Holiday Resort Of Salina
Inspection history, citations, penalties and survey trends for this long-term care facility in Salina, Kansas.
- Location
- 2825 Resort Drive, Salina, Kansas 67401
- CMS Provider Number
- 175423
- Inspections on file
- 26
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 46
Citation history
Health deficiencies cited at Holiday Resort Of Salina during CMS and state inspections, most recent first.
The facility failed to provide consistent bathing and hygiene assistance to several cognitively intact but physically dependent residents whose EMRs and CAAs documented the need for staff support with ADLs and scheduled showers or baths, typically twice weekly. Over about a month, records showed that these residents received significantly fewer showers than scheduled, and observations noted greasy or unkempt hair, urine and body odors, and overgrown facial hair. Multiple residents reported not receiving showers as planned, sometimes going a week or longer without bathing and feeling dirty, smelly, neglected, or uncared for. A CMA reported that residents were not being bathed as they should be and were fortunate to receive a shower every ten days, attributing this to low staffing, while an administrative nurse acknowledged ongoing problems with completion of baths despite a facility policy requiring necessary services to maintain grooming and personal hygiene.
A resident with hemiparesis, hemiplegia post-stroke, depression, anxiety, frequent incontinence, and recent UTI was fully dependent on staff for ADLs, yet only had a care plan addressing advanced directives, black box warnings, and discharge, with no ADL or care directions. The resident was observed with greasy hair and a noticeable odor while lying on one side in bed and reported that staff often declined or delayed repositioning requests and had not informed her of shower days, despite her preferences for repositioning. An administrative nurse admitted awareness that the care plan was incomplete and accepted responsibility, even though facility policy required a comprehensive, individualized care plan with measurable objectives to be developed within a defined timeframe based on the MDS and CAA findings.
A resident with a history of stroke-related hemiparesis/hemiplegia, depression, anxiety, frequent incontinence, and a recent UTI was dependent on staff for all ADLs and had a care plan lacking direction for ADL and care needs. Nursing staff documented blood in the resident’s brief, increased urinary frequency, decreased urine output, and apparent bladder spasms, and the PCP ordered a straight catheter urine specimen with possible culture and sensitivity. Although the order was entered on the TAR, there was no documentation that the catheterization was performed and no urine results in the EMR; the resident was later hospitalized, where a straight catheterization confirmed a UTI. The resident recalled being told she had blood in her urine but did not remember a urine sample being obtained, and an administrative nurse later verified that the physician’s order for the straight catheter urine specimen had not been completed, contrary to facility policy requiring all physician orders to be followed.
A resident with HIV and multiple comorbidities did not receive the prescribed antiretroviral medication, Biktarvy, during their stay because the facility failed to coordinate payment approval with the pharmacy and did not act on information about available grant funding, despite repeated notifications and documentation of the medication's necessity.
Two residents did not receive their prescribed medications due to failures in transcribing physician orders and lack of follow-through by facility staff. One resident missed HIV medication for 13 days because the facility did not respond to pharmacy requests for payment approval, despite being informed of available grant funding. Another resident did not receive a diabetes medication for four weeks because the order was not entered into the facility's records, and there was no documentation of discontinuation. These actions were not in accordance with the facility's medication administration policy.
Dietary staff did not follow standardized recipes or use measured ingredients when preparing pureed meals for a resident on a texture-modified diet, instead blending foods with unmeasured liquids and without recipe reference, contrary to facility policy and placing the resident at risk for inadequate nutrition.
Dietary staff did not fully cover their hair and facial hair while preparing and serving food, and unsanitary conditions were observed in the kitchen, including buildup of grease and fuzz on equipment. These actions were not in compliance with facility policies requiring thorough hair restraint and regular cleaning of food service areas.
The facility's QAA Committee did not adequately identify or address several deficiencies, including improper administration and documentation of antipsychotic medication for a resident with a language barrier, lack of communication devices, failure to notify the Ombudsman during a hospital transfer, absence of comprehensive care plans, missed bathing for dependent residents, unsafe smoking and transfer practices, unposted nursing staffing, lack of non-pharmacological interventions, failure to notify a physician of abnormal blood sugars, improper diet preparation, poor kitchen hygiene, lack of collaboration with hospice, failure to offer Prevnar 20 vaccination, and maintenance issues with the walk-in freezer.
