Overland Park Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Overland Park, Kansas.
- Location
- 5211 W 103rd Street, Overland Park, Kansas 66207
- CMS Provider Number
- 175180
- Inspections on file
- 36
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Overland Park Post Acute during CMS and state inspections, most recent first.
A resident with DM and a left foot ulcer had detailed wound care and pneumatic compression pump orders from a wound care consultant, including daily dressing changes with Dakin’s solution and compression pump use two to three times daily. Facility staff documented that the resident returned from wound care with new orders but entered the dressing change frequency in the EMR as only three times weekly and implemented compression pumps once nightly, without a corresponding provider order for that reduced frequency. The resident and the consultant later reported that Dakin’s solution was not being used as ordered, daily dressing changes were not being performed, and the delivered lymphedema pumps were not used as prescribed. Staff interviews confirmed that the daily dressing order was not updated in the EMR, that nurses often had to reach out to obtain wound care orders, and that the facility discovered the pumps only after finding them at the front of the building, resulting in a failure to follow the consultant’s wound care and compression pump orders.
A resident with DM, mobility impairment, and moderate cognitive deficit had an order for diabetic shoes and heat-molded insoles, with the care plan identifying risk for ADL/mobility decline and need for assistance with ambulation and transfers. Nursing notes documented repeated early efforts to contact a diabetic shoe provider and fax required documents, but after a certain point there was no further EMR evidence of follow-up, even though the resident later reported still needing diabetic shoes and was observed with a rough, calloused right heel. Staff interviews revealed the process had been ongoing for an extended period, that the resident had previously missed an appointment with the shoe provider during a time of psychosis and involuntary placement, and that no subsequent referrals were documented by the provider, while the facility lacked a policy on durable medical equipment or accommodation of needs.
A resident with COPD and moderate cognitive impairment was admitted with a physician order for CPAP at bedtime and related humidifier care, but the care plan addressed only continuous oxygen and omitted CPAP. Over several months, the TAR documented many CPAP administrations and refusals even though no CPAP machine was ever present in the resident’s room, and eMAR notes recorded that the resident did not have a CPAP and stated the facility never obtained one. An LPN reported the resident never had a CPAP in the facility and that "refused" was used on the TAR both when the resident declined and when the device was unavailable, while administrative nursing staff were unaware if the resident had a CPAP and indicated the order should have been discontinued if no machine was available.
A resident with DM and moderate cognitive impairment had a standing order for weekly Mounjaro injections, but over several months only a small fraction of scheduled doses were administered, with most doses documented as unavailable or on order. Nursing documentation repeatedly noted that the drug was unavailable, awaiting delivery, or required clarification or prior authorization, yet there was no clear follow‑through to secure the medication or resolve the issues, and the physician progress note addressing very high fasting blood sugar did not mention the Mounjaro order. The administrative nurse reported not being informed of missed doses or any prior authorization need, while the resident stated they had not been receiving the injections but wanted to be on the medication, contrary to facility policy requiring a sufficient supply and timely administration of prescribed medications.
A resident with severe cognitive impairment and multiple medical conditions experienced two falls from bed, the second resulting in a femur fracture. After the first fall, staff only sent the resident to the hospital for evaluation and did not implement or document additional fall prevention interventions such as floor mats or bolstered mattresses. No thorough investigation or root cause analysis was conducted, and the care plan was not updated with new interventions until after the second fall.
The facility, with 87 residents, failed to employ a qualified CDM, as required for the director of food and nutrition services. Administrative Staff A confirmed the absence of a CDM and the ongoing search for one, while the Registered Dietician was present twice weekly. The facility could not provide a policy on the CDM, risking residents' dietary and nutritional needs.
A facility with 87 residents was found to have deficiencies in food storage and dishwashing practices. Observations revealed missing kitchen tiles, outdated freezer logs, and unlabeled food items, including pre-cooked meats and milk. The high-temperature dishwasher failed to reach the required sanitizing temperature. These issues, acknowledged by staff, placed residents at risk of foodborne illness and cross-contamination.
The facility did not conduct a thorough assessment to determine necessary resources for resident care, failing to specify staffing levels, skill sets, and contingency plans. This oversight placed 87 residents at risk for impaired care.
