Life Care Center Of Kansas City
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Kansas.
- Location
- 3231 N 61st Street, Kansas City, Kansas 66104
- CMS Provider Number
- 175281
- Inspections on file
- 17
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Life Care Center Of Kansas City during CMS and state inspections, most recent first.
Surveyors identified unsanitary conditions in the kitchen, including a sticky floor, overflowing and uncovered trash bins near the stove, and improperly stored food items that were unlabeled, undated, or left open. Dietary staff acknowledged these practices were not in line with facility policy, which requires proper labeling, dating, and sanitation.
The facility did not implement or document the core elements of an antibiotic stewardship program, as shown by missing and inconsistent tracking of infections and antibiotic use, and a lack of evidence for monitoring infection outbreaks. The Infection Preventionist could not confirm whether previous staff had tracked antibiotic administration or infection clusters, despite facility policy requiring such oversight.
The facility did not secure pressurized oxygen tanks in a locked area, leaving them accessible to cognitively impaired, mobile residents. Additionally, after a resident with severe cognitive impairment and a history of falls was moved to a new room, required fall prevention interventions such as non-skid tape and signage were not in place, contrary to the care plan and facility policy.
A bottle of ocular vitamins was found left unsecured on the counter at the nurse's station, contrary to facility policy requiring all medications to be locked. A licensed nurse later secured the medication, and both nursing staff confirmed that medications must be locked and out of resident reach at all times.
Two residents with significant cognitive and physical impairments were not provided with appropriate assistive device use and communication access. One was pushed in a wheelchair without foot pedals in use, contrary to care plan and policy, while another had her call light left out of reach, preventing her from communicating needs. Staff interviews confirmed these actions were not in line with facility expectations.
A resident's protected health information (PHI) was left visible on an unattended nursing cart across from the nurse's station. Staff interviews confirmed that computers should be locked when not attended to protect PHI, and facility policy requires resident privacy to be maintained.
The facility did not provide complete discharge summaries for two residents, omitting required recapitulations of their stays and failing to consistently provide written notifications about bed-hold policies to residents or their representatives at the time of transfer. Staff interviews and record reviews confirmed that documentation and notifications were incomplete or missing, contrary to facility policy.
A resident who was dependent on staff for all ADLs and received tube feeding was not provided with required mouth care, as observed by the presence of a thick yellow substance on her lips and in her mouth. Staff interviews revealed that while all nursing staff were responsible for resident hygiene, there was no documentation or clear accountability for providing oral care to residents with internal feedings, resulting in a failure to follow the care plan and facility policy.
A resident with multiple risk factors for pressure ulcers, including impaired mobility and cognition, was not provided with prescribed pressure-reducing boots while in bed, despite physician orders and care plan directives. Observations confirmed the resident's heels were directly on the mattress, and staff interviews indicated that ensuring the use of such devices was a nursing responsibility documented on the TAR.
A resident with hemiparesis and severe cognitive impairment did not receive prescribed range of motion (ROM) exercises as outlined in the care plan. The restorative aide responsible for these interventions was reassigned to CNA duties due to staffing shortages, resulting in the absence of documented ROM exercises and a failure to follow the facility's restorative nursing policy.
A resident with multiple diagnoses, including heart failure and hypertension, was prescribed Toprol XL but did not receive consistent heart monitoring as required. The Consultant Pharmacist did not identify or report this lack of monitoring in monthly medication reviews, and nursing staff confirmed that such monitoring should have been in place according to facility policy.
A resident with multiple diagnoses, including heart failure and hypertension, was prescribed Toprol XL, but the facility did not consistently document required heart monitoring for over three months. Nursing staff acknowledged the need for monitoring and clarification of orders, and the facility could not provide a policy for medication monitoring.
Several residents were not properly offered or had no documented declination or contraindication for the PCV20 pneumococcal vaccine, despite facility policy requiring this. Nursing staff reported that vaccines are offered at admission and documented if given, but records for some residents lacked evidence that the PCV20 was addressed as required.
