Medicalodges Independence
Inspection history, citations, penalties and survey trends for this long-term care facility in Independence, Kansas.
- Location
- 1000 Mulberry, Independence, Kansas 67301
- CMS Provider Number
- 175464
- Inspections on file
- 17
- Latest survey
- August 4, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Medicalodges Independence during CMS and state inspections, most recent first.
Surveyors found unsanitary conditions in the kitchen and kitchenette, including dirty hand-washing sinks, food debris in freezers and refrigerators, rusted and dirty food carts, unsanitizable cookware, and multiple opened and unlabeled food items. Required cleaning schedules were not followed, and dietary staff confirmed these issues.
The facility did not ensure that DNR orders were properly verified and legally executed for multiple residents. For example, a resident with several serious health conditions had a DNR directive in their record that was not signed by a physician, making it invalid. Staff interviews confirmed that both the resident's and physician's signatures were required, but this was not consistently done, despite facility policy requiring complete and regularly reviewed advance directives.
Staff entered resident rooms without proper announcement or waiting for acknowledgment, including while residents were resting or using the phone. Some staff admitted to entering rooms if residents were asleep or on the phone, and administrative staff confirmed that the facility lacked a specific policy on resident rights and privacy.
A resident with multiple cardiac conditions was transferred to the ER for evaluation of chest pain and shortness of breath, but the facility did not provide written notification of the transfer to the resident, her representative, or the LTCO. Staff confirmed that only verbal notification was given and that there was no policy for written notification or LTCO notification for short-term transfers.
A resident with end-stage renal disease, diabetes, and chronic wounds was not properly monitored for antibiotic effectiveness or side effects, and staff failed to hold a cholesterol-lowering medication as ordered during antibiotic therapy. Nursing staff did not document required monitoring, and the facility did not follow its own medication management policy.
A resident with severe cognitive impairment, chronic renal failure, and high risk for pressure injuries did not consistently receive ordered Skin-prep and border foam dressings to the feet and buttocks, as well as heel protector boots. Observations and staff interviews confirmed that required treatments were frequently missed, despite physician orders and facility policy, resulting in the development and lack of proper management of pressure ulcers.
Two residents received medications outside of physician-ordered parameters, including insulin given when blood glucose was below the hold threshold and antihypertensive drugs administered when blood pressure readings were too low. Despite care plans and policies requiring monitoring and adherence to medication parameters, these errors were documented by pharmacy review and medication records, and not all staff received appropriate education on following medication parameters.
Failure to Maintain Sanitary Food Storage and Preparation Conditions
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen and kitchenette regarding the sanitary preparation and storage of food. In the kitchen, the hand-washing sink contained visible dirt and debris, and the adjacent trash can had dried food debris on its exterior. A three-tiered metal cart used for transporting resident snacks was found with rust and a build-up of food on its wheels. The three-doored freezer and refrigerator both had significant food debris on their shelves, and the refrigerator's front vent had dried-on liquid and a long hair stuck to the inside of one door. The rubber seal on one refrigerator door was hanging loosely and all seals had a thick build-up of food debris. Two skillets hanging by the stove were scratched to the point of being unsanitizable, and two plastic trash cans in the kitchen had dried-on food and liquid. In the kitchenette refrigerator outside the kitchen, several food items were found opened, unlabeled, and undated, including a gallon of vanilla ice cream, a frozen shake, cottage cheese, a premade salad, butter, and an open box of pizza rolls in the freezer. The facility's Cleaning Rotation guide required daily cleaning of hand-washing sinks and food carts, weekly cleaning of trash barrels, and monthly cleaning of refrigerators and freezers, but these standards were not met as evidenced by the observations. Dietary staff confirmed the concerns during the survey.
Failure to Verify and Legalize Advance Directives for DNR Orders
Penalty
Summary
The facility failed to ensure that advance directives, specifically Do Not Resuscitate (DNR) orders, were properly verified and legally executed for several residents. For one resident with multiple significant medical conditions, including morbid obesity, chronic kidney disease, atrial fibrillation, hyperkalemia, heart failure, and hypertension, the electronic health record and care plan indicated a DNR status. However, the scanned DNR directive in the resident's record was not signed by a physician, rendering it not legally valid. Interviews with nursing and administrative staff confirmed that a valid DNR requires both the resident's (or legal representative's) and physician's signatures, and that the current document did not meet these requirements. Facility policy required that advance directives be complete, maintained in the clinical record, and reviewed quarterly or upon significant change. Despite these policies, the resident's DNR directive lacked the necessary physician signature, and staff acknowledged this deficiency. The failure to ensure the DNR directive was properly executed and legally valid was identified through observation, record review, and staff interviews, and was not limited to a single resident.
