alternative interventions, but the documentation and observed care showed that consistent bathing services as care planned were not provided.
Failure to Evaluate and Adjust Fall Interventions for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate and adjust fall interventions for two residents with multiple falls, despite both being consistently assessed as high fall risk. One resident had cerebellar ataxia, autistic disorder, weakness, restlessness, agitation, and severely impaired cognition, and was dependent on staff for all ADLs. Multiple fall risk assessments over several months documented this resident as high risk for falls, and the care plan contained numerous fall-related interventions such as ensuring the call light was within reach, frequent checks when unattended, use of a mattress on the floor, wedges for positioning, Dycem and a touchpad call light, frequent comfort and positioning checks in the wheelchair, and ensuring bed brakes were locked. However, the resident continued to experience falls, including from a chair by the nurse’s station and from the bed area, and the facility did not demonstrate that it systematically evaluated the effectiveness of these interventions in preventing further falls. For this same resident, fall investigations documented specific events but did not consistently lead to thorough evaluation or new targeted interventions. One fall occurred when the resident was seated by the nurse’s station and fell over the right side of the chair; another occurred when the resident was found on the floor next to the wall and bed, with staff later educated about locking the bed. A subsequent unwitnessed fall in the hallway in front of the nurse’s desk resulted in a contusion and transfer to the emergency room. Additionally, nurse’s notes described an incident where the resident became so agitated and thrashing during a mechanical lift transfer that he got himself out of the sling, and staff discovered the bed wheels were flipped almost 180 degrees; the EMR lacked an investigation of this incident, even though administrative nursing staff later verified it should have been considered a fall. Staff interviews revealed that three CNAs sometimes assisted with lift transfers because the resident had previously fallen out of the sling and that the resident was kept near the nurse’s station due to anxiousness and agitation, but there was no documented evaluation of whether existing interventions were effective or needed modification in light of these repeated events. The second resident had diagnoses of weakness, unsteadiness on feet, hypertension, and impaired cognition, and required at least supervision or partial assistance for transfers, toileting, dressing, mobility, and ambulation. Fall risk assessments repeatedly identified this resident as high risk for falls, and the care plan included interventions such as ensuring the call light was within reach, encouraging use of the call light, placing non-skid strips in various locations, adding anti-rollbacks to the wheelchair, using Dycem in the wheelchair, assessing the toilet seat, and placing a sign in the bathroom to use the call light. Despite these measures, the resident experienced multiple falls: being found on the floor fully clothed with shoes and coat on and unable to explain what she was doing; being found on the floor with the wheelchair behind her and brakes unlocked; and sliding out of the wheelchair after leaning too far forward near the heater. The documented responses included a care plan meeting with family and an order to complete a 3-night sleep diary, but the EMR lacked documentation that the sleep diary was completed, and the care plan did not reflect the intervention of placing a bedside table in front of her when she sat by the heater. Further observation and interviews showed that staff actions did not consistently align with the resident’s assessed needs and care plan for supervision with transfers and toileting. During a direct observation, a CNA instructed the resident to wipe herself, then told her she could transfer herself from the toilet to the wheelchair and from the wheelchair to the bed, despite the resident asking for assistance multiple times and demonstrating unsteadiness, nearly missing the wheelchair seat, and having difficulty maneuvering out of the bathroom. The CNA later stated that the resident was supervised with toileting and transfers and suggested the resident only asked for help because the CNA was being observed. A nurse stated the resident was a stand-by assist and that staff should help if she needed assistance, and administrative nursing staff stated they expected staff to assist the resident when requested and acknowledged that the sleep study had not been completed and that a family conference was not an appropriate care plan intervention. Overall, the facility did not show that it evaluated the effectiveness of fall interventions or consistently implemented and documented appropriate, resident-centered fall prevention measures for these two high-risk residents, despite recurrent falls. The facility’s Falls and Fall Risk, Managing policy stated that staff, with physician input, would implement a resident-centered fall prevention plan to reduce specific risk factors, prioritize interventions when multiple options existed, and implement additional or different interventions or justify the current approach if falls recurred. In both residents’ cases, falls recurred despite existing interventions, yet the record lacked evidence of systematic evaluation of why falls continued, whether interventions were effective, or whether new or modified interventions were needed. The absence of investigation for at least one fall event, the lack of follow-through on ordered monitoring (such as the 3-night sleep diary), and the failure to incorporate observed interventions into the care plan contributed to the deficiency in ensuring the environment was free from accident hazards and that adequate supervision and assistance were provided to prevent accidents.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure the proper administration of medication for two residents, leading to deficiencies in professional standards of care. For one resident, the Certified Medication Aide administered Trazodone, a medication with a black box warning, at the incorrect time. The resident was supposed to receive the medication at bedtime, but it was given at noon, causing increased exhaustion. The error was discovered when the resident reported feeling tired, prompting a review of the medication administration process. The facility's policy requires medications to be administered safely and timely, with verification of the right resident, medication, dosage, time, and method, which was not adhered to in this case. Another resident experienced a failure in medication administration when staff left medication in the resident's room without observing its consumption. This resident, who had severely impaired cognition, was found with 15 medication cups containing gabapentin and tramadol, and an additional 19 tramadol pills in a drawer. The facility's policy mandates that staff ensure residents take their medication while being observed, which was not followed, leading to the accumulation of medication in the resident's room. Interviews with staff revealed that the facility expected medications to be administered correctly and residents to be observed taking their medications. However, these expectations were not met, resulting in medication errors and potential risks to the residents' health. The facility's failure to adhere to its medication administration policy contributed to these deficiencies, as staff did not verify medication administration or ensure residents consumed their medications as required.
Inadequate Bowel Management Leads to Resident Surgery
Penalty
Summary
The facility failed to have an adequate system in place to identify the known signs and symptoms of fecal impaction for a resident, who required surgery to remove a large stool ball from his upper rectum under anesthesia. The resident, identified as R77, had a diagnosis of constipation and severely impaired cognition, requiring total assistance with all activities of daily living. Despite being always incontinent of bowel, the facility's records lacked any orders for monitoring or medications for the resident's bowels. The facility's documentation revealed inconsistencies in recording the resident's bowel movements, with some shifts missing documentation entirely. The resident had several documented bowel movements that were charted as normal and formed, but there were days with no bowel movements documented. On one occasion, the resident became lethargic and exhibited signs of distress, including a fever and increased pulse, leading to his transfer to the hospital. A CT scan at the hospital revealed a massive stool burden, and the resident required surgery to remove the fecal impaction. Interviews with facility staff highlighted a lack of clear protocols and training regarding bowel management. Staff members reported confusion over what constituted a normal bowel movement and admitted to incorrectly charting small bowel movements. The facility lacked a policy for monitoring and documentation of bowel movements, relying instead on standing orders for as-needed bowel medications. This deficiency placed all residents at risk in immediate jeopardy, as the facility failed to recognize and address the signs and symptoms of fecal impaction in a timely manner.