Several residents were not offered the pneumococcal PCV20 vaccine, nor was there documentation of consent, declination, or physician contraindication, as required by CDC guidance. Staff interviews confirmed the absence of a system to determine vaccine eligibility or track offers and refusals, and the facility's policy was outdated and not followed.
The facility did not maintain the kitchen walk-in freezer in safe working order, as the door had persistent ice buildup and would not close properly. Staff had to regularly remove ice to keep the door shut, and food was previously discarded due to temperature issues. Multiple contractors were unable to fix the problem, and no preventative maintenance policy was provided.
A resident was administered psychotropic medications without a clear clinical indication or was given medications that restrained their ability to function, resulting in a deficiency related to medication management.
A resident with multiple chronic conditions and significant care needs was discharged without receiving the required Bed Hold Notification or notification to the State Ombudsman Agency. The facility's records did not show that these notifications were provided as required by policy, and staff confirmed the omission.
A deficiency was cited when a resident's care plan did not include all necessary needs, lacked measurable timetables, and failed to specify actionable steps, resulting in incomplete planning and documentation for the resident's care.
A resident with severe cognitive impairment and Spanish as a preferred language did not have individualized communication methods implemented. Staff were often unable to communicate effectively, leading to the resident's agitation and frustration. The care plan lacked a communication focus, and no communication tools or policies were in place to support the resident's needs.
Two residents who required staff assistance with bathing did not consistently receive showers as scheduled, despite care plans and facility policy specifying their preferences. Documentation and observations showed missed showers and lack of refusal documentation, resulting in poor hygiene for both residents.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment did not meet safety standards, and there was a lack of appropriate measures and oversight to protect residents from potential harm.
A resident diagnosed with dementia did not receive the necessary treatment and services appropriate for their condition, as required by regulatory standards.
A resident with diabetes, depression, and dementia had multiple blood glucose readings outside the physician-ordered parameters, but the physician was not notified as required. Staff interviews and record reviews confirmed that the necessary notifications were not documented, despite facility policy and care plan directives.
Two residents receiving hospice care did not have care plans that clearly documented the coordination between facility and hospice staff, including the frequency of hospice visits and the specific care and supplies provided. Staff interviews revealed uncertainty about hospice involvement, and the care plans lacked required details as outlined in the facility's hospice policy.
The facility did not consistently post the required daily nurse staffing information, with observations showing either outdated or missing reports on multiple occasions. Staff confirmed that posting the current day's staffing report was their responsibility, but this was not reliably completed as per facility policy.
A resident experienced a loss of dignity when a CNA failed to return after turning off the call light, leaving the resident incontinent for two hours. The resident, dependent on staff for care due to medical conditions, felt humiliated. Staff interviews revealed that inadequate care was due to staffing shortages, which was acknowledged by the facility's administrative nurse.
The facility failed to provide consistent bathing and showering for three residents, leading to a deficiency in care. A resident with spinal stenosis and severe obesity, another with diabetes and heart failure, and a third with severe cognitive impairment were all affected. Despite being scheduled for regular showers, they received inadequate hygiene care over a month. Staff interviews revealed that lack of staffing was a significant factor, with some staff expressing concern over the inadequate care provided.