Failure to Ensure Resident Privacy During Room Entry and Telephone Use
Penalty
Summary
Staff failed to protect and promote resident privacy during routine activities, as evidenced by multiple observations and interviews. Housekeeping staff entered a resident's room without knocking or announcing their presence while the resident was resting. In another instance, maintenance staff knocked once but did not wait for a response before entering a resident's room, where the resident was also resting. Additionally, a resident reported that staff would enter and remain in her room while she was on the phone, compromising her privacy during personal calls. Interviews with staff revealed inconsistent practices regarding privacy, with some staff stating they would knock and wait for acknowledgment, while others admitted to entering rooms if residents were asleep or on the phone. Administrative staff confirmed that the expectation was for staff to knock, announce themselves, and await a response before entering, and to avoid entering if a resident was on the phone or sleeping unless previously approved. The facility did not provide a specific policy related to resident rights and privacy, stating only that they followed regulations.
Failure to Provide Required Written Notification for Resident Transfer
Penalty
Summary
The facility failed to provide written notification of transfer to a resident and/or her representative, as well as to the Office of the Long Term Care Ombudsman (LTCO), following the resident's transfer to the emergency room for evaluation of chest pain and shortness of breath. The resident, who had diagnoses including congestive heart failure, paroxysmal atrial fibrillation, atrioventricular block, and a cardiac pacemaker, was documented as having intact memory and was at risk for complications related to her cardiac conditions. The electronic health record and facility documentation did not contain evidence that written notification was given to the resident or her representative regarding the transfer, nor was there evidence of notification to the LTCO. Interviews with administrative staff confirmed that the facility's practice was to provide verbal notification and send transfer packets with the resident, but written notifications were not provided or documented. Staff also stated that the LTCO was not notified for short-term transfers and that there was no facility policy related to written notification of resident transfers or discharges to residents and the LTCO. The lack of written notification and failure to notify the LTCO constituted a deficiency in meeting regulatory requirements for resident rights during transfers.
Failure to Monitor Antibiotic Therapy and Adhere to Medication Orders
Penalty
Summary
The facility failed to provide appropriate care and monitoring for a resident with end-stage renal disease, diabetes mellitus, and multiple chronic wounds who was prescribed antibiotics for wound infection. The resident's care plan directed staff to administer antibiotics as ordered and to monitor for adverse reactions and continued signs and symptoms of infection, as well as for dehydration. However, review of the clinical record and medication administration documentation revealed that staff did not consistently monitor or document the effectiveness and side effects of the antibiotics. Additionally, the resident continued to receive atorvastatin, a cholesterol-lowering medication, despite physician instructions to hold this medication while the resident was taking ciprofloxacin, an antibiotic with potential for adverse interactions. Interviews with nursing staff confirmed that monitoring for antibiotic effectiveness and adverse reactions was not performed or documented as required. Staff were also unaware of the order to hold atorvastatin during antibiotic therapy, and the medication was administered concurrently with ciprofloxacin. The facility's medication management policy required ongoing monitoring for safe and effective medication use, but this was not followed in the resident's case, as evidenced by the lack of documentation and failure to adhere to physician orders.
Failure to Provide Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to provide ordered treatments to prevent pressure ulcers and promote healing for a resident with significant risk factors. The resident had a history of chronic renal failure, significant cognitive decline, and was dependent on staff for mobility and hygiene. Despite being identified as high risk for pressure injuries, with a Braden score indicating severe risk and documented weight loss, the resident developed two facility-acquired pressure injuries on the right foot and a Stage 1 pressure ulcer, as well as a deep tissue injury. Physician orders and the care plan directed staff to apply Skin-prep and border foam dressings to the resident's right foot and buttocks on specific days, and to use heel protector boots every shift. However, multiple observations revealed that these treatments were not consistently provided. On several occasions, the resident was found without the required dressings on both the feet and buttocks. Staff interviews confirmed that the dressings were sometimes not applied as ordered, and one CNA stated that the resident had not had a dressing on the buttock for a long time. Administrative staff acknowledged that the dressings should have been in place and that staff were expected to follow treatment orders to prevent further decline. The facility's own wound prevention and management policy emphasized the importance of identifying residents at risk and implementing interventions to decrease pressure areas and promote healing, but these protocols were not followed for this resident.