Removal Plan
- Identify residents who have suffered or are likely to suffer a serious adverse outcome as a result of the alleged noncompliance.
- Clinical managers will interview interviewable residents for last BM, signs and symptoms of constipation, and fecal impaction.
- CNAs will document BMs before the end of their shifts.
- Nurses will assess non-interviewable residents for signs and symptoms of constipation or fecal impaction.
- If any residents are identified with constipation and fecal impaction, MD will be notified, and orders will be followed as needed.
- DON/designee will educate clinical staff on proper BM documentation, urinary output, signs and symptoms of constipation and fecal impaction.
- DON/designee will educate CNAs to document BMs on POC before they leave their shift.
- DON/designee will educate nurses to review POC documentation before end of the shift that CNA has completed BM documentation.
- DON/designee will educate nurses to review alerts on PCC before the end of the shift.
- DON/designee will educate Nurses to assess residents with no BMs, signs and symptoms of impaction, or abdominal pain; notify MD; and follow physician's orders.
- DON/designee will educate clinical staff.
- Unit manager will review POC documentation on clinical meeting to ensure compliance with BM documentation, urinary output and necessary follow up.
- DON will perform random audit on POC documentation, progress notes, MD notification, and medication administration for residents identified with no BM or signs and symptoms of constipation or fecal impaction.
- If additional discrepancies are identified, they will be corrected immediately according to physician's orders.
Failure to Remove Tourniquet Leads to Resident Neglect
Penalty
Summary
The facility failed to provide adequate supervision for a resident, identified as R157, when a tourniquet was left on his arm following a blood draw. The tourniquet was applied on a Friday and was not discovered until the following Monday, remaining on the resident's arm for a total of five days. This oversight was identified during a review of the resident's Electronic Health Record (EHR), which documented a history of transient ischemic attack, sepsis, and lactic acidosis. The EHR also noted an order for lab tests related to hyponatremia, hyperkalemia, and transaminitis. The delay in discovering the tourniquet resulted in a deep blue ring and reddish discoloration on the resident's arm, prompting further medical assessment and intervention. Interviews with facility staff revealed that the lab vendor failed to collect all the ordered labs and left the tourniquet on the resident's arm. Licensed Nurse J assessed the resident's condition and notified the provider, who ordered a doppler study to evaluate the resident's arm. Administrative Staff A confirmed the expectation that the tourniquet should have been discovered much sooner. The facility's policy on abuse, neglect, and exploitation emphasizes the residents' right to be free from neglect, which was not upheld in this instance, as the resident was not provided with the necessary supervision to prevent this oversight.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to implement care plan interventions to prevent the development of facility-acquired, stage 3 pressure ulcers for a resident identified as R14. R14 was readmitted to the facility with diagnoses including metabolic encephalopathy and dementia, and was at risk for pressure ulcers. Despite this, the facility did not apply necessary interventions such as frequent repositioning, use of pressure-relieving devices, and regular skin assessments. Observations revealed that R14 was often left positioned on his buttocks without repositioning or the use of positioning devices, contributing to the development of pressure ulcers. The facility's records indicated that R14 had no pressure ulcers upon readmission, but later developed open areas on the buttocks that were not promptly measured or documented. The care plan included instructions for skin care and the use of pressure-relieving devices, but these were not consistently followed. The facility also failed to ensure that an air mattress was provided in a timely manner, which was only applied after the pressure ulcers had developed. Interviews with staff revealed a lack of communication and coordination in the care of R14. The wound nurse was unable to contact the resident's guardian for consent, delaying wound assessments. Additionally, there was confusion regarding the use of a camera for wound documentation. The facility's failure to implement and monitor appropriate interventions led to the preventable development of stage 3 pressure ulcers on R14's buttocks.
Failure to Assess and Document Resident Fall
Penalty
Summary
The facility failed to ensure proper assessment and documentation following a fall incident involving a resident, identified as R409. The resident, who had a history of falls and fractures, was admitted with a diagnosis of unspecified fracture of the left femur and required substantial assistance with daily activities. Despite being on fall precautions, the resident fell from an unlocked wheelchair, resulting in a right-side fracture of the pelvis. The incident was not documented in the nurse's notes, and there was no record of a fall assessment or adherence to the facility's fall protocol. Interviews with staff revealed that the fall was reported to the charge nurse, but the resident was moved before an assessment was completed. The facility's policy on fall management, which requires identification of interventions to prevent falls and minimize complications, was not followed. The lack of documentation and assessment after the fall was confirmed by the facility's investigation, which noted the absence of a fall assessment and documentation in the resident's records until after the resident was transferred to a hospital.
Failure to Monitor and Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to adequately monitor and address the significant weight loss of a cognitively impaired resident, identified as R14, who experienced a 20.54% weight loss in one month. R14 had a history of anorexia, metabolic encephalopathy, and dementia, and required total staff assistance with activities of daily living. Despite these needs, the facility did not develop or implement effective care plan interventions to address the resident's weight loss, which was documented as severe. The resident's care plan included instructions for staff to monitor weights, observe for chewing or swallowing problems, and provide a diet per physician orders. However, the facility did not ensure these interventions were followed. The resident was placed on an NPO diet and received tube feedings, but there was a lack of documentation and follow-up on the speech therapy evaluation, which was crucial for assessing the resident's ability to safely consume food orally. Additionally, the facility's policy required weights to be monitored and documented, but there were inconsistencies in the recording and communication of the resident's weight changes. Interviews with staff revealed that the speech evaluation was completed but not documented in the electronic health record, and the resident's weight loss was not addressed in a timely manner. The facility's failure to adhere to its policies and procedures for weight monitoring and care planning contributed to the resident's significant weight loss, which was not adequately addressed by the interdisciplinary team. This deficiency had the potential to negatively impact the resident's physical well-being.
