Holton Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Holton, Kansas.
- Location
- 1121 W 7th Street, Holton, Kansas 66436
- CMS Provider Number
- 175435
- Inspections on file
- 21
- Latest survey
- August 26, 2025
- Citations (last 12 mo.)
- 39
Citation history
Health deficiencies cited at Holton Health Care Center during CMS and state inspections, most recent first.
The facility did not provide sufficient nursing staff on weekends, as confirmed by PBJ data and administrative staff interviews. The facility also lacked a policy for addressing low weekend staffing, affecting the care of multiple residents.
Two CNAs employed for over a year did not have documented annual performance evaluations, and facility leadership confirmed responsibility for ensuring these were completed. No policy regarding annual performance reviews was provided.
The facility did not employ a full-time certified dietary manager to oversee food and nutrition services for its 34 residents. Instead, a staff member without the required certification or enrollment in a dietary manager program was responsible for these duties, with oversight from an RD who visited monthly. No policy for the dietary manager position was available.
Surveyors found unsanitary conditions in the kitchen and dining area kitchenette, including undated and unlabeled food, dirty equipment, improper dish storage, and pest presence. Staff were unclear about cleaning responsibilities and did not consistently follow facility policies for food safety and sanitation.
Surveyors identified multiple infection control deficiencies, including two residents' respiratory equipment not being stored in a sanitary manner, lack of gown use by laundry staff when sorting soiled linens, and clean laundry being transported uncovered. The facility also failed to maintain documentation for Legionella monitoring due to missing records.
The facility did not implement the required elements of an antibiotic stewardship program, as evidenced by missing documentation in the Infection Control Log, including organism identification, antibiotic duration, and infection details. Administrative staff were unable to provide complete surveillance records, and the antibiotic surveillance binder could not be located, despite a policy requiring systematic tracking.
Two CNAs employed for over a year did not complete the required 12 hours of annual in-service education, including training in dementia care and abuse prevention. Administrative staff confirmed responsibility for tracking these requirements, but no policy was provided to support compliance.
Surveyors found that the facility failed to provide a clean and homelike environment, with equipment left in hallways, a hole in a resident's wall, and flies present in common areas. Staff interviews indicated a lack of awareness and inconsistent adherence to facility policies regarding cleanliness and equipment storage.
Surveyors identified failures in psychotropic medication management, including lack of physician order clarification for an antidepressant, missing documentation of gradual dose reduction for an antipsychotic, absence of required 14-day stop dates on PRN antianxiety medications for two residents, and failure to monitor behaviors for a resident on antidepressants. Staff interviews revealed gaps in knowledge and oversight, and facility policies regarding order clarification and medication review were not followed.
The facility did not complete required Care Area Assessment (CAA) analyses for several residents, with multiple care areas either missing analysis or only documented as 'will continue to monitor.' This failure was confirmed by staff interviews and record reviews, and resulted in incomplete assessments for areas such as functional abilities, nutrition, falls, incontinence, cognitive loss, and pressure ulcers, placing residents at risk for unidentified care needs.
Hazardous areas and materials, such as an unlocked electrical panel closet and a cabinet with chemicals and a razor, were left unsecured despite the presence of cognitively impaired, mobile residents. Additionally, a resident with significant cognitive and physical impairments who regularly smoked did not have a current smoking safety assessment in the EMR, and staff could not provide one when asked.
The facility did not ensure that monthly drug regimen reviews by the consultant pharmacist were properly conducted, documented, or acted upon for several residents. This included failures to attempt or document gradual dose reductions for antipsychotic medications, to clarify orders lacking administration parameters or dosing instructions, and to monitor the continued use of certain medications as recommended. Nursing and administrative staff interviews revealed a lack of follow-through on pharmacy recommendations and missing documentation.
Surveyors found that drugs and biologicals, including insulin and tuberculosis vials, were not labeled with open dates and that multiple expired medications were stored in medication carts and the medication room. Nursing staff confirmed the lack of labeling and the presence of expired medications, which were not removed as required by facility policy.
The facility did not ensure adequate dietary staffing, resulting in only one staff member being present in the kitchen, which led to delays in meal service and challenges in maintaining kitchen cleanliness. Administrative staff were aware of the shortage, and residents experienced late meal distribution compared to posted service times.
A resident who had consented to receive the PCV20 and Influenza vaccines did not receive them, and there was no documentation of administration. Additionally, two other residents were not offered these vaccines, and the facility could not provide records of vaccine offers or declinations. Staff were unable to locate the necessary documentation, despite facility policy requiring all residents to be offered these immunizations.