Failure to Provide Consistent Bathing and Hygiene Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent bathing and hygiene assistance for multiple residents who were dependent on staff for ADLs. Five cognitively intact residents with significant physical impairments—hemiparesis, hemiplegia, multiple sclerosis, severe obesity, and other chronic conditions—were scheduled for regular showers or baths per the EMR bathing schedules, generally two times per week. Record review showed that over roughly a one‑month period, each of these residents received substantially fewer showers than scheduled, with some receiving as few as two to six baths or showers during that time. Care plans and CAAs documented that these residents required staff assistance with ADLs, including bathing, but in some cases the care plans lacked specific directions for bathing assistance. Surveyor observations on the day of the visit documented that several residents had greasy, oily, or unkempt hair, distinct body or urine odors, and overgrown facial hair, consistent with inadequate hygiene care. One resident with hemiparesis and hemiplegia was observed with greasy, oily hair and a distinct odor and reported not receiving showers as scheduled, stating she was used to daily showers and was sometimes waiting 7–10 days between showers. Another resident with DM, HTN, depression, and chronic kidney disease was observed with an overgrowth of gray beard and body odor and stated he had only received three baths in the last 30 days, felt neglected, and that the facility could not reliably provide even two showers per week as offered. Additional residents with MS, gout, severe obesity, and post‑stroke hemiplegia/hemiparesis reported not receiving showers as scheduled, describing feeling dirty, smelly, gross, neglected, and uncared for. Observations included oily, unkempt hair and urine odor in more than one resident. A CMA stated that residents were not being showered or bathed as they were supposed to be and were “lucky” to receive one every ten days, citing low staffing as the reason. An administrative nurse acknowledged problems with baths being completed and stated he was reviewing bathing sheets to determine whether showers were not done or not charted. The facility’s ADL policy required that residents who are unable to carry out ADLs receive necessary services to maintain grooming and personal hygiene, but the documented bathing frequencies and resident conditions showed this was not consistently implemented.
Failure to Develop and Implement Comprehensive ADL Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized care plan for a resident with significant physical and medical needs. The resident’s EMR documented hemiparesis and hemiplegia following a stroke, depression, anxiety, frequent urinary and bowel incontinence, and a recent UTI. The admission MDS showed a BIMS score of 15, indicating intact cognition, and documented that the resident had impairments in both upper and lower extremities and was dependent on staff for all ADLs. The Functional Abilities CAA stated that the resident’s diagnoses made ADLs difficult or impossible to perform independently and that staff would assist with ADLs. Despite this, the care plan initiated contained only three areas—advanced directives, black box warnings, and discharge—and lacked any direction regarding ADLs and other care needs. During observation, the resident was noted to have greasy, oily hair and a distinct odor while lying in bed on her right side. The resident reported that she did not think staff knew how to care for her, stating she often requested to be turned because she became sore from remaining in one position, but staff would respond, "Not right now." She also stated she did not know her scheduled shower days because no one had informed her and expressed a preference to be turned toward the door. An administrative nurse acknowledged awareness that the resident did not have a complete care plan and stated this was his fault, further noting his expectation that residents would have a comprehensive care plan in place a month and a half after admission. The facility’s own care plan policy required a comprehensive care plan with measurable objectives to be developed within seven days of completion of the MDS and CAAs or within 21 days after admission, and to reflect individualized problems, goals, and interventions based on the resident’s preferences and wishes.
Failure to Follow Physician Order for Straight Catheter Urine Specimen
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order to obtain a straight catheter urine specimen for a resident with signs and symptoms of a possible UTI. The resident’s EMR documented a history of hemiparesis and hemiplegia following a stroke, UTI, depression, and anxiety, with an MDS showing intact cognition but dependence on staff for all ADLs and frequent bowel and bladder incontinence. The resident’s care plan, initiated earlier in the year, lacked any direction regarding ADL and care needs, addressing only advanced directives, black box warnings, and discharge. Nursing documentation showed that staff observed blood in the resident’s brief and on wiping, increased urinary frequency, decreased urine output at times, and apparent bladder spasms. Staff notified the primary care physician, who ordered a straight catheterization to obtain a urine sample and send it for culture and sensitivity if indicated. The order for the straight catheter urine specimen was entered on the Treatment Administration Record, but there was no documentation that the procedure was completed, and the EMR contained no urine specimen results. Subsequently, the resident was admitted to the hospital with hypoxia, where a straight catheterization was performed and a UTI was identified, and the resident was started on IV antibiotics. During a later observation, the resident was noted to have greasy, oily hair and a distinct odor while lying in bed, and she reported that she had been hospitalized for a UTI and that her granddaughter told her the facility had not obtained the ordered urine specimen. The administrative nurse, upon review of the EMR, confirmed that the straight catheterization order had not been completed by staff, despite facility policy stating that physician orders must be followed and processed by a licensed nurse.