A resident with severely impaired cognition and a history of elopement risk exited a facility without staff knowledge, reaching the parking lot. Despite having a WanderGuard, the resident was not adequately supervised, and the incident was not documented. Staff interviews revealed frequent door alarms and an unsecured gate, contributing to the elopement.
The facility failed to accurately complete the MDS for a resident, leading to unidentified care needs. The resident had multiple diagnoses and frequent complaints of tooth pain, which were not properly documented in the MDS assessments. An administrative nurse admitted to not thoroughly reviewing the resident's oral assessment, resulting in incomplete and inaccurate MDS documentation.
A resident with a history of serious medical conditions experienced untreated dental issues and pain due to the facility's failure to follow up on dental assessments and complaints. Despite an oral assessment indicating probable extensive decay and moderate inflammation, the resident's care plan lacked dental care interventions, and staff were unaware of the resident's pain and the emergency nature of a scheduled dental appointment.
Sanitary Violations in Kitchen Food Storage and Waste Management
Penalty
Summary
Surveyors observed multiple sanitary violations in the facility's kitchen, including a sticky floor, overflowing and uncovered trash bins next to the stove, and improper food storage practices. Specifically, food items such as fish wrapped in plastic wrap were found in the freezer without labels or dates, and other items like a bottle of pink Minute Maid lemonade, a tub of ice cream, and a bag of cookie dough were opened and undated. Dietary staff confirmed that all foods should be labeled and dated, the kitchen floor should be clean, and trash bins should not be overflowing or uncovered. The facility's Food Safety policy requires food to be stored and maintained in a clean, safe, and sanitary manner in accordance with federal, state, and local guidelines.
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 from August 2024 through July 2025 revealed a lack of evidence for tracking and identifying possible infection outbreaks, as well as inconsistent identification of infections and antibiotic administration. The facility was unable to provide documentation of consistent infection control surveillance for the period from August 2024 through March 2025. During an interview, the current Infection Preventionist, who started in April 2025, was unable to confirm whether the previous Infection Preventionist had tracked antibiotic administration or monitored clusters of infections or organisms. The facility's antibiotic stewardship policy stated that the program should promote appropriate antibiotic use and include a monitoring system, but there was no evidence that these practices were being followed.
Failure to Secure Oxygen Tanks and Implement Fall Interventions
Penalty
Summary
The facility failed to secure 44 full E-pressurized medical oxygen tanks in a locked area, leaving them accessible in an unlocked storage room despite the presence of eight cognitively impaired, independently mobile residents. Multiple inspections over several days found the oxygen storage room door with a keypad that did not lock when shut, and staff interviews revealed confusion about whether the room should be locked. Facility policy required oxygen to be stored safely, but this was not followed, as confirmed by both direct observation and staff statements. Additionally, the facility did not ensure that fall prevention interventions for a resident with severe cognitive impairment, muscle weakness, and a history of falls were in place after she was moved to a new room. The resident's care plan required non-skid traction tape and signage to be present in her room, but an inspection found these interventions missing. Staff interviews confirmed that these fall interventions should have been transferred to the new room, and facility policy required staff to ensure interventions were implemented after a room change.
Unsecured Medication at Nurse's Station
Penalty
Summary
A bottle of ocular vitamins dated 07/07/25 was found unsecured on the counter at the nurse's station during an inspection of the 200 Hall. The bottle was labeled with a warning to keep out of reach of children and included instructions for accidental overdose. The medication was not locked in the medication cart as required by facility policy. A licensed nurse subsequently secured the vitamins after the observation. Both a licensed nurse and an administrative nurse confirmed that medications are required to be locked at all times and out of resident reach, in accordance with the facility's Medication Access and Storage policy revised in 09/2024.