The facility failed to implement proper infection control measures, including the absence of signage for Enhanced Barrier Precautions (EBP) and unsanitary storage of respiratory equipment. Additionally, there was no Legionella management plan, and laundry water temperatures were insufficient for disinfection. Staff did not consistently perform hand hygiene, and soiled laundry was improperly handled, placing residents at risk for infections.
The facility did not ensure agency staff received required communication training, risking impaired care for 87 residents. Training records for CNAs were unavailable, and the facility relied on the agency to track training without verification. This violated the policy requiring all staff to participate in orientation and annual in-service training.
The facility failed to ensure agency staff received required resident rights training, as they did not maintain or verify training records for CNAs. This oversight placed residents at risk for impaired care and decreased quality of life.
The facility failed to ensure that agency staff, including CNAs, received the required infection control training as part of its infection prevention and control program. The facility did not maintain training records for agency staff, relying on the agency company to track their training. This deficiency was identified when the facility could not provide proof of training records for agency staff, as confirmed by an administrative nurse.
The facility failed to provide adequate activities on weekends, offering only self-led activities without staff involvement. The Activity Calendar for August and September 2024 showed no structured or group activities on weekends. The Resident Council and staff confirmed the absence of activities staff on weekends, contrary to the facility's policy to provide activities reflecting residents' interests and social needs.
The facility failed to ensure monthly drug regimen reviews were conducted for several residents, leading to unaddressed medication irregularities. A resident's antipsychotic medication lacked a CMS-approved indication or GDR, while another resident's medication was administered outside physician-ordered parameters. Additionally, dosing instructions for a topical medication were missing for two residents.
A resident with severe cognitive and physical impairments did not receive the necessary dining accommodations, such as a divided plate and built-up utensils, as specified in her care plan. Despite her medical conditions requiring these tools for self-feeding, staff failed to consistently provide them, leading to unmet care needs. Interviews revealed confusion among staff about responsibilities, and the facility lacked a policy to ensure proper accommodations.
The facility failed to provide the correct SNF Advance Beneficiary Notice (ABN) form, CMS-10055, to three residents, omitting the estimated cost for continued skilled services. Instead, form CMS-R-131 was issued, lacking necessary cost information. Staff interviews revealed a misunderstanding about the correct form, with the updated CMS-10055 form only recently provided for future use. This deficiency risked uninformed decisions by the residents.
A facility failed to provide written notice of transfer for a resident with multiple health conditions during hospital transfers. Despite the resident's intact cognition and need for careful monitoring, the facility did not issue written notifications, relying instead on phone calls. Staff interviews revealed confusion about notification responsibilities, and the facility lacked a relevant policy, leading to the deficiency.
The facility failed to complete quarterly MDS assessments for two residents within the required 92-day timeframe. One resident's assessment was started but not completed after an admission MDS, and another's quarterly MDS was initiated but remained incomplete. Administrative Staff C, responsible for MDS assessments, was unaware of the overdue assessments due to reliance on system alerts, placing residents at risk for unmet care needs.
A resident with severe cognitive impairment and multiple health issues did not receive consistent bathing assistance from staff, as required. Despite being dependent on staff for all ADLs, the resident did not receive a bath or shower for a period of time, leading to poor hygiene. Staff interviews revealed a lack of clarity regarding documentation and follow-up procedures for bathing, contributing to the deficiency.
Two residents at a facility were at risk for pressure ulcers due to improperly set low air-loss mattresses. One resident's mattress was set at 350 lbs despite weighing 206 lbs, and another's was unplugged and set at 350 lbs despite weighing 107.2 lbs. The facility lacked documentation and policies for proper mattress settings, contributing to the deficiency.
The facility failed to provide necessary restorative care and range of motion (ROM) services for three residents, leading to a risk of worsening contractures. One resident with Huntington's disease did not receive documented ROM exercises, another with left-sided hemiplegia from a stroke was only given self-led exercises without staff assistance, and a third with multiple sclerosis did not have a prescribed palm guard splint applied consistently. The facility lacked a restorative program and proper documentation, placing these residents at risk for further decline.
A facility failed to ensure proper communication and monitoring for a resident receiving dialysis. The resident, with end-stage renal failure, was not weighed before dialysis on multiple occasions, and communication sheets were often incomplete. Staff interviews confirmed the responsibility for these tasks, but the facility's policy was not consistently followed, risking the resident's health.