Failure to Administer Medications Within Ordered Parameters
Penalty
Summary
The facility failed to ensure that medications were administered within physician-ordered parameters for two residents, resulting in a deficiency related to unnecessary drug use. One resident with diabetes mellitus, who was cognitively intact and on a therapeutic diet, had a physician's order for fast-acting insulin to be held if blood sugar was less than 100 mg/dL. Despite this, the resident received insulin on multiple occasions when blood sugar readings were below the ordered threshold, as documented by both the consultant pharmacist and the Medication Administration Record. There was also a lack of documentation on one occasion regarding whether the medication was administered or if blood sugar was checked. Another resident with a history of stroke, hypertension, and sleep apnea had physician's orders for antihypertensive medications (amlodipine and metoprolol) with specific parameters to hold the medications if blood pressure or heart rate fell below certain levels. The resident received these medications on several occasions when blood pressure readings were below the ordered parameters, as identified in both the consultant pharmacist's review and the Medication Administration Record. The care plan for this resident included monitoring for medications with Black Box Warnings and reporting concerns to the physician, but the administration of medications outside of parameters still occurred. Staff interviews confirmed that nurses were expected to follow medication parameters before administration, and that some staff had received training after errors were identified. However, the education was only provided to staff who had been found to administer medications incorrectly, rather than all staff. The facility's Medication Management policy required ongoing monitoring to ensure drug regimens were free from unnecessary drugs and that medications were administered safely and effectively, but this was not consistently followed for the residents involved.
Latest citations in Kansas
Surveyors identified unsanitary food storage and preparation conditions, including food debris in a reach-in freezer, an unknown spilled liquid in a reach-in refrigerator, missing two-inch air gap on an ice machine drain, dirty carts used for clean dishes, and a steamtable shelf with built-up food debris. A dietary staff member acknowledged these areas needed cleaning, and it was determined the facility lacked a cleaning schedule or policy for kitchen cleanliness.
The facility failed to complete and analyze Care Area Assessments (CAAs) for multiple residents after Admission, Annual, and Significant Change MDS assessments triggered areas such as cognition, mood/behavior, functional status, urinary incontinence/indwelling catheter, nutrition, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, and visual function. Instead of documenting individualized analysis of underlying causes and contributing factors, an LPN reported she had stopped writing CAA notes and relied mainly on check-off worksheets and the fact that triggers appeared in the MDS CAA section. No facility policy on CAAs was provided to surveyors, and the CAAs consistently lacked required analytical documentation for residents with diverse and significant clinical needs.
A resident with dementia, severe cognitive impairment, and an indwelling urinary catheter was repeatedly observed sitting in common areas with his catheter drainage bag resting on his lower leg, visibly filled with dark amber urine and lacking a privacy cover, despite a care plan directing staff to cover the drainage bag. CNAs reported that the bag often slid down from the resident’s thigh, that they did not use catheter dignity bags on their hall, and that they simply moved the bag back up when it slid down. An administrative nurse stated she had not considered the use of dignity bags on the memory care unit, even though the facility’s resident rights policy affirms each resident’s right to a dignified existence, privacy, and confidentiality.
Two residents with documented cognitive ability to participate in care planning were not invited to any care plan meetings, and their EMRs lacked evidence of care plan conferences, invitations, or Interdisciplinary Care Conference assessments. Administrative staff stated that invitations should be mailed or hand-delivered and uploaded to the EMR, and that an Interdisciplinary Care Conference note should be completed, but none of this documentation existed for these residents, contrary to facility policy and federal requirements for resident and/or representative participation in care planning.
A resident with C-diff and CHF, newly admitted and with a baseline care plan that did not address call light use, was repeatedly found without access to a call light. Surveyors observed the resident yelling for help with her room door closed and later noted the call light on the floor under the bed and again on the floor while the resident sat in a recliner and stated she wanted to return to bed but could not do so independently. Staff reported using a binder clip to attach the call light to the resident’s clothing because the cord lacked a clip, acknowledged the resident sometimes threw the call light to the floor, and stated that call lights should be kept within residents’ reach. An administrative nurse confirmed the expectation that call lights be accessible at all times and was unsure about the use of a binder clip, and no facility policy on call lights was provided.