Failure to Provide Quarterly Trust Account Statements
Penalty
Summary
The facility failed to provide quarterly statements for the personal trust accounts of 57 residents. The facility had a total census of 102 residents, with 57 having active trust accounts managed by the facility. Upon review, no quarterly statements were available for these accounts. During an interview, Administrative Staff PP stated that the facility printed and hand-delivered statements to residents with high cognitive functioning or mailed them to representatives of residents with low cognitive functioning. However, the facility could not provide documentation to confirm that these statements were distributed. Additionally, the facility did not have a policy related to the management of trust funds, contributing to the deficiency in providing quarterly statements for the residents' personal funds entrusted to the facility.
Failure to Ensure Competent Nursing Care and Fall Assessment
Penalty
Summary
The facility failed to ensure competent nursing staff when a Licensed Nurse (LN) did not apply a pressure dressing to a resident's ruptured and heavily bleeding hematoma on the right lower leg. The resident, who had a history of hemiplegia and hemiparesis following a stroke, was observed with acute swelling and pain in the leg, which was initially treated with a pressure dressing. However, when the bleeding became extreme, the LN failed to apply pressure or a pressure dressing, instead obtaining an order to send the resident to the emergency room. The facility subsequently removed the LN from the schedule and terminated her employment. Another deficiency involved the facility's failure to assess and document a fall for a resident who had a history of fractures and was at risk for falls. The resident, who required substantial assistance with activities of daily living and used a wheelchair, was sent to the hospital for changes in mental status and pain, where a pelvic fracture was diagnosed. The facility's investigation revealed that the resident had fallen while attempting to stand from an unlocked wheelchair, but the incident was not documented, and the facility's fall protocol was not followed. Interviews with staff indicated a lack of appropriate response to the resident's fall, with the charge nurse failing to assess the resident or document the incident. The facility's policy on fall management required staff to identify interventions to prevent falls and minimize complications, but this was not adhered to in the case of the resident's fall. The facility's failure to assess and document the fall and the resident's status afterward contributed to the deficiency.
Failure to Conduct Annual Performance Reviews for Direct Care Staff
Penalty
Summary
The facility failed to conduct annual performance reviews for five direct care staff members, including certified medication aides and certified nurse aides, who had been employed for one year or more. This deficiency was identified through observation, interviews, and record reviews, which revealed that none of the five staff members had received the required annual performance evaluations. These evaluations are essential to identify weaknesses and develop action plans to improve staff performance, ensuring that residents receive adequate care. Administrative Staff A confirmed the absence of these evaluations and acknowledged that the facility lacked a policy to address the completion of required performance reviews.
Inadequate Call System in Resident Areas
Penalty
Summary
The facility failed to provide an adequate call system for residents to communicate with staff from their bedside, toilet, and bathing facilities. Observations revealed that the call lights in resident rooms and bathing areas only activated a light above the door in the hallway, with no audible indicator or connection to a centralized console. This system required staff to physically walk the halls to identify activated call lights, as there were no pagers or screens to indicate which light was on. Interviews with staff confirmed that the only way to know if a call light was activated was to visually check the hallways, which was not possible from the nurse station due to limited visibility. Resident council minutes from November 2024 to February 2025 documented ongoing complaints about delayed call light responses, with reported wait times ranging from one to three hours. Despite these complaints, no effective response or policy was produced by the facility to address the issue. Interviews with administrative staff revealed a lack of awareness of the resident council's complaints and a misunderstanding of the visibility limitations from the nurse station. The facility's failure to provide a direct communication system for residents potentially delayed response times and posed a risk of serious injury.
Failure to Provide Mandatory ANE Training
Penalty
Summary
The facility, with a census of 102 residents, failed to ensure the continuing competence of its nurse aides by not providing annual mandatory training on abuse, neglect, and exploitation (ANE). A review of employment files for five certified medication aides/certified nurse aides (CMA/CNA) employed at the facility for over a year revealed that none had received the required continuing education or training on ANE. The staff members identified were CNA VV, CNA WW, CMA XX, CMA YY, and CNA ZZ. On February 10, 2025, Administrative Staff A confirmed these findings and acknowledged the lack of assurance that the mandatory in-services for ANE had been provided to the noted staff. The facility's policy, dated April 2021, mandates staff orientation and training programs that include topics such as abuse prevention, identification, and reporting of abuse, stress management, and handling verbally or physically aggressive residents. However, the facility did not adhere to this policy, resulting in the deficiency.
Deficiency in Nurse Aide Training and Competence
Penalty
Summary
The facility failed to ensure the continuing competence of nurse aides, as evidenced by a lack of required continuing education and training. A review of employment files for five certified medication aides/certified nurse aides (CMA/CNA) employed at the facility for over a year revealed that none of them had completed the mandatory 12 hours of continuing education. This education should have included training on abuse, neglect, and exploitation (ANE), as well as dementia management and addressing areas of weakness identified in performance reviews. The absence of this training was confirmed by Administrative Staff A, who acknowledged the facility's responsibility to provide such education to ensure adequate care for residents. The facility's policy on the Abuse Prevention Program, dated April 2021, mandates staff orientation and training programs that cover topics such as abuse prevention, identification, and reporting of abuse, as well as stress management and handling aggressive behavior. However, the facility did not have a system in place to ensure that all staff received these mandatory in-services. This lack of training and oversight could potentially impact the quality of care provided to residents, particularly those with special needs as determined by the facility staff.
Failure to Document Resident Preferences and Care Needs
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for four residents, leading to potential negative impacts on their well-being. Resident 88, who had moderately impaired cognition, required substantial assistance with activities of daily living and expressed a preference for the type and timing of bathing. However, the care plan did not document these preferences, which was confirmed by interviews with nursing staff who acknowledged the expectation to include such details in care plans. Similarly, Resident 75, with intact cognition, also had preferences for bathing that were not documented in the care plan. Despite the resident's ability to communicate these preferences, the care plan lacked any indication of the preferred times, days, or type of bathing. Interviews with nursing staff reiterated the expectation that care plans should reflect residents' preferences, yet this was not adhered to in practice. Resident 82, who was cognitively intact, had specific preferences for bathing frequency and type, which were not included in the care plan. The facility lacked a policy to address the development of care plans related to bathing preferences. Additionally, Resident 14, who had severe cognitive impairment and required tube feeding, did not have the care plan updated to reflect this significant change in care needs. The delay in updating the care plan for tube feeding interventions was acknowledged by administrative staff, highlighting a failure to ensure timely updates to care plans following significant changes in residents' conditions.
