Nottingham Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Olathe, Kansas.
- Location
- 14200 W 134th Place, Olathe, Kansas 66062
- CMS Provider Number
- 175540
- Inspections on file
- 16
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Nottingham Health And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found multiple medication and treatment carts unlocked and unattended in hallways, despite containing enteral meds, PRN creams, insulin pens, scheduled meds, and OTC meds. On different units, carts were observed left without staff present while holding resident-specific and general treatment supplies. In interviews, an LN and an administrative nurse acknowledged that carts are required to be locked when out of view or not in use, and facility policy specified that medications must be stored in accordance with state and federal requirements.
A resident with hemiplegia and intact cognition had no documented self-administration of medication assessment in the EMR and no care plan addressing self-medication, yet medications were left at the bedside in a pill cup by a CMA. The resident questioned what the pills were, and an LN, upon entering the room, could only tentatively identify one pill and had to remove the cup to verify with the CMA. The resident reported never being assessed to self-administer medications, while administrative staff later stated that appropriate self-administration should be care planned with a provider order and that medications should not be left at the bedside, contrary to the observed practice and the facility’s own medication administration policy.
A resident with hemiparesis after a stroke, severely impaired cognition (BIMS 0), neuromuscular bladder dysfunction, and unsteadiness on feet required extensive assistance with ADLs and was care planned for fall risk, including having frequently used items within reach and education on call light use. During observation, the resident was found in bed yelling for help to be repositioned while both the portable and cord call lights were out of reach—one on the bedside table and the other wrapped around and caught under the bed. Staff, including a CNA, an LN, and an administrative nurse, acknowledged that at least one call light should always be within easy reach of the resident, and the facility’s falls policy required maintaining an environment free from accident hazards with adequate supervision and assistive devices, which was not met in this situation.
The facility failed to secure hazardous areas, leaving laundry rooms with high-voltage panels and chemicals unlocked, accessible to cognitively impaired residents. Additionally, fall interventions for two residents were not implemented as per their care plans, with wheelchairs placed out of reach, increasing fall risk.
A facility with 74 residents was found to have deficiencies in food storage practices across its four kitchens. Observations revealed issues such as unlabeled and undated food items, an open ice machine with a plastic bowl on top, and opened food exposed to air. These practices were contrary to the facility's Dietary Food Storage policy, which requires labeling and dating of opened food to prevent spoilage and contamination, placing residents at risk for food-borne illness.
The facility failed to follow infection control standards, including enhanced barrier precautions, hand hygiene, and disinfection of shared mechanical lifts. A CNA did not sanitize a Hoyer lift after use and failed to perform hand hygiene before serving drinks. Soiled linens were also improperly handled. Staff interviews confirmed these actions were against the facility's infection control policy, putting residents at risk for infectious diseases.
A resident with heart failure and other conditions was provided personal care with open window blinds, exposing them to the street view. Staff interviews confirmed that blinds should be closed to maintain dignity, aligning with the facility's policy. This oversight risked negative psychosocial outcomes for the resident.
A facility failed to update a resident's care plan to include toileting after meals, despite the resident's risk for falls and a history of hemiparesis, osteoarthritis, and recent femur fracture. The resident was found on the floor after attempting to use the restroom independently, highlighting the omission of this critical intervention. Staff interviews confirmed that care plans should be reviewed and updated to ensure safe care.
A facility failed to consistently perform pre-dialysis assessments for a resident requiring hemodialysis, as outlined in their care plan. Despite having a process in place for communication between shifts and with the dialysis center, records lacked evidence of these assessments on multiple occasions. The resident had a complex medical history, including diabetes, hypertension, and renal failure.
A resident with muscle weakness and mobility issues was provided with side rails without a documented risk assessment or informed consent. The resident injured his elbow on the side rail, and staff interviews revealed inconsistencies in the assessment process. The facility's policy on bed device safety was not followed, compromising the resident's safety.
The facility failed to obtain consents or informed declinations for the PCV20 and influenza vaccinations for a resident. The resident's clinical record lacked documentation of whether these vaccines were offered, given, or declined. Although a declination was provided, it was not clear if it was for the current period. The infection preventionist noted that the facility reviews vaccine consent during care plans but does not require yearly signatures for declinations.