A facility failed to conduct a proper safety assessment for a resident's use of bed rails, obtain consent, and inform the resident or responsible party of associated risks and benefits. The resident had severe cognitive impairment and required assistance with daily activities. The facility's policy required an assessment of the resident's environment and safety risks before implementing bed rails, which was not followed.
The facility failed to administer antihypertensive medication per physician orders for a resident, and did not provide dosing instructions for Voltaren gel for two residents. These actions placed residents at risk for unnecessary medication use and side effects, as confirmed by staff interviews and record reviews.
The facility failed to ensure that three residents had a CMS-approved indication or required physician documentation for antipsychotic medication use without attempts at gradual dose reduction (GDR). Despite receiving antipsychotic medications, there was no documentation of GDR attempts or physician documentation contraindicating GDR for these residents, placing them at risk for unnecessary medication administration and possible adverse side effects.
A facility failed to implement a communication process with a hospice provider for a resident receiving end-of-life care. The resident's care plan lacked documentation of hospice services, creating a risk of missed or delayed care. Staff were unsure about the location and responsibility for updating care plans, and the facility lacked a hospice policy.
The facility did not provide mail delivery services to residents on Saturdays, resulting in mail being stored over the weekend and distributed on Monday. The absence of weekend activity staff, who previously handled mail distribution, led to this deficiency. Interviews with staff confirmed a lack of awareness or responsibility for weekend mail delivery, contrary to the facility's policy requiring mail to be delivered within 24 hours.
A resident with Parkinson's disease and intact cognition was subjected to abuse when a CNA attempted to pull a call light from their hands, causing the resident to fall from the bed and sustain a back injury. Despite the facility's policy to protect residents from abuse, the incident occurred, and the resident reported the abuse to staff and police, consistently describing the event.
Failure to Transcribe and Implement Wound Care and Compression Pump Orders
Penalty
Summary
The deficiency involves the facility’s failure to correctly transcribe and follow wound care provider orders for a resident with a diabetic foot ulcer. The resident had type 2 DM with a foot ulcer, difficulty walking, and generalized muscle weakness, and was cognitively intact with a BIMS score of 15. Her care plan identified a diabetic foot ulcer on the left foot and interventions including administering treatments and supplements as ordered, obtaining labs as ordered, monitoring and documenting wound size and depth, and observing and reporting signs of infection. The Pressure Ulcer/Injury CAA documented that she was at risk for pressure ulcers due to decreased mobility and incontinence. Consultant wound care orders dated 12/10 and 01/07 directed the use of pneumatic compression pumps two to three times daily for one-hour increments as tolerated. On 01/28, the wound care provider issued detailed left foot wound care orders specifying cleansing with Dakin’s solution for three to five minutes, applying A&D ointment around the wound, weaving InterDry between toes, applying Hydrofera Blue to the wound, covering with Drawtex and an ABD pad, and wrapping with a CoFlex calamine multi-layer compression wrap, with dressing changes to occur daily except on days the resident went to the wound care center, and continued orders for pneumatic compression pumps two to three times daily. The nurse’s note on 01/28 documented that the resident returned from the wound care provider with new lab and wound care orders but did not specify the content of those orders. Instead of entering the daily dressing change frequency, an order starting 01/30 was entered for dressing changes only on Monday, Wednesday, and Friday, and a later order starting 02/05 directed lymphatic pumps to be applied once daily at night for 60 minutes, without documentation of a corresponding provider order for that reduced frequency. The wound care provider’s 02/04 progress note documented that the resident reported the facility was not using Dakin’s solution for wound cleansing as ordered, that the DME company confirmed delivery of the lymphedema pumps but staff had not used them, and that although daily dressing changes were ordered, the facility continued to perform dressing changes only two to three times per week. The provider also documented leaving several messages with the facility without response. On observation, the resident reported that her left foot dressing was not changed daily as ordered and that staff told her the compression dressing could stay on for a couple of days. Multiple administrative and licensed nursing staff interviews confirmed that the EMR still reflected a Monday/Wednesday/Friday schedule despite the 01/28 orders for daily dressing changes, that staff relied on wound care notes and sometimes had to call to obtain orders, and that the dressing change frequency had not been updated after the 01/28 visit. Staff also acknowledged that the facility learned of the compression pumps’ delivery only after finding them at the front of the building and that they should have followed up with the wound care provider regarding initiation of the pumps. Facility policies on wound care and medication/treatment orders required physician orders for procedures and administration of treatments only upon written orders, but did not address order transcription after appointments, and the failure to correctly transcribe and implement the wound care provider’s orders led to the identified deficiency.