The facility did not document the offering, administration, or informed declination of the COVID-19 vaccine for three residents, and was unable to provide records or a policy regarding vaccination. Administrative staff confirmed the absence of required documentation and cited staff changes as a possible cause.
Multiple flies were observed in dining, kitchen, and nurse's station areas, with residents and staff reporting persistent fly problems and using fly swatters during meals. Staff interviews revealed a lack of awareness and action regarding pest control, and records showed the last pest control service occurred months earlier, contrary to facility policy requiring regular pest management.
Two residents were not reasonably accommodated when one was repeatedly left without access to her call light, despite care plan instructions, and another was pushed in a wheelchair without foot pedals. Staff confirmed that call lights should be within reach and foot pedals should be used during transport, but these practices were not followed.
A resident was not provided with the required cost information on the Advanced Beneficiary Notice (ABN) for continued skilled services, as the ABN lacked documentation of the cost for ongoing care. This was confirmed by an administrative nurse, and the facility's policy requires that such information be included to inform Medicare beneficiaries of their potential payment liability.
A resident with chronic pain, diabetes, depression, anxiety, muscle weakness, respiratory failure, and vision difficulties did not have a comprehensive care plan addressing key areas such as medication administration, dehydration risk, falls, pressure ulcers, psychosocial well-being, ADLs, activities, vision, and bowel/bladder function. Although assessments and CAAs identified these needs, the care plan lacked specific interventions, and staff confirmed the care plan was incomplete despite having access to it.
A resident with ESRD and dependent on dialysis did not have their care plan updated to include critical information such as the dialysis provider, visit frequency, chair time, or access site details. The EMR also lacked a physician order for dialysis and access site monitoring, and MDS assessments did not document dialysis care. Staff confirmed access to care plans, but the required updates were not made, contrary to facility policy.
A resident with severe cognitive impairment and multiple medical conditions did not have her required level of eating assistance and monitoring documented in her care plan. Staff relied on verbal communication and the Kardex for care instructions, resulting in the resident being left alone and struggling to eat without help.
A resident with COPD and multiple comorbidities had their nebulizer mask left on a bedside table without a sanitary container, contrary to physician orders and facility policy. Staff interviews confirmed that respiratory equipment should be cleaned and stored in a labeled plastic bag, but this was not done, resulting in a failure to maintain proper respiratory care practices.
A resident with end-stage renal disease requiring hemodialysis did not have daily monitoring or documentation of their AV fistula access site for complications, and there was no physician order for dialysis or access site monitoring in the medical record. Nursing staff assessed the site only on dialysis days, contrary to facility policy and care plan requirements.
A resident with PTSD and other mental health diagnoses did not have trauma-based triggers identified or individualized interventions implemented in their care plan. The trauma-informed care assessment was missing from the record, and the care plan lacked direction for PTSD, despite facility policy requiring such measures. Staff interviews confirmed the expectation for trauma-informed care, but documentation and planning did not meet these standards.
A resident was not provided with hospice services, nor was assistance given to transfer the resident to a facility that could arrange for hospice care.
The facility did not maintain or retain daily posted nurse staffing data for the required period, as confirmed by record review and staff interviews. The DON was identified as ultimately responsible for ensuring compliance with the facility's policy, which mandates that nurse staffing information be readily available and kept for at least 18 months.
A resident with a history of cerebral infarction, dementia, and Parkinson's disease fell from her wheelchair and sustained nasal bone fractures when a CNA propelled her without using foot pedals. The resident, who required assistance for mobility, planted her feet and fell forward. The facility's policies emphasized the importance of using appropriate interventions to minimize fall risks, but the failure to use foot pedals directly led to the incident.
A resident experienced a fall in a facility van, resulting in a shoulder injury. Despite complaints of pain and an x-ray showing a shoulder subluxation, staff failed to notify the physician and delayed obtaining an orthopedic referral. The resident's condition worsened, requiring surgical intervention, highlighting a deficiency in timely communication and follow-up procedures.
A resident with dementia and cerebral infarction, dependent on staff for all ADLs, sustained a fracture due to improper transfer by a CNA who did not use the required Hoyer lift. The care plan specified total dependence on staff for transfers, but the CNA transferred the resident without the lift, leading to the injury. The facility's investigation confirmed the CNA's failure to follow the care plan.
A resident experienced a medial subluxation of the right shoulder after her electric wheelchair tipped during a van transport when the seatbelt came unfastened. The facility's transportation policy lacked specific guidelines for wheelchair use and seat belt safety, contributing to the incident.
