Lansing Care And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Lansing, Kansas.
- Location
- 210 Plaza Drive, Lansing, Kansas 66043
- CMS Provider Number
- 175228
- Inspections on file
- 21
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Lansing Care And Rehab during CMS and state inspections, most recent first.
A cognitively impaired, wheelchair-dependent resident with severe dementia, impaired balance, and a history of falls required extensive staff assistance and two-person participation for bed mobility and transfers per the care plan. During an attempted transfer to bed while the resident was resisting, two CNAs repositioned the wheelchair, causing the resident’s angled left leg to strike the bed frame, after which the resident screamed that staff had broken her knee; one CNA then performed a hug transfer without the other’s help. The event was reported to a nurse, who initially noted no visible injury and believed the resident’s pain was at baseline, but bruising and significant pain on palpation were identified later, and imaging subsequently revealed an oblique proximal tibia and fibula fracture with soft tissue swelling that orthopedics characterized as acute. The facility’s accident policy emphasized maintaining an environment free from accident hazards and providing supervision and assistance based on individual risk factors.
A resident's CPAP mask was found unbagged and resting directly on a bedside table, contrary to facility protocols requiring respiratory equipment to be stored in dated bags when not in use. Staff interviews confirmed inconsistent adherence to this practice. Additionally, the facility lacked a comprehensive, facility-specific water management program to address Legionella and other waterborne pathogens, with only general documentation and a single test on record, and no evidence of ongoing risk assessment or monitoring.
Staff did not consistently lock medication and treatment carts containing treatment supplies, PRN creams, and insulin pens when the carts were not within the nurses' line of sight. Facility policy and staff interviews confirmed that carts should be locked when unattended to ensure safe and secure storage of drugs and biologicals.
Two residents experienced a lack of dignity and respect during care interactions. One resident, dependent on staff for all ADLs and cognitively intact, was spoken to disrespectfully by a CNA in her room. Another resident with severe cognitive impairment and physical limitations was fed by staff standing over him in the dining area, with his bare abdomen exposed to others. Staff interviews and facility policy confirmed these actions did not meet expected standards for resident dignity and respectful care.
A resident with severe cognitive impairment and total dependence on staff for care was subjected to verbal and emotional abuse when a CNA forcibly took away her comfort item and used derogatory language. This action violated the resident's care plan and the facility's abuse prevention policy, which require staff to treat all residents with respect and dignity.
A resident with dementia and severely impaired cognition was administered antipsychotic medications without appropriate physician documentation, including rationale, evidence of unsuccessful nonpharmacological interventions, or risk-benefit assessment. The facility's records included an unsigned consent form and lacked the required supporting documentation, despite policy requirements for such oversight.
A resident with multiple chronic conditions was admitted to hospice, but the facility did not complete the required Significant Change MDS or Care Area Assessment within the mandated timeframe. The resident's EMR also lacked a hospice admission order, and staff interviews revealed delays and unclear responsibility for MDS completion.
A resident with severe cognitive impairment, multiple medical diagnoses, and a history of falls did not have fall prevention interventions implemented as directed by the care plan. Observations revealed the call light was out of reach and the fall mat was not placed by the bed as required, despite staff and facility policy stating these measures should be in place.
A consultant pharmacist did not identify or report the absence of an Abnormal Involuntary Movement Scale (AIMS) test for a resident prescribed Reglan, despite the resident's medical history and ongoing medication regimen. Monthly medication reviews lacked documentation or recommendations for the required AIMS test, and nursing staff confirmed the assessment was not completed or available when requested.
A resident receiving Reglan for nausea, with a history of CHF, diabetes, and GERD, was not monitored for adverse effects using the AIMS test or any alternative method. Staff indicated that the facility's system did not trigger AIMS testing for this medication, and no policy for monitoring medication side effects was available upon request.
A resident with multiple chronic conditions was admitted to hospice, but the facility did not document the required physician order for hospice admission, failed to complete the Significant Change MDS and CAA within required timeframes, and omitted details about hospice-provided medications and equipment from the care plan. Staff interviews confirmed that this information should have been included per facility policy.