Failure to Provide Adequate Bathing Services Due to Lack of Hot Water
Penalty
Summary
The facility failed to provide necessary bathing services to six residents who were dependent on staff for activities of daily living (ADL) care. The residents, identified as R27, R80, R79, R76, R88, and R82, did not receive regular baths or showers due to the unavailability of hot water in the facility. This deficiency was observed through a review of the residents' Electronic Health Records (EHRs), which documented infrequent bathing over a specified period. Interviews with staff confirmed the lack of hot water and the absence of alternative bathing solutions, such as bath wipes. Resident R88, who had diagnoses of edema, pain, and anxiety, and was documented as having moderately impaired cognition, required substantial assistance with ADLs, including bathing. The resident's care plan indicated a need for staff assistance with showering. However, the EHR revealed that R88 received showers only five times out of ten opportunities, with significant gaps between bathing sessions. Staff interviews further highlighted the ongoing issue of water availability, which hindered the provision of adequate personal hygiene care. The facility's policy on ADLs, dated March 2018, stated that residents unable to perform ADLs independently should receive necessary support to maintain good personal hygiene. Despite this policy, the facility did not ensure that residents received the required services, as evidenced by the lack of hot water and the unavailability of alternative bathing methods. Interviews with administrative staff revealed expectations for staff to accommodate the lack of hot water, but these measures were not effectively implemented, resulting in the deficiency.
Failure to Serve Food at Appropriate Temperatures
Penalty
Summary
The facility failed to provide residents with food that was palatable, attractive, and served at the appropriate temperature. Multiple residents reported that the food was often cold and unappetizing. Observations revealed that food items, such as pureed corn, were served at temperatures below the required 135 degrees Fahrenheit. The dietary staff used improper methods to clean the thermometer between temperature checks, using the same cloth towel repeatedly, which could compromise food safety. The facility's grievance forms and resident council meeting notes documented ongoing complaints about cold food, indicating a pattern of dissatisfaction among residents. Interviews with staff, including a registered dietician and administrative personnel, confirmed that the food temperatures were unacceptable and that there were expectations for proper food handling and serving practices. Despite these expectations, the facility's policy on food preparation and service was not adhered to, as evidenced by the repeated grievances and observations of improper food temperature management. The lack of a comprehensive response to grievances and the absence of an effective action plan to address the issue contributed to the deficiency.
Deficient Food Storage and Handling Practices
Penalty
Summary
The facility failed to store, prepare, and serve food in a sanitary manner, which could potentially lead to food-borne illnesses among residents. During an observation of the kitchen and food storage areas, several issues were noted, including a large bag of panko crumbs with a ripped hole that was not properly sealed, several opened and unsealed bags of pasta, and a bag of honey granola without a date label. Additionally, two standing freezers contained several unidentifiable frozen items without dates or labels, and turkey burgers were found without expiration dates or labels. A bag of cut-up potatoes and some kind of pink meat were also found without labels or dates. In the walk-in cooler, two heads of lettuce and a bag of cheese were opened without dates, and a bag of toasted bread was found without a date or label. Further observations revealed that the drain for the ice maker was lying directly on the floor, which was visibly dirty, and the nourishment room's refrigerator contained a gallon of open milk with no date. Interviews with dietary staff and a licensed nurse revealed a lack of awareness regarding the requirement for labeling and dating food items. The facility's policy on food receiving and storage, dated 2001, documented that food should be received and stored in a manner that complies with safe food handling practices, including labeling and dating dry foods removed from original packaging and all foods stored in the refrigerator/freezer. The facility's failure to adhere to these practices had the potential to negatively affect the residents by increasing the risk of food-borne illness.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to protect the dignity of two residents, R80 and R27, by not addressing their personal grooming needs and privacy. R80 was observed with over one inch of unwanted facial hair, which he expressed a preference to be clean-shaven, and reported that staff frequently entered his room without knocking or announcing themselves. Similarly, R27 was observed with two inches of facial hair and long fingernails, which she found shameful and reported that staff did not assist her with grooming. These observations were made during interviews and visits, where both residents expressed dissatisfaction with the lack of assistance from the staff. Additionally, the facility staff failed to maintain privacy during care activities. During an incontinence care session for R80, CNAs SS and TT did not close the window blinds, exposing the resident to a public sidewalk and parking lot. Interviews with staff confirmed that blinds should be closed during such activities. Administrative Staff A acknowledged that nail care should be offered twice a month and facial hair removal should occur during bathing, but grievances had been filed by residents regarding the lack of nail care. The facility did not provide a policy related to protecting residents' dignity when requested.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not providing choices related to bathing preferences. Resident 82, who had intact cognition and was partially dependent on staff for bathing, expressed a preference for showers four times a week. However, the facility did not document these preferences in the care plan and failed to offer the resident her preferred type of bath consistently. During a period when the facility experienced issues with the hot water boiler, the resident was only offered her preferred shower once in 25 days, and alternative bathing methods were not consistently provided. The resident reported feeling unclean and dissatisfied with the alternative bathing methods offered, such as bed baths with wipes, which were not provided consistently due to the lack of hot water. Despite the resident's grievances being reported to the administrator, there was no follow-up or resolution. The facility's policy on bed baths did not include directions for accommodating resident preferences, contributing to the deficiency in providing resident-centered care.
Failure to Provide Required Beneficiary Notice
Penalty
Summary
The facility failed to provide the correct and complete Beneficiary Protection Notification Forms to a resident, identified as R56, as required by regulations. During a review on February 10, 2025, it was found that the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage Form (CMS-10055) was missing for R56. This form is necessary when a facility proposes to stop providing extended care items or services because it anticipates that Medicare will not continue to cover them. On February 11, 2025, Administrative Staff A confirmed that the form should have been issued to the resident. The facility's policy, dated September 2024, mandates that residents receive this notice before the termination of services expected to be non-covered by Medicare. The absence of this form for R56 indicates a failure to comply with the policy and regulatory requirements.