Failure to Maintain Adequate Weekend Nursing Staff
Penalty
Summary
The facility failed to ensure adequate nursing staff was available every day to meet the needs of all residents, specifically on weekends. A review of the CMS Payroll-Based Journal (PBJ) data for two fiscal quarters showed the facility triggered for excessively low weekend staffing. During interviews, administrative staff confirmed that the facility experienced low staffing levels on weekends during the identified period and acknowledged ongoing struggles with staffing. Additionally, the facility was unable to provide a policy addressing low weekend staffing. These findings were based on a census of 34 residents, with a sample of 12 residents reviewed.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete yearly performance evaluations for two Certified Nurse Aides (CNAs) who had been employed for more than 12 months. A review of staffing records showed that both CNAs did not have documented annual performance evaluations available upon request. During an interview, the administrative nurse confirmed that she and the director of nursing were responsible for ensuring these evaluations were completed annually for direct care staff. Additionally, the facility was unable to provide a policy regarding the requirement for yearly performance reviews.
Lack of Certified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager to oversee food and nutrition services for its 34 residents. Interviews with dietary staff revealed that the current staff member responsible for dietary management was not registered for a dietary manager program and had only been with the facility for a few months. Administrative staff confirmed that there was no certified dietary manager employed and that the individual in the role was not enrolled in the necessary training. The facility relied on a Registered Dietitian who visited monthly, and no policy for the dietary manager position was provided during the review.
Failure to Maintain Sanitary Food Storage and Preparation Standards
Penalty
Summary
Surveyors observed multiple failures to maintain sanitary dietary standards in the facility's kitchen and dining area kitchenette. The dietary manager was not wearing a hair net, and dishes were not stored inverted as required. The steam table and refrigerator had visible dried food and sticky, dirty handles. Inside the refrigerator, several food items, including goulash, mixed vegetables, Cool Whip, sour cream, cucumbers, and cut-up lettuce, were found undated and open. The freezer contained undated and unlabeled hamburger patties, French fries, and chicken strips, all open to air. Sugar and flour bins on the floor were open, undated, and had old food particles and sticky substances. The ice machine in the dining area kitchenette had a dark brown substance along the spout and drain, and a bucket under the kitchen cabinet contained a black substance surrounded by dead bugs. The refrigerator temperature log was outdated, and food items in the refrigerator and freezer were undated and unlabeled. Flies were observed on plates and bowls, and dried eggs were present on the steam table. Interviews with dietary staff revealed a lack of knowledge regarding proper dating and labeling of food, as well as uncertainty about cleaning responsibilities for certain areas and equipment. Staff admitted to being short-staffed and behind on cleaning and temperature logging. The facility's policies required head coverings, regular cleaning, and clear assignment of cleaning tasks, but these were not being followed. These actions and inactions resulted in unsanitary food storage, preparation, and serving conditions, placing residents at risk for food-borne illness.
Infection Control Deficiencies in Respiratory Equipment, Laundry Handling, and Legionella Monitoring
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in several areas. Two residents' respiratory equipment was not stored in a sanitary manner: one resident's nasal cannula was found wrapped around a canister handle in the room, and another resident's nebulizer was left on a bedside table without a clean barrier or sanitary container. Staff interviews confirmed that respiratory equipment should be cleaned, air-dried, and stored in a plastic bag with the resident's name and date, as per facility policy, but this was not followed in these instances. Additionally, the laundry room lacked a gown for staff to wear while sorting dirty laundry, and laundry staff were unaware of the requirement to use a gown. Clean laundry was observed being transported uncovered, with clothing and linens placed on top of the cart, contrary to facility policy that requires clean laundry to be covered and handled in a sanitary manner. The facility was also unable to provide documentation of trend and tracking for Legionella monitoring, as required by their policy, due to a change in staffing and missing records.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement the core elements of an antibiotic stewardship program as part of its infection prevention and control efforts. A review of the Infection Control Log for the period from August 2024 through July 2025 revealed missing documentation, including organism identifications, duration of antibiotic prescriptions, and the specific infections treated. When requested, the facility was unable to provide evidence of tracking antibiotic use, as the binder for antibiotic surveillance could not be located. Administrative staff confirmed the inability to locate more than one month of surveillance records. The facility's own Antibiotic Stewardship policy, revised in June 2023, stated the purpose was to optimize antibiotic use and reduce unnecessary laboratory tests through a systematic approach, but the required documentation and tracking were not in place.