Surveyors found that a resident’s bathroom and handwashing area were not maintained in a safe, sanitary, and comfortable condition, including a loose baseboard with black substance behind it, a cracked toilet seat, and an empty, improperly mounted hand soap dispenser. Maintenance staff confirmed these conditions, noted that the soap dispenser was nonfunctional, and reported that although a QR code system existed for reporting maintenance issues, these problems had not been reported. Maintenance staff also stated there were no facility policies for maintenance repair in resident rooms and no policy provided for ensuring a safe, homelike environment.
Multiple residents were affected by inaccurate MDS assessments, including a resident with dementia and an indwelling catheter who was miscoded as always incontinent of urine and independent in ADLs despite staff and EMR documentation showing long-term catheter use and total dependence for dressing and wheelchair positioning. Another resident with a history of stroke was incorrectly coded as having a restraint, even though bed grab bars were used as enablers to assist with repositioning and did not limit voluntary movement. A resident with diabetes and unsteadiness experienced two documented falls that were not captured on the MDS, and another resident with diabetes, depression, CAD, and CKD was actively receiving hospice services per EMR, social services, and staff interviews, yet hospice was not coded on the MDS. The consultant MDS nurse confirmed these were significant coding errors not in accordance with the RAI User’s Manual.
A resident with C. diff and CHF was admitted, and while a baseline care plan documenting contact precautions was created, the resident later reported not knowing what a baseline care plan was. The resident was also found yelling for help with her call light on the floor under the bed. Nursing staff stated that baseline care plans are started on the day of admission and reviewed with residents, but also indicated that residents and families are not given written copies. An administrative nurse claimed a 48-hour interdisciplinary care conference had been completed, yet no corresponding documentation existed in the EMR, and explanations about who was responsible and why it was missing were inconsistent. No facility policy for baseline care plans was provided.
A resident with dementia and severe cognitive impairment was inaccurately assessed and care planned as needing only setup or independent assistance with dressing, despite actually requiring total staff assistance. The EMR lacked clear ADL documentation, and the ADL CAA did not trigger, leading to inaccurate MDS entries and a care plan that did not match the resident’s functional status. Surveyors observed the resident sitting in a wheelchair wearing dirty, food-stained pants and being taken to the dining room without a clothing change, with the soiled pants not changed until later when two CNAs provided total assistance. Staff, including CNAs, an LN, and an administrative nurse, acknowledged that the resident needed total help with dressing and should always be in clean clothing, revealing a failure to provide appropriate ADL support and maintain clean attire.
A resident with dementia and severe cognitive impairment was transported multiple times in a wheelchair without staff ensuring that his feet remained safely on the foot pedals. Although assessments inaccurately documented that he was independent with walking using a walker and/or wheelchair, his care plan did not instruct staff on proper use of wheelchair foot pedals. During observed transports by CNAs, the resident’s shoed feet repeatedly fell off the pedals and skimmed the floor between them. Staff acknowledged that his feet did not stay on the pedals and that the pedals were not effectively adjusted, and nursing leadership confirmed expectations that feet should remain on the pedals during transport. No wheelchair safety policy was provided.
Unsanitary Kitchen Conditions and Lack of Cleaning Policy
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions when surveyors observed multiple cleanliness and equipment issues in the kitchen. During an initial kitchen tour on 04/27/26 at 08:57 AM, the three-door reach-in freezer was found with food debris on the bottom shelf, and the three-door reach-in refrigerator had an unknown spilled liquid on the bottom shelf. The drain to the ice machine did not have the required two-inch air gap. Two black two-tiered plastic carts used to store clean dishes had food debris on the bottom tier, and the bottom shelf of the steamtable, which was used to store plate covers, had a buildup of food debris. On 04/28/26 at 01:57 PM, a dietary staff member confirmed these areas required cleaning, and it was identified that the facility did not have a cleaning schedule or a policy regarding kitchen cleanliness. No specific residents, medical histories, or clinical conditions were mentioned in the report in relation to this deficiency.
