Meridian Rehabilitation And Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wichita, Kansas.
- Location
- 1555 N Meridian Street, Wichita, Kansas 67203
- CMS Provider Number
- 175274
- Inspections on file
- 30
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Meridian Rehabilitation And Health Care Center during CMS and state inspections, most recent first.
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.
A resident with a diagnosis of constipation and moderately impaired cognition had PRN orders for docusate sodium and Glycolax but went multiple five-day periods without a documented BM, and staff did not administer the ordered PRN bowel medications. Documentation showed the resident was always bowel incontinent and used disposable briefs, and a triggered CAA lacked analysis. A CNA confirmed the resident experienced constipation and that BMs were recorded in the EMR, while a nurse verified the absence of BMs on the noted days and the lack of PRN medication use. An administrative nurse stated nurses were expected to give PRN bowel meds after three or more days without a BM, and no bowel management policy was provided.
A resident with incomplete quadriplegia, limited mobility, and a Braden score indicating risk for pressure ulcers developed multiple in-house acquired pressure injuries, including a worsening left gluteal ulcer and a right heel DTI. Admission and subsequent care plans called for heel offloading, pressure-reducing devices, and repositioning every two hours with two staff, but the EMR Tasks contained no scheduled turn/reposition program, no documented heel offloading tasks, and no evidence that a low air loss mattress was provided or refused. Skin and wound evaluations often omitted turning/repositioning as an additional care, daily notes sometimes reported no new skin distress despite new wounds, and there were no nutritional notes related to the wounds. CNAs reported relying solely on EMR Tasks and not on the care plan or Kardex, while nursing and administrative staff believed care plan entries would auto-generate Tasks, which did not occur. The facility’s own skin policy required preventative measures and scheduled repositioning for at-risk residents, but these were not consistently implemented or documented for this resident, resulting in the cited deficiency in pressure ulcer prevention and care.
The facility failed to ensure proper garbage disposal by not keeping the dumpster lids closed. Surveyors observed open dumpster doors and surrounding litter, including used disposable gloves, used hairnets, and empty restaurant take-out containers. A dietary staff member reported that staff often did not close the dumpster doors after discarding trash, and the facility lacked a policy requiring the dumpster doors to remain closed.
The facility failed to maintain a safe and sanitary laundry environment, as surveyors observed unsealed concrete flooring, a folding table with missing laminate and exposed wood, and clean-linen shelving with bare, unpainted wood surfaces. Additional issues included missing ceiling paint, numerous broken floor tiles in the laundry folding area, and a dryer room ceiling opening covered with cardboard and tape after a vent cover was removed. A housekeeping/maintenance staff member acknowledged these conditions and further reported that the facility lacked policies addressing laundry maintenance and repairs.
The facility failed to submit multiple completed abuse, neglect, exploitation, and misappropriation investigation reports to the State Agency within the required five working days after the incidents were reported. Several investigations were only provided much later during an on-site survey or by e-mail, and at least one investigation was neither submitted within the required timeframe nor available to surveyors. Administrative leadership acknowledged that some investigations were incomplete, contributing to delays, despite facility policy requiring the administrator to thoroughly investigate allegations, complete final reports, and submit them promptly to the appropriate agencies without withholding any reports.
A resident with a history of mental health disorders and exit-seeking behavior was neglected by facility staff, who failed to respond to his suicidal ideation after an elopement incident. Despite known risks, the resident's care plan was not effectively implemented, and there were delays in updating medication orders. The resident was found hanging in his room, highlighting the facility's failure to address his mental health crisis and ensure his safety.
A cognitively impaired resident with a history of elopement risk was left unsupervised in a courtyard, allowing them to climb a fence and leave the facility. The resident, diagnosed with dementia and other conditions, was found two miles away after traversing busy areas. Staff failed to adhere to the care plan and elopement policy, which required supervision and safety devices.
A resident with a history of mental health disorders and suicidal ideation was not provided appropriate care and monitoring by the facility. Despite expressing a desire to leave and making suicidal statements, the staff failed to respond adequately, leading to the resident's tragic death by hanging. The facility's neglect in addressing the resident's mental health needs placed him in immediate jeopardy.
The facility did not conduct annual performance evaluations for its CNAs, as revealed by a review of personnel files. Interviews with administrative staff showed confusion over who was responsible for these evaluations, and the facility lacked a policy to ensure their completion.
The facility failed to ensure CNAs completed the required 12-hour in-service education, as revealed by a review of personnel files for five CNAs employed for over a year. Interviews indicated staff awareness of the issue, with some CNAs lacking access to computer training and the facility lacking a policy for the training requirement.
The facility failed to provide effective behavioral health training for staff, as revealed by a review of CNA personnel files showing incomplete or unstarted training modules. Interviews with staff indicated that not all had access to computer training, and training often involved merely reading and signing off on documents. This deficiency placed all 96 residents at risk of not achieving their highest practicable well-being.
The facility failed to accommodate the bathing preferences of several residents, including those with cognitive impairments and physical disabilities. Residents reported not receiving baths according to their preferences, with care plans lacking specific directions for bathing schedules. Observations revealed inadequate personal hygiene care, and electronic medical records did not document offered or refused bathing opportunities. The facility's bathing schedule was based on room numbers rather than individual preferences, and there was no policy addressing residents' bathing preferences.
The facility failed to maintain a safe and clean environment for 28 residents who smoked, with cigarette butts littering designated smoking areas and a dirty service hallway. A resident expressed concerns about navigating the unclean hallway in a wheelchair, fearing infection due to existing wounds. Additionally, the facility delayed returning a resident's topcoat, which was missing for months, highlighting a lack of policy on personal property management.