Failure to Ensure Required In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that two Certified Nurse Aides (CNAs), both employed for more than 12 months, completed the required 12 hours of in-service education within the past year. Record review showed that neither CNA had documentation of completing the necessary in-services, including education in dementia care and abuse prevention. During an interview, the administrative nurse confirmed that she and the director of nursing were responsible for ensuring completion of yearly in-service requirements. Additionally, the facility was unable to provide a policy related to required yearly in-services.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to maintain a clean, safe, and homelike environment for its residents. During a walk-through, equipment such as a wheelchair, a Hoyer lift, and two commodes were found stored in the hallway, and a six-inch square hole was noted in the wall behind a resident's bed. Additionally, flies were present in several areas of the facility, including the dining room, kitchen, and nurse's desk, over a period of several days. Interviews with staff revealed that while work orders for repairs were reportedly submitted and maintenance made regular rounds, some staff were unaware of the equipment being left in hallways and the extent of the fly problem. The facility's policy required a safe, clean, and comfortable environment, but these observations and staff statements indicated that the policy was not consistently followed, resulting in an environment that did not meet the required standards for cleanliness and homelikeness.
Deficient Psychotropic Medication Management and Oversight
Penalty
Summary
The facility failed to ensure proper management and oversight of psychotropic and related medications for several residents, as evidenced by multiple deficiencies in physician order clarification, gradual dose reduction (GDR) processes, PRN medication stop dates, and monitoring requirements. For one resident, the physician's order for an antidepressant was not clarified regarding its indication, despite the resident having multiple comorbidities including atrial fibrillation, COPD, and heart failure. Nursing staff and administration acknowledged that clarification should occur when an order is unclear or has an unusual indication, but this was not done in this case. Another resident receiving antipsychotic medication did not have documentation of a GDR attempt or a physician's statement that a GDR was contraindicated, as required by facility policy. Consulting pharmacist recommendations for GDR were not addressed by the physician, and monthly medication reviews were missing for several months. The director of nursing was expected to ensure these reviews were completed and retained, but this did not occur. Additionally, two residents had PRN orders for antianxiety medications (Lorazepam and Ativan) that lacked the required 14-day stop dates. Nursing staff were unaware of this requirement, and the director of nursing was responsible for entering orders and reviewing pharmacy recommendations. Another resident prescribed antidepressant medication did not have documented monitoring of behaviors for anxiety and depression, and staff were unaware that such monitoring was necessary. These failures were contrary to facility policies on order transcription, physician order clarification, and psychotropic drug management.
Failure to Complete Required Care Area Assessment Analyses
Penalty
Summary
The facility failed to complete the Care Area Assessment (CAA) analysis for several residents within the required time frame, as identified through observation, record review, and interviews. Specifically, the CAAs for multiple care areas such as Functional Abilities, Nutritional Status, Falls, Urinary Incontinence and Indwelling Catheter, Psychotropic Drug Use, Cognitive Loss/Dementia, Psychosocial Well-Being, Mood State, Behavioral Symptoms, Activities, Communication, Delirium, and Pressure Ulcer were either missing or lacked proper analysis. In several instances, the documentation only stated 'will continue to monitor' (wctm) instead of providing a comprehensive analysis of the triggered care areas. This was observed in the records of four residents, where the required CAA analysis was not completed as per facility policy and regulatory requirements. Interviews with facility staff confirmed that the MDS assessments were completed off-site by regional staff, and that all triggered CAAs should include a complete analysis with measurable goals to inform the resident's person-centered care plan. The facility's policy emphasized that the Care Area Assessment Summary is essential for developing individualized care plans and that all Care Area Triggers must be addressed. The lack of proper CAA analysis placed residents at risk for unidentified care needs, as the assessments did not adequately address underlying causes, risk factors, or other contributing factors for the identified care areas.
Failure to Secure Hazards and Complete Smoking Assessment
Penalty
Summary
The facility failed to secure hazardous areas and materials, including an unlocked closet containing electrical panels and an unlocked cabinet with a razor and cleaning chemicals, despite the presence of eight cognitively impaired, independently mobile residents. Observations revealed that the electrical panel closet remained unsecured over multiple days, and staff members, including licensed nurses, housekeeping, and maintenance, were unsure or unaware of the requirement to keep these areas locked. Additionally, a shower room cabinet containing potentially dangerous items was found with the padlock open and the key left in the lock, and hazardous products were left out in the open. The facility's own policy required the environment to be as free of accident hazards as possible, but this was not followed. The facility also failed to assess a resident with multiple diagnoses, including hemiparesis, aphasia, bipolar disorder, dysphagia, anxiety, depression, and vascular dementia, for smoking safety. The resident's care plan noted that smoking was a favorite activity, but there was no current smoking assessment in the electronic medical record, and staff could not provide one when requested. The resident was observed requesting to go outside to smoke on several occasions, and staff interviews confirmed that smoking assessments were expected to be completed but were not present for this resident.