Failure to Complete and Analyze Care Area Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive Care Area Assessments (CAAs) with analysis of underlying causes, contributing factors, and risk factors for multiple residents following MDS assessments. Record review showed that numerous residents had Admission, Annual, or Significant Change MDS assessments that triggered CAAs in areas such as mood/behavior, cognitive loss/dementia, functional abilities, communication, urinary incontinence/indwelling catheter, nutritional status, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, visual function, and psychosocial well-being. For each of these triggered areas, the corresponding CAAs lacked analysis of the findings. This pattern was identified for residents with a wide range of clinical issues, including dementia, incontinence, falls, pressure ulcers, nutritional concerns, psychotropic medication use, pain, and functional decline. During an interview, a licensed nurse reported that she had stopped writing CAA notes the previous year after being told to do so by someone she could not identify. She stated that she did not write anything on the triggered CAAs and that, at times, she would document risk concerns only on a main check-off worksheet, relying on the fact that the triggers were already reflected in the MDS CAA section. The facility did not provide a policy regarding CAAs when requested. These findings demonstrate that the facility did not ensure that comprehensive assessments were fully completed as required when residents were first admitted and periodically thereafter.
Failure to Maintain Dignity and Privacy for Resident with Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to a dignified existence by not maintaining privacy for his urinary catheter drainage bag as directed in his care plan. The resident had diagnoses including bladder calculus and dementia, with a BIMS score of one indicating severe cognitive impairment, and was dependent on staff for toileting hygiene with an indwelling urinary catheter and constant urinary incontinence. His care plan, revised 03/23/26, instructed staff to cover his drainage bag with a privacy cover. However, during observations on 04/27/26, the resident was seen sitting in his wheelchair at his room doorway and later in the dining room with his catheter drainage bag resting on his lower left leg, supported by his shoe, containing dark amber urine and visible to visitors and other residents, without a privacy cover. Staff interviews confirmed that the catheter drainage bag frequently slid from the resident’s left thigh down to his lower leg and that staff did not consistently reposition it or use dignity/privacy bags. One CNA stated he had never placed a dignity bag on the resident’s drainage bag, and another CNA reported that staff on their hall did not utilize catheter dignity bags, instead just moving the bag back up when it slid down. An administrative nurse acknowledged she had not considered staff use of dignity bags for urinary catheters on the memory care unit. The facility’s Resident Rights policy, approved 12/2024, stated that each resident has the right to a dignified existence including privacy and confidentiality, which was not followed in this case.
Failure to Involve Cognitively Able Residents in Care Plan Meetings
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were given the opportunity to participate in the development and implementation of their person-centered plans of care. For one resident with a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognition, the electronic medical record showed an admission MDS and a Significant Change MDS, but there was no documentation of any care plan meeting in the prior four months. This resident reported not being invited to any care plan meeting. For a second resident with a BIMS score of 14, indicating intact cognition, the electronic medical record contained an admission MDS and a Quarterly MDS, but there was no documentation of a care plan meeting in the prior two months. This resident also reported not being invited to any care plan meeting. Administrative staff reported that residents and/or family members were supposed to be mailed or hand-delivered invitations to attend care planning meetings and that a copy of the invitation should be uploaded into the EMR. They further stated that an Interdisciplinary Care Conference assessment should be completed in the EMR during the care plan meeting. However, the administrative nurse confirmed that there was no documentation of invitations, Interdisciplinary Care Conference assessments, or completed care plan meetings for the two residents. The facility’s care planning policy stated that social services should attend care plan meetings and that the team presents information to the resident and/or representative about progress toward care plan goals, and referenced federal law requiring resident and/or representative participation in care plan meetings to the extent possible, but this process was not carried out or documented for the two residents identified.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach and to reasonably accommodate the resident’s needs and preferences. The resident had documented diagnoses of C-diff and CHF, and her baseline care plan dated 04/23/26 directed staff to evaluate for changes in level of consciousness but did not include any direction regarding call light use or accessibility. On 04/28/26 at 08:06 AM, surveyors observed the resident’s room door closed while she yelled loudly for help several times. When a licensed nurse entered the room, the resident was lying on her left side in bed, stated she wanted to get up, and reported she could not find her call light. The call light was observed on the floor under her bed. Later that morning, a CNA attached the call light to the resident’s shirt using a black and silver binder clip because the call light cord did not have its own clip. On 04/29/26 at 12:15 PM, the resident was seated in a recliner with the call light again lying on the floor out of her reach; she reported she wanted to go to bed and could not get herself back into bed. Staff interviews revealed that the CNA used the binder clip to keep the call light attached to the resident, and the licensed nurse stated staff should make sure the call light is clipped to the resident’s clothes and reported that the resident would throw her call light on the floor. An administrative nurse stated she expected staff to ensure all residents always have their call lights in reach and was unsure about using a binder clip to hold a call light in place. The facility did not provide a policy regarding call lights.
