Maple Heights Nursing & Rehabilitative Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hiawatha, Kansas.
- Location
- 302 E Iowa Street, Hiawatha, Kansas 66434
- CMS Provider Number
- 175508
- Inspections on file
- 17
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Maple Heights Nursing & Rehabilitative Center during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia, dysphagia, and upper extremity weakness, who had documented hot liquid safety interventions in place, was served a second cup of coffee in a lidded mug without staff checking the temperature. Shortly after receiving the refill, the resident spilled the coffee in the dining area, and nursing staff found redness and blistering from below the belt line to the groin and inner thighs. Post-incident measurement of the remaining coffee showed a temperature of 151°F, and hospital records documented partial-thickness scald burns to the groin and bilateral thighs after exposure to coffee measured at 157°F. Staff interviews confirmed that dietary staff were expected to check every cup of hot liquid to ensure it was below 135°F, but the dietary worker who refilled the cup could not recall taking the temperature, and another staff member acknowledged the second cup’s temperature had not been checked, leading to the resident’s burn injury.
Surveyors found that the kitchen serving all residents had multiple unsanitary conditions, including greasy and dusty air vents above the stove, missing covers on overhead fluorescent lights, and soiled exhaust hood components. Dietary and maintenance staff confirmed these issues, with some surfaces not cleaned for extended periods and light fixture covers missing for about a year.
A resident with limited mobility, dementia, and a recent hip fracture developed a facility-acquired, unstageable pressure ulcer on the left heel despite being identified as at risk and having a care plan that included pressure redistribution devices and weekly skin assessments. The ulcer developed due to inadequate prevention measures, particularly related to the resident's use of a recliner and wheelchair, where her heel was not consistently protected or off-loaded as required.
A consultant pharmacist did not identify or report that a resident was prescribed risperidone, an antipsychotic, without an approved indication. The resident, diagnosed with dementia and exhibiting behavioral symptoms, received the medication for various reasons, but documentation and monthly reviews lacked justification or risk-benefit analysis. Staff were unaware of a proper diagnosis for the medication, and no irregularity was reported, resulting in the risk of inappropriate psychotropic use.
Surveyors found that two residents' insulin flex pens were either not labeled with open or expiration dates or were not discarded after expiration. Nursing staff confirmed the requirement to label and remove expired medications, but these procedures were not followed, resulting in expired and unlabeled insulin pens remaining in use.
Staff did not adequately clean a resident's carpet and recliner, resulting in persistent stains and a urine odor in the room. The Housekeeping Supervisor and administrative staff confirmed awareness of the issue, and repeated cleaning attempts were unsuccessful in removing the odor, which may have penetrated the carpet pad.
Failure to Monitor Hot Liquid Temperature Resulting in Resident Burns
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision related to hot liquid service, resulting in a cognitively impaired resident sustaining burns from spilled coffee. The resident had diagnoses including generalized muscle weakness, dementia, dysphagia, and a cognitive communication deficit, with MDS assessments documenting progression from moderate to severe cognitive impairment. Care plans and a prior hot liquids safety evaluation identified the need for specific interventions with hot liquids, including use of a cup with a lid, non-spill thermal mug if accepted, clothing protector over the chest and lap, consumption of hot liquids only at the table or with staff supervision, and addition of ice cubes to hot beverages and soups per family request. On the day of the incident, the resident was seated in the dining room for breakfast and requested a second cup of coffee. Dietary staff refilled the resident’s metal coffee cup, added sweetener, placed the lid on the cup, and returned it to the resident without confirming whether the coffee temperature was within the facility’s stated safe range. Shortly thereafter, staff in the serving room heard the resident holler and observed coffee on the floor. A CNA checked on the resident and found coffee on the resident’s lap, began to pat it dry, and requested a nurse to assess the resident. The nurse’s assessment documented erythema from below the belt line to the groin, pain in the groin and bilateral thighs, and blistering on the inner thighs consistent with a burn injury. Following the spill, dietary staff measured the remaining coffee in the resident’s cup and recorded a temperature of 151°F. An Emergency Department note documented that the resident had eaten breakfast, spilled coffee in her lap, and was later found during showering to have significant firmness and peeling skin in the lap area. The burn center admission note documented partial thickness scald burns to the bilateral thighs and perineum after spilling coffee measured at 157°F in her lap. Facility staff interviews indicated that dietary staff were expected to obtain the temperature of every cup of hot liquid and not serve it if it exceeded 135°F, and that a list existed to direct which residents required lids and other hot liquid interventions. However, the dietary staff member who refilled the second cup of coffee for the resident could not recall obtaining the temperature before serving it, and another dietary staff member acknowledged that the temperature of the second cup had not been checked, leading to the resident being served excessively hot coffee that spilled and caused the documented burn injuries. The facility’s own reportable investigation concluded that the incident was accidental and related to the resident’s health condition, noting that the resident had a lid on her coffee cup per her care plan but dropped the cup and the lid came off. The investigation also documented that the resident had no prior history of dropping her coffee. Despite existing care plan interventions and a hot liquid safety evaluation specifying the need for controlled hot liquid service and supervision, the failure to verify the temperature of the second cup of coffee before serving it, combined with the resident’s cognitive impairment and physical limitations, resulted in the resident being exposed to a hot liquid hazard and sustaining second-degree burns to the inner groin and bilateral thighs.
