Greeley County Hospital Ltcu
Inspection history, citations, penalties and survey trends for this long-term care facility in Tribune, Kansas.
- Location
- 506 3rd Street, Tribune, Kansas 67879
- CMS Provider Number
- 17E071
- Inspections on file
- 18
- Latest survey
- November 6, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Greeley County Hospital Ltcu during CMS and state inspections, most recent first.
Housekeeping staff sorted soiled laundry using only gloves as PPE, without gowns or other clothing barriers, as confirmed by staff interviews and facility policy. This practice created the potential for transfer of infectious material from soiled to clean laundry during sorting and folding.
Three residents who had previously received a single dose of Prevnar 13 did not have documentation showing they were offered or refused the updated CDC-recommended pneumococcal (PVC20) immunization. The facility's records and staff interviews confirmed that the required vaccinations had not been offered or documented for these individuals, despite a policy stating vaccines would be administered per CDC guidelines.
A resident with dementia, major depressive disorder, and Parkinson's disease was administered Seroquel without clear documentation of the targeted behaviors, unsuccessful nonpharmacological interventions, or a risk versus benefit analysis. Physician orders listed varying diagnoses for the antipsychotic use, and the care plan lacked specific behavioral indications, resulting in a deficiency related to unnecessary psychotropic medication use.
A resident with significant cognitive and mobility impairments, identified as high risk for falls, experienced a fall resulting in a head hematoma and hip fracture. Staff did not ensure the resident wore appropriate footwear or that the required chair alarm was in use, as outlined in the care plan. The fall occurred when the resident attempted to ambulate without assistance, and the alarm was found inactive and not positioned correctly, contributing to the incident.
The Consultant Pharmacist did not identify or address missing administration parameters for PRN opioid and diuretic medications for a resident, nor did they address an unapproved diagnosis for antipsychotic use in another resident. Orders lacked specific guidelines, and monthly medication reviews failed to recommend clarifications, despite facility policies requiring such oversight.
A resident with chronic pain and edema received PRN opioid and diuretic medications without specific physician parameters for administration. Staff relied on the resident’s requests and their own judgment to determine dosing and frequency, as the orders lacked clear instructions regarding pain levels or criteria for use, resulting in inconsistent medication administration.
A resident with multiple sclerosis and other conditions was served a hot beverage in a Styrofoam cup instead of the prescribed Kennedy cup, leading to a spill and second-degree burn. The incident occurred due to outdated COVID-19 guidelines, resulting in the use of disposable containers. The resident's limited mobility and hand contractures contributed to the accident.
The facility failed to submit accurate staffing information through the PBJ, as required by CMS, indicating no licensed nurse coverage on specific dates. However, payroll data showed that a licensed nurse was on duty 24/7. This discrepancy placed 16 residents at risk for inadequate staffing.
A facility failed to perform weekly skin assessments and follow-up documentation for a resident with a history of dermatitis, venous thrombosis, and anemia, who was at risk for skin issues. Despite the care plan requiring weekly skin inspections, the facility did not adhere to this, missing several weeks of assessments. Skin issues identified on two occasions were not followed up in a timely manner, placing the resident at risk for further complications.
A facility failed to date a vial of Fiasp insulin for a resident, risking the administration of expired or ineffective medication. An observation revealed the vial was accessed but not dated, contrary to the facility's policy requiring opened vials to be dated and discarded within 28 days. This oversight was confirmed by an administrative nurse.
Failure to Use Appropriate PPE Barriers During Soiled Laundry Sorting
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices in the laundry department. During observations and interviews, housekeeping staff reported that soiled laundry was sorted using only gloves as personal protective equipment (PPE), without the use of gowns or other clothing barriers. Staff acknowledged that this practice had been ongoing and recognized the potential for transferring infectious material from soiled to clean laundry during sorting and folding. Review of the facility's laundry procedures confirmed that the policy required only gloves when handling dirty or soiled laundry and did not address the use of gowns or aprons as additional barriers.
Failure to Offer and Document CDC-Recommended Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer or document the offering of the CDC-recommended pneumococcal (PVC20) immunization to three residents. Each of these residents had documentation in their electronic health records of having previously received a single dose of Prevnar 13 on various dates, but there was no evidence that they had been offered or refused any further pneumococcal vaccinations as required by current guidelines. This lack of documentation and offering was identified through observation, interview, and record review. During an interview, an administrative nurse confirmed that the facility had been reviewing the pneumococcal immunization status of current residents but had not yet offered the updated pneumococcal vaccinations. The facility's policy stated that pneumonia vaccines would be administered per CDC guidelines, but the required actions had not been completed for the affected residents at the time of the survey.