Failure to Maintain Safe and Sanitary Resident Bathroom Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, functional, sanitary, and comfortable environment in Resident 87’s bathroom and handwashing area. During an environmental tour with Maintenance Staff UU, surveyors observed an approximately four-foot section of loose baseboard to the left of and behind the toilet, with a black substance present on the wall and floor behind the loose baseboard. They also noted an approximately three-inch crack in the toilet seat and an empty hand soap dispenser hanging above the handwashing sink, mounted with exposed lag bolt fasteners. Maintenance Staff UU confirmed these conditions, acknowledged that the soap dispenser did not work, and stated that the toilet seat should be replaced, the bathroom baseboard removed, the black substance tested for mold, and the sheetrock removed and replaced. Further interview with Maintenance Staff UU revealed that the facility had implemented a QR code system for staff and visitors to report maintenance items, but the issues in this resident’s bathroom had not been reported through that system. He also reported that there had been a leak behind the handwashing sink that had flowed into the bathroom area, leading to the sink’s replacement, but he had received no report of the specific deficiencies observed in the bathroom. Additionally, Maintenance Staff UU stated that the facility did not have policies for maintenance repair in residents’ rooms, and the facility did not provide a policy for ensuring a safe, homelike environment.
Inaccurate MDS Coding for ADLs, Restraints, Falls, and Hospice Services
Penalty
Summary
The deficiency involves the facility’s failure to complete accurate Minimum Data Set (MDS) assessments in accordance with the Resident Assessment Instrument (RAI) User’s Manual, resulting in multiple residents’ clinical status not being correctly reflected. For one resident with dementia and severe cognitive impairment, the Significant Change and subsequent Quarterly MDS assessments coded him as always incontinent of bladder and independent with eating and upper body dressing, with use of a walker and wheelchair. However, the electronic medical record showed ongoing indwelling catheter care each shift and no documentation of walker use, wheelchair mobility, or dressing requirements during the review period. Staff interviews revealed that this resident had an indwelling catheter for more than a year, had not walked for several years, and was dependent on staff for all ADLs, including dressing and wheelchair positioning, contradicting the MDS coding. Observations showed the resident slumped in a wheelchair, wearing a hospital gown over clothing, with a visible catheter bag on his lower leg and feet frequently skimming the floor despite foot pedals being present, further indicating dependence and catheter use not accurately captured on the MDS. Another deficiency involved a resident with a history of stroke, hemiplegia, and hemiparesis whose Significant Change MDS coded the use of “other restraint.” During observation, the resident was seen in bed with bilateral grab bars at the head of the bed and her right arm positioned on a pillow. The resident reported using the grab bars to help move and reposition herself in bed. CNAs and administrative nursing staff confirmed that the facility did not use restraints and that the grab bars were used as enablers to assist residents with repositioning and to increase independence. Administrative staff acknowledged that the MDS coding for restraints was inaccurate because the grab bars did not limit the resident’s voluntary movement or access to her body. A further inaccuracy was identified for a resident with diabetes, atrial fibrillation, unsteadiness of feet, and a toe fracture. Both a Significant Change and a Quarterly MDS documented intact cognition, partial/moderate assistance with transfers, no ambulation, and no falls. However, progress notes in the EMR documented two unwitnessed falls during the look-back period, including one where the resident was found on the floor next to the bed with a forehead skin tear and another where the resident was found sitting on a fall mat on the floor with a scratch on the ankle. These documented falls were not reflected on the MDS. In addition, another resident with diabetes, depression, CAD, and chronic kidney disease had a Significant Change MDS that coded no hospice services, while the EMR contained a hospice certification and physician orders initiating hospice services, and social service notes and staff interviews confirmed that hospice services, including bathing by a hospice aide, were being provided during the look-back period. The consultant MDS nurse confirmed that these assessments were inaccurate and not completed in accordance with the RAI User’s Manual, constituting significant errors in coding for urinary status, ADL dependence, restraints, falls, and hospice services. The consultant MDS nurse stated that the resident with the indwelling catheter should have been coded as not rated for urinary continence due to catheter placement rather than as always incontinent, and that his ADL status should not have been coded as independent given his dependence on staff for dressing and wheelchair positioning. For the resident with grab bars, the nurse confirmed that the grab bars were used as enablers and not as restraints, making the restraint coding inaccurate. For the resident with documented falls, the MDS failed to capture falls that occurred within the look-back period, and for the resident receiving hospice services, the MDS did not reflect hospice care that was active during the look-back period. These miscodings met the RAI Manual’s definition of significant error, in which the resident’s overall clinical status is not accurately represented on the assessment and the error has not been corrected by a more recent assessment.