Unlocked and Unattended Medication and Treatment Carts
Penalty
Summary
Surveyors identified a deficiency related to improper storage of medications and biologicals when multiple medication and treatment carts were found unlocked and unattended in facility hallways. During the initial tour on 04/06/26 at 07:50 AM, a treatment cart on Holiday House was observed unlocked and unattended; it contained one resident’s enteral medications, resident supplies, and PRN creams. At 08:10 AM the same day, a treatment cart on another unit was found unlocked and unattended, containing residents’ treatment supplies, PRN creams, and two insulin pens. At 08:20 AM on 04/06/26, a medication cart on that same unit was observed unlocked and unattended in the hallway with three insulins and creams for treatments inside. On 04/07/26 at 07:36 AM, another medication cart on the same unit was again observed unlocked and unattended in the hallway, containing scheduled medications and over-the-counter medications. During interviews, a licensed nurse stated that treatment and medication carts should be locked when out of the nurse’s view, and an administrative nurse confirmed that medication and treatment carts should be locked when not being used. The facility’s Medication Labeling and Storage policy dated 01/30/26 documented that medications would be labeled and stored in accordance with facility requirements and Kansas and Federal laws, including appropriate and safe labeling of medications dispensed to all residents.
Failure to Assess Resident Before Leaving Medications at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to assess a resident for the ability to safely self-administer medications before leaving medications at the bedside unsupervised. The resident had a diagnosis of hemiplegia affecting the left nondominant side and an Annual MDS showing a BIMS score of 15, indicating intact cognition. However, the resident’s EMR contained no Self-Administration of Medications assessment, and the Baseline Care Plan did not address self-medication. Despite this lack of assessment and care plan direction, staff practice resulted in medications being left in the resident’s room. During observation, the resident was noted to have a pill cup with two pills on the bedside table and stated she had a question about what the pills were. When a licensed nurse entered, the resident asked what the pills were; the nurse stated one looked like Tylenol but would need to check on the other pill and then said she needed to ask the CMA who had placed and left the medications in the room. The nurse removed the pills to consult the CMA. The resident reported she had never been assessed to self-administer medications to her recollection. When interviewed, administrative staff stated that residents appropriate for self-administration would be identified in the care plan after provider notification and an order, and also stated that medications should not be left at the bedside, which contrasted with the observed practice and the facility’s own Medication Administration Policy referencing a Self-Administration Policy and Procedure.
Failure to Keep Call Lights Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call lights were within reach, as required to keep the environment free from accident hazards and provide adequate supervision to prevent accidents. The resident had multiple significant diagnoses, including hemiparesis/hemiplegia following a stroke, neuromuscular bladder dysfunction, unsteadiness on feet, and major depressive disorder. A recent MDS documented a BIMS score of zero, indicating severely impaired cognition, and showed the resident required setup or cleanup for eating, substantial/maximal assistance with bathing and oral care, and was dependent on staff for toileting. The MDS also documented impairment of one side of the upper and lower extremities and that the resident had not had any falls since admission. A Falls Care Area assessment documented that the falls CAA triggered due to a fall and medications that could increase fall risk, and that the resident would receive medications as ordered, assistance with ADLs, nonskid footwear, and therapy. The care plan included directions for staff to place frequently used items within reach at night, re-educate the resident on call light use, place nonskid strips around the bed, address fall risk due to unawareness of limitations, and use bolsters on the bed. On the survey date, the resident was observed lying in bed with her upper body and right arm leaning to the right and her legs on the left side of the bed, while she yelled out for help to be repositioned. At that time, her portable box call light was on the bedside table and her cord call light was wrapped around the overhead table and caught under the bed, so neither call light was within her reach. Staff interviews confirmed that the resident’s portable call light should be on the overhead table where she could reach it, and that either the portable or cord call light should always be within reach of the resident. An administrative nurse also stated that residents’ call lights should be placed within their reach. The facility’s Falls policy stated that each resident would receive services and care to ensure the environment remained as free from accident hazards as possible and that each resident would receive adequate supervision and assistive devices to prevent accidents, which was not followed in this instance when the resident’s call lights were not accessible.
Failure to Secure Hazardous Areas and Implement Fall Interventions
Penalty
Summary
The facility failed to secure hazardous areas, such as laundry rooms containing high-voltage circuit panels and cleaning chemicals, which were left unlocked and accessible to nine cognitively impaired, independently mobile residents. This oversight was observed during a walkthrough, where it was noted that the rooms contained unlocked electrical panels and hazardous chemicals, posing a risk of preventable accidents. Despite the facility's policy requiring these areas to be locked and inaccessible to residents, staff did not adhere to these safety protocols, thereby exposing residents to potential harm. Additionally, the facility did not implement appropriate fall interventions for two residents, R43 and R2, who were at risk of falls due to their medical conditions. R43, who had a history of falls and required assistance for transfers, was found with his wheelchair placed out of reach, contrary to his care plan. Staff interviews revealed that the care plan was not followed, as the wheelchair should have been placed next to his bed within reach. This failure to adhere to the care plan increased the risk of falls for R43. Similarly, R2, who had a history of falls and required assistance with activities of daily living, was not provided with the necessary fall interventions as outlined in her care plan. Observations showed that her wheelchair was not placed beside her as required, and staff were not fully aware of the interventions needed to prevent falls. The facility's failure to ensure that R2's fall interventions were followed placed her at risk for falls and related injuries.