Failure to Provide Physician-Ordered HIV Medication Due to Lack of Coordination and Approval
Penalty
Summary
A deficiency occurred when the facility failed to provide a physician-ordered medication, Biktarvy, to a resident diagnosed with HIV, among other conditions such as COPD, osteoporosis, and multiple fractures. The resident's electronic health record and care plans documented the need for Biktarvy, and the physician's order specified daily administration. Despite this, the medication was not available or administered throughout the resident's stay, as evidenced by repeated nursing notes indicating the medication was 'waiting on delivery' or 'on order' for an extended period. The pharmacy received the order for Biktarvy and attempted to process it, but insurance denied coverage. The pharmacy then contacted the facility for payment approval, as the medication cost exceeded the threshold requiring facility authorization. Multiple emails were sent to the facility requesting approval, but the facility did not respond in a timely manner. Administrative staff acknowledged the lack of response and indicated that the process for obtaining pre-approval or alternative funding was not completed prior to the resident's admission, despite being informed by the discharging hospital that grant funding was available to cover the medication. Interviews with facility staff confirmed awareness of the resident's need for Biktarvy and the existence of grant funding, but no action was taken to secure the medication or utilize the available funding. The facility's own medication administration policy required medications to be administered as ordered and for refusals or issues to be documented and communicated, but these procedures were not followed. As a result, the resident did not receive the prescribed HIV medication during their stay.
Failure to Transcribe and Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to ensure that physician orders for medications were correctly transcribed and administered to two residents upon admission, resulting in significant medication errors. One resident, with diagnoses including HIV, COPD, osteoporosis, and multiple fractures, did not receive the prescribed HIV medication, Biktarvy, for 13 days during their stay. Documentation in the Medication Administration Record (MAR) and nurses' notes repeatedly indicated that the medication was 'waiting on delivery' or 'on order,' but the medication was never provided. The pharmacy had attempted to obtain payment approval from the facility due to the high cost of the medication, but did not receive a response from the facility's administrative nursing staff, despite multiple emails and assurances that a response would be given. Social services staff had been informed by the discharging hospital that a grant would cover the medication, and this information was shared with the facility's administrative nurses, but no further action was taken to secure the medication for the resident. A second resident, admitted with diagnoses including protein-calorie malnutrition, diabetes mellitus, atrial fibrillation, and cerebral infarction, did not receive the prescribed diabetes medication, Mounjaro, for four weeks. The hospital discharge orders included Mounjaro, but the medication was not transcribed into the facility's Medication Administration Record (MAR) or electronic medical record (EMR), and there was no documentation that the order had been discontinued. The pharmacy consultant confirmed that the medication list sent by the facility did not include Mounjaro, and nursing staff verified that the physician's order for Mounjaro had not been discontinued and should have been continued at the facility. The facility's own medication administration policy required that medications be administered in accordance with written physician orders and that all administration, refusals, or holds be documented in the MAR. In both cases, the failure to correctly transcribe and follow through on physician orders led to residents not receiving essential medications as prescribed, with documentation and interviews confirming the lapses in communication and follow-through among facility staff and between the facility and the pharmacy.
Failure to Use Standardized Recipes for Pureed Diet Preparation
Penalty
Summary
Dietary staff failed to follow standardized recipes when preparing pureed diets for a resident requiring texture-modified meals. Observations showed that staff blended various food items, such as a barbecued rib patty, vegetables, potatoes, and a lemon bar, without referencing or using measured amounts of liquids as specified in facility recipes. The staff used unmeasured amounts of meat juice and milk to achieve the desired consistency, and there was no evidence that recipes were consulted during preparation. The facility's policy required the use of standardized recipes for all mechanically altered foods to ensure quality, flavor, and nutritive value. However, during the preparation of pureed meals, staff did not adhere to these requirements, as confirmed by the absence of recipes at the preparation stations and the lack of measured ingredients. This failure placed residents at risk for inadequate nutrition due to improper preparation of pureed diets.
Failure to Maintain Sanitary Food Preparation and Service Practices
Penalty
Summary
Dietary staff failed to adhere to proper hair restraint protocols while preparing and serving food. Observations revealed that staff members wore beard nets and hair nets that did not fully cover their facial hair or the back of their hair. One staff member was seen entering the kitchen without a hair net, only putting it on after retrieving it from a closet. These actions were in direct violation of the facility's Hair Restraint policy, which requires all hair and facial hair to be fully covered by appropriate restraints during food production, dishwashing, and serving. Additionally, the kitchen environment was found to be unsanitary, with a stove hood covered in brownish gray fuzz and convection ovens with fan and motor assemblies coated in brownish grease and gray fuzz. The facility's Cleaning Rotation policy mandates regular cleaning and sanitation of kitchen equipment and areas, with tasks assigned and documented by staff. The Certified Dietary Manager confirmed that both dietary and maintenance staff are responsible for cleaning, and verified the presence of the unsanitary conditions during the survey.