Unsanitary Kitchen Conditions Affecting Food Safety
Penalty
Summary
Surveyors observed multiple unsanitary conditions in the facility's kitchen, which serves all 44 residents. Specifically, two air vents located above the cooking stove area were covered with a brownish grease and a gray fuzzy substance, blowing directly onto the food preparation and stove cooking areas. Four overhead fluorescent light fixtures above the food preparation area were missing covers, and a return air grill was found to be covered with a brownish gray fuzzy substance. Additionally, six round light bulbs with wire cages in the exhaust hood above the stove top were coated with a brownish gray fuzzy substance, and two fire suppression spigots in the same area were similarly soiled. Dietary and maintenance staff confirmed the presence of these unsanitary conditions, noting that the light fixture covers had been missing for about a year and that the air grill and registers had last been cleaned about a month prior. The facility's policy required regular cleaning and disinfection of environmental surfaces, but these standards were not met, as evidenced by the visible accumulation of dirt and debris on critical kitchen surfaces and equipment.
Failure to Prevent Facility-Acquired Pressure Ulcer on Resident's Heel
Penalty
Summary
The facility failed to initiate effective interventions to prevent the development of a facility-acquired, unstageable pressure ulcer on the left heel of a resident. The resident had a history of a healing left femur fracture, dementia, osteoporosis, and muscle weakness, and was assessed as being at moderate risk for pressure ulcers due to limited mobility, moist skin, and dependence on staff for transfers and activities of daily living. The care plan and physician orders directed the use of a pressure redistribution mattress and pressure relief cushions, as well as weekly skin assessments and reporting of any skin concerns. Despite these interventions, the resident developed a new unstageable pressure ulcer on the left heel, which was not present on admission. Documentation indicated that the resident required extensive assistance with mobility and was chairfast, with the Braden Scale indicating risk for pressure injury. The pressure ulcer was first identified by staff, who noted the area of concern and subsequently added heel protector boots and off-loading interventions. However, it was determined that the ulcer likely developed due to the resident resting her heel on the footrest of her recliner, which was not adequately addressed in the initial care plan or interventions. Observations confirmed that the resident continued to be at risk, as her heel was seen slipping between the metal footrest pedals of her wheelchair, even after the pressure relieving boot was applied. The facility's policy required comprehensive assessment and identification of risk factors for pressure ulcers, as well as appropriate preventative approaches, but the interventions in place were not sufficient to prevent the development of the pressure ulcer in this case.
Consultant Pharmacist Failed to Identify and Report Unapproved Antipsychotic Use
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported the lack of an approved indication for the use of an antipsychotic medication prescribed to a resident with dementia. The resident's electronic medical record documented diagnoses of dementia without behavioral disturbance, vitamin D deficiency, and hypothyroidism. The resident exhibited severely impaired cognition, required assistance with daily activities, and displayed physical and verbal behaviors, wandering, and rejection of care. Despite these behaviors, the resident was prescribed risperidone, an antipsychotic, for various indications including anxiety, agitation, and later for dementia without behavioral disturbance. The medication orders changed multiple times, but documentation in the medical record and monthly pharmacist reviews from December to March did not include an approved indication or a risk versus benefit analysis for the continued use of risperidone. Interviews with staff revealed that the administrative nurse was unaware of a proper diagnosis supporting the use of risperidone and had not received any irregularity reports from the CP regarding the medication. The facility's pharmacy services policy required pharmaceutical services to meet resident needs and comply with regulations, but the CP did not document or report the irregularity of prescribing risperidone without an approved indication. This failure placed the resident at risk for inappropriate use of psychotropic medication.
Failure to Properly Label and Remove Expired Insulin Pens
Penalty
Summary
Surveyors observed that insulin flex pens for two residents were not properly labeled according to professional standards and facility policy. Specifically, two Lantus insulin flex pens for one resident were found without an open or expiration date, and a Humalog insulin flex pen for another resident was labeled with an open date but had not been discarded after its expiration date had passed. These observations were made during a review of the treatment carts in two facility halls. Administrative staff confirmed that nursing staff are responsible for labeling insulin pens with both the date opened and the expiration date, and for discarding expired pens. The facility's policy requires all drugs and biologicals to be labeled with expiration dates and stored properly, with expired medications removed from active stock. The failure to follow these procedures resulted in the presence of expired and unlabeled insulin pens in active use areas.
Failure to Maintain Sanitary Resident Room Environment
Penalty
Summary
Staff failed to maintain a safe and sanitary environment for a resident by not adequately cleaning the carpet and recliner in the resident's room. Observations revealed a black stain on the carpet in front of the recliner, a red stain on the left arm of the recliner, and a yellow stain on the left arm cover. Both the room and the recliner had a noticeable urine odor. The Housekeeping Supervisor confirmed the presence of the urine odor and stated that repeated cleaning attempts had not removed the smell, suggesting the odor may have penetrated the carpet pad. Administrative staff acknowledged awareness of the urine odor and stains, noting that the carpet stain was partially due to a previous paint spill when the resident was able to do crafts. The facility's policy required cleaning and disinfection of environmental surfaces according to CDC and OSHA standards.
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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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