Lawrence Presbyterian Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Lawrence, Kansas.
- Location
- 1429 Kasold Dr, Lawrence, Kansas 66049
- CMS Provider Number
- 175305
- Inspections on file
- 15
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Lawrence Presbyterian Manor during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, depression, and impaired cognition who required staff assistance with ADLs was observed with greasy hair, several days of facial hair growth, and a shirt with dried food stains from a prior meal. Documentation showed the resident needed help with bathing, personal hygiene, and dressing and preferred daily shaving, yet bathing occurred only intermittently and the resident reported not remembering the last bath. Staff interviews confirmed expectations to offer showers, provide bed baths if refused, and change clothing and perform hygiene when residents appeared unclean, but these practices were not carried out for this resident, resulting in a failure to provide needed grooming, shaving, and clean clothing.
The facility failed to complete the required yearly performance evaluations for two CNAs, placing residents at risk for inadequate care. Administrative Nurse D acknowledged the oversight and stated that the evaluations had not been completed despite starting the process in August 2023.
A facility failed to ensure a resident's low air loss mattress was set correctly for their weight, increasing the risk of pressure ulcers. The resident, with multiple diagnoses and dependent on staff for all ADLs, had a mattress set at 210 pounds instead of their actual weight of 140.50 pounds. Staff were unclear about the correct settings and believed hospice was responsible for adjustments.
A facility failed to store a resident's CPAP mask in a sanitary manner, increasing the risk of respiratory infection. The resident, with diagnoses of asthma and obstructive sleep apnea, was observed with her CPAP mask laying unbagged on her bedside table. Staff had differing understandings of proper storage, and the facility lacked a clear policy on respiratory equipment care.
The facility failed to ensure nonpharmacological interventions were attempted and documented before administering an antipsychotic medication to a resident with dementia and other conditions. The resident's care plan included monitoring for side effects of Seroquel, but there was no evidence that nonpharmacological approaches were tried first, contrary to the facility's policy.
The facility failed to ensure a communication process was implemented between the facility and the hospice provider, leading to a risk for missed or delayed services and impaired care for a resident with Alzheimer's, dementia, and other conditions. The hospice communication binder lacked essential documentation, and staff were uncertain about its contents and use.
The facility failed to obtain signed consent or declination for the pneumococcal vaccination Prevnar 20 (PCV20) for three residents. The clinical records lacked evidence of receiving Prevnar 20 or having a signed declination, despite the residents having received other pneumococcal vaccinations. Staff acknowledged the oversight and mentioned that they had recently received new guidance regarding Prevnar 20 but had not yet updated their procedures.
The facility failed to retain the daily posted nursing staffing data for the required 18 months. A review found that the data for December 2023 was missing. The nursing staff scheduler was responsible for this task, but the previous staff member did not retain the forms as required by the facility's policy.
Failure to Assist Resident With Grooming, Shaving, and Clean Clothing
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living (ADLs), specifically grooming, shaving, and maintaining clean clothing for Resident 25. The resident’s EMR documented Alzheimer’s disease, major depressive disorder, hypertension, lack of coordination, and a need for assistance with personal care. A recent MDS showed moderately impaired cognition with a BIMS score of 12 and documented that the resident required setup or cleanup assistance with eating, supervision or touch assistance with oral hygiene, partial/moderate assistance with toileting, and substantial/maximal assistance for bathing. The Care Area Assessment indicated the resident triggered for further review of functional abilities due to cognitive status and increased ADL assistance needs, and the care plan documented dependence on staff for bathing, moderate assistance for personal hygiene and dressing, and a preference to be shaved daily. Despite these identified needs and care plan directives, observations showed the resident sitting in a recliner with greasy hair, three-to-four days of facial hair growth, and a blue shirt with two large food stains that the resident reported were from the previous evening’s supper and had not been changed. The resident stated he liked his face shaved every day and could not remember his last bath. Bathing records showed only sporadic baths and one documented refusal, and staff interviews confirmed that while residents were asked about baths and refusals were reported to nurses, CNAs were expected to change clothing and provide hygiene when residents appeared unclean. Administrative staff stated the expectation that residents receive at least one shower weekly and that CNAs wash and change residents’ clothes and shave them as desired, but the observed condition of the resident and the resident’s statements demonstrated that these expectations were not met, resulting in a failure to ensure assistance with grooming, shaving, and clean clothing in accordance with the resident’s needs and preferences.
Failure to Complete Yearly Performance Evaluations for CNAs
Penalty
Summary
The facility failed to ensure that two of the five Certified Nurse Aides (CNAs) reviewed had the required yearly performance evaluations completed. CNA N, hired on 01/10/14, and CNA M, hired on 05/26/22, did not have their yearly performance evaluations available upon request. Administrative Nurse D acknowledged that he started updating the nursing staff's yearly performance reviews in August 2023 but had not completed the evaluations for CNA M and CNA N. The facility's Staff Competency policy, last reviewed on 10/11/21, mandates that all clinical employees must complete a competency test at their annual review. The lack of completed performance evaluations placed the residents at risk for inadequate care.
Failure to Ensure Correct Mattress Setting for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that a resident's low air loss mattress was set at the appropriate setting for the resident's weight, who was prone to pressure-related injury. The resident had multiple diagnoses, including dementia, Parkinson's disease, and hypertension, and was dependent on staff for all activities of daily living. The resident's care plan documented the need for a low air loss mattress and regular checks for redness and application of barrier cream. However, the care plan did not specify the correct setting for the mattress, and the mattress was observed to be set at 210 pounds, significantly higher than the resident's actual weight of 140.50 pounds. Licensed nurses and administrative staff were unsure about the correct settings and believed that the hospice was responsible for adjusting the mattress settings. The facility's Skin Integrity policy required nursing staff to evaluate skin integrity, implement preventative measures, and treat skin breakdown. Despite this policy, the facility did not ensure that the low air loss mattress was set correctly, placing the resident at increased risk for the development of pressure ulcers. Interviews with staff revealed a lack of clarity and responsibility regarding the adjustment of mattress settings, indicating a gap in the facility's procedures and communication regarding pressure ulcer prevention and care.