Failure to Provide Safe, Assisted Transfer Resulting in Leg Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision during a transfer for a cognitively impaired resident with severe dementia, generalized muscle weakness, impaired balance, history of falls, and dependence on staff for transfers and mobility. The resident’s MDS and care plans documented severe cognitive impairment (BIMS score of 4), dependence on staff for wheelchair mobility and transfers, and the need for substantial to maximal assistance with bed mobility, transfers, and ADLs. The care plan further specified that two staff were to participate in repositioning and turning the resident in bed, and that staff were to observe for and report redness, open areas, scratches, cuts, and bruises to the nurse. On the date of the incident, two CNAs attempted to assist the resident into bed while the resident was resisting and hitting staff. One CNA reported that, due to the wheelchair’s “weird” position, the assisting CNA swung the wheelchair toward the bed frame to turn it while the resident’s left leg was positioned behind the right leg at an angle. During this maneuver, the resident’s left knee hit the bed frame, and the resident immediately screamed and yelled that staff had broken her knee, using expletives. The witness CNA stated that the bed frame height aligned with the area of the resident’s later-observed bruise and that the resident’s leg position at the time of impact was as she demonstrated, with the left leg angled behind the right. The witness CNA further reported that, after repositioning the wheelchair, the assisting CNA decided to perform a “hug” transfer of the resident into bed without the witness CNA’s help, and the resident again cried out that staff had broken her knee. The CNAs reported to the nurse that the resident had bumped her leg on the bed frame and cried out in pain. Following the incident, the nurse who was informed the next morning assessed the resident and did not initially observe redness or bruising, and believed the resident’s pain was at baseline, noting the resident had a history of leg pain and frequent refusal of pain medication. Two days after the incident, a CNA reported bruising below the resident’s left knee, and a nurse documented facial grimacing and yelling upon palpation of the lower leg. An x-ray obtained at that time showed an oblique fracture of the proximal tibia and proximal fibula with soft tissue swelling and age-indeterminate fractures. The orthopedic clinic later documented that, although the exact timing and mechanism of the fracture were unclear, there were acute findings on the x-rays, including well-defined fracture lines and absence of healing, and the fracture would be treated as acute. The facility’s own accident policy stated that the environment should be as free from accident hazards as possible and that resident safety, supervision, and assistance to prevent accidents were facility-wide priorities, using a systems approach that considers environmental hazards and individual resident risk factors.
Deficiencies in Infection Control: Improper CPAP Mask Storage and Inadequate Water Management Program
Penalty
Summary
The facility failed to ensure that a resident's continuous positive airway pressure (CPAP) mask was stored in a sanitary manner. During observation, the resident's unbagged CPAP mask was found resting directly on the bedside table, with no storage bag visible. The resident confirmed that the mask was usually not stored in a bag and that she did not have one for her CPAP mask. Interviews with staff revealed that the facility's practice was to store respiratory masks in dated bags when not in use, with the night shift responsible for ensuring bags were available and the day shift responsible for placing the mask in the bag. However, this protocol was not followed for the resident in question. Additionally, the facility failed to develop, implement, and maintain a comprehensive water management program to reduce the risk of Legionella and other waterborne pathogens. While documentation of Legionella testing and general monitoring instructions were available, they were not specific to the facility and lacked evidence of a risk assessment or ongoing monitoring to identify potential sources of Legionella growth. The maintenance staff was only aware of a single test conducted and did not have a detailed water management plan or diagram, indicating a lack of a systematic approach to water safety as required by facility policy.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
Staff failed to ensure that medication carts and treatment carts containing residents' treatment supplies, PRN creams, and insulin pens were always locked when not within the nurses' line of sight. On one occasion, a treatment cart was observed unlocked in a hallway, and an administrative nurse subsequently locked it. Interviews with nursing staff confirmed that facility policy requires medication and treatment carts to be locked if staff are not able to see them. The facility's policy, revised in October 2024, states that all drugs and biologicals must be stored in a safe, secure, and orderly manner.