Failure to Administer Ordered Medication
Penalty
Summary
The facility failed to provide necessary care for a resident, identified as R88, by not obtaining and administering the ordered Replens external comfort vaginal gel for vaginal dryness. R88's medical history included diagnoses of edema, pain, and anxiety, with a BIMS score indicating moderately impaired cognition. The resident required substantial assistance with activities of daily living and was occasionally incontinent of the bladder. An order for the vaginal gel was placed on 12/09/24, but subsequent progress notes indicated repeated delays and failures in obtaining the medication, with the gel being on order or pending delivery multiple times. Despite the order being placed, the gel was not delivered or administered, leading to R88 experiencing vaginal itching and eventually being diagnosed with candidiasis during a hospital visit. Interviews with facility staff revealed that the gel was not found in the treatment cart, and the pharmacy had not delivered it until a later date. The facility was unable to provide a policy regarding the medication order and delivery process when requested, highlighting a deficiency in ensuring the resident received the necessary care as per the medical orders.
Failure to Follow Enteral Feeding Protocols
Penalty
Summary
A resident with a history of anorexia, metabolic encephalopathy, dementia, dysphagia, and moderate malnutrition was reviewed for tube feeding management. The resident was on a physician-ordered NPO diet and received Glucerna 1.5 Cal via tube feeding every four hours, with instructions to monitor tube feeding tolerance, residuals, and weights. During an observation, a licensed nurse administered a bolus tube feeding without checking for tube placement or gastric residuals prior to the feeding, despite facility policy and expectations to do so. The nurse acknowledged that there was no specific order to check placement but admitted that it should have been done regardless. Additionally, after the bolus feeding was administered, staff failed to maintain the resident's head of bed at a minimum of 30 degrees elevation for at least 60 minutes, as required by facility policy to prevent aspiration. The head of bed was elevated less than 30 degrees for only four minutes before the resident was transferred out of bed. Administrative nursing staff confirmed the lapse in maintaining head elevation and were uncertain about the required duration for elevation post-feeding. These actions were inconsistent with the facility's enteral feeding safety precautions and had the potential to negatively affect the resident's physical well-being.
Failure to Ensure Consistent Dialysis Communication and Assessment
Penalty
Summary
The facility failed to ensure proper coordination of care and communication between the dialysis center and the facility for a resident diagnosed with end stage renal disease (ESRD) who required regular dialysis. The resident's care plan and physician orders required staff to complete pre- and post-dialysis assessments, monitor vital signs, weights, and the dialysis access site, and document this information using a dialysis communication form for each dialysis session. However, a review of the resident's electronic health record revealed that pre-dialysis communication forms were not completed for 33 documented dialysis days over a five-month period. The resident also reported that staff did not always assess his vital signs, weight, and access site before and after dialysis as required. Interviews with facility staff confirmed that the expected documentation and assessments were not consistently performed or recorded in the electronic health record. The facility's own policy required ongoing communication and coordination with the dialysis center, including the use of a dialysis communication form to ensure safe and effective care. The lack of completed documentation and communication forms indicated a failure to follow established protocols for residents receiving dialysis, resulting in inadequate communication between the facility and the dialysis center for this resident.
Misappropriation of Medications in LTC Facility
Penalty
Summary
The facility failed to protect a resident from the misappropriation of medications when two tablets of Percocet, a narcotic pain medication, were unaccounted for and never found. The resident, who had diagnoses of generalized muscle weakness and primary generalized osteoarthritis, was receiving scheduled opioid medications for chronic pain. The incident occurred when a Certified Medication Aide (CMA) and a Licensed Nurse (LN) discovered a discrepancy in the narcotic count during their shift change. They attempted to correct the count by administering an additional pill, but the count was still short by two tablets the following morning. The facility's investigation revealed that the medication cart on the East wing was short two Percocet tablets at shift change. The CMA and LN involved were suspended pending investigation, and drug tests for opiates returned negative results. Despite efforts to trace the missing tablets, the facility was unable to substantiate theft or pinpoint a single person responsible for the discrepancy. The facility's Controlled Substance Administration and Accountability policy required that all controlled substances be recorded on a designated usage form, and discrepancies were to be reported immediately. The facility's policies on abuse, neglect, and exploitation directed them to protect residents from misappropriation of property. However, the failure to account for the missing Percocet tablets indicated a lapse in these protections. The incident was treated as a potential misappropriation and a medication error, but the facility could not determine the exact cause or responsible party for the missing medication.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent falls for a resident identified as R2, who was at risk for falls due to multiple medical conditions including hemiplegia, hemiparesis, and severe cognitive impairment. Despite being dependent on staff for activities of daily living, R2's care plan included specific interventions such as ensuring the call light was within reach, placing the bed in a low position, and using a perimeter mattress with fall mats. However, these interventions were not consistently implemented, as observed during a survey when R2's bed was not in the lowest position, the call light was out of reach, and no fall mats were present. An incident occurred where R2 fell from the bed while receiving a bed bath, highlighting the failure to adhere to the care plan's directives. Staff interviews revealed that while they were aware of the fall risk interventions through the care plan and Kardex, these measures were not always put into practice. The facility's Fall Prevention Program outlined the need for environmental interventions to reduce fall risks, but these were not effectively executed, leading to the deficiency noted in the report.
Latest citations in Kansas
Surveyors identified unsanitary food storage and preparation conditions, including food debris in a reach-in freezer, an unknown spilled liquid in a reach-in refrigerator, missing two-inch air gap on an ice machine drain, dirty carts used for clean dishes, and a steamtable shelf with built-up food debris. A dietary staff member acknowledged these areas needed cleaning, and it was determined the facility lacked a cleaning schedule or policy for kitchen cleanliness.
The facility failed to complete and analyze Care Area Assessments (CAAs) for multiple residents after Admission, Annual, and Significant Change MDS assessments triggered areas such as cognition, mood/behavior, functional status, urinary incontinence/indwelling catheter, nutrition, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, and visual function. Instead of documenting individualized analysis of underlying causes and contributing factors, an LPN reported she had stopped writing CAA notes and relied mainly on check-off worksheets and the fact that triggers appeared in the MDS CAA section. No facility policy on CAAs was provided to surveyors, and the CAAs consistently lacked required analytical documentation for residents with diverse and significant clinical needs.