Multiple Deficiencies in Quality Assessment and Resident Care
Penalty
Summary
The facility failed to ensure its Quality Assessment and Assurance Committee effectively identified and addressed multiple deficient practices affecting resident care and facility operations. Deficiencies included the lack of clinical rationale and documentation for administering antipsychotic medication to a resident with a language barrier, failure to notify the Ombudsman and provide a bed hold policy during a hospital transfer, and the absence of a comprehensive care plan addressing communication, dementia care, and antipsychotic use. Additionally, the facility did not provide communication devices for a Spanish-speaking resident, failed to provide bathing as care planned for dependent residents, and did not ensure a safe smoking environment or use a gait belt for safe transfers, resulting in a fall. Further deficiencies were observed in the failure to post daily nursing staffing, provide non-pharmacological interventions before administering antipsychotic medication, notify a physician of out-of-range blood sugars, and follow a pureed diet recipe. The facility also did not maintain proper kitchen hygiene, including staff not covering facial hair, unclean equipment, expired supplements, and unlabeled food. There was a lack of collaboration between facility and hospice care plans, failure to offer Prevnar 20 vaccination, and maintenance issues with the walk-in freezer door. QAA meetings were held monthly and included the medical director, but these ongoing issues indicate the committee did not adequately identify or address these areas of deficient practice.
Failure to Offer and Document Pneumococcal Vaccination per CDC Guidance
Penalty
Summary
The facility failed to offer, obtain informed declination, or secure physician-documented contraindications for the pneumococcal PCV20 vaccination for several residents, as required by the latest CDC guidance. Record reviews for five residents revealed that none had documentation indicating they were offered the PCV20 vaccine, had received it, or had signed a consent or declination form. Additionally, there was no evidence that the facility or resident representatives had been provided with or signed the necessary consent or declination forms for the vaccine. Interviews with facility staff confirmed that there was no definitive system in place to determine resident eligibility for the PCV20 vaccine or to track whether residents had been offered or declined the vaccination. The facility's existing policy referenced offering pneumococcal vaccinations and obtaining vaccination histories at admission, but it did not reflect current CDC recommendations for PCV20, nor was it being followed in practice. As a result, eligible residents were not consistently assessed or documented for pneumococcal vaccination status.
Failure to Maintain Walk-In Freezer in Safe Operating Condition
Penalty
Summary
The facility failed to ensure that the kitchen walk-in freezer was maintained in a safe operating condition. Observations revealed that the freezer door had significant ice buildup on the frame, making it difficult to close completely. Maintenance staff acknowledged ongoing issues with the freezer door, including frequent ice accumulation and the need for staff to manually remove ice to keep the door shut. It was also noted that about a year prior, food stored in the freezer had to be discarded due to the freezer's temperature being out of range. Dietary staff confirmed that the ice buildup had been a persistent problem, requiring regular intervention to maintain functionality. Consultant staff reported that multiple local contractors had been contacted to repair the freezer, but none were able to fully resolve the issue, and documentation of these attempts was not available. The facility had also experienced related issues, such as a leaking roof that contributed to water entering the freezer and the freezer door coming off at one point, which was subsequently repaired and sealed. Despite ongoing efforts to address the problem, including contacting an out-of-town contractor, the freezer remained in disrepair. Additionally, the facility was unable to provide a preventative maintenance policy when requested.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear clinical indication or were given medications that limited their functional abilities, contrary to regulatory requirements.