Failure to Maintain Resident Dignity and Respect During Care Interactions
Penalty
Summary
The facility failed to provide a dignified care environment for two residents, resulting in deficiencies related to respect and dignity. One resident with quadriplegia, diabetes, anxiety disorder, and major depressive disorder, who was cognitively intact and dependent on staff for all activities of daily living, experienced an incident where a Certified Nurse's Aide (CNA) entered her room and responded to her inquiry with, "it's none of your business." The resident alleged the CNA used abusive language, which was partially corroborated by the CNA's admission to making a disrespectful comment. The care plan for this resident required at least two staff members to be present during interactions due to a history of allegations, but the report does not specify if this protocol was followed during the incident. Another resident with a history of stroke, diabetes, aphasia, and severe cognitive impairment, who was dependent on staff for all activities of daily living except eating, was observed being assisted with meals in a manner that did not maintain his dignity. Staff were seen standing over the resident while feeding him at the dining table, and his bare abdomen and right side were exposed to peers. Facility staff interviews confirmed that the expected practice was to sit beside residents while assisting with eating and to ensure residents' skin was covered in the dining area, but these standards were not upheld during the observed incidents. Facility policies on resident rights and respect and dignity, as well as staff interviews, emphasized the importance of treating residents with respect, maintaining their dignity, and following specific protocols for care and communication. However, the observed actions and interactions with the two residents did not align with these policies, resulting in a failure to honor the residents' rights to a dignified existence and respectful treatment.
Staff-to-Resident Verbal and Emotional Abuse Incident
Penalty
Summary
A staff-to-resident verbal and emotional abuse incident occurred involving a resident with severe cognitive impairment, dementia, muscle weakness, repeated falls, and dependence on staff for all activities of daily living. The resident, who used a wheelchair and relied on a stuffed bear as a coping mechanism, was subjected to abusive language by a Certified Nurse's Aide (CNA). The CNA forcibly took the resident's bear away against her wishes and called her a derogatory name. This incident was witnessed by another CNA, who reported the event. The resident's care plan required staff to provide structured routines, positive feedback, and activities compatible with her abilities, emphasizing respect and dignity. Despite these directives and the facility's policy prohibiting all forms of abuse, the staff member failed to uphold these standards, resulting in verbal and emotional abuse. The facility's policy defined mental abuse to include verbal conduct causing humiliation or agitation, which was directly violated in this incident.
Lack of Physician Documentation for Antipsychotic Use in Resident with Dementia
Penalty
Summary
The facility failed to ensure that a resident with dementia and severely impaired cognition received antipsychotic medications only with appropriate physician documentation and rationale. The resident, who also had diagnoses of repeated falls, muscle weakness, and Parkinson's disease, was prescribed Haloperidol for hallucinations and Seroquel for anxiousness. The medical record and care plan indicated ongoing use of these medications, with monthly pharmacist reviews and physician oversight of recommendations. However, the facility was unable to provide documentation from the physician that included a clear rationale for the continued use of antipsychotic medications, evidence of multiple unsuccessful attempts at nonpharmacological interventions, or an assessment of the risks versus benefits for this resident. Additionally, the consent form for psychoactive medication therapy was unsigned and lacked the required physician documentation. Interviews confirmed that the facility used preprinted consent forms and that the resident was on hospice services, with the family requesting continuation of the antipsychotic medication. The facility's policy required that psychotropic drugs be used only when necessary for specific conditions and not for staff convenience or discipline, and that residents or their representatives have the right to refuse such treatment. Despite these requirements, the necessary physician documentation supporting the use of antipsychotic medication for this resident was not present.
Failure to Complete Significant Change MDS and CAA for Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment and the associated Care Area Assessment (CAA) for a resident who was admitted to hospice services. The resident, who had diagnoses of congestive heart failure, diabetes mellitus, and gastroesophageal reflux, was admitted to hospice, but the required Significant Change MDS was not completed within the mandated timeframe. Additionally, the CAA was not completed within 14 days after the initiation of the Significant Change MDS. The resident's electronic medical record did not contain an order for hospice admission, although an order was present on the hospice provider's certification form. Interviews with facility staff revealed that the nurse responsible for completing the MDS was behind due to providing direct care to residents. Another staff member indicated that both administrative and corporate staff were responsible for ensuring timely MDS completion as required by CMS. The facility was unable to provide a policy regarding the required timing for MDS completion when requested by surveyors.