Deficiencies in Food Storage Practices
Penalty
Summary
The facility, with a census of 74 residents, was found to have deficiencies in food storage practices during a survey. Observations during the initial tour revealed several issues with food storage across the facility's four kitchens. In the Uptown Bistro storage area, an ice machine was found with its lid open and a plastic bowl sitting on top of the ice, which could lead to contamination. Additionally, a small steam table pan in the freezer contained ground meat in a plastic bag that was neither labeled nor dated. Other items, such as a bag of mixed vegetables and a bag of frozen cookie dough, were found opened to air and undated in the freezer. Further observations in the [NAME]/[NAME] house pantry showed a bag of flour on the shelf that was opened and not dated, along with bags of lime gelatin, packets of au gratin cheese mix, bags of pasta, and boxes of cream of wheat, all without dates. In the [NAME]/[NAME] hallway refrigerator, bags of sliced turkey and ham were undated. In [NAME]'s kitchen, a box of egg whites was open to air with no label or date, and small bags of tomatoes, cabbage, and onions were in the vegetable container without labels and dates. Dietary staff confirmed that foods should be labeled and dated as soon as they are opened, as per the facility's Dietary Food Storage policy. The failure to adhere to these standards placed residents at risk for food-borne illness due to potential contamination and spoilage.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to sanitary infection control standards, particularly concerning enhanced barrier precautions, hand hygiene, and the disinfection of shared mechanical lifts. Observations revealed that a Certified Nurse Aide (CNA) pushed a Hoyer lift out of a resident's room without sanitizing it. Additionally, soiled linens were found on the floor of another resident's room. Another CNA was observed exiting a resident's room with a Hoyer lift while wearing an enhanced barrier precaution gown, which was discarded without sanitizing the lift. This CNA also failed to perform hand hygiene after handling the lift and before serving drinks to residents. Interviews with staff, including a Licensed Nurse and an Administrative Nurse, confirmed that the facility's infection control policy required hand hygiene between resident care and when visibly soiled, as well as the cleaning and sanitization of shared equipment like the Hoyer lift. The policy also mandated the proper handling of soiled linens. Despite these guidelines, the facility's practices did not align with the infection control standards, placing residents at risk for infectious diseases.
Failure to Ensure Resident Dignity During Personal Care
Penalty
Summary
The facility failed to ensure a resident's right to dignity and respect during personal care. The incident involved a resident with a history of heart failure, hypertension, and peripheral vascular disease, who required assistance with dressing. Despite the resident's cognitive status being documented as moderately impaired to intact, staff provided personal care with the window blinds open, exposing the resident to the view of the side street. This action was observed when a Certified Nurse Aide and a Certified Medication Aide transferred the resident using a mechanical lift and assisted with dressing while the blinds remained open. Interviews with facility staff, including a Certified Medication Aide, a Licensed Nurse, and an Administrative Nurse, confirmed that the window blinds should be closed during personal care to maintain resident dignity. The facility's Right to Dignity policy, reviewed earlier in the year, emphasized the importance of providing care that promotes respect and dignity. The failure to close the blinds during personal care placed the resident at risk for negative psychosocial outcomes and decreased dignity.
Failure to Update Care Plan for Toileting Needs
Penalty
Summary
The facility failed to revise the care plan for Resident 44 to include toileting needs after meals, despite this intervention being discussed in an interdisciplinary team note. Resident 44, who has a medical history including hemiparesis, osteoarthritis, anxiety disorder, cerebral infarction, and a recent femur fracture, was identified as being at risk for falls. The resident's Minimum Data Set (MDS) indicated mild cognitive impairment and frequent incontinence, requiring substantial assistance with activities of daily living. Despite these needs, the care plan did not reflect the necessary toileting intervention after meals, which was identified as a preventive measure following a fall incident. The deficiency was highlighted when Resident 44 was found on the floor after attempting to use the restroom independently, indicating a lack of communication and implementation of the discussed care plan changes. The facility's policy required ongoing assessments to ensure care plans accurately reflect residents' needs, but this was not adhered to in Resident 44's case. Interviews with staff confirmed that care plans should be reviewed and updated to include all necessary interventions, yet the omission of the toileting after meals intervention placed the resident at risk for further accidents and falls.