Failure to Ensure Proper Drug Regimen Review and Physician Response
Penalty
Summary
The facility failed to ensure that monthly drug regimen reviews (MRRs) by the consultant pharmacist were properly conducted, documented, and acted upon for multiple residents. For one resident with diagnoses including schizoaffective disorder and Parkinson’s disease, the medical record and MDS lacked documentation that a gradual dose reduction (GDR) for antipsychotic medication was attempted or that the physician documented a contraindication. The facility was unable to provide evidence of physician responses to the consultant pharmacist’s recommendations for GDR, and several months of MMRs were missing. Interviews revealed that nursing staff did not address the MMRs, and administrative staff expected the director of nursing to ensure physician review and retention of these records. Another resident with heart failure and atrial fibrillation had orders for as-needed diuretic medication that lacked administration parameters. The consultant pharmacist did not identify or report this irregularity, and the facility could not provide evidence of notification or clarification. Additionally, the consultant pharmacist requested clarification for the indication of an antidepressant, but the facility was unable to provide MMRs for several months. Nursing staff acknowledged that orders should have administration instructions and that unclear orders should be clarified, but did not address the MMRs as required. Further deficiencies included a resident with end-stage renal disease who had an order for Voltaren gel without dosing instructions, which was not identified or reported by the consultant pharmacist. Another resident receiving antidepressant medication did not have evidence of monitoring for continued use as recommended by the consultant pharmacist. Lastly, a resident prescribed lorazepam as needed for anxiety lacked documentation that the consultant pharmacist’s recommendation for a 14-day stop date was acknowledged or acted upon. Staff interviews confirmed a lack of awareness regarding the need for monitoring and stop dates, and administrative staff stated that the director of nursing was responsible for ensuring pharmacy reviews were completed.
Failure to Properly Label and Remove Expired Medications
Penalty
Summary
Surveyors observed that drugs and biologicals in the facility were not consistently labeled or stored according to accepted professional standards. During reviews of medication carts and the medication room, several vials of insulin and tuberculosis medication were found without dates indicating when they were opened. Additionally, some insulin vials were found to be expired. Licensed nursing staff confirmed the lack of open dates and the presence of expired vials, acknowledging that these should have been destroyed. Further inspection revealed multiple expired oral medications, including midodrine, meclizine, furosemide, and cyclobenzaprine, stored in the medication carts for several residents. Nineteen expired over-the-counter medications were also found on supply shelves in the medication room. Staff confirmed the expired status of these medications and removed them from storage. The facility's policy required medications to be stored according to manufacturer recommendations and for the pharmacist to routinely inspect for outdated or discontinued medications, but these procedures were not followed as observed.
Insufficient Dietary Staffing Leads to Delayed Meal Service and Poor Kitchen Sanitation
Penalty
Summary
The facility failed to provide sufficient staff with the appropriate competencies and skill sets to carry out the functions of the Food and Nutrition Services. On the day of the survey, only one dietary staff member was present in the kitchen, who reported being unable to keep the kitchen clean, cook food, and do dishes due to understaffing. Two other dietary staff members were unavailable on Mondays and Tuesdays, and although there were applicants, no new hires had been made. Administrative staff acknowledged awareness of the staffing shortage. Observations showed that approximately ten residents were waiting in the dining room past the posted breakfast service time before trays were distributed. The facility did not provide a policy for dietary staffing.
Failure to Administer and Document Flu and Pneumonia Vaccines
Penalty
Summary
The facility failed to administer the Pneumococcal Conjugate Vaccine (PCV20) and Influenza vaccine to a resident who had provided signed consent and was within the required vaccination date range. The resident's electronic medical record and consent form confirmed eligibility and consent for both vaccines, as well as receipt of educational information. However, there was no evidence in the clinical record that either vaccine had been administered, and the facility was unable to provide documentation of administration upon request. Additionally, the facility did not offer the PCV20 and Influenza vaccines to two other residents, and there was no documentation or evidence that these vaccines were offered or declined. Administrative staff and nursing staff were unable to locate records of vaccine administration or signed declinations, citing staff changes as a possible reason for the missing information. The facility's own policy required that all residents be offered these immunizations, but this was not followed for the residents in question.