Lack of Documented Indication and Rationale for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident received antipsychotic medication only with an appropriate indication and documented physician rationale, including unsuccessful attempts at nonpharmacological interventions and a risk versus benefit analysis for continued use. The resident in question had diagnoses of dementia, major depressive disorder, and Parkinson's disease, and was assessed as having moderately impaired cognition. The care plan documented the use of Seroquel, an antipsychotic, for depression and dementia, but did not specify the targeted behaviors for which the medication was prescribed. Additionally, the care plan directed staff to monitor for side effects and effectiveness, but lacked documentation of the specific behaviors being targeted by the medication. Physician orders for the antipsychotic medication listed varying diagnoses over time, including dementia with behaviors, major depressive disorder, and anxiety, without clear documentation supporting the indication for use. The facility's policy required clear and accurate physician orders, including diagnosis or indication for use, and periodic reassessment of the medication's effectiveness. However, the records did not show evidence of unsuccessful nonpharmacological interventions or a documented risk versus benefit analysis for the continued use of the antipsychotic medication, leading to the deficiency.
Failure to Implement Fall Prevention Interventions Results in Resident Injury
Penalty
Summary
Staff failed to implement fall prevention interventions for a resident with multiple high-risk factors, including atrial fibrillation, dementia, major depressive disorder, Parkinson's disease, and a history of falls. The resident required substantial to maximal staff assistance for transfers and mobility, used a walker and wheelchair, and was assessed as a high fall risk. The care plan specified the use of a chair sensor alarm to notify staff when the resident attempted to get up unassisted, and staff were instructed to ensure the alarm was moved between seating surfaces and was functioning when in use. The care plan also required staff to ensure the resident wore appropriate footwear and that the environment was free of hazards. On the day of the incident, the resident was found on the floor in front of the bathroom, alert but holding her head and complaining of pain. She was wearing regular socks, with her shoes left by her recliner, and her call light was attached to the recliner, not within her reach. The chair sensor alarm, which was supposed to be in use, was found at the foot of the bed and was not active at the time of the fall. There were no environmental hazards identified in the room. The resident sustained a head hematoma and was later diagnosed with a fractured hip, requiring hospitalization and surgery. The facility's investigation could not determine the exact cause of the fall, as it was unwitnessed, but identified contributing factors including the resident ambulating without non-skid footwear and the absence of an active chair alarm. The failure to ensure the implementation of these fall prevention interventions, as outlined in the resident's care plan, directly led to the resident's fall and subsequent injuries.
Consultant Pharmacist Failed to Identify Missing PRN Parameters and Unapproved Antipsychotic Diagnosis
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and addressed the lack of specific parameters for the use of as-needed (PRN) opioid and diuretic medications for one resident, and failed to address an unapproved diagnosis for the use of an antipsychotic medication for another resident. For the first resident, the medical record showed multiple diagnoses including chronic pain, polyneuropathy, and major depressive disorder. The resident received PRN oxycodone and bumetanide, but the physician's orders lacked specific parameters for administration, such as pain level or type, and guidelines for edema. The Medication Administration Records indicated frequent administration of these medications, and both nursing staff and administrative staff confirmed that the orders lacked necessary parameters. The monthly medication regimen reviews conducted by the CP did not include recommendations or clarifications regarding these missing parameters. For the second resident, the medical record documented diagnoses of dementia, major depressive disorder, and Parkinson's disease. The resident received Seroquel, an antipsychotic, with the physician's order citing major depressive disorder and anxiety as the indications. However, the care plan did not specify targeted behaviors for the use of Seroquel, and the diagnosis for its use was changed by nursing staff without proper documentation or physician input. The CP did not address the appropriateness of the diagnosis for the antipsychotic during monthly reviews. Administrative staff acknowledged that the diagnosis for Seroquel was not appropriately documented and that the CP had not raised this issue. Facility policies required pharmacy services to be provided in accordance with state and federal regulations, including clear and accurate physician orders for antipsychotic medications and regular review of medication appropriateness by the CP. Despite these policies, the CP did not identify or report the lack of specific parameters for PRN medications or the inappropriate diagnosis for antipsychotic use, resulting in deficiencies in medication management and oversight.
