Heritage Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chanute, Kansas.
- Location
- 1630 W 2nd Street, Chanute, Kansas 66720
- CMS Provider Number
- 175249
- Inspections on file
- 21
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Heritage Health Care Center during CMS and state inspections, most recent first.
A resident with a history of stroke sequelae, depression, and dependence on staff for ADLs experienced an unwitnessed fall while attempting to self-toilet and was found sitting on the floor by the bed. Instead of assisting the resident up, an RN/LPN changed the resident’s socks and instructed the resident to turn, get onto hands and knees in a “prayer position,” and pull up from the floor into bed without staff assistance, reportedly stating this was to “teach a lesson” about falls. The resident later reported feeling angry and very embarrassed by the interaction, while other staff stated they would have assisted a resident from the floor and followed fall protocol.
The facility failed to ensure proper reconciliation and regular counting of controlled substances, including overflow narcotics, which led to the discovery that 12 hydrocodone tablets were missing for a resident. A CMA and an LN found only 18 tablets in an overflow bottle that was documented as containing 30, and the LN altered the count on the narcotic sheet without promptly notifying administration, while the CMA delayed reporting the discrepancy until the next day. The hydrocodone had been received from a third-party pharmacy and locked in overflow storage without an initial pill count at the time the narcotic sheet was created, and no further counts were performed for several days until staff attempted to refill the med cart and identified the shortage.
Surveyors identified unsanitary conditions in food preparation and storage areas, including soiled equipment, undated and unlabeled food items, improper thawing of meat at room temperature, and food debris on surfaces and carts. These actions did not comply with facility policies for sanitation and food safety.
Surveyors observed that all dumpsters outside the kitchen were left open with trash scattered around them, and this condition persisted over multiple observations. Dietary staff confirmed that dumpsters were supposed to remain closed, and facility policy required covered dumpsters and clean surrounding areas to prevent insect or rodent attraction.
The facility did not ensure that controlled substances on a medication cart were properly reconciled by two staff members at shift changes, as required by policy. Documentation showed missing signatures and incomplete verification, with staff confirming that both outgoing and incoming personnel should sign off on the narcotic count.
Surveyors found that a medication cart was left unlocked and unattended, containing various medications including narcotics, and that insulin vials and pens in a treatment cart were either expired or not dated when opened. Staff interviews confirmed that carts should be locked and insulin pens dated, but these practices were not consistently followed, contrary to facility policy.
A resident with panic disorder and depression was prescribed multiple psychotropic and antipsychotic medications without documented informed consent. Facility policy required that residents or their representatives be informed of the benefits, risks, and alternatives before starting such medications, but this was not done in this case.
Two residents were discharged or transferred from the facility without the required notification to the state Ombudsman, as confirmed by record review and staff interview. One resident had severe cognitive impairment and was discharged to the community, while another with CHF and moderate cognitive impairment was transferred to a hospital. Documentation of Ombudsman notification was missing in both cases.
A resident with multiple complex medical conditions, including a pressure ulcer and dependence on staff for ADLs, did not receive scheduled bathing assistance as required. Documentation showed only one shower was provided in a month, with no refusals recorded, despite the resident's requests for showers and facility policy requiring regular bathing and documentation. Staff interviews confirmed the expectation for regular bathing and proper documentation, but these were not met for this resident.
Two residents with pressure ulcers did not receive wound care and assessments in accordance with professional standards, as weekly nurse skin assessments were either missing or lacked required measurements and descriptions. Nursing staff confirmed that wound assessments should include measurements and detailed descriptions, but these were not documented, and the facility did not provide a policy for pressure ulcer monitoring.
Staff did not consistently clean, date, or properly store nebulizer equipment for several residents receiving breathing treatments. Equipment was observed left open to air on furniture, not dated, and not stored in bags as required by facility policy. Residents and staff confirmed that proper cleaning and storage procedures were not followed.
Resident Required to Self-Lift After Fall, Causing Anger and Embarrassment
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse when a licensed nurse required the resident to get up from the floor without assistance after an unwitnessed fall. The resident had a history of cerebral infarction with sequelae and depression, used a wheelchair and walker, and required staff assistance with all ADLs, including transfers and toileting. His care plan identified him as at risk for falls related to weakness and high‑risk medications and directed staff to carry out all interventions to prevent falls and to provide partial to moderate assistance with toilet use, transfers, and bed mobility. Despite these documented needs, after the resident experienced an unwitnessed fall while attempting to self‑toilet and was found sitting on the floor leaning against his bed, staff did not physically assist him up. Nursing documentation showed that staff replaced the resident’s slick socks with gripper socks and slippers, then encouraged him to turn around, get on his knees, and pull himself up from the floor into bed. Official statements recorded that a CMA heard the nurse state she made the resident remain on the floor “to teach him a lesson” while she completed tasks and then made him get off the floor without assistance. Another statement documented that the resident reported the nurse told him to get into a “prayer position” and pick himself up, and that she was upset and argued with him about how many falls he had. During interview, the resident confirmed that the nurse instructed him to get into a praying position and get himself off the floor without her assistance, which made him feel angry and very embarrassed. Other staff interviewed indicated that they would have assisted a resident up from the floor and notified the nurse, and administrative staff characterized the nurse’s actions as inappropriate.