Failure to Implement Fall Prevention Interventions as Directed by Care Plan
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plan for a resident with multiple medical conditions, including hypertension, diabetes, a history of stroke, pelvic fracture, dysphagia, aphasia, and severe cognitive impairment. The resident was dependent on staff for all activities of daily living except eating, was nonverbal or rarely understood, and used a staff-propelled Broda chair for mobility. The care plan specified that the resident's bed should be kept in the lowest position, a fall mat should be placed next to the bed, and the call light should be within reach. However, during observations, the call light was found out of the resident's reach, and the fall mat was not positioned next to the bed as required, but instead was folded up next to the Broda chair. Interviews with facility staff, including a Certified Medication Aide, a Licensed Nurse, and an Administrative Nurse, confirmed that call lights should be within reach and fall mats should be placed by the bed for residents who require them. The facility's own policy emphasized the importance of maintaining an environment free from accident hazards and prioritizing resident safety and supervision. Despite these policies and care plan directives, the required fall prevention measures were not consistently implemented for this resident.
Failure to Identify and Report Missing AIMS Test During Drug Regimen Review
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported medication irregularities for a resident with multiple diagnoses, including congestive heart failure, diabetes mellitus, and gastroesophageal reflux. The resident had intact cognition and was receiving insulin, a diuretic, and an antidepressant, as documented in the Minimum Data Set (MDS) and Care Area Assessment (CAA). The resident was also prescribed Reglan (Metoclopramide HCl), an antiemetic, to be taken before meals for nausea. Despite this, the Monthly Medication Reviews (MMRs) for August and September did not include documentation or recommendations for an Abnormal Involuntary Movement Scale (AIMS) test, which is necessary to monitor for adverse effects associated with Reglan. Interviews with nursing staff revealed that AIMS testing was not completed for the resident, and the facility was unable to provide evidence of an AIMS test when requested. The administrative nurse acknowledged that the CP should have identified the lack of an AIMS test and that the issue was brought to the attention of both the CP and the corporate office. The facility's policy required the pharmacy to have access to complete medical records and the ability to document in the resident's record, but the deficiency occurred due to the CP's failure to identify and report the missing AIMS test during the monthly drug regimen review.
Failure to Monitor for Adverse Effects of Reglan
Penalty
Summary
The facility failed to ensure appropriate monitoring for adverse effects of the medication Reglan (Metoclopramide HCl) for a resident with diagnoses including congestive heart failure, diabetes mellitus, and gastroesophageal reflux. The resident's medical record documented the use of multiple medications, including insulin, a diuretic, and an antidepressant, and indicated intact cognition. The care plan specified that medications would be administered as ordered and that the resident would be monitored for side effects, with documentation of effectiveness. Despite a physician's order for Reglan to be administered before meals for nausea, the facility was unable to provide evidence of an Abnormal Involuntary Movement Scale (AIMS) test or any other method of monitoring for side effects related to this medication. Staff interviews revealed that AIMS testing was not triggered for this resident because Reglan was not classified as a psychotropic medication in the facility's system. Additionally, the facility could not provide a policy related to monitoring medication side effects when requested.
Failure to Document Hospice Services and Orders in Resident Records
Penalty
Summary
The facility failed to provide a comprehensive description of the medication and equipment supplied by hospice services for a resident with diagnoses of congestive heart failure, diabetes mellitus, and gastroesophageal reflux. The resident was admitted to hospice services, but the Electronic Medical Record (EMR) did not include an order for hospice admission, and the order provided was only found on the hospice provider's certification form. Additionally, the Significant Change Minimum Data Set (MDS) was not completed following the resident's admission to hospice, and the Care Area Assessment (CAA) was not completed within the required 14-day period after the MDS was initiated. The resident's care plan documented the frequency of hospice nurse and aide visits but lacked details regarding the specific equipment and medications provided by hospice. Interviews with facility staff confirmed that care plans and Kardexes should include hospice information, such as equipment, medications, and services, but these details were missing. The facility's policy required written identification of hospice services and a physician's order with diagnosis and prognosis, but these requirements were not met for the resident in question.
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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