A resident with dementia, severe cognitive impairment, and an indwelling urinary catheter was repeatedly observed sitting in common areas with his catheter drainage bag resting on his lower leg, visibly filled with dark amber urine and lacking a privacy cover, despite a care plan directing staff to cover the drainage bag. CNAs reported that the bag often slid down from the resident’s thigh, that they did not use catheter dignity bags on their hall, and that they simply moved the bag back up when it slid down. An administrative nurse stated she had not considered the use of dignity bags on the memory care unit, even though the facility’s resident rights policy affirms each resident’s right to a dignified existence, privacy, and confidentiality.
Two residents with documented cognitive ability to participate in care planning were not invited to any care plan meetings, and their EMRs lacked evidence of care plan conferences, invitations, or Interdisciplinary Care Conference assessments. Administrative staff stated that invitations should be mailed or hand-delivered and uploaded to the EMR, and that an Interdisciplinary Care Conference note should be completed, but none of this documentation existed for these residents, contrary to facility policy and federal requirements for resident and/or representative participation in care planning.
A resident with C-diff and CHF, newly admitted and with a baseline care plan that did not address call light use, was repeatedly found without access to a call light. Surveyors observed the resident yelling for help with her room door closed and later noted the call light on the floor under the bed and again on the floor while the resident sat in a recliner and stated she wanted to return to bed but could not do so independently. Staff reported using a binder clip to attach the call light to the resident’s clothing because the cord lacked a clip, acknowledged the resident sometimes threw the call light to the floor, and stated that call lights should be kept within residents’ reach. An administrative nurse confirmed the expectation that call lights be accessible at all times and was unsure about the use of a binder clip, and no facility policy on call lights was provided.
Surveyors found that a resident’s bathroom and handwashing area were not maintained in a safe, sanitary, and comfortable condition, including a loose baseboard with black substance behind it, a cracked toilet seat, and an empty, improperly mounted hand soap dispenser. Maintenance staff confirmed these conditions, noted that the soap dispenser was nonfunctional, and reported that although a QR code system existed for reporting maintenance issues, these problems had not been reported. Maintenance staff also stated there were no facility policies for maintenance repair in resident rooms and no policy provided for ensuring a safe, homelike environment.
Multiple residents were affected by inaccurate MDS assessments, including a resident with dementia and an indwelling catheter who was miscoded as always incontinent of urine and independent in ADLs despite staff and EMR documentation showing long-term catheter use and total dependence for dressing and wheelchair positioning. Another resident with a history of stroke was incorrectly coded as having a restraint, even though bed grab bars were used as enablers to assist with repositioning and did not limit voluntary movement. A resident with diabetes and unsteadiness experienced two documented falls that were not captured on the MDS, and another resident with diabetes, depression, CAD, and CKD was actively receiving hospice services per EMR, social services, and staff interviews, yet hospice was not coded on the MDS. The consultant MDS nurse confirmed these were significant coding errors not in accordance with the RAI User’s Manual.
A resident with C. diff and CHF was admitted, and while a baseline care plan documenting contact precautions was created, the resident later reported not knowing what a baseline care plan was. The resident was also found yelling for help with her call light on the floor under the bed. Nursing staff stated that baseline care plans are started on the day of admission and reviewed with residents, but also indicated that residents and families are not given written copies. An administrative nurse claimed a 48-hour interdisciplinary care conference had been completed, yet no corresponding documentation existed in the EMR, and explanations about who was responsible and why it was missing were inconsistent. No facility policy for baseline care plans was provided.
A resident with dementia and severe cognitive impairment was inaccurately assessed and care planned as needing only setup or independent assistance with dressing, despite actually requiring total staff assistance. The EMR lacked clear ADL documentation, and the ADL CAA did not trigger, leading to inaccurate MDS entries and a care plan that did not match the resident’s functional status. Surveyors observed the resident sitting in a wheelchair wearing dirty, food-stained pants and being taken to the dining room without a clothing change, with the soiled pants not changed until later when two CNAs provided total assistance. Staff, including CNAs, an LN, and an administrative nurse, acknowledged that the resident needed total help with dressing and should always be in clean clothing, revealing a failure to provide appropriate ADL support and maintain clean attire.
A resident with dementia and severe cognitive impairment was transported multiple times in a wheelchair without staff ensuring that his feet remained safely on the foot pedals. Although assessments inaccurately documented that he was independent with walking using a walker and/or wheelchair, his care plan did not instruct staff on proper use of wheelchair foot pedals. During observed transports by CNAs, the resident’s shoed feet repeatedly fell off the pedals and skimmed the floor between them. Staff acknowledged that his feet did not stay on the pedals and that the pedals were not effectively adjusted, and nursing leadership confirmed expectations that feet should remain on the pedals during transport. No wheelchair safety policy was provided.
Unsanitary Kitchen Conditions and Lack of Cleaning Policy
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions when surveyors observed multiple cleanliness and equipment issues in the kitchen. During an initial kitchen tour on 04/27/26 at 08:57 AM, the three-door reach-in freezer was found with food debris on the bottom shelf, and the three-door reach-in refrigerator had an unknown spilled liquid on the bottom shelf. The drain to the ice machine did not have the required two-inch air gap. Two black two-tiered plastic carts used to store clean dishes had food debris on the bottom tier, and the bottom shelf of the steamtable, which was used to store plate covers, had a buildup of food debris. On 04/28/26 at 01:57 PM, a dietary staff member confirmed these areas required cleaning, and it was identified that the facility did not have a cleaning schedule or a policy regarding kitchen cleanliness. No specific residents, medical histories, or clinical conditions were mentioned in the report in relation to this deficiency.
Failure to Complete and Analyze Care Area Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive Care Area Assessments (CAAs) with analysis of underlying causes, contributing factors, and risk factors for multiple residents following MDS assessments. Record review showed that numerous residents had Admission, Annual, or Significant Change MDS assessments that triggered CAAs in areas such as mood/behavior, cognitive loss/dementia, functional abilities, communication, urinary incontinence/indwelling catheter, nutritional status, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, visual function, and psychosocial well-being. For each of these triggered areas, the corresponding CAAs lacked analysis of the findings. This pattern was identified for residents with a wide range of clinical issues, including dementia, incontinence, falls, pressure ulcers, nutritional concerns, psychotropic medication use, pain, and functional decline. During an interview, a licensed nurse reported that she had stopped writing CAA notes the previous year after being told to do so by someone she could not identify. She stated that she did not write anything on the triggered CAAs and that, at times, she would document risk concerns only on a main check-off worksheet, relying on the fact that the triggers were already reflected in the MDS CAA section. The facility did not provide a policy regarding CAAs when requested. These findings demonstrate that the facility did not ensure that comprehensive assessments were fully completed as required when residents were first admitted and periodically thereafter.