Failure to Reconcile Overflow Narcotics Resulting in Missing Hydrocodone
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper narcotic reconciliation, including regular counts of all controlled substances and those stored as overflow, which resulted in missing hydrocodone tablets for a resident. The facility reported that staff discovered 12 hydrocodone tablets were missing after a discrepancy was identified between the documented count and the actual number of pills in the bottle. The narcotic dispensing record for the resident’s hydrocodone showed that a count of 30 tablets had been crossed out and changed to 18, with the change initialed by two individuals and dated and timed, followed by documentation that one tablet was administered, leaving a remaining count of 17. According to witness statements, a CMA requested assistance from an LN to obtain hydrocodone from the overflow cabinet to refill the medication cart. When they counted the pills in the overflow bottle, they found only 18 tablets, while the narcotic count sheet indicated 30. The LN then corrected the count on the sheet from 30 to 18 without immediately notifying administration of the discrepancy, and the CMA also delayed reporting the error until the following day. The facility’s investigation determined that when the hydrocodone was originally picked up from a third-party pharmacy and placed in the overflow cabinet, the LN who secured the medication created a narcotic count sheet but did not count the contents of the bottle at that time. The investigation further documented that the hydrocodone bottle was not recounted between the initial correct count performed later that same day by two LNs and the subsequent count several days later when the 12 missing tablets were discovered. During this period, no additional counts of the overflow narcotics were performed, and the discrepancy was only identified when staff attempted to move the medication from overflow storage to the medication cart. The facility’s failure to consistently perform and reconcile narcotic counts, including for overflow medications, and the delay in reporting the discrepancy by involved staff, led to the identification of missing hydrocodone tablets for the resident.
Failure to Maintain Sanitary Food Preparation and Storage Conditions
Penalty
Summary
Surveyors observed multiple failures in food preparation and storage practices that did not meet sanitary standards. During a kitchen tour, they found a heavily soiled microwave, window areas with dried-on food and liquid, and a stationary can opener with moist food residue. The preparation table and a three-tiered cart used for breakfast had food debris, and several plastic containers for condiments and baking ingredients were grimy and sticky. A large roast was found thawing at room temperature, contrary to facility policy. In the reach-in refrigerator, several opened food items, including sour cream and liquid eggs, were undated, and containers of peaches, mayonnaise, and mustard had dried-on food substances. Spilled salsa contaminated other items and surfaces in the refrigerator. In the dining room snack area, the counter and snack cart were sticky and dirty, with food debris and grime on the cart wheels. The resident refrigerator/freezer contained multiple opened and undated or unlabeled food items, including mixed fruit, sodas, shakes, and ice cream, with some items having exploded in the freezer. Dietary staff confirmed improper thawing practices and acknowledged the need for correction. Facility policies required regular cleaning and proper labeling and dating of foods, as well as approved thawing methods, which were not followed in these instances.
Improper Disposal of Garbage and Refuse
Penalty
Summary
During an environmental tour of the kitchen, surveyors observed that the lids to all three dumpsters located outside the kitchen were left open, with trash present on the ground around the dumpsters. These observations were made at two separate times on the same day, confirming that the issue persisted. Further interview with dietary staff confirmed that staff were expected to keep dumpster lids closed at all times. Review of the facility's policy indicated that dumpsters should be kept covered when not being loaded and that the surrounding area should remain clean to minimize debris and the attraction of insects or rodents.
Failure to Reconcile Controlled Substances on Medication Cart
Penalty
Summary
The facility failed to properly reconcile controlled substances on the medication cart, as required by policy. Specifically, review of the controlled substance reconciliation log for the east hallway cart showed that on one occasion, only the day shift nurse signed off, with no evidence of a second staff member verifying the count. Additionally, there was no documentation or signatures indicating that a reconciliation was completed for a subsequent shift. Interviews with a Certified Medication Aide and an administrative nurse confirmed that the expectation is for two staff members to count and verify controlled substances at each shift change, in accordance with facility policy. The lack of dual verification and missing signatures on the reconciliation log demonstrated a failure to follow established procedures for controlled substance accountability.