Failure to Ensure Proper Use of Assistive Devices and Call Light Accessibility
Penalty
Summary
The facility failed to ensure proper use of assistive devices and communication tools for two residents, resulting in deficiencies related to accident prevention and resident safety. One resident, who had diagnoses including cognitive communication deficit, dementia, muscle weakness, and a history of falls, was observed being pushed in a wheelchair without the use of foot pedals. The resident's care plan and facility policy required the use of foot pedals to prevent feet from dragging and reduce fall risk, but staff did not follow this protocol. Staff interviews confirmed that the expectation was to use foot pedals when transporting residents in wheelchairs. Another resident, with severe cognitive impairment, Parkinson's disease, muscle weakness, and total dependence on staff for activities of daily living, was found with her call light out of reach on the floor. The care plan for this resident required that the call light be kept within reach at all times to allow communication of needs. Staff interviews and facility policy confirmed that call lights should be accessible to residents during each encounter, but this was not adhered to, leaving the resident unable to call for assistance.
Failure to Secure Resident PHI on Unattended Nursing Cart
Penalty
Summary
The facility failed to secure protected health information (PHI) for one resident, as evidenced by an unattended nursing cart left across the hallway from the nurse's station with a resident's PHI displayed on it. During a walkthrough, surveyors observed the cart unattended and the PHI visible. Shortly after, a licensed nurse exited a nearby room and locked the computer screen. Interviews with nursing staff and administration confirmed that the expectation was for computer screens to be locked when not attended to protect residents' PHI. A review of the facility's Resident Rights policy indicated that the facility is responsible for ensuring each resident's privacy and educating residents about their rights.
Failure to Provide Complete Discharge Summaries and Bed-Hold Notifications
Penalty
Summary
The facility failed to provide a final summary of the resident's status at discharge for two residents, resulting in incomplete documentation of their care and discharge process. For one resident with multiple complex diagnoses, including malnutrition, cerebral palsy, rectal cancer, muscle weakness, depression, dysphagia, and anemia, the records showed that although the discharge plan indicated a comprehensive summary would be developed, the actual discharge charge summary was undated and lacked a recapitulation of the resident's stay. Nursing notes documented the resident's departure, refusal of medication, and that paperwork was sent with the resident, but did not include a comprehensive summary as required by facility policy. For another resident with diagnoses such as respiratory failure with hypoxia, dyspnea, insomnia, anxiety, and COPD, the records indicated that the resident was transferred to the hospital. Staff interviews revealed that while the bed-hold policy was verbally communicated and sent with the resident, written notification to the resident's legal representative was not consistently provided at the time of transfer. The facility's policy required that written information about the bed-hold policy be given upon admission and upon transfer, but this was not always documented as completed. Facility policies specified that both nursing and social services staff are responsible for developing a discharge summary that recapitulates the resident's stay and status at discharge to ensure continuity of care. However, in these cases, the required documentation was either incomplete or missing, and written notifications regarding bed-hold policies were not always provided as required. These deficiencies were confirmed through record review and staff interviews.
Failure to Provide Required Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary oral care for a resident who was dependent on staff for all activities of daily living and required tube feeding. The resident had multiple diagnoses, including hypothyroidism, anxiety, major depressive disorder, muscle weakness, Parkinson's disease, and hypoxia, and was documented as having severely impaired cognition and being rarely or never understood. The care plan specified that mouth care was to be provided at least daily due to oral/dental health problems, including inflamed gums, and that the resident was nothing by mouth (NPO) and received continuous tube feeding. During observation, the resident was found in bed with a thick yellow substance on her lips and in her mouth, indicating that mouth care had not been performed as required. Interviews with staff revealed a lack of clear documentation and accountability regarding the provision of mouth care for residents with internal feedings. The licensed nurse acknowledged that cleaning of the mouth for residents with internal feedings was not documented, although staff were aware it should be done at least every shift. Certified nurse aides and administrative nursing staff stated that it was the responsibility of all nursing staff to ensure residents remained clean, but there was no evidence that mouth care had been provided for this resident as directed by the care plan and facility policy.