Failure to Perform Pre-Dialysis Assessments
Penalty
Summary
The facility failed to consistently perform and communicate pre-dialysis assessments for a resident, identified as R7, who required hemodialysis due to end-stage renal failure. R7's medical history included diabetes mellitus, hypertension, renal failure, epilepsy, cognitive communication deficit, and protein calorie malnutrition. The care plan for R7 required nursing staff to communicate the resident's condition with the dialysis center using a written communication form for each visit. However, the clinical record review revealed a lack of evidence for pre-hemodialysis assessments on multiple specified dates. Interviews with facility staff, including a Licensed Nurse and an Administrative Nurse, indicated that the process involved the night shift nurse filling out a pre-assessment with vital signs and medications, which was then sent with the resident to the dialysis center. Upon the resident's return, the afternoon nurse was responsible for documenting any new orders and conducting a post-assessment. Despite this process, the facility's records did not consistently reflect the completion of pre-dialysis assessments, as required by the facility's Hemo-Dialysis policy, which emphasized accurate and consistent communication to maintain medical management and coordination of care.
Failure to Document Side Rail Assessment and Consent
Penalty
Summary
The facility failed to ensure that a resident, identified as R60, had a documented risk assessment for the use of side rails, consent for their use, and failed to inform the resident or their representative of the associated risks and benefits. R60's electronic medical record indicated diagnoses of generalized muscle weakness, need for assistance with personal care, difficulty with walking, and hypertension. Despite these conditions, there was no evidence of a safety assessment for side rails prior to their installation. The facility provided a side rail assessment with handwritten information, but it was not found in the resident's clinical record during the survey. Additionally, R60 experienced an injury when he hit his right elbow on the small side rail of his bed while trying to reach his phone, resulting in swelling and pain. Interviews with staff revealed inconsistencies in the process of assessing and installing side rails. A Licensed Nurse stated she had never completed a side rail assessment, and the decision for side rail installation was made by the Director of Nursing. The facility's policy indicated that bed devices should be assessed for need and safety, but this was not adhered to, placing R60 at risk for uninformed decisions and impaired safety.
Failure to Obtain Vaccination Consents for a Resident
Penalty
Summary
The facility failed to offer and obtain consents or informed declinations for the Pneumococcal Conjugate Vaccine (PCV20) and influenza vaccination for a resident identified as R17. R17 was admitted on an unspecified date, and a review of their clinical record showed a lack of documentation indicating whether the PCV20 vaccine or the influenza vaccine for the last flu season was offered, given, or declined. Although the facility provided a declination dated 10/06/22, it was not clear if this was for the current vaccination period. Administrative Nurse E, the infection preventionist, stated that the facility reviews vaccine consent during care plans but does not require residents or their representatives to sign yearly for declinations. The facility's Immunization Policy, dated 01/31/24, acknowledges the importance of vaccines in reducing healthcare costs and preventing illness, hospitalization, and death. However, the failure to obtain the necessary consents or declinations for R17 placed the resident at increased risk for acquiring, transmitting, or experiencing complications from pneumococcal disease or influenza.
Latest citations in Kansas
Surveyors identified unsanitary food storage and preparation conditions, including food debris in a reach-in freezer, an unknown spilled liquid in a reach-in refrigerator, missing two-inch air gap on an ice machine drain, dirty carts used for clean dishes, and a steamtable shelf with built-up food debris. A dietary staff member acknowledged these areas needed cleaning, and it was determined the facility lacked a cleaning schedule or policy for kitchen cleanliness.
The facility failed to complete and analyze Care Area Assessments (CAAs) for multiple residents after Admission, Annual, and Significant Change MDS assessments triggered areas such as cognition, mood/behavior, functional status, urinary incontinence/indwelling catheter, nutrition, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, and visual function. Instead of documenting individualized analysis of underlying causes and contributing factors, an LPN reported she had stopped writing CAA notes and relied mainly on check-off worksheets and the fact that triggers appeared in the MDS CAA section. No facility policy on CAAs was provided to surveyors, and the CAAs consistently lacked required analytical documentation for residents with diverse and significant clinical needs.
A resident with dementia, severe cognitive impairment, and an indwelling urinary catheter was repeatedly observed sitting in common areas with his catheter drainage bag resting on his lower leg, visibly filled with dark amber urine and lacking a privacy cover, despite a care plan directing staff to cover the drainage bag. CNAs reported that the bag often slid down from the resident’s thigh, that they did not use catheter dignity bags on their hall, and that they simply moved the bag back up when it slid down. An administrative nurse stated she had not considered the use of dignity bags on the memory care unit, even though the facility’s resident rights policy affirms each resident’s right to a dignified existence, privacy, and confidentiality.