The facility failed to accurately complete the MDS for several residents, leading to potential uncommunicated needs for care. Errors included incorrect documentation of medication administration and unreported falls, as confirmed by administrative staff.
The facility failed to update care plans for several residents, leading to deficiencies in addressing bathing preferences and fall prevention. A resident with hemiparesis did not have his bathing preferences documented, resulting in infrequent baths. Another resident with moderate cognitive impairment reported not receiving baths for months, and his care plan lacked directions for hygiene. Additionally, residents at risk for falls did not have appropriate interventions in their care plans. The facility lacked a policy on care plan revision, and staff interviews confirmed that care plans were not updated in a timely manner.
The facility failed to provide adequate personal hygiene care for several residents, including those with cognitive impairments and physical disabilities. Residents reported not receiving regular baths, and observations revealed unkempt appearances and inadequate grooming. Care plans lacked specific instructions for personal hygiene, and the facility did not have policies addressing residents' preferences and scheduling for bathing and grooming.
The facility failed to serve food at safe and appetizing temperatures, with residents reporting meals served late and at incorrect temperatures. Observations revealed meals were served from open carts without insulated covers, and sample trays showed cold foods exceeding recommended temperatures. Staff confirmed the lack of sufficient insulated covers and acknowledged the issue.
The facility failed to provide adequate ventilation in the beauty shop, lacking an outside ventilation system as required. An administrative staff member indicated that certain treatments were not performed, so an exhaust fan was deemed unnecessary. The facility also could not provide a policy on beauty shop ventilation when requested.
A facility failed to notify a resident of the termination of Medicare Part A services by not providing the required Notice of Medicare Non-Coverage (NOMNC) or Advance Beneficiary Notice (ABN). The review found that the necessary CMS forms were not completed, and the facility lacked a policy for issuing these notices, as confirmed by administrative staff.
The facility failed to provide consistent activities for two residents in the Memory Care Unit, both with severely impaired cognition. Observations showed residents seated without engagement, and care plans lacked documented activity preferences. Staff interviews revealed reliance on CNAs and part-time staff, with a full-time activity position vacant for months. The facility lacked a policy on providing activities, leading to a deficiency in resident care.
A facility failed to document post-dialysis vital signs for a resident with end-stage renal disease, as required by their care plan. Despite the policy mandating the review and documentation of post-dialysis information, staff did not consistently record vital signs or check the dialysis site, as evidenced by missing documentation on 62 occasions. Interviews revealed that staff did not follow the facility's dialysis communication policy, compromising the resident's post-dialysis monitoring.
A resident with severely impaired cognition was served pork despite documented preferences against it, due to a new computer system error and lack of a facility policy on food preferences. The oversight was acknowledged by dietary staff and confirmed by administrative staff as unacceptable.
A resident with intact cognition and multiple care needs was not included in quarterly care plan development, despite expressing a desire to participate. The facility failed to document his attendance or invitation to care plan meetings, contrary to its policy requiring resident involvement.
The facility failed to ensure residents' rights to retain and use personal possessions, affecting a resident with a motorized wheelchair and another with a missing coat. The first resident, with multiple health issues, was not informed about her wheelchair's delivery and had to use a manual one, causing exhaustion. The second resident's coat was missing for months after dry cleaning, with staff initially unaware. The facility lacked a policy on personal property rights, contributing to these issues.
A resident with HIV did not receive prescribed medications due to the facility's failure to ensure availability, as documented in the MAR. The resident reported missed doses, and an administrative nurse confirmed that staff did not follow the policy for timely reordering or notify the physician when medications were unavailable.
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.
Failure to Administer PRN Bowel Medications for Constipation
Penalty
Summary
The deficiency involves the facility’s failure to administer ordered PRN bowel medications for a resident with a diagnosis of constipation. The resident’s EMR documented constipation, and PRN orders were in place for docusate sodium 100 mg by mouth every 12 hours and Glycolax 17 g by mouth every 8 hours, both for constipation. The resident’s MDS assessments showed moderately impaired cognition with a BIMS score of 11 and documented that he was always bowel incontinent, with no constipation noted on one assessment. His care plan, revised in late February, addressed episodes of bowel incontinence and directed staff to use disposable briefs, but did not address constipation management. A CAA for urinary incontinence/indwelling catheter triggered but lacked an analysis of findings. The EMR task documentation showed the resident had no recorded bowel movement for two separate five-day periods in April, yet the April MAR contained no documentation that either PRN bowel medication was administered during those times. A CNA reported that the resident did have periods of constipation and that all bowel movements were documented in the EMR. A nurse confirmed that the resident did not have bowel movements on the identified dates and that staff had not administered PRN bowel medications. An administrative nurse stated that the expectation was for nurses to administer PRN medications when a resident had no bowel movement for three or more days. The facility did not provide a bowel management policy.