Failure to Implement Pressure-Reducing Measures for High-Risk Resident
Penalty
Summary
The facility failed to ensure that pressure-reducing measures were implemented for a resident with significant risk factors for pressure ulcer development. The resident had multiple diagnoses, including hypertension, diabetes mellitus, COPD, muscle weakness, communication deficit, hemiparesis following a stroke, and severely impaired cognition. The resident was identified as being at high risk for pressure ulcers, with a Braden Scale score of 12, and had a history of pressure injury. Physician orders and the care plan specified the use of bilateral boots to be worn even while in bed, with removal every shift for skin checks, and the application of skin prep to the heels. Despite these orders, observations showed that the resident's heels were directly on the mattress without the prescribed boots in place. Interviews with nursing staff and review of facility policy confirmed that ensuring the application of pressure-reducing boots was a nursing responsibility, documented on the Treatment Administration Record (TAR), and could be delegated to CNAs with follow-through required by the nurse. The facility's policy outlined procedures for managing skin integrity and preventing pressure ulcers. However, the lack of adherence to these procedures and physician orders resulted in the resident being left without the necessary pressure-reducing devices, placing them at increased risk for pressure ulcer development.
Failure to Provide Prescribed ROM Exercises Due to Staffing Issues
Penalty
Summary
A deficiency was identified when a resident with a history of cerebral infarction, hemiparesis affecting the left side, muscle weakness, and severely impaired cognition did not receive prescribed range of motion (ROM) exercises as documented in their care plan. The care plan specified that nursing and restorative aides were to perform active ROM to the resident's bilateral lower extremities for 20 minutes, and staff were to observe and report any immobility or contracture formation. However, review of the resident's electronic medical record (EMR) showed no documentation that ROM exercises were performed, nor were there any recorded refusals by the resident. Interviews with facility staff revealed that the restorative aide, who was responsible for carrying out these exercises, had been reassigned to regular CNA duties due to understaffing and was unable to perform restorative duties during that period. The facility's restorative nursing policy required proactive identification, care planning, and monitoring of residents' needs, as well as training for nursing assistants in restorative techniques. Despite these requirements, the resident did not receive the necessary ROM interventions, resulting in a failure to provide appropriate care to maintain or improve mobility and prevent contractures.
Failure to Identify and Report Irregularities in Antihypertensive Medication Monitoring
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities related to the monitoring of antihypertensive medication for a resident. The resident had diagnoses including adult failure to thrive, cognitive communication deficit, congestive heart failure, and hypertension, and required substantial to maximum assistance with activities of daily living. The resident was prescribed Toprol XL, an antihypertensive medication, but a review of the Medication Administration Record (MAR), Treatment Administration Record (TAR), and electronic medical record over a period of 111 days showed a lack of consistent heart monitoring associated with this medication. Additionally, the monthly medication reviews from August 2024 to July 2025 did not include documented recommendations for heart monitoring or instructions for hold parameters and physician notification related to the antihypertensive medication. Interviews with nursing staff confirmed that monitoring should occur for antihypertensive medications and that the CP is expected to identify any lack of appropriate monitoring. The facility's policy on Pharmacy Services and Medication Regimen Review requires oversight by a licensed pharmacist to maintain residents' well-being and prevent adverse medication consequences, but this oversight was not demonstrated in the case of the resident receiving Toprol XL.
Failure to Monitor Antihypertensive Medication as Recommended
Penalty
Summary
The facility failed to follow the pharmacist's recommendation for monitoring antihypertensive medication for a resident diagnosed with adult failure to thrive, cognitive communication deficit, congestive heart failure, and hypertension. The resident's medical record showed an order for Toprol XL, an antihypertensive medication, but there was no consistent documentation of heart monitoring in the Medication Administration Record, Treatment Administration Record, or electronic medical record over a period of 111 days. The care plan indicated that staff would administer medications as ordered, but did not address the lack of monitoring for the antihypertensive medication. Interviews with nursing staff confirmed that monitoring should occur when administering antihypertensive medications, and that clarification should be sought if physician orders lack specific parameters. The administrative nurse also acknowledged that the care plan should identify the need for correct medication monitoring. The facility was unable to provide a policy related to medication monitoring, further demonstrating the lack of appropriate oversight for residents receiving antihypertensive therapy.