Failure to Provide and Communicate Baseline Care Plan to New Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide a summary of the baseline care plan to a newly admitted resident and to ensure that the baseline care plan process was completed and documented as required. The resident’s EMR documented diagnoses of C. difficile and CHF. The Entry MDS was completed on the admission date, and the admission MDS was noted as in progress with no information available. A baseline care plan dated the day after admission documented contact precautions, including staff use of gowns and masks when changing contaminated linens and proper handling and bagging of soiled linens. However, during an interview several days after admission, the resident reported she did not know what a baseline care plan was, indicating that the plan had not been explained or summarized to her. Further observations and interviews showed additional failures in implementing and communicating the baseline care plan. On one occasion, the resident was heard yelling for help with her room door closed; when a nurse entered, the resident stated she wanted to get up but could not find her call light, which was observed on the floor under the bed. A nurse reported that the baseline care plan was started on the day of admission and that nurses would review it with the resident, but also stated that the charge nurse would not provide a written copy of the baseline care plan to the resident or family. An administrative nurse reported she would review the baseline care plan with the resident and/or family and claimed to have completed a 48-hour interdisciplinary care conference, but there was no opened or completed conference note in the EMR. She gave inconsistent explanations regarding who was responsible and why the conference note was missing. The facility did not provide a policy for baseline care plans.
Failure to Provide Accurate ADL Assessment and Timely Clothing Changes
Penalty
Summary
The facility failed to provide appropriate assistance with activities of daily living (ADLs), specifically dressing and clothing changes, for a resident with severe cognitive impairment. The resident had a diagnosis of dementia and repeated Brief Interview for Mental Status (BIMS) scores of one, indicating severe cognitive impairment. Despite this, both a Significant Change MDS and a Quarterly MDS inaccurately documented that the resident required only setup assistance with lower body dressing. The ADL Care Area Assessment did not trigger, and the resident’s care plan, revised on 03/23/26, inaccurately instructed staff that the resident was independent with dressing. The electronic medical record lacked staff documentation of the resident’s ADL needs, resulting in care instructions that did not reflect the resident’s actual functional status. On the day of observation, the resident was seen sitting in a wheelchair wearing black pants with food crumbs on them in the morning, and later was transported by a CNA to the dining room still wearing the same dirty pants. The pants were not changed until early afternoon, at which time two CNAs provided total assistance to change the dirty pants, and the resident was unable to participate in dressing or undressing. During interviews, the CNAs, a licensed nurse, and an administrative nurse all stated that residents should always be dressed in clean clothing and confirmed that this resident required total staff assistance with dressing. These observations and interviews showed that the resident’s actual need for total assistance with dressing and clothing changes was not accurately reflected in the MDS, care plan, or ADL documentation, and that the facility did not ensure the resident was kept in clean clothing as expected by facility policy for ADL care.
Failure to Maintain Safe Wheelchair Foot Positioning During Resident Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision during wheelchair transport for a resident with dementia. The resident’s EMR documented a diagnosis of dementia and a BIMS score of one on both a Significant Change MDS and a Quarterly MDS, indicating severe cognitive impairment. These MDS assessments inaccurately documented that the resident was independent with walking using a walker and/or wheelchair, and the ADL CAA did not trigger. The resident’s care plan, revised 03/23/26, identified cognitive impairment due to dementia but did not include instructions for staff on the use of wheelchair foot pedals while propelling the resident. On multiple observed occasions, staff propelled the resident in a wheelchair without maintaining his feet safely on the foot pedals. During transport from his room to the dining room, the resident’s left shoed foot fell from the foot pedal and skimmed the floor between the pedals, and later, during transport from the dining room to the shower room, both shoed feet skimmed the floor between the pedals. CNAs reported that the resident’s feet never stayed on the foot pedals and described the pedals as useless because he could not keep his feet on them. A licensed nurse confirmed the resident’s feet did not always remain on the foot pedals when staff propelled him and stated the pedals should be adjusted to better fit his needs. An administrative nurse stated it was the expectation that staff ensure the resident’s feet remained on the foot pedals during transport and that pedals should be lowered if needed. The facility did not provide a policy regarding wheelchair safety.
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