Failure to Provide Bed Hold and Ombudsman Notification at Discharge
Penalty
Summary
The facility failed to provide a Bed Hold Notification and notification to the State Ombudsman Agency regarding the discharge of a resident with multiple complex medical conditions, including hemiplegia, hemiparesis following a stroke, chronic kidney disease, diabetes mellitus, obesity, nicotine dependence, lymphedema, polyarthritis, COPD, and chronic respiratory failure with hypoxia. The resident required significant assistance with activities of daily living, used a wheelchair for mobility, and was frequently incontinent of urine. The resident's medical record documented several discharges and entries, but lacked evidence of a Bed Hold Notification for one of the discharges, as required by facility policy. Social Services staff confirmed responsibility for providing discharged residents with the facility's bed hold policy and notifying the State Ombudsman Agency, but acknowledged that this was not done for the resident in question during certain hospitalizations. The facility's written policy required that a notice specifying the duration of the bed-hold policy be issued to the resident or their representative upon transfer to a hospital or therapeutic leave, but this was not consistently followed in this case.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain all necessary elements to ensure comprehensive care as required.
Failure to Provide Alternative Communication Methods for Non-English Speaking Resident
Penalty
Summary
The facility failed to implement alternative communication methods for a resident with severe cognitive impairment whose preferred language was Spanish. The resident had diagnoses including dementia, Alzheimer's disease, major depressive disorder, and diabetes mellitus, and required substantial staff assistance for activities of daily living. The resident's care plan did not include an individualized area addressing communication needs. Observations showed that staff were unable to effectively communicate with the resident, as most did not speak Spanish and resorted to gestures or told the resident to speak English. The lack of Spanish-speaking staff and absence of communication tools led to repeated instances where the resident became agitated, anxious, or cried out in Spanish without being understood. Interviews with staff confirmed that communication barriers existed, with staff acknowledging they often did not know what the resident wanted or was saying. Staff reported that the resident would become frustrated and agitated when not understood, and medication was administered to manage this agitation. Although an application to assist with communication was mentioned, it had not been downloaded or made available to staff. The facility was unable to provide a policy for communication, further indicating a lack of structured approach to address the resident's communication needs.
Failure to Provide Consistent Bathing Services
Penalty
Summary
The facility failed to provide consistent bathing services for two residents who required staff assistance with bathing. One resident with multiple sclerosis, heart failure, and dementia was care planned to receive assistance with washing her back and hair during showers twice per week, as per her preference. However, bathing records showed that she did not receive a shower for a 13-day period, and there was no documentation of her refusing showers during that time. Observations confirmed that her hair was greasy, and she reported not receiving showers as scheduled. Staff interviews indicated that the resident did not refuse her baths, and the facility's policy required that baths and showers be performed and documented according to resident preferences. Another resident with intellectual disabilities and vascular dementia, who was dependent on staff for showering, was scheduled to receive showers twice a week in the evenings. Documentation showed significant gaps between showers, with the last recorded shower followed by a period of five days without a shower, and the resident was observed with greasy hair. The facility's policy required that showers be provided and documented as scheduled to maintain hygiene and dignity, but this was not consistently followed for these residents.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the occurrence of accidents. The deficiency centers on the lack of appropriate measures to identify and eliminate hazards, as well as insufficient oversight to safeguard residents from potential harm.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
A deficiency was identified regarding the provision of appropriate treatment and services to a resident who displays or is diagnosed with dementia. The report indicates that the facility failed to ensure that a resident with dementia received the necessary care and services tailored to their diagnosis and needs. Specific actions or omissions by facility staff led to this deficiency, as the required interventions or supports for the resident's dementia were not provided as expected.