Failure to Ensure Timely Diabetic Footwear and Foot Care Follow-Up
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary foot care and services for a resident with diabetes and mobility issues, specifically related to obtaining diabetic shoes. The resident had diagnoses including right knee pain, cognitive communication deficit, difficulty walking, and diabetes mellitus, with MDS assessments showing moderate cognitive impairment. The care plan identified actual risk for ADL/mobility decline and documented the need for staff assistance with ambulation and transfers, as well as encouragement of activity and exercise. A podiatry order form documented an order for diabetic shoes and heat-molded insoles, and nursing notes showed that staff attempted to contact the diabetic shoe provider multiple times over several days, faxing requested documents and leaving voicemails. After the last documented contact with the shoe provider, the EMR contained no further evidence of follow-up by the facility, despite the resident later stating she still needed diabetic shoes. Observation showed the resident seated or lying in her room, with a rough, calloused appearance on the right heel. A licensed nurse reported the facility had been working on obtaining the shoes for a year and a half and that the provider had not responded. An administrative nurse stated she expected weekly follow-up by nursing staff and acknowledged that the resident should at least have had an appointment date by that time. She later learned the resident had missed a prior appointment with the shoe provider and had not wanted to reschedule during a period of psychosis and involuntary placement, and that the provider had no record of further referrals beyond that missed appointment. The facility did not provide a policy on durable medical equipment or accommodation of needs.
Failure to Obtain and Provide Ordered CPAP Equipment
Penalty
Summary
The deficiency involves the facility’s failure to obtain and provide a physician‑ordered CPAP machine for a resident with COPD who was admitted with an active CPAP order. The resident’s EMR showed diagnoses including COPD and moderate cognitive impairment, with repeated BIMS scores of eight. The care plan dated 01/15/26 addressed continuous oxygen at 2 L and related interventions such as changing humidification and tubing, educating the resident on oxygen use, and observing oxygen precautions, but did not address the existing CPAP order. The EMR contained orders starting 08/08/25 for CPAP use at bedtime per home settings and for replacing distilled water in the humidifier prior to CPAP/BiPAP use. Review of the TAR from 08/08/25 to 01/31/26 showed numerous scheduled CPAP administrations documented as given, refused, on hold, or with other notations, despite the resident not having a CPAP machine in the facility. Multiple eMAR notes documented that the resident did not have CPAP equipment, did not use a CPAP, and stated the facility never obtained one. On observation, no CPAP machine was present in the resident’s room, and the resident confirmed she never received one and only used oxygen at night. A nurse acknowledged the resident never had a CPAP in the facility but had an order for it and stated she documented “refused” on the TAR both when the resident declined and when the machine was not available. Administrative nursing staff reported they did not know if the resident had a CPAP, indicated that residents usually brought their own machines, and stated the CPAP order should have been discontinued if no machine was available. The facility’s CPAP/BiPAP policy addressed reviewing physician orders for settings but did not address providing a CPAP machine.
Failure to Provide Ordered Mounjaro for Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide a physician‑ordered diabetes medication, Mounjaro, to a resident over an extended period. The resident had diagnoses including diabetes mellitus, pain in the right knee, cognitive communication deficit, difficulty in walking, and dementia with moderate cognitive impairment documented by BIMS scores of eight on both admission and quarterly MDS assessments. The resident’s care plan identified diabetes and included an intervention that staff would administer medications as ordered. An order in the EMR directed that Mounjaro 2.5 mg/0.5 mL be injected every Monday morning for diabetes starting in August. Review of the Treatment Administration Record showed that, between early September and the end of January, staff administered only two of 22 scheduled Mounjaro doses, with two doses left blank and 18 doses marked as “Other/See Nurses Notes.” Multiple eMAR notes documented that Mounjaro was unavailable, on order, or awaiting delivery or clarification, and later entries repeatedly stated that the medication was unavailable. One note indicated the facility was awaiting clarification on Mounjaro without specifying what clarification was needed, and another documented that the NP was notified without stating what was communicated. During this same period, a physician progress note recorded a fasting blood sugar over 500 mg/dL and ordered an increase in Lantus and an endocrinology appointment, but did not address the ongoing Mounjaro order. Nursing staff interviews revealed that the nurse responsible for the resident’s medications understood that Mounjaro required prior authorization and that the pharmacy had indicated it would be covered once but would need prior authorization for subsequent fills. The nurse stated her usual practice was to place residents needing prior authorization into the provider’s folder and document this in the EMR, and to call the provider if a resident had not received a medication. However, the administrative nurse reported she had not received any reports that the resident was not receiving Mounjaro and had not seen any prior authorization request for it, despite expecting staff to notify her and the physician after one missed dose. The resident reported not receiving Mounjaro injections and expressed a desire to be on the medication. The facility’s Pharmacy Services Overview policy required that residents have a sufficient supply of prescribed medications and receive them in a timely manner, which was not met in this case.