Failure to Document COVID-19 Vaccination Status and Informed Declinations
Penalty
Summary
The facility failed to offer or obtain informed declinations or a physician-documented contraindication for the COVID-19 vaccination for three residents. Record reviews for these residents showed no documentation in the electronic medical record (EMR) under the Immunization tab indicating that the COVID-19 vaccine was offered, declined, historically administered, or that a physician-documented contraindication was present. Upon request, the facility was unable to provide any records of consent, declination, or physician-documented contraindication for these residents. Interviews with administrative staff confirmed that documentation for the vaccines given or signed declinations could not be found. Staff changes were cited as a possible reason for the missing information, and the facility was also unable to provide a policy related to the administration of the COVID-19 vaccination. This lack of documentation and policy resulted in a failure to ensure proper vaccination status tracking for the affected residents.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of flies in resident and staff areas. On several occasions, flies were seen in the dining area, nutrition kitchenette, nurse's station, and kitchen, including on plates and bowls. Residents were observed swatting flies before meals, and one resident reported that her table partner brings a fly swatter to meals due to the persistent presence of flies. Staff interviews confirmed the ongoing issue, with a Certified Medication Aide noting that flies enter through the patio, especially when wheelchair residents take time to go outside to smoke. Further interviews revealed a lack of awareness and action regarding the fly problem among nursing staff and administration. A Licensed Nurse stated she was unaware of a pest control program specifically for flies, and the Administrative Nurse indicated she was not aware of the issue, believing maintenance should address it. The facility's pest control policy requires a written agreement with an outside pest service for regular, comprehensive pest control, but the last documented pest control service was several months prior, and no evidence was provided of ongoing or targeted efforts to address the fly infestation.
Failure to Ensure Call Light Accessibility and Safe Wheelchair Transport
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents. One resident, who had diagnoses including hypertension, dementia, anxiety, major depressive disorder, and emphysema, and was assessed as having moderately impaired cognition, was found on two separate occasions with her call light clipped to the privacy curtain at the bottom of her bed, out of her reach. Her care plan specifically directed staff to ensure the call light was within her reach and to encourage her to use it for assistance. Staff interviews confirmed that call lights should always be within residents' reach and should not be clipped to the privacy curtain. Additionally, another resident was observed being pushed by staff into the dining room without foot pedals attached to her wheelchair. Staff interviews confirmed that foot pedals should be applied when pushing a resident in a wheelchair. The facility did not provide a policy regarding accommodation of needs. These actions and inactions resulted in a failure to meet the residents' needs as outlined in their care plans and facility expectations.
Failure to Provide Cost Information on ABN for Skilled Services
Penalty
Summary
The facility failed to provide required cost information on the Advanced Beneficiary Notice (ABN) CMS form 10055 for a resident receiving skilled services. Specifically, the ABN for one resident did not include documentation regarding the cost for continued skilled services ending on 7/24/25. This omission was identified during a review of records for three residents sampled for Medicare Liability Notices out of a total sample of twelve. An administrative nurse confirmed that the ABN should have included the cost to properly notify the resident. The facility's policy, dated 11/05/24, requires timely notices about Medicare eligibility and coverage, including informing beneficiaries of their potential payment liability.
Failure to Develop Comprehensive Care Plan for Resident with Multiple Needs
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with multiple complex medical conditions, including chronic pain, diabetes mellitus, depression, anxiety, muscle weakness, respiratory failure, and vision difficulties. Despite documentation in the resident's electronic medical record and Minimum Data Set (MDS) assessments indicating the need for assistance with activities of daily living (ADLs), toileting, bed mobility, and bathing, the care plan lacked direction for several critical areas such as medication administration, risk of dehydration, falls, pressure ulcers, psychosocial well-being, ADLs, activities, vision difficulties, and bowel and bladder function. The Care Area Assessments (CAAs) identified these needs and recommended follow-up or monitoring, but these were not translated into specific, measurable care plan interventions. Staff interviews confirmed that all nursing staff had access to the resident's care plan and Kardex, and that the director of nursing was responsible for ensuring the care plan was developed and updated. However, the care plan did not reflect the resident's individualized care needs as identified in the assessments and CAAs. The facility's policy required the development and implementation of a comprehensive, person-centered care plan with measurable objectives and time frames, but this was not followed for the resident in question.
Failure to Update Care Plan for Dialysis-Dependent Resident
Penalty
Summary
The facility failed to revise the care plan for a resident with end-stage renal disease (ESRD) who was dependent on dialysis. The resident's care plan did not include essential information such as the dialysis provider, frequency of visits, days of the week, chair time, or the location and assessment frequency of the access site. Additionally, the electronic medical record lacked a physician order for dialysis and monitoring of the access site. The Minimum Data Set (MDS) assessments did not document that the resident had received dialysis during the observation periods. The care plan only included general monitoring instructions and did not specify individualized dialysis-related care needs. Interviews with facility staff confirmed that all nursing staff had access to the resident's care plan and Kardex, and that the director of nursing was responsible for ensuring the care plan was current and person-centered. Despite this, the care plan was not updated to reflect the resident's dialysis requirements. The facility's policy required comprehensive, person-centered care plans to be developed and revised by the interdisciplinary team after each assessment, but this was not followed for the resident in question.