Failure to Notify Physician of Out-of-Parameter Blood Glucose Readings
Penalty
Summary
The facility failed to notify the physician when a resident's blood glucose levels were outside of the parameters specified in the physician's orders. The resident in question had diagnoses of diabetes mellitus, major depressive disorder, and dementia, and required substantial assistance with daily activities. The care plan and physician's order directed staff to monitor blood glucose before meals and at bedtime, and to notify the physician if the blood glucose was greater than 300 mg/dL or less than 70 mg/dL. Despite this, the Medication Administration Record documented multiple instances where the resident's blood sugar readings were either above 300 mg/dL or below 70 mg/dL, and there was no evidence that the physician was notified as required. Staff interviews confirmed that the process for notifying the physician involved documenting the notification in a progress note, but review of the records did not show that such notifications occurred for the out-of-parameter blood glucose readings. The facility's policy required immediate consultation with the physician for significant changes in a resident's status, but this was not followed in the documented cases. The failure to notify the physician of abnormal blood glucose levels constituted a deficiency in ensuring the resident's drug regimen was free from unnecessary drugs and that care was provided according to physician orders.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure a coordinated plan of care for two residents who were receiving hospice services. For one resident with diagnoses including dementia, Alzheimer's disease, major depressive disorder, and diabetes mellitus, the care plan directed staff to coordinate with hospice and maintain comfort, but did not specify when hospice staff would be present or what care and supplies hospice would provide. The resident's care plan also lacked details on the specific roles and responsibilities of hospice staff in relation to the facility staff. Another resident, with chronic kidney disease, diabetes mellitus, overactive bladder, chronic lymphocytic leukemia, polyarthritis, Crohn's disease, and chronic pain syndrome, had a care plan that instructed staff to coordinate with hospice for comfort and care. However, this care plan also lacked information about the frequency of hospice staff visits, the specific disciplines involved, and the medications and supplies provided by hospice. Interviews with facility staff revealed uncertainty about the frequency of hospice nurse and aide visits, and the care plan did not reflect the actual coordination occurring between the facility and hospice provider. The facility's own hospice policy required that a significant change in status assessment be initiated and the plan of care updated to reflect coordination with hospice services. Despite this, the care plans for both residents did not include essential details about hospice involvement, such as visit schedules and supplies, resulting in a lack of clear coordination between the facility and hospice providers.
Failure to Consistently Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to consistently post the actual scheduled hours worked for nursing staff directly responsible for resident care per shift, as required by their policy. Observations revealed that on one occasion, the Daily Nurse Staffing Report posted was for the previous day, and on another occasion, there was no staffing report posted for part of the day. Interviews with staff confirmed that it was the night shift's responsibility to ensure the current day's staffing report was posted, but this was not done as required. The facility's policy specified that the number of licensed nurses and unlicensed nursing personnel providing direct care should be posted daily for each shift, but this was not consistently followed.
Failure to Maintain Resident Dignity Due to Staffing Issues
Penalty
Summary
The facility failed to protect a resident's dignity when a Certified Nurse's Aide (CNA) responded to the resident's call light, turned it off, and promised to return shortly but did not come back for two hours. During this time, the resident, who had a bowel movement, was left incontinent in bed, leading to feelings of humiliation and anger. The resident, who had intact cognition and was dependent on staff for most activities of daily living due to spinal stenosis, diabetes mellitus, and severe obesity, expressed that this incident made him feel humiliated and angry as he expected proper care for the money he paid. Observations and interviews with staff revealed a lack of adequate care due to staffing shortages, with multiple staff members, including a Certified Medication Aide (CMA), a CNA, and a Licensed Nurse (LN), acknowledging the issue. The facility's Resident Rights Policy emphasized the right to a dignified existence, which was not upheld in this instance. The administrative nurse expressed regret over the incident, acknowledging that a resident's dignity should always be maintained and care provided timely.
Inconsistent Bathing and Showering for Residents
Penalty
Summary
The facility failed to provide consistent bathing and showering for three residents, leading to a deficiency in care. Resident 1, who had diagnoses including spinal stenosis, diabetes mellitus, and severe obesity, was dependent on staff for most activities of daily living. Despite being scheduled for showers twice a week, Resident 1 only received four showers over a month, resulting in an unclean appearance and personal dissatisfaction. Similarly, Resident 3, who required moderate assistance for bathing, also received only four showers in the same period, leading to feelings of being dirty and smelly. Resident 11, with severe cognitive impairment and hemiplegia, was also affected by the facility's failure to provide scheduled bathing. This resident was dependent on staff for all personal hygiene needs and was scheduled for showers twice a week but only received three showers in a month. Observations noted an oily hair condition and a distinct odor of urine, indicating a lack of proper hygiene care. Interviews with facility staff, including a Certified Medication Aide, a Certified Nurse's Aide, and a Licensed Nurse, revealed that the lack of staffing was a significant factor contributing to the deficiency in care. Staff members expressed concern over the inadequate care provided to residents, with some stating that showers were not being completed as scheduled. An Administrative Nurse suggested that the issue might be related to documentation rather than the actual provision of care, indicating a need for staff training on proper documentation procedures.
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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