Failure to Implement and Document Fall Prevention Interventions After Resident Falls
Penalty
Summary
The facility failed to investigate, determine causative factors, and implement relevant interventions to prevent further falls for a resident with severe cognitive impairment and multiple medical conditions, including Lewy body dementia, brain neoplasms, reduced mobility, and a history of stroke. The resident was dependent on staff for bed mobility, transfers, and toileting, and used a wheelchair. Despite being identified as at risk for falls due to deconditioning, gait, and balance problems, the care plan did not include additional fall interventions after the resident was found lying face down on the floor at the bedside following a fall. After the initial fall, staff assessed the resident, found no visible injuries, and sent her to the hospital for evaluation. The only intervention documented in response to this fall was the hospital evaluation; no further fall prevention measures, such as floor mats or bolstered mattresses, were implemented at that time. The facility did not conduct a thorough investigation or root cause analysis beyond noting that the resident did not know what happened and had rolled out of bed. There was no evidence of additional interventions being added to the care plan following this incident. Subsequently, the resident experienced another unwitnessed fall from bed, resulting in a left femur fracture. Staff again assessed the resident, provided pain management, and sent her to the hospital after continued complaints of pain. Only after this second fall were interventions such as a bolstered mattress and fall mat put in place. Interviews with facility staff confirmed that no additional fall interventions were added after the first fall, and there was no documented investigation or comprehensive review of the incident. The facility's policy required staff to identify and implement interventions based on specific risks and causes, but this was not followed after the initial fall.
Lack of Qualified Dietary Manager in Facility
Penalty
Summary
The facility, with a census of 87 residents, failed to ensure that the director of food and nutrition services possessed the required qualifications of a certified dietary manager (CDM). This deficiency was identified through observation, record review, and interviews. Administrative Staff A acknowledged that the facility was in the process of hiring a new CDM and additional dietary staff. It was noted that the Registered Dietician was present at the facility at least twice a week, but there was no CDM currently employed. The facility was unable to provide a policy regarding the CDM when requested, indicating a lack of compliance with staffing requirements for the food and nutrition services department. This situation placed residents at risk for unmet dietary and nutritional needs.
Deficiencies in Food Storage and Dishwashing Practices
Penalty
Summary
The facility, with a census of 87 residents, was found to have deficiencies in food storage and dishwashing practices during a survey. Observations revealed that the kitchen had an area with missing ceramic tiles, exposing cement flooring, and the freezer temperature logs had not been updated since two days prior to the survey. Additionally, clean plates were stored without covers, and several food items in the refrigerator and freezer were not labeled or dated, including pre-cooked hot dogs, sausage links, roast beef slices, and opened milk jugs. These practices did not comply with the facility's updated Food Receiving and Storage policy, which requires all food to be covered, labeled, and dated. Furthermore, the facility's high-temperature dishwasher was not functioning properly, as it failed to reach the required temperature of at least 180 degrees during the rinse cycle, necessary for sanitizing kitchenware and dishes. This issue was reported to maintenance for repair. The dietary consultant acknowledged the lack of labeling and dating of food items and mentioned ongoing renovations, including fixing the kitchen flooring. The administrative staff confirmed that a specialist was contracted to repair the dishwasher. These deficiencies in food storage and dishwashing placed residents at risk of foodborne illness and cross-contamination.