Failure to Document and Provide Required Eating Assistance
Penalty
Summary
The facility failed to ensure that a resident's care plan accurately reflected the required assistance and monitoring needed during meals. The resident in question had multiple diagnoses, including severely impaired cognition, and was documented as needing supervision or touching assistance with eating, as well as partial to full assistance with other activities of daily living. Despite these needs, the resident's care plan only addressed nutritional goals and meal monitoring, lacking specific instructions regarding the level of assistance and monitoring required while eating. Observations showed the resident eating alone in the dining room without staff present, struggling to access food on her plate. Interviews with staff revealed that information about residents' assistance needs was communicated verbally or through the Kardex, rather than being clearly documented in the care plan. Some staff were unsure if or how the required assistance should be reflected in the care plan, and the facility's policy required a comprehensive, person-centered care plan based on assessment findings.
Nebulizer Mask Not Stored Sanitarily After Use
Penalty
Summary
Staff failed to ensure that a resident's nebulizer mask was stored in a sanitary manner, as required by facility policy and physician orders. The resident, who had diagnoses including hypertension, dementia, anxiety, major depressive disorder, and emphysema with COPD, required assistance with most activities of daily living and had a care plan specifying that her nebulizer should be rinsed after each use and kept dry. Despite these instructions, observations showed the nebulizer was left on the bedside table without a clean barrier or sanitary container. Interviews with facility staff, including a Certified Medication Aide, a Licensed Nurse, and an Administrative Nurse, confirmed that respiratory equipment should be cleaned, air dried, and stored in a labeled plastic bag when not in use. The facility's own policy also directed staff to keep delivery devices covered in a plastic bag. However, these procedures were not followed for the resident in question, resulting in a failure to provide safe and appropriate respiratory care.
Failure to Monitor and Document Dialysis Access Site
Penalty
Summary
The facility failed to provide appropriate monitoring and documentation for a resident with end-stage renal disease who required hemodialysis. Specifically, the nursing staff did not monitor the resident's arteriovenous (AV) fistula access site for complications at least daily, nor did they document the presence of thrill and bruit every day as required. The resident's care plan included instructions for monitoring and reporting signs of infection, insufficiency, bleeding, and peripheral edema, but there was no physician order in the electronic medical record for dialysis or for monitoring the access site. Additionally, the Minimum Data Set (MDS) assessments did not document that the resident received dialysis during the observation periods. Licensed nursing staff reported assessing the access site only before and after dialysis sessions and documenting these assessments on the dialysis communication sheet, but not on non-dialysis days. The facility's dialysis policy required that residents needing dialysis receive services consistent with professional standards and the care plan. Administrative staff confirmed that a physician's order for dialysis and daily monitoring of the access site was expected but not present in the resident's record.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to identify trauma-based triggers and implement individualized interventions for a resident with a diagnosis of post-traumatic stress disorder (PTSD). The resident's electronic medical record documented multiple mental health diagnoses, including PTSD, panic disorder, major depressive disorder, anxiety, and bipolar disorder, with a Brief Interview of Mental Status (BIMS) score indicating intact cognition. Despite these diagnoses, the resident's care plan did not include any direction or interventions specific to PTSD, and the trauma-informed care assessment was missing from the resident's record. The Psychotropic Drug Use Care Area Assessment also lacked analysis related to trauma-informed care. Interviews with facility staff confirmed that the social services department was responsible for completing trauma-informed care assessments and that residents with PTSD should have care plans to prevent re-traumatization. However, the care plan for this resident only noted a favorite activity and did not address past trauma or provide personalized interventions. The facility's own policy required culturally competent, trauma-informed care that minimized triggers and re-traumatization, but this was not reflected in the resident's documentation or care planning.
Failure to Arrange Hospice Services
Penalty
Summary
The facility failed to arrange for the provision of hospice services for a resident or assist the resident in transferring to a facility that would provide such services. This deficiency indicates that the necessary steps were not taken to ensure the resident received appropriate hospice care or was transferred to a setting where hospice services could be arranged.
Failure to Maintain and Retain Nurse Staffing Data
Penalty
Summary
The facility failed to maintain and retain daily posted nurse staffing data for the required 18-month period. During a review of staffing sheets covering a specific timeframe, the facility was unable to provide the requested documentation. Interviews with administrative staff revealed that the management team had assigned responsibility for posting and retaining daily nursing hours, with the DON ultimately accountable for compliance with the regulation. The facility's policy required that nurse staffing information be readily available and maintained in the Human Resources Department for at least 18 months or as required by state law. However, the required documentation was not available for review as mandated.