Failure to Implement and Document Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
The deficiency involves the facility’s failure to prevent the development and promote the healing of pressure ulcers for a resident with incomplete quadriplegia, limited mobility, and muscle weakness. On admission, the resident had intact cognition, required maximal assistance with bed mobility, and was identified as at risk for pressure ulcers with a Braden score of 16. Admission documentation noted an actual skin impairment on the sacrum but did not specify the nature of the impairment or the preventative skin care needed. The admission care plan directed staff to float the resident’s heels in bed and use a pressure-reduction cushion in the chair, and a subsequent care plan instructed repositioning every two hours with two staff assisting. However, the Pressure Ulcer/Injury Care Area Assessment completed later lacked an analysis of findings, and the EMR Tasks section did not contain a scheduled turning and repositioning program. Within days of admission, the resident developed a facility-acquired Stage 2 pressure ulcer on the left gluteal area, later documented as progressing to Stage 3 and then to an unstageable pressure ulcer with increasing measurements. Skin and wound evaluations repeatedly listed preventive measures such as moisture barrier and an air mattress, but the turning and repositioning program was not consistently checked as an additional care. The EMR lacked evidence that a low air loss mattress was provided or that it was offered and declined. There was also no documentation of a turning and repositioning program in the EMR Tasks, and no documentation that the resident refused repositioning, despite staff later reporting that the resident sometimes refused to turn. Daily skilled progress notes on some dates documented no new skin distress even when new skin areas and treatments had been identified in other records. The resident also developed a facility-acquired deep tissue injury (DTI) on the right heel, with orders for skin prep, foam dressing, and C-boots for offloading while in bed. Care plan updates instructed staff to avoid shearing during repositioning, monitor pressure areas, and offload pressure from the heels while in a chair. Despite these written directions, CNAs reported they relied on EMR Tasks to know when to turn and position residents or elevate heels and did not routinely use the care plan or Kardex. Nursing staff reported that only certain administrative nurses could schedule Tasks in the EMR, and both administrative and regional staff believed that care plan entries would automatically generate Tasks, which did not occur for this resident. The EMR lacked nutritional notes related to the wounds, and the facility’s own skin policy required implementation of preventative measures, individualized care planning, and scheduled regular and frequent repositioning for bed- and chair-bound residents, which were not consistently reflected in the resident’s EMR or task documentation. Interviews with CNAs and licensed nursing staff confirmed that frontline staff depended on EMR Tasks to identify residents on turn and reposition programs and to document completion or refusal of these interventions. CNAs stated they did not have access to the care plan or were unaware of the Kardex, and they relied on other staff to inform them of required preventative measures. Administrative nursing staff acknowledged that the resident did not have a turn and reposition program scheduled in the EMR during the stay and that the resident did not have an air mattress, with no documentation of any refusal. Administrative staff also stated it was generally assumed that bedridden residents required turning every two hours, but the turn and reposition program was not available on point-of-care documentation for this resident. The facility’s policy required completion of Braden assessments, initiation of preventative interventions, notification of wound care staff and DON upon pressure injury identification, and scheduling of regular repositioning, but the resident’s records and staff interviews showed gaps in implementing and documenting these measures. The cumulative findings show that the resident, who was at high risk due to quadriplegia and limited mobility, developed multiple in-house acquired pressure injuries, including a left gluteal ulcer that worsened in stage and size and a right heel DTI. The EMR lacked consistent documentation of a turning and repositioning program, heel offloading, use or refusal of a low air loss mattress, and nutritional assessments related to wound care. Staff interviews revealed confusion and incorrect assumptions about how turn and reposition programs and other preventative interventions were communicated and scheduled in the EMR. These actions and inactions, including incomplete assessments, missing task scheduling, lack of documented refusals, and failure to ensure ordered or care-planned interventions were implemented, led to the identified deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing for this resident.
Failure to Maintain Closed Dumpster and Proper Garbage Disposal
Penalty
Summary
The facility failed to dispose of garbage and refuse properly by not ensuring the dumpster lids were kept closed. During an initial kitchen tour, surveyors observed that both doors to the outside dumpster were open, and the surrounding ground was littered with used disposable gloves, used hairnets, empty restaurant take-out containers, and other unidentifiable objects. In a subsequent interview, a dietary staff member stated that staff often did not close the dumpster doors after disposing of trash, despite this being required. Record review further showed that the facility did not have a policy addressing the requirement to keep the dumpster doors closed.
Failure to Maintain Safe and Sanitary Laundry Environment
Penalty
Summary
The facility failed to ensure a safe and sanitary environment in the laundry area, as evidenced by multiple structural and maintenance deficiencies observed during surveyor inspection. On 04/28/2026 at 11:55 AM, surveyors, accompanied by Housekeeping/Maintenance Staff WW, observed unsealed concrete floor surfaces throughout the laundry room, a folding tabletop with missing laminate and exposed wood, and shelving in the clean laundry area with exposed bare wood. Additional findings included missing paint on a ceiling area approximately one foot by two feet, eighteen broken tiles on the laundry floor in the folding area, and a three-foot section of clean linen shelving and upright post with bare wooden shelves and exposed wood, including a second shelf from the bottom corner with missing paint. In the dryer room, the ceiling had a piece of cardboard taped over an opening approximately four inches by eight inches, which Housekeeping/Maintenance Staff UU later explained was due to a vent cover being removed and the opening being covered with cardboard and tape. On 04/29/2026 at 10:26 AM, Housekeeping/Maintenance Staff UU also reported that the facility did not have policies to address laundry maintenance and repairs. No residents or specific patient conditions were mentioned in relation to these findings.
Failure to Submit Completed Abuse/Neglect Investigations to State Agency Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to submit completed abuse/neglect/misappropriation investigation reports to the State Agency (SA) within the required five working days after alleged incidents were reported. The facility had a census of 96 residents, with seven residents reviewed for abuse, neglect, exploitation, and/or misappropriation of resident property. Review of the facility’s notifications to the SA showed multiple incident numbers reported on various dates; however, the corresponding completed investigations were either not submitted within the required timeframe or not submitted at all. For several incidents, the completed investigations were only provided much later during an on-site survey or via e-mail, and for at least one incident, the completed investigation was neither submitted within five working days nor provided to the surveyor during the visit. During an interview on 02/02/26 at 4:00 PM, Administrative Staff A acknowledged that some of the investigations were incomplete, which contributed to the delay in reporting and/or providing the completed investigation reports to the surveyor. Administrative Staff A stated awareness of the required timeframe for submitting completed investigations to the SA and confirmed that the facility’s expectation was for the administrator to complete and submit investigations to the appropriate agencies within that timeframe. The facility’s Abuse, Prevention and Prohibition Policy, dated 11/2025, documented that the administrator would ensure a thorough investigation of allegations, complete the final report, submit it to the required agencies, and maintain the report in a locked file in the administrator’s office, and that no reports would be screened or withheld from appropriate agencies.