Inadequate Facility-Wide Assessment for Resident Care
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment did not specify the staffing levels required for each unit, including the number of RNs, LPNs/LVNs, CMAs, and CNAs needed based on patient acuity and census. Additionally, the assessment lacked details on staffing-specific skill sets for each resident unit, a contingency plan for non-emergency events that could impact resident care, and a strategy for recruiting and retaining direct care staff. Furthermore, the assessment did not incorporate input from residents and their representatives. During an interview, Administrative Nurse D mentioned that the facility was in the process of updating the assessment. However, the facility was unable to provide a policy related to the facility assessment when requested. This oversight placed all 87 residents at risk for impaired care due to the lack of a thorough and updated assessment.
Inadequate Infection Control and Water Management
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, as evidenced by the lack of signage or indicators for Enhanced Barrier Precautions (EBP) in rooms of residents requiring such precautions. During inspections, it was observed that several residents with medical devices such as PEG tubes, tracheostomies, and catheters did not have readily available personal protective equipment (PPE) or appropriate signage to alert staff and visitors of the necessary precautions. Additionally, respiratory equipment was found stored in an unsanitary manner, with nebulizer masks and cannulas left uncontained. The facility also failed to maintain adequate water management practices, particularly concerning Legionella prevention. There was no documented plan for managing and preventing Legionella contamination, and the water temperature in the laundry facilities was insufficient for effective cleaning and disinfection. The washer temperature was recorded at only 134 degrees Fahrenheit, below the required 165 degrees Fahrenheit, due to issues with the hot water system. Furthermore, staff did not consistently perform adequate hand hygiene, as observed when CNAs donned gloves without washing their hands and handled soiled laundry without proper containment. These practices, along with the lack of sanitary storage for respiratory equipment and improper transport of linens, placed residents at risk for infectious diseases. The facility's policies on maintenance, hand hygiene, and EBP were not effectively implemented, contributing to these deficiencies.
Failure to Ensure Agency Staff Training
Penalty
Summary
The facility failed to ensure that agency staff received the required communication training, which placed residents at risk for impaired care and decreased quality of life. The facility had a census of 87 residents and was unable to provide proof of training records for agency staff, specifically for Certified Nurse's Aides (CNA) N, O, and P. During an interview, Administrative Nurse D stated that the facility did not keep records for agency staff onsite and relied on the agency company to track their training. The facility's policy required all staff, including agency or contractual staff, to participate in orientation and annual in-service training, but the facility did not verify or maintain records of such training for agency staff.
Failure to Ensure Agency Staff Training on Resident Rights
Penalty
Summary
The facility, with a census of 87 residents, failed to ensure that agency staff received the required resident rights training, which is essential for providing proper care and maintaining the quality of life for residents. During a review on 09/11/24, the facility was unable to provide proof of training records for agency staff, specifically for Certified Nurse's Aides (CNA) N, O, and P. Administrative Nurse D confirmed that the facility did not keep records for agency staff onsite, relying instead on the agency company to track their training. The facility's policy required all staff, including agency or contractual staff, to participate in orientation and annual in-service training, but the facility did not verify or maintain records of such training for agency staff. This oversight placed residents at risk for impaired care and decreased quality of life.
Failure to Ensure Infection Control Training for Agency Staff
Penalty
Summary
The facility, with a census of 87 residents, failed to ensure that agency staff received the required infection control training, which is a part of its infection prevention and control program. During a review on 09/11/24, the facility was unable to provide proof of training records for agency staff, specifically for Certified Nurse's Aides (CNA) N, O, and P. Administrative Nurse D confirmed that the facility did not maintain records for agency staff training onsite, relying instead on the agency company to track their training. The facility's policy required all staff, including agency or contractual staff, to participate in orientation and annual in-service training. However, the facility did not verify or keep records of the agency staff's training, leading to a deficiency in ensuring the completion of the required infection control training for staff providing care in the facility.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility, with a census of 87 residents, failed to provide adequate activities on weekends that met the residents' interests, social needs, and preferences. A review of the facility's Activity Calendar for July, August, and September 2024 revealed that only self-led activities were offered on Saturdays and Sundays in August and September, with no structured or group activities available. The Resident Council reported a lack of activities on weekends due to the absence of available staff to direct or assist with activities. Activities Staff Z confirmed that she worked Monday through Friday and had an assistant who previously provided activities on weekends, but he no longer worked those days. Certified Nurse's Aide M also noted that activities staff were not present on weekends, leaving residents with only self-led activities. The facility's Activities policy, revised in May 2013, stated that residents should be provided with activities reflecting their choices and interests, but this was not adhered to on weekends, placing residents at risk for boredom, isolation, and decreased quality of life.