Failure to Maintain Dignity and Privacy for Resident with Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to a dignified existence by not maintaining privacy for his urinary catheter drainage bag as directed in his care plan. The resident had diagnoses including bladder calculus and dementia, with a BIMS score of one indicating severe cognitive impairment, and was dependent on staff for toileting hygiene with an indwelling urinary catheter and constant urinary incontinence. His care plan, revised 03/23/26, instructed staff to cover his drainage bag with a privacy cover. However, during observations on 04/27/26, the resident was seen sitting in his wheelchair at his room doorway and later in the dining room with his catheter drainage bag resting on his lower left leg, supported by his shoe, containing dark amber urine and visible to visitors and other residents, without a privacy cover. Staff interviews confirmed that the catheter drainage bag frequently slid from the resident’s left thigh down to his lower leg and that staff did not consistently reposition it or use dignity/privacy bags. One CNA stated he had never placed a dignity bag on the resident’s drainage bag, and another CNA reported that staff on their hall did not utilize catheter dignity bags, instead just moving the bag back up when it slid down. An administrative nurse acknowledged she had not considered staff use of dignity bags for urinary catheters on the memory care unit. The facility’s Resident Rights policy, approved 12/2024, stated that each resident has the right to a dignified existence including privacy and confidentiality, which was not followed in this case.
Failure to Involve Cognitively Able Residents in Care Plan Meetings
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were given the opportunity to participate in the development and implementation of their person-centered plans of care. For one resident with a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognition, the electronic medical record showed an admission MDS and a Significant Change MDS, but there was no documentation of any care plan meeting in the prior four months. This resident reported not being invited to any care plan meeting. For a second resident with a BIMS score of 14, indicating intact cognition, the electronic medical record contained an admission MDS and a Quarterly MDS, but there was no documentation of a care plan meeting in the prior two months. This resident also reported not being invited to any care plan meeting. Administrative staff reported that residents and/or family members were supposed to be mailed or hand-delivered invitations to attend care planning meetings and that a copy of the invitation should be uploaded into the EMR. They further stated that an Interdisciplinary Care Conference assessment should be completed in the EMR during the care plan meeting. However, the administrative nurse confirmed that there was no documentation of invitations, Interdisciplinary Care Conference assessments, or completed care plan meetings for the two residents. The facility’s care planning policy stated that social services should attend care plan meetings and that the team presents information to the resident and/or representative about progress toward care plan goals, and referenced federal law requiring resident and/or representative participation in care plan meetings to the extent possible, but this process was not carried out or documented for the two residents identified.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach and to reasonably accommodate the resident’s needs and preferences. The resident had documented diagnoses of C-diff and CHF, and her baseline care plan dated 04/23/26 directed staff to evaluate for changes in level of consciousness but did not include any direction regarding call light use or accessibility. On 04/28/26 at 08:06 AM, surveyors observed the resident’s room door closed while she yelled loudly for help several times. When a licensed nurse entered the room, the resident was lying on her left side in bed, stated she wanted to get up, and reported she could not find her call light. The call light was observed on the floor under her bed. Later that morning, a CNA attached the call light to the resident’s shirt using a black and silver binder clip because the call light cord did not have its own clip. On 04/29/26 at 12:15 PM, the resident was seated in a recliner with the call light again lying on the floor out of her reach; she reported she wanted to go to bed and could not get herself back into bed. Staff interviews revealed that the CNA used the binder clip to keep the call light attached to the resident, and the licensed nurse stated staff should make sure the call light is clipped to the resident’s clothes and reported that the resident would throw her call light on the floor. An administrative nurse stated she expected staff to ensure all residents always have their call lights in reach and was unsure about using a binder clip to hold a call light in place. The facility did not provide a policy regarding call lights.
Failure to Maintain Safe and Sanitary Resident Bathroom Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, functional, sanitary, and comfortable environment in Resident 87’s bathroom and handwashing area. During an environmental tour with Maintenance Staff UU, surveyors observed an approximately four-foot section of loose baseboard to the left of and behind the toilet, with a black substance present on the wall and floor behind the loose baseboard. They also noted an approximately three-inch crack in the toilet seat and an empty hand soap dispenser hanging above the handwashing sink, mounted with exposed lag bolt fasteners. Maintenance Staff UU confirmed these conditions, acknowledged that the soap dispenser did not work, and stated that the toilet seat should be replaced, the bathroom baseboard removed, the black substance tested for mold, and the sheetrock removed and replaced. Further interview with Maintenance Staff UU revealed that the facility had implemented a QR code system for staff and visitors to report maintenance items, but the issues in this resident’s bathroom had not been reported through that system. He also reported that there had been a leak behind the handwashing sink that had flowed into the bathroom area, leading to the sink’s replacement, but he had received no report of the specific deficiencies observed in the bathroom. Additionally, Maintenance Staff UU stated that the facility did not have policies for maintenance repair in residents’ rooms, and the facility did not provide a policy for ensuring a safe, homelike environment.