Neglect of Resident with Suicidal Ideation
Penalty
Summary
The facility failed to prevent the neglect of a cognitively impaired resident, identified as R53, who had a history of mental health disorders, including dementia, bipolar disorder, and conduct disorder. R53 was known to have episodes of agitation and anxiety, and had a history of exit-seeking behavior. Despite these known risks, the facility staff did not adequately respond to R53's suicidal ideation statements following an elopement incident. After being returned to the facility, R53 expressed a desire to harm himself, including making statements about wanting a gun to shoot himself, but staff did not take immediate action to address these threats. R53's care plan included interventions for monitoring and managing his behaviors, but these were not effectively implemented. The resident was placed on one-hour checks and later on 15-minute checks, but these measures were not consistently maintained. Additionally, there were significant delays in updating R53's medication orders, which were intended to address his mood and behavior issues. The facility's records lacked documentation of progress notes during critical periods, and staff failed to maintain continuous observation of R53, despite his known risk factors and previous elopement. Ultimately, the facility's inaction and failure to respond appropriately to R53's mental health needs and suicidal ideation resulted in a tragic outcome. R53 was found hanging in his room, having used a television cable to harm himself. The facility's neglect in addressing R53's mental health crisis and ensuring his safety placed him in immediate jeopardy, leading to his death.
Removal Plan
- An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting held by interdisciplinary team.
- The Administrator notified the Medical Director.
- The President of Clinical Operations re-educated the Administrator and Director of Nursing on community process for recognizing signs and symptoms of suicidal.
- The Corporate Director of Clinical Reimbursement educated the Administrator, Social Service staff, and Director of Nursing regarding the community process of the social service comprehensive assessment and trauma informed care assessment. Education included intended scheduled, psychosocial care planning.
- Current associates will be re-educated by the community by the Administrator or designee on community. Trauma Informed Care process with specific focus on identification of suicidal symptoms and suicidal ideation, required notifications and immediate actions.
- Social Service comprehensive assessments will be completed upon admission, annually and with significant change. Assessment will be documented in resident medical record.
- Residents identified with need for trauma preventative services will have a trauma informed assessment completed upon admission, annually and with identified significant change in condition. Assessments will be documented in resident medical record. Care plan will be updated as indicated.
- Routine angle rounds will be completed by assigned interdisciplinary team members routinely and will include staff members interviews to validate understanding of resident suicide awareness and notification requirements. Results of the angel rounds will be reported during routine morning stand up meetings. If discrepancies are identified immediate one on one educations will be completed with associate involved.
- During weekly risk review meetings, the interdisciplinary team will review the clinical record of newly admitted residents or residents identified change in condition to validate completion of required social service assessments and or trauma informed care evaluations when indicated. The review will be documented in the resident medical record.
- The Administrator or designee will routinely review sample selected residents to validate compliance of the following: completion of the social service comprehensive assessment as appropriate, completion of trauma informed care assessment as appropriate, psychosocial care plan present when indicated that include resident specific interventions based upon assessment findings; any noted suicidal ideation as indicated.
- Monthly review of completed weekly risk review and angle rounds results and trends will be completed by the Administrator or designee and reported to the QAPI committee and then re-evaluate to determine if further monitoring is indicated.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to a cognitively impaired resident, identified as a high risk for elopement. The resident, who had diagnoses including dementia, bipolar disorder, and conduct disorder, was admitted to the facility in December 2022. Despite being identified as an elopement risk on multiple occasions, the resident was left unsupervised in the courtyard, allowing them to climb a fence and leave the facility. The resident was found approximately two miles away, having traversed busy residential areas and crossed multiple crosswalks and river bridges. The resident's medical records indicated moderately impaired cognition and episodes of agitation and anxiety. The care plan instructed staff to monitor the resident closely and provide redirection if they became restless or agitated. However, on the day of the incident, staff allowed the resident to be outside unsupervised, which led to the elopement. The facility's investigation revealed that staff failed to follow the care plan and elopement policy, which required supervision and the use of safety devices like a Wander Guard bracelet. Interviews with staff indicated a lack of awareness and adherence to the facility's elopement policy. Some staff members were unsure of the resident's elopement history and the removal of the Wander Guard bracelet. The facility's policy required door alarms, personal safety devices, and staff supervision for residents at risk of elopement, but these measures were not effectively implemented, resulting in the resident's unsupervised departure.
Removal Plan
- The Community Interdisciplinary Team completed a review of the community with four additional residents identified as being at risk for elopement and placed in wander guard alarms.
- An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting held by interdisciplinary team.
- The Administrator notified the Medical Director.
- Current clinical associates were re-educated by the Director of Nursing or designee on the Community Elopement policy and Community Elopement Evaluation process. Education included identification of at-risk residents, and courtyard oversight requirements.
- Residents with a new risk for elopement or change in elopement risk will be reviewed by clinical interdisciplinary team during routine clinical huddle to verify elopement risk assessment accuracy, physician notification and preventative interventions in place as indicated. If discrepancies identified, immediate corrective action will be completed, and one on one education completed as indicated.