Failure to Conduct Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review (MRR) for several residents, including those identified as R31, R79, R28, R39, and R50. The MRRs from October 2023 to December 2023 were not provided, and the facility could not locate the consultant pharmacist's (CP) recommendations for this period. This lack of documentation and review placed residents at risk for unnecessary medication effects and related complications. For Resident 31, the facility did not ensure that the CP identified and recommended a CMS-approved indication or a gradual dose reduction (GDR) for the antipsychotic medication Seroquel. The resident's records lacked a physician's documented clinical rationale for the continued use of Seroquel without a GDR or approved indication. Similarly, Resident 79's records showed a lack of CP recommendations for a CMS-approved indication for Seroquel or a GDR, and the facility failed to identify and report the lack of dosing instructions for Voltaren gel. Resident 28's records also lacked evidence of CP recommendations for a GDR or CMS-approved indication for the antipsychotic medication quetiapine. Additionally, the facility failed to identify and report the lack of dosing instructions for Voltaren gel. For Resident 39, the facility did not ensure that the CP identified and reported that antihypertensive and diuretic medications were administered outside the physician-ordered parameters. These deficiencies placed the residents at risk for unnecessary medication use, side effects, and physical complications.
Failure to Provide Necessary Dining Accommodations
Penalty
Summary
The facility failed to provide necessary accommodations for a resident, identified as R44, who required specific utensils and a divided plate to feed herself due to her medical conditions. R44's medical history included schizophrenia, obesity, hypertension, edema, anemia, anxiety, weakness, hypoxia, and dysphagia, with a severely impaired cognitive status and physical impairments on both sides of her body. Her care plan specified the use of a divided plate and built-up utensils, yet observations revealed that these accommodations were not consistently provided. On multiple occasions, R44 was given regular plates and utensils without foam grips, requiring her to request the appropriate items from staff. Interviews with staff members, including a Certified Nurse's Aide, a Licensed Nurse, and an Administrative Nurse, indicated a lack of clarity and responsibility regarding the provision of the correct dining tools. The dietary department was supposed to supply the necessary items, while nursing staff were expected to ensure their use. However, this coordination failed, as evidenced by R44's repeated need to ask for the correct utensils and plates. The facility did not have an accommodation of needs policy available, contributing to the oversight and leaving R44 vulnerable to unmet care needs.
Failure to Provide Correct ABN Form to Residents
Penalty
Summary
The facility failed to provide the correct Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage (ABN) form, CMS-10055, to three residents, which should have included the estimated cost for continued skilled services. Instead, the facility issued form CMS-R-131, which did not contain the necessary cost information. This oversight affected residents who had completed their Medicare Part A episodes but remained in the facility for custodial care. Specifically, the records for three residents showed that they were not given the appropriate notice, potentially impacting their ability to make informed decisions about their care. Interviews with facility staff revealed a misunderstanding regarding the correct ABN form to use. Social Services staff indicated that they were instructed to use a different form, and the Director of Nursing had only recently provided the updated CMS-10055 form to be used starting in October 2024. The facility's policy, last revised in September 2022, stated that residents should be informed in advance of any changes to their billing, but this was not adhered to in these cases. This deficiency placed the residents at risk of making uninformed decisions regarding their continued care.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide written notice of transfer or discharge for a resident, identified as R39, during facility-initiated transfers to the hospital. R39, who had diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, hypertension, and sleep apnea, was transferred to the hospital on multiple occasions without receiving the required written notification. The resident's electronic medical record and care plan indicated intact cognition and an increased risk of adverse side effects from medications, necessitating careful monitoring and communication. Despite these needs, the facility did not provide evidence of written notification to R39 or their legal representative for the transfers. Interviews with facility staff revealed a lack of clarity regarding responsibility for sending such notifications, with Social Services and nursing staff assuming phone notifications sufficed. The facility also lacked a policy related to written notification for facility-initiated transfers, contributing to the deficiency and placing R39 at risk of uninformed choices and miscommunication regarding care needs.