Two residents with documented cognitive ability to participate in care planning were not invited to any care plan meetings, and their EMRs lacked evidence of care plan conferences, invitations, or Interdisciplinary Care Conference assessments. Administrative staff stated that invitations should be mailed or hand-delivered and uploaded to the EMR, and that an Interdisciplinary Care Conference note should be completed, but none of this documentation existed for these residents, contrary to facility policy and federal requirements for resident and/or representative participation in care planning.
A resident with C-diff and CHF, newly admitted and with a baseline care plan that did not address call light use, was repeatedly found without access to a call light. Surveyors observed the resident yelling for help with her room door closed and later noted the call light on the floor under the bed and again on the floor while the resident sat in a recliner and stated she wanted to return to bed but could not do so independently. Staff reported using a binder clip to attach the call light to the resident’s clothing because the cord lacked a clip, acknowledged the resident sometimes threw the call light to the floor, and stated that call lights should be kept within residents’ reach. An administrative nurse confirmed the expectation that call lights be accessible at all times and was unsure about the use of a binder clip, and no facility policy on call lights was provided.
Surveyors found that a resident’s bathroom and handwashing area were not maintained in a safe, sanitary, and comfortable condition, including a loose baseboard with black substance behind it, a cracked toilet seat, and an empty, improperly mounted hand soap dispenser. Maintenance staff confirmed these conditions, noted that the soap dispenser was nonfunctional, and reported that although a QR code system existed for reporting maintenance issues, these problems had not been reported. Maintenance staff also stated there were no facility policies for maintenance repair in resident rooms and no policy provided for ensuring a safe, homelike environment.
Multiple residents were affected by inaccurate MDS assessments, including a resident with dementia and an indwelling catheter who was miscoded as always incontinent of urine and independent in ADLs despite staff and EMR documentation showing long-term catheter use and total dependence for dressing and wheelchair positioning. Another resident with a history of stroke was incorrectly coded as having a restraint, even though bed grab bars were used as enablers to assist with repositioning and did not limit voluntary movement. A resident with diabetes and unsteadiness experienced two documented falls that were not captured on the MDS, and another resident with diabetes, depression, CAD, and CKD was actively receiving hospice services per EMR, social services, and staff interviews, yet hospice was not coded on the MDS. The consultant MDS nurse confirmed these were significant coding errors not in accordance with the RAI User’s Manual.
A resident with C. diff and CHF was admitted, and while a baseline care plan documenting contact precautions was created, the resident later reported not knowing what a baseline care plan was. The resident was also found yelling for help with her call light on the floor under the bed. Nursing staff stated that baseline care plans are started on the day of admission and reviewed with residents, but also indicated that residents and families are not given written copies. An administrative nurse claimed a 48-hour interdisciplinary care conference had been completed, yet no corresponding documentation existed in the EMR, and explanations about who was responsible and why it was missing were inconsistent. No facility policy for baseline care plans was provided.
A resident with dementia and severe cognitive impairment was inaccurately assessed and care planned as needing only setup or independent assistance with dressing, despite actually requiring total staff assistance. The EMR lacked clear ADL documentation, and the ADL CAA did not trigger, leading to inaccurate MDS entries and a care plan that did not match the resident’s functional status. Surveyors observed the resident sitting in a wheelchair wearing dirty, food-stained pants and being taken to the dining room without a clothing change, with the soiled pants not changed until later when two CNAs provided total assistance. Staff, including CNAs, an LN, and an administrative nurse, acknowledged that the resident needed total help with dressing and should always be in clean clothing, revealing a failure to provide appropriate ADL support and maintain clean attire.
A resident with dementia and severe cognitive impairment was transported multiple times in a wheelchair without staff ensuring that his feet remained safely on the foot pedals. Although assessments inaccurately documented that he was independent with walking using a walker and/or wheelchair, his care plan did not instruct staff on proper use of wheelchair foot pedals. During observed transports by CNAs, the resident’s shoed feet repeatedly fell off the pedals and skimmed the floor between them. Staff acknowledged that his feet did not stay on the pedals and that the pedals were not effectively adjusted, and nursing leadership confirmed expectations that feet should remain on the pedals during transport. No wheelchair safety policy was provided.
Unsanitary Kitchen Conditions and Lack of Cleaning Policy
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions when surveyors observed multiple cleanliness and equipment issues in the kitchen. During an initial kitchen tour on 04/27/26 at 08:57 AM, the three-door reach-in freezer was found with food debris on the bottom shelf, and the three-door reach-in refrigerator had an unknown spilled liquid on the bottom shelf. The drain to the ice machine did not have the required two-inch air gap. Two black two-tiered plastic carts used to store clean dishes had food debris on the bottom tier, and the bottom shelf of the steamtable, which was used to store plate covers, had a buildup of food debris. On 04/28/26 at 01:57 PM, a dietary staff member confirmed these areas required cleaning, and it was identified that the facility did not have a cleaning schedule or a policy regarding kitchen cleanliness. No specific residents, medical histories, or clinical conditions were mentioned in the report in relation to this deficiency.