Inaccurate MDS Coding for ADLs, Restraints, Falls, and Hospice Services
Penalty
Summary
The deficiency involves the facility’s failure to complete accurate Minimum Data Set (MDS) assessments in accordance with the Resident Assessment Instrument (RAI) User’s Manual, resulting in multiple residents’ clinical status not being correctly reflected. For one resident with dementia and severe cognitive impairment, the Significant Change and subsequent Quarterly MDS assessments coded him as always incontinent of bladder and independent with eating and upper body dressing, with use of a walker and wheelchair. However, the electronic medical record showed ongoing indwelling catheter care each shift and no documentation of walker use, wheelchair mobility, or dressing requirements during the review period. Staff interviews revealed that this resident had an indwelling catheter for more than a year, had not walked for several years, and was dependent on staff for all ADLs, including dressing and wheelchair positioning, contradicting the MDS coding. Observations showed the resident slumped in a wheelchair, wearing a hospital gown over clothing, with a visible catheter bag on his lower leg and feet frequently skimming the floor despite foot pedals being present, further indicating dependence and catheter use not accurately captured on the MDS. Another deficiency involved a resident with a history of stroke, hemiplegia, and hemiparesis whose Significant Change MDS coded the use of “other restraint.” During observation, the resident was seen in bed with bilateral grab bars at the head of the bed and her right arm positioned on a pillow. The resident reported using the grab bars to help move and reposition herself in bed. CNAs and administrative nursing staff confirmed that the facility did not use restraints and that the grab bars were used as enablers to assist residents with repositioning and to increase independence. Administrative staff acknowledged that the MDS coding for restraints was inaccurate because the grab bars did not limit the resident’s voluntary movement or access to her body. A further inaccuracy was identified for a resident with diabetes, atrial fibrillation, unsteadiness of feet, and a toe fracture. Both a Significant Change and a Quarterly MDS documented intact cognition, partial/moderate assistance with transfers, no ambulation, and no falls. However, progress notes in the EMR documented two unwitnessed falls during the look-back period, including one where the resident was found on the floor next to the bed with a forehead skin tear and another where the resident was found sitting on a fall mat on the floor with a scratch on the ankle. These documented falls were not reflected on the MDS. In addition, another resident with diabetes, depression, CAD, and chronic kidney disease had a Significant Change MDS that coded no hospice services, while the EMR contained a hospice certification and physician orders initiating hospice services, and social service notes and staff interviews confirmed that hospice services, including bathing by a hospice aide, were being provided during the look-back period. The consultant MDS nurse confirmed that these assessments were inaccurate and not completed in accordance with the RAI User’s Manual, constituting significant errors in coding for urinary status, ADL dependence, restraints, falls, and hospice services. The consultant MDS nurse stated that the resident with the indwelling catheter should have been coded as not rated for urinary continence due to catheter placement rather than as always incontinent, and that his ADL status should not have been coded as independent given his dependence on staff for dressing and wheelchair positioning. For the resident with grab bars, the nurse confirmed that the grab bars were used as enablers and not as restraints, making the restraint coding inaccurate. For the resident with documented falls, the MDS failed to capture falls that occurred within the look-back period, and for the resident receiving hospice services, the MDS did not reflect hospice care that was active during the look-back period. These miscodings met the RAI Manual’s definition of significant error, in which the resident’s overall clinical status is not accurately represented on the assessment and the error has not been corrected by a more recent assessment.
Failure to Provide and Communicate Baseline Care Plan to New Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide a summary of the baseline care plan to a newly admitted resident and to ensure that the baseline care plan process was completed and documented as required. The resident’s EMR documented diagnoses of C. difficile and CHF. The Entry MDS was completed on the admission date, and the admission MDS was noted as in progress with no information available. A baseline care plan dated the day after admission documented contact precautions, including staff use of gowns and masks when changing contaminated linens and proper handling and bagging of soiled linens. However, during an interview several days after admission, the resident reported she did not know what a baseline care plan was, indicating that the plan had not been explained or summarized to her. Further observations and interviews showed additional failures in implementing and communicating the baseline care plan. On one occasion, the resident was heard yelling for help with her room door closed; when a nurse entered, the resident stated she wanted to get up but could not find her call light, which was observed on the floor under the bed. A nurse reported that the baseline care plan was started on the day of admission and that nurses would review it with the resident, but also stated that the charge nurse would not provide a written copy of the baseline care plan to the resident or family. An administrative nurse reported she would review the baseline care plan with the resident and/or family and claimed to have completed a 48-hour interdisciplinary care conference, but there was no opened or completed conference note in the EMR. She gave inconsistent explanations regarding who was responsible and why the conference note was missing. The facility did not provide a policy for baseline care plans.
Failure to Provide Accurate ADL Assessment and Timely Clothing Changes
Penalty
Summary
The facility failed to provide appropriate assistance with activities of daily living (ADLs), specifically dressing and clothing changes, for a resident with severe cognitive impairment. The resident had a diagnosis of dementia and repeated Brief Interview for Mental Status (BIMS) scores of one, indicating severe cognitive impairment. Despite this, both a Significant Change MDS and a Quarterly MDS inaccurately documented that the resident required only setup assistance with lower body dressing. The ADL Care Area Assessment did not trigger, and the resident’s care plan, revised on 03/23/26, inaccurately instructed staff that the resident was independent with dressing. The electronic medical record lacked staff documentation of the resident’s ADL needs, resulting in care instructions that did not reflect the resident’s actual functional status. On the day of observation, the resident was seen sitting in a wheelchair wearing black pants with food crumbs on them in the morning, and later was transported by a CNA to the dining room still wearing the same dirty pants. The pants were not changed until early afternoon, at which time two CNAs provided total assistance to change the dirty pants, and the resident was unable to participate in dressing or undressing. During interviews, the CNAs, a licensed nurse, and an administrative nurse all stated that residents should always be dressed in clean clothing and confirmed that this resident required total staff assistance with dressing. These observations and interviews showed that the resident’s actual need for total assistance with dressing and clothing changes was not accurately reflected in the MDS, care plan, or ADL documentation, and that the facility did not ensure the resident was kept in clean clothing as expected by facility policy for ADL care.
Failure to Maintain Safe Wheelchair Foot Positioning During Resident Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision during wheelchair transport for a resident with dementia. The resident’s EMR documented a diagnosis of dementia and a BIMS score of one on both a Significant Change MDS and a Quarterly MDS, indicating severe cognitive impairment. These MDS assessments inaccurately documented that the resident was independent with walking using a walker and/or wheelchair, and the ADL CAA did not trigger. The resident’s care plan, revised 03/23/26, identified cognitive impairment due to dementia but did not include instructions for staff on the use of wheelchair foot pedals while propelling the resident. On multiple observed occasions, staff propelled the resident in a wheelchair without maintaining his feet safely on the foot pedals. During transport from his room to the dining room, the resident’s left shoed foot fell from the foot pedal and skimmed the floor between the pedals, and later, during transport from the dining room to the shower room, both shoed feet skimmed the floor between the pedals. CNAs reported that the resident’s feet never stayed on the foot pedals and described the pedals as useless because he could not keep his feet on them. A licensed nurse confirmed the resident’s feet did not always remain on the foot pedals when staff propelled him and stated the pedals should be adjusted to better fit his needs. An administrative nurse stated it was the expectation that staff ensure the resident’s feet remained on the foot pedals during transport and that pedals should be lowered if needed. The facility did not provide a policy regarding wheelchair safety.
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