- Residents identified with a change in elopement risk or who have had an actual elopement attempt will be reviewed during routine risk meeting by clinical interdisciplinary team. Review will be documented in the resident electronic medical record.
- Routine elopement drills scheduled per community policy on varying shifts to confirm staff competency.
- Findings of elopement drills are to be reported to the community Administrator and reviewed at the following morning meeting. If discrepancies are identified immediate correction will be completed and one on one education provided as indicated.
Failure to Address Suicidal Ideation in Resident with Mental Health Disorders
Penalty
Summary
The facility failed to provide appropriate treatment and services to a cognitively impaired resident, identified as R53, who had a history of mental health disorders, including dementia, bipolar disorder, and conduct disorder. R53 exhibited anger related to living in the facility, had a history of exit-seeking behavior, and expressed suicidal ideation. Despite these known risks, the facility staff did not adequately respond to R53's suicidal statements following an elopement incident. On one occasion, R53 eloped from the facility and was found two miles away, after which he was returned to the facility and placed on a WanderGuard bracelet and one-hour checks. R53 continued to express a desire to leave the facility and made statements indicating suicidal thoughts, such as asking for a gun to shoot himself. The staff's response to these statements was insufficient, as they failed to provide immediate and appropriate intervention. The facility's records showed gaps in documentation, and there was a delay in implementing new orders from the psychiatric provider. Despite being placed on one-on-one supervision at times, R53's behaviors and statements were not consistently addressed, leading to a lack of comprehensive care planning and monitoring. Ultimately, the facility's failure to respond to R53's suicidal ideation and manage his mental health needs resulted in a tragic outcome. R53 was found hanging in his room, having used a television cable to commit suicide. The facility's neglect in addressing R53's mental health needs and suicidal ideation placed him in immediate jeopardy, highlighting significant deficiencies in the care provided to him.
Removal Plan
- An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting held by interdisciplinary team.
- The Administrator notified the Medical Director.
- The President of Clinical Operations re-educated the Administrator and Director of Nursing on community process for recognizing signs and symptoms of suicidal.
- The Corporate Director of Clinical Reimbursement educated the Administrator, Social Service staff, and Director of Nursing regarding the community process of the social service comprehensive assessment and trauma informed care assessment. Education included intended scheduled, psychosocial care planning.
- Current associates will be re-educated by the community by the Administrator or designee on Trauma Informed Care process with specific focus on identification of suicidal symptoms and suicidal ideation, required notifications and immediate actions.
- Social Service comprehensive assessments will be completed upon admission, annually and with significant change. Assessment will be documented in resident medical record.
- Residents identified with need for trauma preventative services will have a trauma informed assessment completed upon admission, annually and with identified significant change in condition. Assessments will be documented in resident medical record. Care plan will be updated as indicated.
- Routine angle rounds will be completed by assigned interdisciplinary team members routinely and will include staff members interviews to validate understanding of resident suicide awareness and notification requirements. Results of the angel rounds will be reported during routine morning stand up meetings. If discrepancies are identified immediate one on one educations will be completed with associate involved.
- During weekly risk review meetings, the interdisciplinary team will review the clinical record of newly admitted residents or residents identified change in condition to validate completion of required social service assessments and or trauma informed care evaluations when indicated. The review will be documented in the resident medical record.
- The Administrator or designee will routinely review sample selected residents to validate compliance of the following: completion of the social service comprehensive assessment as appropriate, completion of trauma informed care assessment as appropriate, psychosocial care plan present when indicated that include resident specific interventions based upon assessment findings; any noted suicidal ideation as indicated.
- Monthly review of completed weekly risk review and angle rounds results and trends will be completed by the Administrator or designee and reported to the QAPI committee and then re-evaluate to determine if further monitoring is indicated.
- Residents identified with a change in elopement risk or who have had an actual elopement attempt will be reviewed during routine risk meeting by clinical interdisciplinary team. Review will be documented in the resident electronic medical record.
- Routine elopement drills scheduled per community policy on varying shifts to confirm staff competency.
- Findings of elopement drills are to be reported to the community Administrator and reviewed at the following morning meeting. If discrepancies are identified immediate correction will be completed and one on one education provided as indicated.
Failure to Conduct Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct annual performance evaluations for its certified nursing assistants (CNAs), which are essential to assess their strengths and weaknesses in providing resident care. The review of personnel files for five CNAs revealed that none had received an annual review, despite their varying hire dates ranging from 2019 to 2022. Interviews with administrative staff indicated a lack of clarity regarding responsibility for completing these evaluations, with one staff member believing it was the Director of Nursing's duty, while another thought it was the Administrator's responsibility. Additionally, the facility did not have a policy in place to ensure the completion of these evaluations, leading to the oversight.
Deficiency in CNA In-Service Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an in-service training program to ensure that Certified Nurse Assistants (CNAs) completed the required 12-hour in-service education. This deficiency was identified through a review of personnel files and in-service training records for five CNAs who had been employed at the facility for at least one year. Each of these CNAs, identified as UU, VV, S, PP, and T, lacked the necessary 12 hours of in-service education, with CNA T having received only 0.5 hours. This lack of training placed residents at risk of decreased quality of care. Interviews with facility staff revealed awareness of the deficiency. Administrative Nurse D acknowledged the issue, stating it was a work in progress, and the Director of Nurses had begun monitoring the training. Licensed Nurse L reported that while some staff had access to computer training, not all had login credentials, and training was sometimes conducted through meetings or paper sign-offs. Administrative staff A confirmed that the computer training system was not being used as intended. Additionally, the facility lacked a policy outlining the 12-hour in-service training requirement.