Improper Storage of CPAP Mask
Penalty
Summary
The facility failed to ensure that a resident's CPAP mask was stored in a sanitary manner, which increased the risk of respiratory infection. The resident, who had diagnoses of asthma, pulmonary nodule, and obstructive sleep apnea, was observed on multiple occasions with her CPAP mask laying directly on her bedside table unbagged. Despite having intact cognition and requiring extensive assistance with activities of daily living, the resident's CPAP mask was not stored properly when not in use. This was confirmed through observations on two separate days and interviews with staff members who acknowledged the mask should be bagged or stored in a container with a cleaning solution. The facility did not have a policy related to the care of respiratory equipment, and staff members had differing understandings of how the CPAP mask should be stored. A Certified Nurse Aide believed the mask should be stored in a plastic bag, while a Licensed Nurse stated the resident's daughter was responsible for cleaning and replacing the mask. An Administrative Nurse indicated that the nursing staff should clean the mask and store it in a container. The lack of a clear policy and consistent practice led to the deficient practice of improper storage of the CPAP mask, placing the resident at an increased risk of developing a respiratory infection.
Failure to Attempt Nonpharmacological Interventions Before Administering Antipsychotic Medication
Penalty
Summary
The facility failed to ensure nonpharmacological interventions were attempted and documented prior to the administration of an antipsychotic medication for Resident 2, who had a diagnosis of dementia, Parkinson's disease with Lewy bodies, neurocognitive disorder, psychotic disorder, and hypertension. The resident's electronic medical record lacked documentation or evidence of nonpharmacological symptom management interventions that were implemented and failed before starting Seroquel. The care plan for Resident 2 included monitoring for potential side effects of Seroquel, but there was no evidence that nonpharmacological approaches were tried first. Licensed Nurse G stated that antipsychotic medications were acceptable for residents with a dementia diagnosis and that nonpharmacological interventions would be tried first if possible. Administrative Nurse D also acknowledged that a nonpharmacological approach would be best but noted that residents often came into the facility already on antipsychotic medications. The facility's policy on psychotropic medication use emphasized that such medications should not be used unless necessary to treat medical symptoms and that gradual dose reductions and behavioral interventions should be attempted unless clinically contraindicated. Despite this policy, the facility did not document attempts at nonpharmacological interventions for Resident 2 before administering Seroquel.
Failure to Implement Communication Process with Hospice Provider
Penalty
Summary
The facility failed to ensure a communication process was implemented between the facility and the hospice provider, which included how the communication would be documented. This deficiency was identified during a review of a resident's (R32) care. R32 had diagnoses of Alzheimer's disease, dementia, hearing loss, anxiety, and dysphagia, and was dependent on two staff assistants for all activities of daily living. The resident's care plan documented that the facility would coordinate care and services with the hospice provider, including weekly nurse visits and hospice aide visits for various care needs. However, the hospice communication binder lacked the plan of care for R32 and the physician-signed terminal diagnosis for admission to hospice, with the last documentation of hospice care dated 05/02/24. Interviews with staff revealed uncertainty about the contents and use of the hospice binders, and the facility was unable to provide a policy related to hospice services. The deficiency created a risk for missed or delayed services and impaired care for R32. The facility's failure to implement a clear communication process and document the necessary information in the hospice binder led to this issue. Staff interviews indicated that hospice information was kept in binders, but there was confusion about what to look for and where to find specific care plans. The administrative nurse confirmed that the facility collaborated with hospice through care plans, but R32's care plan had been scanned into the medical records instead of being placed in the hospice binder. The lack of a documented communication process between the facility and the hospice provider contributed to the deficiency.
Failure to Obtain Consent or Declination for Prevnar 20 Vaccination
Penalty
Summary
The facility failed to obtain signed consent or declination for the pneumococcal vaccination Prevnar 20 (PCV20) for three residents. Specifically, the clinical records of these residents lacked evidence of receiving Prevnar 20 or having a signed declination for the vaccination. This deficiency was identified during a review of the clinical records and interviews with the facility staff. The residents involved had previously received other pneumococcal vaccinations (Prevnar 13 and Pneumovax 23) but not the Prevnar 20, which is now recommended as per the latest guidance. The facility staff, including licensed nurses and administrative nurses, acknowledged the oversight and mentioned that they had recently received new guidance regarding the importance of Prevnar 20. However, the facility's existing policy on immunizations, last revised in January 2022, did not reflect this new guidance. The staff stated that they had started working on updating their procedures to include Prevnar 20 but had not yet completed the process. This lapse in updating and implementing the new immunization guidance led to the failure in obtaining the necessary consents or declinations for the affected residents.
Failure to Retain Daily Nursing Staffing Data
Penalty
Summary
The facility failed to retain the daily posted nursing staffing data for the required 18 months. The facility identified a census of 35 residents. Upon review, it was found that the daily posted nursing staffing data for December 2023 (31 days) was missing. An interview with Administrative Nurse D revealed that the nursing staff scheduler was responsible for ensuring the retention of these records. However, the previous staff member who was responsible for maintaining the posted nursing staff hours had not retained the forms as required. The facility's policy, last reviewed on 10/11/21, stated that the Daily Nurse Staffing Form should be maintained for a minimum of 18 months and filed in the business office. The failure to retain these records was a violation of this 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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