Failure to Document and Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer or obtain informed declinations or physician-documented contraindications for the Pneumococcal Conjugate Vaccine (PCV20) and pneumococcal vaccination for several residents. Specifically, record reviews showed that while the Pneumococcal Polysaccharide Vaccine (PPSV23) was offered and declined for some residents, there was no documentation that the PCV20 was offered, declined, or previously administered, nor was there a physician-documented contraindication. This lack of documentation was noted for multiple residents in the sample reviewed. Interviews with nursing staff revealed that vaccinations were typically offered at admission, and if consented, ordered from the pharmacy and documented in the electronic medical record. However, the records for certain residents did not reflect that the PCV20 vaccine was addressed according to policy. The facility's own policy required that each resident be offered pneumococcal immunization unless medically contraindicated or already immunized, with appropriate documentation in the medical record, but this was not consistently followed.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and appropriate interventions for a resident, identified as R1, who exited the building without staff knowledge. R1 had a history of attempting to leave the facility unattended and was identified as an elopement risk due to impaired safety awareness. Despite having a WanderGuard in place, R1 managed to exit the facility and was found outside in the courtyard and later in the back parking lot. The facility's records lacked documentation of this elopement incident, indicating a failure in monitoring and recording the resident's movements and behaviors. R1's medical history included diagnoses of metabolic encephalopathy, muscle weakness, gait abnormalities, and severely impaired cognition, as indicated by a BIMS score of six. The resident required supervision or touch assistance for mobility and had a care plan that included interventions for safe wandering and monitoring of the WanderGuard. However, staff failed to adequately supervise R1, as evidenced by the resident's ability to exit the building and reach the parking lot without staff intervention. Interviews with staff revealed that door alarms were frequently triggered, and the gate leading from the courtyard to the parking lot lacked a locking mechanism, allowing easy access to the outside. Staff members, including a Licensed Nurse and a Certified Medication Aide, were aware of the incident but did not take immediate action to prevent R1 from leaving the facility. The facility's elopement policy required staff to assess the resident's condition and notify the physician and responsible party, but these steps were not documented in R1's case.
Failure to Accurately Complete MDS for Resident
Penalty
Summary
The facility failed to accurately and thoroughly complete the Minimum Data Sets (MDS) for a resident, identified as R1, which placed the resident at risk for unidentified care needs. R1's Electronic Medical Record (EMR) documented several diagnoses, including traumatic subdural hemorrhage, respiratory failure, convulsions, and depression. Despite these conditions, the Annual MDS and subsequent Quarterly MDS assessments did not accurately reflect R1's oral and dental status. Specifically, the Dental Care Area Assessment (CAA) did not trigger, and the Quarterly MDS assessments lacked documentation of a Brief Interview for Mental Status (BIMS) or a staff assessment, and failed to address R1's oral and dental status. An oral assessment by a dental vendor noted probable extensive decay and moderate inflammation, with R1 frequently complaining of tooth pain. However, this information was not incorporated into the MDS assessments. During an interview, R1 confirmed ongoing tooth pain, which was known to the nurses. Administrative Nurse E admitted to not thoroughly reviewing R1's oral assessment in the EMR and acknowledged that the MDS should have been marked as not assessed instead of leaving the area blank or documenting no issues. This oversight in the MDS assessment process led to the deficiency in accurately identifying and addressing R1's care needs.
Failure to Address Resident's Dental Needs
Penalty
Summary
The facility failed to identify and respond to a resident's dental needs, resulting in tooth pain and untreated dental issues. The resident had a history of traumatic subdural hemorrhage, respiratory failure, convulsions, and depression, and was documented as having intact cognition. Despite an oral assessment by a dental vendor indicating probable extensive decay and moderate inflammation, and the resident's complaints of tooth pain, the facility did not follow up on these concerns. The resident's care plan lacked interventions related to dental care and monitoring, and there was no evidence of oral assessments from January 2023 to April 2024. On the day of the dental appointment, the resident was observed in bed with a flat affect and reported ongoing tooth pain. Interviews with staff revealed a lack of awareness of the resident's dental pain and the emergency nature of the dental appointment. The facility's policy stated that it was responsible for assisting residents in obtaining needed dental services, but this was not adhered to in the resident's case, leading to untreated dental issues and pain.
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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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