Inadequate Behavioral Health Training for Staff
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all staff, specifically in the area of behavioral health care and services. This deficiency was identified through a review of personnel files and course completion histories of five Certified Nursing Assistants (CNAs). The review revealed that several CNAs had not started or completed required training modules on Alzheimer's Disease and Related Disorders: Behaviors and Behavioral Health, with due dates ranging from 2022 to 2024. The lack of training was acknowledged by the administrative nurse and other staff members, who reported that the training was a work in progress and that not all staff had access to the computer training system. Interviews with staff further highlighted the inadequacy of the training program. A Licensed Nurse reported that while some computer training was available, not all staff had login access, and training often consisted of reading and signing off on a piece of paper rather than receiving actual instruction on handling residents with behavioral issues. Administrative staff also admitted that the computer training was not being utilized as intended, and there was no policy in place regarding the requirements for behavioral training. This lack of an effective training program placed all 96 residents at risk of not reaching their highest practicable well-being.
Failure to Accommodate Resident Bathing Preferences
Penalty
Summary
The facility failed to honor and facilitate resident self-determination by not accommodating the bathing preferences of several residents. Resident 92, who had cognitive intactness and required substantial assistance due to hemiparesis, reported that he was only allowed a bath once a week, despite his preference for at least two baths per week. The facility's shower schedule was based on room numbers rather than individual preferences, and the care plan lacked specific directions regarding his bathing schedule and preferences. The resident's electronic medical record showed he received a bath only three times in the previous 30 days, and there was no documentation of offered bathing opportunities or refusals. Resident 74, with severe cognitive impairment and dependent on staff for daily living activities, also experienced a lack of accommodation for bathing preferences. The care plan directed staff to assist with showering twice weekly, but it did not address specific preferences or schedules. Observations revealed the resident had long, unkempt fingernails and a stale urine odor, indicating inadequate personal hygiene care. The electronic medical record showed the resident received a bath only twice in the previous 30 days, with no documentation of offered or refused bathing opportunities. Resident 73, with moderate cognitive impairment and dependent on staff for personal hygiene, reported not having a bath for months and expressed a preference for a weekly bed bath. The care plan did not specify the type of assistance or bathing schedule, and the resident's electronic medical record lacked documentation of offered or refused bathing opportunities. The resident also reported issues with grooming, as his hair and beard were not trimmed, and his fingernails were unclean. The facility's master schedule for bathing was based on room numbers, not individual preferences, and there was no policy addressing residents' bathing preferences and scheduling.
Deficiencies in Smoking Area Maintenance and Personal Property Management
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for 28 residents who smoked in three designated smoking areas and the service hallway leading to the southeast smoking area. Observations revealed that the smoking areas were not maintained, with cigarette butts littering the ground and broken cigarette disposal towers. The service hallway had missing floor tiles, chipped chair rails, and a buildup of grime, which residents had to navigate to access the smoking area. These conditions were confirmed by both activity and administrative staff, who acknowledged the need for cleaning and repairs. A resident, who was alert and oriented, expressed concerns about the cleanliness and maintenance of the smoking area. She reported having to use her hands to propel her wheelchair through the dirty hallway, fearing infection due to her existing wounds and diabetes. Despite staff supervision during smoke breaks, the smoking areas remained unclean, posing a risk to residents' safety and comfort. Additionally, the facility failed to ensure a resident received his personal property back in a timely manner. The resident's topcoat, which required dry cleaning and button replacement, was missing for a couple of months. Despite the resident's repeated requests to administrative and social service staff, the coat was only returned after the survey, without the buttons replaced. The facility lacked a policy on personal property, contributing to the delay in returning the resident's belongings.
Inaccurate MDS Documentation for Multiple Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for several residents, leading to potential uncommunicated needs for care and services. Resident 28's MDS inaccurately documented the administration of hypoglycemic medication, which was not supported by the electronic medical record or physician's orders. This discrepancy was confirmed by Administrative Nurse E, who acknowledged the error in the MDS assessment. Resident 47's MDS inaccurately recorded the use of hypnotic medication, which was not administered during the assessment period. The resident's care plan and physician's orders did not support the use of hypnotic medication, and this error was also confirmed by Administrative Nurse E. Similarly, Resident 41's MDS failed to capture a documented fall, despite progress notes indicating a fall that resulted in hospitalization. The lack of accurate documentation on the MDS was acknowledged by the administrative staff. Residents 54 and 82 also had inaccuracies in their MDS assessments related to falls. Resident 54 experienced multiple falls that were not documented in the MDS, despite being noted in progress notes and care plans. Resident 82's MDS failed to document a fall with injury, and the Care Area Assessment (CAA) lacked necessary documentation. These inaccuracies were confirmed by Administrative Nurse E, who noted the absence of a facility policy for MDS completion, relying instead on the Resident Assessment Instrument (RAI) manual.