Failure to Complete and Analyze Care Area Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive Care Area Assessments (CAAs) with analysis of underlying causes, contributing factors, and risk factors for multiple residents following MDS assessments. Record review showed that numerous residents had Admission, Annual, or Significant Change MDS assessments that triggered CAAs in areas such as mood/behavior, cognitive loss/dementia, functional abilities, communication, urinary incontinence/indwelling catheter, nutritional status, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, visual function, and psychosocial well-being. For each of these triggered areas, the corresponding CAAs lacked analysis of the findings. This pattern was identified for residents with a wide range of clinical issues, including dementia, incontinence, falls, pressure ulcers, nutritional concerns, psychotropic medication use, pain, and functional decline. During an interview, a licensed nurse reported that she had stopped writing CAA notes the previous year after being told to do so by someone she could not identify. She stated that she did not write anything on the triggered CAAs and that, at times, she would document risk concerns only on a main check-off worksheet, relying on the fact that the triggers were already reflected in the MDS CAA section. The facility did not provide a policy regarding CAAs when requested. These findings demonstrate that the facility did not ensure that comprehensive assessments were fully completed as required when residents were first admitted and periodically thereafter.
Failure to Maintain Dignity and Privacy for Resident with Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to a dignified existence by not maintaining privacy for his urinary catheter drainage bag as directed in his care plan. The resident had diagnoses including bladder calculus and dementia, with a BIMS score of one indicating severe cognitive impairment, and was dependent on staff for toileting hygiene with an indwelling urinary catheter and constant urinary incontinence. His care plan, revised 03/23/26, instructed staff to cover his drainage bag with a privacy cover. However, during observations on 04/27/26, the resident was seen sitting in his wheelchair at his room doorway and later in the dining room with his catheter drainage bag resting on his lower left leg, supported by his shoe, containing dark amber urine and visible to visitors and other residents, without a privacy cover. Staff interviews confirmed that the catheter drainage bag frequently slid from the resident’s left thigh down to his lower leg and that staff did not consistently reposition it or use dignity/privacy bags. One CNA stated he had never placed a dignity bag on the resident’s drainage bag, and another CNA reported that staff on their hall did not utilize catheter dignity bags, instead just moving the bag back up when it slid down. An administrative nurse acknowledged she had not considered staff use of dignity bags for urinary catheters on the memory care unit. The facility’s Resident Rights policy, approved 12/2024, stated that each resident has the right to a dignified existence including privacy and confidentiality, which was not followed in this case.
Failure to Involve Cognitively Able Residents in Care Plan Meetings
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were given the opportunity to participate in the development and implementation of their person-centered plans of care. For one resident with a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognition, the electronic medical record showed an admission MDS and a Significant Change MDS, but there was no documentation of any care plan meeting in the prior four months. This resident reported not being invited to any care plan meeting. For a second resident with a BIMS score of 14, indicating intact cognition, the electronic medical record contained an admission MDS and a Quarterly MDS, but there was no documentation of a care plan meeting in the prior two months. This resident also reported not being invited to any care plan meeting. Administrative staff reported that residents and/or family members were supposed to be mailed or hand-delivered invitations to attend care planning meetings and that a copy of the invitation should be uploaded into the EMR. They further stated that an Interdisciplinary Care Conference assessment should be completed in the EMR during the care plan meeting. However, the administrative nurse confirmed that there was no documentation of invitations, Interdisciplinary Care Conference assessments, or completed care plan meetings for the two residents. The facility’s care planning policy stated that social services should attend care plan meetings and that the team presents information to the resident and/or representative about progress toward care plan goals, and referenced federal law requiring resident and/or representative participation in care plan meetings to the extent possible, but this process was not carried out or documented for the two residents identified.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach and to reasonably accommodate the resident’s needs and preferences. The resident had documented diagnoses of C-diff and CHF, and her baseline care plan dated 04/23/26 directed staff to evaluate for changes in level of consciousness but did not include any direction regarding call light use or accessibility. On 04/28/26 at 08:06 AM, surveyors observed the resident’s room door closed while she yelled loudly for help several times. When a licensed nurse entered the room, the resident was lying on her left side in bed, stated she wanted to get up, and reported she could not find her call light. The call light was observed on the floor under her bed. Later that morning, a CNA attached the call light to the resident’s shirt using a black and silver binder clip because the call light cord did not have its own clip. On 04/29/26 at 12:15 PM, the resident was seated in a recliner with the call light again lying on the floor out of her reach; she reported she wanted to go to bed and could not get herself back into bed. Staff interviews revealed that the CNA used the binder clip to keep the call light attached to the resident, and the licensed nurse stated staff should make sure the call light is clipped to the resident’s clothes and reported that the resident would throw her call light on the floor. An administrative nurse stated she expected staff to ensure all residents always have their call lights in reach and was unsure about using a binder clip to hold a call light in place. The facility did not provide a policy regarding call lights.