Lack of Parameters for PRN Opioid and Diuretic Administration
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs by not obtaining specific parameters for as needed (PRN) administration of opioid and diuretic medications. For one resident with multiple diagnoses including chronic pain, polyneuropathy, and edema, physician orders for PRN oxycodone and bumetanide lacked clear guidelines regarding the level or type of pain, the number of tablets to administer, or specific criteria for edema. The resident’s medical record showed frequent use of PRN pain medication and diuretics, with medication administration records indicating variable dosing and frequency without documented parameters. Staff interviews confirmed that the resident often determined the dose of oxycodone to take and requested PRN bumetanide as needed, with no specific instructions from the physician regarding administration criteria. The facility’s policy required medications to be administered only as prescribed and in a safe and effective manner, but the orders for PRN medications did not provide sufficient detail to guide staff in their administration. Observations and interviews revealed that staff relied on the resident’s requests and their own judgment rather than clear physician instructions, resulting in inconsistent medication administration. The lack of specific parameters for PRN opioid and diuretic use constituted a failure to ensure the resident’s drug regimen was free from unnecessary drugs, as required by regulation.
Failure to Prevent Hot Liquid Accident
Penalty
Summary
The facility failed to ensure an environment free from accidents for a resident with multiple sclerosis, major depressive disorder, dysphagia, and weakness. The resident, who had intact cognition and required set-up assistance with eating, was assessed to be at risk for spills from hot liquids and was supposed to receive hot beverages in a lidded cup. However, during a period of isolation due to COVID-19, the resident was served a hot beverage in a Styrofoam cup instead of the prescribed Kennedy cup. The incident occurred when the resident, due to limited mobility, hand contractures, and weakness, accidentally punctured the Styrofoam cup, causing the lid to pop off and the hot liquid to spill onto her abdomen. This resulted in a second-degree burn, characterized by redness, fluid-filled blisters, and tenderness. The resident was subsequently taken to the hospital for assessment and treatment of the burn. The deficiency was attributed to the dietary staff operating under outdated COVID-19 guidelines, which led to the use of disposable containers instead of the resident's prescribed Kennedy cup. The facility's failure to adhere to the resident's care plan and hot liquid assessment resulted in the accident and subsequent injury.
Inaccurate PBJ Data Submission
Penalty
Summary
The facility failed to submit complete and accurate staffing information through the Payroll Based Journal (PBJ) as required by the Centers for Medicare & Medicaid Services (CMS). The PBJ report for Fiscal Year 2024 Quarter 1 indicated that there was no licensed nurse coverage on several specific dates. However, a review of the facility's licensed nurse payroll data for those dates revealed that a licensed nurse was indeed on duty 24 hours a day, seven days a week. This discrepancy was verified by Administrative Nurse D, who confirmed that the facility had submitted nursing hours and data that lacked the coverage of agency and hospital RN coverage. The failure to submit accurate PBJ data placed the residents at risk for unidentified and ongoing inadequate staffing. The facility had a census of 16 residents at the time of the survey. The report highlights that the facility's submission of staffing information did not include the necessary details about the category of work for each person on direct care staff, such as whether the individual was an RN, LPN, certified nursing assistant, therapist, or other type of medical personnel as specified by CMS. This oversight in data submission could potentially lead to misinterpretations of staffing adequacy and compliance with regulatory requirements.
Failure to Conduct Weekly Skin Assessments and Follow-Up
Penalty
Summary
The facility failed to perform weekly skin assessments and follow-up documentation for a resident, identified as R9, who was at risk for skin issues. R9's medical history included dermatitis, venous thrombosis, and anemia, and the resident was noted to be at risk for pressure ulcers. Despite these risks, the facility did not conduct weekly skin assessments as required by the resident's care plan and the facility's skin assessment policy. The care plan specified that staff should perform weekly skin inspections and report any changes, but this was not adhered to. The deficiency was highlighted by the lack of follow-up documentation for skin issues identified on two separate occasions. On one occasion, an open wound was noted on R9's lower left leg, but no follow-up assessment was documented until three and a half weeks later. Similarly, another skin issue was identified on R9's toe, with no follow-up assessment for over two weeks. The facility's failure to document and follow up on these skin issues placed R9 at risk for further skin complications. This was confirmed by an administrative nurse who acknowledged the lack of documentation and follow-up.
Failure to Date Insulin Vial
Penalty
Summary
The facility failed to properly label and date a vial of insulin for a resident, identified as R15, which could lead to the administration of expired or ineffective medication. During an observation in the medication storage room, a vial of Fiasp insulin was found to have been accessed but not dated. This oversight was confirmed by Administrative Nurse D, who acknowledged that the vial should have been dated upon opening. The facility's policy mandates that multi-dose vials be dated when opened and discarded within 28 days unless otherwise specified by the manufacturer. The failure to date the insulin vial placed the resident at risk of receiving ineffective insulin.
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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