Deficiencies in Care Plan Revisions for Bathing Preferences and Fall Prevention
Penalty
Summary
The facility failed to review and revise care plans for several residents, leading to deficiencies in addressing their bathing preferences and fall prevention needs. Resident 92, who had cognitive intactness and required assistance with bathing due to hemiparesis, reported dissatisfaction with the bathing schedule and frequency, which was not reflected in his care plan. Despite being scheduled for showers twice a week, the electronic medical record showed he only received three baths in the previous month, and there was no documentation of offered or refused bathing opportunities. Social services confirmed multiple grievances from residents about not receiving baths, and staff interviews revealed that residents' preferences should be documented and respected, which was not the case for Resident 92. Resident 73, with moderate cognitive impairment and dependent on staff for activities of daily living, also had a care plan that failed to address his bathing preferences and schedule. He reported not receiving a bath for months and expressed a preference for a weekly bed bath, which was not accommodated. His care plan lacked directions for hygiene and grooming, and the facility's documentation did not reflect offered or refused bathing opportunities. Staff interviews confirmed that residents should receive a minimum of two baths a week, and their preferences should be documented in the care plan, which was not done for Resident 73. Residents 74 and 81 also had care plans that did not reflect their bathing preferences, with Resident 74 receiving only two baths in the previous month and Resident 81's care plan lacking specific days and times for preferred baths. Additionally, Residents 54 and 41, who were at risk for falls, had care plans that did not include necessary interventions to prevent falls. Resident 54 had multiple falls due to tripping on blankets, and Resident 41 had a fall that resulted in hospitalization, yet their care plans were not updated with appropriate interventions. The facility lacked a policy on care plan revision, and staff interviews revealed that care plans were not always revised or updated in a timely manner, contributing to these deficiencies.
Deficiencies in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for several residents, including those with cognitive impairments and physical disabilities. Resident 92, who had a history of spastic hemiplegia and hemiparesis, reported not receiving a bath for over a week, despite his preference for at least two baths per week. The care plan for Resident 92 lacked specific directions regarding his bathing schedule and preferences, and the facility's documentation did not reflect that bathing opportunities were offered or refused. Resident 74, diagnosed with Alzheimer's disease and receiving hospice care, was found with long, jagged fingernails and a stale urine odor, indicating a lack of personal hygiene care. The facility's records showed that Resident 74 received only two baths in the previous 30 days, and there was no documentation of nail care or refusals of offered care. Similarly, Resident 73, who had multiple health issues including diabetes and a chronic ulcer, reported not receiving a bath for months and had long, unkempt hair and nails. The care plan for Resident 73 also lacked specific instructions for personal hygiene care. Resident 81, with end-stage renal disease and diabetes, received inadequate bathing services, with records showing only a few baths over several months. The care plan did not specify the resident's preferences for bathing. Additionally, Resident 82, who had dementia and required assistance with daily living activities, was observed with long facial hair, indicating a lack of grooming care. The facility lacked policies addressing residents' bathing preferences, scheduling, and personal hygiene care, contributing to the deficiencies observed.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to serve food that is palatable and at a safe and appetizing temperature for its residents. During an entrance tour, it was observed that meal trays were being served from open metal carts without insulated covers or closed insulated food service carts. Residents expressed concerns about the food being served at incorrect temperatures, with some reporting that meals were served late and that hot foods were cold while cold foods were warm. Social Service Staff confirmed that residents had complained about food temperatures during Resident Council meetings, and it was noted that the facility had been serving meals in residents' rooms due to COVID-19, using open carts without sufficient insulated covers. Further investigation revealed that the facility lacked enough insulated covers or closed meal carts to maintain appropriate food temperatures for all residents eating in their rooms. A sample tray tested showed cold food items, such as potato salad and egg salad, were served at temperatures exceeding the recommended 42 degrees Fahrenheit, while hot items were served on the same plate, further compromising the cold food temperatures. Dietary Staff confirmed these temperatures were unacceptable, and Administrative Staff acknowledged that cold foods should not be served on heated plates. The facility's policy on cooking and cooling did not address maintaining food temperature through the point of service.
Inadequate Ventilation in Beauty Shop
Penalty
Summary
The facility, with a reported census of 96 residents, failed to provide adequate ventilation in the beauty shop. During an observation on August 5, 2024, it was noted that the beauty shop lacked ventilation to the outside through a window, mechanical vent, or a combination of both, which is required to promote good air circulation. An interview with Administrative Staff A revealed that the beautician did not perform certain treatments like perms or bleaching in the beauty shop, leading to the belief that an exhaust fan was not necessary. Additionally, the facility was unable to provide a policy regarding beauty shop ventilation when requested on the same day.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to notify a resident, identified as R22, of the termination of Medicare Part A services as required by regulations. The deficiency was identified during a review of discharged Medicare A residents, where it was found that R22, who was discharged from Part A services, did not receive the necessary Notice of Medicare Non-Coverage (NOMNC) or Advance Beneficiary Notice (ABN). These forms are crucial as they inform residents about the end of Medicare-covered services and any potential financial responsibilities they may incur. The review revealed that the facility did not complete the required CMS forms, specifically the CMS-10055 and CMS-10123, which are used to document the provision of these notices. During an interview, Administrative Staff B confirmed the absence of the required forms for R22 and acknowledged the facility's procedure to issue a NOMNC and/or ABN three days before discharge. However, the facility was unable to provide a policy regarding Beneficiary Notice when requested, further highlighting the deficiency in their process. The lack of documentation and adherence to the notification procedure resulted in the failure to inform R22 of the Medicare Part A service termination and the remaining benefit days, as required by regulations.
Inconsistent Activity Provision in Memory Care Unit
Penalty
Summary
The facility failed to provide consistent activities for residents in the Memory Care Unit, specifically affecting two residents, R41 and R82. R41, with severely impaired cognition, was observed multiple times seated in the lounge with the television on, without engaging in any activities. The care plan for R41 lacked any documented activity preferences, and there were no activity notes in the progress records from April to July 2024. Family members and staff confirmed the absence of activities, and the facility relied on CNAs to provide activities, which were not consistently delivered. Similarly, R82, also with severely impaired cognition, was observed seated in her wheelchair facing a wall, with no activities provided. Although R82's care plan included activity preferences such as music and painting, there was little evidence of these activities being offered. The progress notes indicated minimal engagement, with only a nail spa activity documented in May 2024. Staff interviews revealed a lack of understanding and implementation of scheduled activities, with reliance on part-time staff and CNAs who did not consistently provide the activities listed on the calendar. The facility's activity department was understaffed, with a full-time position vacant for about three months, leading to inadequate activity provision. The facility lacked a policy on providing activities, contributing to the deficiency. This failure to provide consistent activities placed residents at risk for complications related to decreased psychosocial wellbeing.