Failure to Maintain Safe and Sanitary Resident Bathroom Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, functional, sanitary, and comfortable environment in Resident 87’s bathroom and handwashing area. During an environmental tour with Maintenance Staff UU, surveyors observed an approximately four-foot section of loose baseboard to the left of and behind the toilet, with a black substance present on the wall and floor behind the loose baseboard. They also noted an approximately three-inch crack in the toilet seat and an empty hand soap dispenser hanging above the handwashing sink, mounted with exposed lag bolt fasteners. Maintenance Staff UU confirmed these conditions, acknowledged that the soap dispenser did not work, and stated that the toilet seat should be replaced, the bathroom baseboard removed, the black substance tested for mold, and the sheetrock removed and replaced. Further interview with Maintenance Staff UU revealed that the facility had implemented a QR code system for staff and visitors to report maintenance items, but the issues in this resident’s bathroom had not been reported through that system. He also reported that there had been a leak behind the handwashing sink that had flowed into the bathroom area, leading to the sink’s replacement, but he had received no report of the specific deficiencies observed in the bathroom. Additionally, Maintenance Staff UU stated that the facility did not have policies for maintenance repair in residents’ rooms, and the facility did not provide a policy for ensuring a safe, homelike environment.
Inaccurate MDS Coding for ADLs, Restraints, Falls, and Hospice Services
Penalty
Summary
The deficiency involves the facility’s failure to complete accurate Minimum Data Set (MDS) assessments in accordance with the Resident Assessment Instrument (RAI) User’s Manual, resulting in multiple residents’ clinical status not being correctly reflected. For one resident with dementia and severe cognitive impairment, the Significant Change and subsequent Quarterly MDS assessments coded him as always incontinent of bladder and independent with eating and upper body dressing, with use of a walker and wheelchair. However, the electronic medical record showed ongoing indwelling catheter care each shift and no documentation of walker use, wheelchair mobility, or dressing requirements during the review period. Staff interviews revealed that this resident had an indwelling catheter for more than a year, had not walked for several years, and was dependent on staff for all ADLs, including dressing and wheelchair positioning, contradicting the MDS coding. Observations showed the resident slumped in a wheelchair, wearing a hospital gown over clothing, with a visible catheter bag on his lower leg and feet frequently skimming the floor despite foot pedals being present, further indicating dependence and catheter use not accurately captured on the MDS. Another deficiency involved a resident with a history of stroke, hemiplegia, and hemiparesis whose Significant Change MDS coded the use of “other restraint.” During observation, the resident was seen in bed with bilateral grab bars at the head of the bed and her right arm positioned on a pillow. The resident reported using the grab bars to help move and reposition herself in bed. CNAs and administrative nursing staff confirmed that the facility did not use restraints and that the grab bars were used as enablers to assist residents with repositioning and to increase independence. Administrative staff acknowledged that the MDS coding for restraints was inaccurate because the grab bars did not limit the resident’s voluntary movement or access to her body. A further inaccuracy was identified for a resident with diabetes, atrial fibrillation, unsteadiness of feet, and a toe fracture. Both a Significant Change and a Quarterly MDS documented intact cognition, partial/moderate assistance with transfers, no ambulation, and no falls. However, progress notes in the EMR documented two unwitnessed falls during the look-back period, including one where the resident was found on the floor next to the bed with a forehead skin tear and another where the resident was found sitting on a fall mat on the floor with a scratch on the ankle. These documented falls were not reflected on the MDS. In addition, another resident with diabetes, depression, CAD, and chronic kidney disease had a Significant Change MDS that coded no hospice services, while the EMR contained a hospice certification and physician orders initiating hospice services, and social service notes and staff interviews confirmed that hospice services, including bathing by a hospice aide, were being provided during the look-back period. The consultant MDS nurse confirmed that these assessments were inaccurate and not completed in accordance with the RAI User’s Manual, constituting significant errors in coding for urinary status, ADL dependence, restraints, falls, and hospice services. The consultant MDS nurse stated that the resident with the indwelling catheter should have been coded as not rated for urinary continence due to catheter placement rather than as always incontinent, and that his ADL status should not have been coded as independent given his dependence on staff for dressing and wheelchair positioning. For the resident with grab bars, the nurse confirmed that the grab bars were used as enablers and not as restraints, making the restraint coding inaccurate. For the resident with documented falls, the MDS failed to capture falls that occurred within the look-back period, and for the resident receiving hospice services, the MDS did not reflect hospice care that was active during the look-back period. These miscodings met the RAI Manual’s definition of significant error, in which the resident’s overall clinical status is not accurately represented on the assessment and the error has not been corrected by a more recent assessment.