Failure to Secure and Label Medications and Insulin in Carts
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling, storage, and security of drugs and biologicals. An unlocked and unattended medication cart was found in the east hall, containing various medications including Talzenna, Gabapentin, and narcotics stored in a lock box. Additionally, the east treatment cart contained an opened Novolog insulin vial that had expired, as well as Tresiba and Lantus insulin pens that were not dated when opened, making it impossible for staff to determine their expiration. Interviews with staff confirmed that medication carts should be locked when unattended and that insulin pens are expected to be dated upon opening, in accordance with facility policy. The facility's policy also requires all medications and biologics to be kept in locked compartments, with scheduled two medications under double lock, but these procedures were not consistently followed.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was fully informed and understood their health status, care, and treatments, specifically regarding the use of psychotropic and antipsychotic medications. Record review revealed that a resident with diagnoses of panic disorder and depression was prescribed multiple psychotropic medications, including duloxetine, risperidone, and trazodone, for depression, resistant depression, and insomnia. However, the electronic medical record did not contain documentation of informed consent for these medications. An administrative nurse confirmed that it was the facility's expectation for staff to obtain psychotropic drug consents prior to medication initiation. The facility's policy required that residents, families, or representatives be informed of the benefits, risks, and alternatives before starting or increasing psychotropic medications. Despite this policy, there was no evidence that informed consent was obtained for the resident's psychotropic and antipsychotic medications.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the state Ombudsman of the discharge or transfer of two residents, as required by facility policy. One resident with severe cognitive impairment was admitted with the goal of discharging to the community and was later discharged accompanied by family, but there was no documentation in the electronic medical record (EMR) that the Ombudsman was notified of this discharge. Social Services staff confirmed that the Ombudsman had not been notified as required. The facility's policy states that the Ombudsman, along with the resident and their representative, must be notified of emergency transfers or discharges. Another resident with a diagnosis of congestive heart failure and moderately impaired cognition was discharged to a critical access hospital. The EMR for this resident also lacked documentation of Ombudsman notification regarding the discharge. Upon request, the facility was unable to provide evidence that the Ombudsman had been notified for either resident. The deficiency was identified through interviews and record reviews, which confirmed the lack of required notifications.
Failure to Provide Required Bathing Assistance for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for activities of daily living (ADLs), including bathing, did not receive the necessary assistance with bathing. The resident had multiple diagnoses, including a cutaneous abscess, COPD, end stage renal disease, a periprosthetic fracture, a Stage 2 pressure ulcer, and anxiety disorder. Documentation in the electronic health record and shower sheets showed that the resident received only one shower during the month of July, with no documented refusals for bathing. The care plan and assessments indicated the resident required staff assistance for bathing and other ADLs, and the facility policy required staff to provide and document bathing or refusals. Observations confirmed that the resident was dependent on staff for mobility and hygiene, and interviews with the resident and staff revealed that the resident had requested showers but did not receive them as scheduled, resulting in the resident having to perform bed baths independently. Staff interviews confirmed that bathing was to be offered at least twice weekly, and refusals were to be documented, but there was no evidence of refusals or consistent bathing provided. This failure to provide necessary ADL care was based on direct observation, record review, and interviews.
Failure to Provide Proper Pressure Ulcer Assessment and Documentation
Penalty
Summary
The facility failed to provide necessary wound care and services in accordance with professional standards of practice for two residents with pressure ulcers. For one resident with multiple diagnoses including COPD, hypothyroidism, and a Stage 3 pressure ulcer, the care plan directed weekly skin assessments and wound care per facility guidelines. However, electronic health records showed that weekly nurse skin assessments were either not performed or lacked required wound measurements and descriptions. There was also a delay in initiating the weekly assessments, and some assessments were missing entirely. The facility did not provide a policy related to pressure ulcer monitoring. Another resident, diagnosed with mild protein-calorie malnutrition and cachexia, was admitted with two Stage 2 and one Stage 3 pressure ulcers. The care plan directed weekly skin assessments but did not specify preventative measures for pressure sores. Physician orders were in place for wound care, but documentation in the electronic medical record lacked evidence of wound measurements, wound bed evaluation, and effectiveness of treatments. Weekly skin assessments and skilled evaluations failed to include measurements or descriptions of the wounds. Interviews with nursing staff and administrative nurses confirmed that wound assessments were supposed to include measurements and detailed descriptions, but these were not documented. Staff were unable to determine the healing status of the wounds due to incomplete documentation. The facility did not provide a policy related to pressure ulcer monitoring, and the lack of proper documentation and assessment placed the residents at risk for complications and delayed healing.
Failure to Maintain Sanitary Storage and Cleaning of Nebulizer Equipment
Penalty
Summary
Facility staff failed to implement sanitary storage and maintenance of nebulizer breathing treatment devices for multiple residents. Observations revealed that nebulizer equipment, including tubing and masks, was left open to the air on chairs and bedside tables, not dated, and sometimes placed on paper towels to dry but not stored in a sanitary manner. In several instances, the equipment was attached to machines sitting on the floor or chair, and there was no evidence of proper cleaning or dating. Residents reported that their nebulizer equipment was regularly left out in this manner, and one resident stated that his nebulizer had not been rinsed out since his admission. Interviews with staff confirmed that nebulizers and oxygen tubing should have been dated, cleaned after each use, and stored in a bag once dry, in accordance with facility policy. However, observations and resident reports indicated that these procedures were not consistently followed. The facility's own policy required cleaning, disassembly, rinsing with sterile or distilled water, air drying, and storage in a zip lock bag, but these steps were not observed in practice for the residents sampled.
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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