Failure to Document Post-Dialysis Vital Signs
Penalty
Summary
The facility failed to ensure that staff obtained vital signs or checked the dialysis site after Resident 81 returned from dialysis. Resident 81, who has a diagnosis of diabetes mellitus and end-stage renal disease, requires dialysis three times a week. The care plan for Resident 81 specifies that staff should monitor and document any new orders, communication, or information received after dialysis, and report any signs of infection or bleeding at the access site. However, a review of the dialysis book forms from August 7, 2023, to July 30, 2024, revealed that the facility lacked documentation of post-dialysis vital signs and nurses' signatures on 62 occasions. Interviews with staff indicated a lack of adherence to the facility's policy on dialysis communication. Licensed Nurse K mentioned documenting vitals in the Electronic Medical Record but not on the dialysis form, while Administrative Nurse D noted that staff do not remove the dialysis book from the resident's wheelchair upon return. The facility's policy requires the nurse in charge to review the communication form and obtain necessary post-dialysis information, which was not consistently done. This failure to document and monitor post-dialysis vital signs compromised the ability to ensure Resident 81's stability and detect any adverse reactions to the dialysis procedure.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a food preference for a resident, identified as R41, who was served pork despite having a documented preference against it. R41 had a severely impaired cognition as indicated by a BIMS score of 00 and required assistance with meal setup. The resident's care plan and physician's order both specified no pork or shellfish, yet these preferences were not consistently honored. On one occasion, R41 was served a salami sandwich, and on another, a bowl of ham and bean soup, both of which contained pork. These incidents were brought to the attention of staff by R41's family member. The dietary staff acknowledged the oversight, attributing it to a new computer system that failed to print extra comments on meal tickets, which staff relied on during meal preparation. Despite the meal ticket clearly stating "NO PORK," the dietary staff missed this instruction. The facility lacked a policy on food preferences, contributing to the oversight. Administrative staff confirmed the issue and deemed it unacceptable, highlighting a deficiency in the facility's ability to provide adequate care and services by not adhering to documented food preferences.
Failure to Include Resident in Care Plan Development
Penalty
Summary
The facility failed to include Resident 61 in the development and planning of his care plan quarterly, despite his intact cognition and expressed desire to participate. The resident's electronic medical record documented diagnoses including acute kidney failure, HIV, and muscle weakness, and indicated a BIMS score of 15, showing intact cognition. The resident had various care needs, including assistance with ADLs, occasional bladder incontinence, and moisture-associated skin damage. Despite these needs and the resident's interest in being involved in care discussions, the facility did not document his participation or invitation to care plan meetings beyond an initial conference. Interviews with facility staff revealed that the resident reported never being given the opportunity to participate in his care plan, which he felt was important. Social services staff and administrative nurses confirmed that the facility lacked documentation of the resident's attendance or invitation to care plan meetings. The facility's policy stated that residents should be given notice and options for participation in care plan meetings, but this was not adhered to in the case of Resident 61, leading to a deficiency in ensuring resident involvement in care planning.
Failure to Ensure Residents' Rights to Personal Possessions
Penalty
Summary
The facility failed to uphold the resident's right to retain and use personal possessions, specifically concerning a motorized wheelchair for one resident and a missing coat for another. Resident 63, who has multiple diagnoses including diabetes, COPD, and anxiety disorder, was not informed about the delivery of her motorized wheelchair to the facility. Despite being cognitively intact and expressing the importance of her personal belongings, she was left to use a manual wheelchair, which caused her exhaustion when navigating to the designated smoking area. The facility did not conduct an assessment to determine her ability to safely operate the motorized wheelchair, and staff were unaware of its presence in the facility. Another resident, Resident 54, who has dementia and muscle weakness but is cognitively intact, reported his topcoat missing after it was sent for dry cleaning. Despite his repeated requests and discussions with staff, the coat was not returned for several months. The facility's records lacked any documentation regarding the missing coat, and staff were initially unaware of the issue. Eventually, the coat was located and returned, but the delay in its return was not addressed in a timely manner. The facility lacked a policy on resident rights related to retaining and using personal property, which contributed to these deficiencies. The absence of such a policy and the staff's lack of awareness and communication regarding the residents' personal possessions led to the failure to ensure the residents' rights were respected.
Failure to Ensure Medication Availability for Resident
Penalty
Summary
The facility failed to ensure that a resident's medication was available for administration without missed doses, which placed the resident at risk of unnecessary complications. The resident, who had a diagnosis of Human Immunodeficiency Virus (HIV), required specific medications, Abacavir Sulfate-Lamivudine and Efavirenz, to be administered daily at bedtime as ordered by the physician. However, the Medication Administration Record (MAR) indicated that these medications were not administered as prescribed, and the progress notes lacked documentation explaining why the medications were on hold. The deficiency was further highlighted when the resident reported not always receiving medications as ordered. An administrative nurse confirmed that the staff failed to notify the physician for further guidance when the medications were unavailable. The facility's policy required timely reordering of medications when only a three-day supply remained, but this was not adhered to, resulting in the resident being out of medication. The staff also failed to utilize the emergency drug kit or notify the director of nursing and the practitioner when the medication was not available.
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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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