Failure to Provide and Communicate Baseline Care Plan to New Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide a summary of the baseline care plan to a newly admitted resident and to ensure that the baseline care plan process was completed and documented as required. The resident’s EMR documented diagnoses of C. difficile and CHF. The Entry MDS was completed on the admission date, and the admission MDS was noted as in progress with no information available. A baseline care plan dated the day after admission documented contact precautions, including staff use of gowns and masks when changing contaminated linens and proper handling and bagging of soiled linens. However, during an interview several days after admission, the resident reported she did not know what a baseline care plan was, indicating that the plan had not been explained or summarized to her. Further observations and interviews showed additional failures in implementing and communicating the baseline care plan. On one occasion, the resident was heard yelling for help with her room door closed; when a nurse entered, the resident stated she wanted to get up but could not find her call light, which was observed on the floor under the bed. A nurse reported that the baseline care plan was started on the day of admission and that nurses would review it with the resident, but also stated that the charge nurse would not provide a written copy of the baseline care plan to the resident or family. An administrative nurse reported she would review the baseline care plan with the resident and/or family and claimed to have completed a 48-hour interdisciplinary care conference, but there was no opened or completed conference note in the EMR. She gave inconsistent explanations regarding who was responsible and why the conference note was missing. The facility did not provide a policy for baseline care plans.
Failure to Provide Accurate ADL Assessment and Timely Clothing Changes
Penalty
Summary
The facility failed to provide appropriate assistance with activities of daily living (ADLs), specifically dressing and clothing changes, for a resident with severe cognitive impairment. The resident had a diagnosis of dementia and repeated Brief Interview for Mental Status (BIMS) scores of one, indicating severe cognitive impairment. Despite this, both a Significant Change MDS and a Quarterly MDS inaccurately documented that the resident required only setup assistance with lower body dressing. The ADL Care Area Assessment did not trigger, and the resident’s care plan, revised on 03/23/26, inaccurately instructed staff that the resident was independent with dressing. The electronic medical record lacked staff documentation of the resident’s ADL needs, resulting in care instructions that did not reflect the resident’s actual functional status. On the day of observation, the resident was seen sitting in a wheelchair wearing black pants with food crumbs on them in the morning, and later was transported by a CNA to the dining room still wearing the same dirty pants. The pants were not changed until early afternoon, at which time two CNAs provided total assistance to change the dirty pants, and the resident was unable to participate in dressing or undressing. During interviews, the CNAs, a licensed nurse, and an administrative nurse all stated that residents should always be dressed in clean clothing and confirmed that this resident required total staff assistance with dressing. These observations and interviews showed that the resident’s actual need for total assistance with dressing and clothing changes was not accurately reflected in the MDS, care plan, or ADL documentation, and that the facility did not ensure the resident was kept in clean clothing as expected by facility policy for ADL care.
Failure to Maintain Safe Wheelchair Foot Positioning During Resident Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision during wheelchair transport for a resident with dementia. The resident’s EMR documented a diagnosis of dementia and a BIMS score of one on both a Significant Change MDS and a Quarterly MDS, indicating severe cognitive impairment. These MDS assessments inaccurately documented that the resident was independent with walking using a walker and/or wheelchair, and the ADL CAA did not trigger. The resident’s care plan, revised 03/23/26, identified cognitive impairment due to dementia but did not include instructions for staff on the use of wheelchair foot pedals while propelling the resident. On multiple observed occasions, staff propelled the resident in a wheelchair without maintaining his feet safely on the foot pedals. During transport from his room to the dining room, the resident’s left shoed foot fell from the foot pedal and skimmed the floor between the pedals, and later, during transport from the dining room to the shower room, both shoed feet skimmed the floor between the pedals. CNAs reported that the resident’s feet never stayed on the foot pedals and described the pedals as useless because he could not keep his feet on them. A licensed nurse confirmed the resident’s feet did not always remain on the foot pedals when staff propelled him and stated the pedals should be adjusted to better fit his needs. An administrative nurse stated it was the expectation that staff ensure the resident’s feet remained on the foot pedals during transport and that pedals should be lowered if needed. The facility did not provide a policy regarding wheelchair safety.
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