Failure to Use Wheelchair Foot Pedals Leads to Resident Fall
Penalty
Summary
The facility failed to prevent an avoidable accident involving a resident who was being propelled in a wheelchair without the use of foot pedals. The incident occurred when a Certified Nurse Aide (CNA) was pushing the resident, who had a history of cerebral infarction, dementia, and Parkinson's disease, down the hallway. The resident, who was dependent on staff for wheelchair mobility, planted her feet, leaned forward, and fell out of the wheelchair, resulting in nasal bone fractures. The resident's medical records indicated she had impaired cognition and poor safety awareness, requiring moderate to maximum assistance with mobility. Her care plan highlighted an increased risk for falls due to confusion, balance problems, and poor safety awareness. Despite these documented needs, the CNA did not utilize the foot pedals on the wheelchair, which were present but not in use at the time of the incident. The facility's policies on falls and assistive devices emphasized the importance of implementing relevant interventions to minimize fall risks and ensuring the appropriateness of devices for resident conditions. However, the failure to use foot pedals during wheelchair propulsion directly led to the resident's fall and subsequent injuries.
Removal Plan
- The facility updated R1's care plan to include foot pedal usage.
- The facility started educating nursing staff on using foot pedals during staff wheelchair propulsion.
- CNA M received a corrective action.
Failure to Report Abnormal X-ray Findings and Delay in Treatment
Penalty
Summary
The facility failed to ensure that a resident received care consistent with the standards of practice when staff did not report abnormal x-ray findings and did not obtain timely physician involvement for treatment. The resident, who had a history of essential hypertension and bone density disorders, experienced a fall in the facility's van, resulting in a shoulder injury. Despite the resident's complaints of shoulder pain and an x-ray revealing a medial subluxation of the shoulder joint, the staff did not notify the resident's physician of the x-ray results. The resident continued to experience shoulder pain affecting their activities of daily living, yet the facility delayed obtaining a referral to an orthopedic specialist. Although an order for a referral was obtained, the staff did not follow up to ensure an appointment was made until several weeks later. This delay resulted in the resident not receiving an orthopedic consultation until nearly two months after the initial injury, at which point the orthopedic physician identified a more severe injury requiring surgical intervention. The facility's inaction and lack of timely communication with healthcare providers placed the resident in immediate jeopardy. The resident's medical records lacked evidence of proper notification to the physician regarding the x-ray results and ongoing pain. Interviews with facility staff revealed a lack of consistent follow-up procedures for referrals and physician notifications, contributing to the delay in addressing the resident's medical needs.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to provide safe activities of daily living (ADLs) care to a resident, resulting in a fracture across the right distal femur. The resident, who had diagnoses of dementia and cerebral infarction, was dependent on staff for all ADLs. Her care plan specified the use of a Hoyer lift for transfers, indicating total dependence on staff. However, a Certified Nurse Aide (CNA) transferred the resident without the lift, using a one-to-one method, which was inconsistent with the care plan. The incident occurred when CNA M transferred the resident from her bed to a wheelchair without using the Hoyer lift, despite the care plan's directive. The CNA's witness statement revealed that she cradled the resident during the transfer, which was not the approved method. This action led to the resident sustaining a bruise and subsequent fracture, which was discovered later that day. The facility's investigation confirmed that the CNA did not follow the care plan, and she was placed on the do not return list. Interviews with other staff members indicated that the resident was typically transferred using a Hoyer lift with the assistance of two staff members. The facility's policy required staff to provide care in accordance with the care plan, which was not followed in this instance. The failure to adhere to the care plan and use the appropriate transfer method directly contributed to the resident's injury.
Failure to Prevent Accident During Resident Transport
Penalty
Summary
The facility failed to prevent an accident involving a resident during a van transport to a medical appointment. On the specified date, the resident's seatbelt came unfastened, causing her electric wheelchair to tip towards the right, resulting in her right arm and shoulder hitting the lift gate. This incident led to a medial subluxation of the resident's right glenohumeral joint, as confirmed by an x-ray taken two days later. The resident involved had a history of essential hypertension and disorders of bone density and structure in the right shoulder. She required varying levels of assistance with activities of daily living (ADLs) due to impairments in her upper and lower extremities. Despite having intact cognition, the resident was at an increased risk for falls and injuries due to impaired balance and mobility limitations, as documented in her care plan and assessments. The facility's transportation policy lacked specific guidelines for wheelchair use, seat belt safety, and accident prevention. During the incident, the transportation staff had secured the resident's wheelchair with anchors and a lap band, but the seatbelt became unbuckled, leading to the accident. The facility was unable to determine how the seatbelt came unfastened, and the incident was not addressed in the facility's transportation policy.
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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