Failure to Complete Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments for two residents, R84 and R17, within the required 92-day timeframe. For R84, an Admission MDS was completed on 04/30/24, with the next quarterly assessment reference date (ARD) set for 07/31/24. However, the quarterly MDS was started on 07/26/24 but never completed, leaving no completed and accepted MDS assessments since 04/30/24. Similarly, for R17, a quarterly MDS was completed on 04/19/24, with the next quarterly ARD set for 07/19/24. The quarterly MDS was started on 07/19/24 but remained incomplete, with no completed and accepted MDS assessments since 04/19/24. Administrative Staff C, who took over completing the MDS assessments after an ownership change, stated that she completed the assessments remotely and relied on reports from nurses, social workers, and therapists for any changes and pertinent information. She acknowledged the requirement to update MDS assessments quarterly, annually, and with significant changes. Despite reviewing the system and flagging due assessments, she was unaware that R17 and R84's assessments were past due, as the system typically flagged and alerted her. This oversight placed the residents at risk for unidentified and unmet care needs.
Failure to Provide Consistent Bathing for a Resident
Penalty
Summary
The facility failed to ensure consistent bathing for a resident, identified as R44, who required assistance from staff to complete activities of daily living (ADLs). R44's medical history included schizophrenia, obesity, hypertension, edema, anemia, anxiety, weakness, hypoxia, and dysphagia. The resident was documented as having severely impaired cognition and was dependent on staff for all ADLs. Despite this, the facility's records showed that R44 did not receive a bath or shower from August 31, 2024, through September 10, 2024. Observations noted that R44's hair appeared greasy, and she had long fingernails, indicating a lack of personal hygiene care. Interviews with staff revealed that Certified Nurse Aides (CNAs) were responsible for filling out bath sheets to ensure residents received baths, and nursing staff were expected to check these sheets. However, there was uncertainty among staff about whether baths were documented in the Electronic Medical Record (EMR). The facility's bathing policy required staff to notify supervisors if a resident refused a bath and to report any issues according to facility policy. The failure to provide consistent bathing for R44 placed her at risk for complications related to poor hygiene and impaired dignity.
Inadequate Pressure Ulcer Prevention Due to Improper Mattress Settings
Penalty
Summary
The facility failed to ensure that the low air-loss mattress pumps for two residents, R37 and R26, were set and functioning correctly for adequate pressure relief, placing them at risk for complications related to skin breakdown and pressure ulcers. R37, who had severe cognitive impairment and was dependent on staff for activities of daily living, had a low air-loss mattress set at 350 lbs, which was not adjusted according to his weight of 206 lbs. The care plan for R37 lacked guidance on the appropriate settings for the mattress, and there was no documentation in the electronic medical records regarding the mattress settings. R26, who was at high risk for pressure ulcers due to severe cognitive impairment and other medical conditions, also had a low air-loss mattress set at 350 lbs, despite weighing only 107.2 lbs. Additionally, the mattress was found to be unplugged and deflated during an inspection. The care plan for R26 did not provide direction on the use of the low air-loss mattress or the appropriate weight settings. Interviews with staff revealed that the mattresses were installed and set by central supply based on the residents' weights, but there was a lack of clarity and documentation regarding the specific settings required for each resident. The facility did not provide a policy related to pressure ulcer prevention or the use of low air-loss mattress systems, contributing to the deficiency in care for these residents.
Failure to Provide Restorative Care and ROM Services
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve the range of motion (ROM) for three residents, R26, R50, and R9, leading to a risk of worsening contractures. R26, diagnosed with Huntington's disease and other conditions, was dependent on staff for all activities of daily living (ADLs) and was not receiving restorative treatment. Observations noted that R26's hands were curled and closed, indicating a lack of ROM exercises. Interviews with staff revealed that the facility did not have a restorative program in place, and there was no documentation of ROM exercises being performed for R26. R50, who had suffered a stroke resulting in left-sided hemiplegia, was also not receiving the necessary restorative services to maintain her ROM and ADL abilities. Despite being dependent on staff for various ADLs, R50 was only provided with a list of self-led exercises, which she struggled to perform due to her condition. The facility lacked documentation of any passive or active ROM activities for R50, and staff did not monitor or assist her with the exercises, leaving her at risk for further decline while waiting for therapy services to begin. R9, diagnosed with multiple sclerosis and a contracture of the right hand, was supposed to have a palm guard splint applied daily to reduce digit contracture. However, the splint was not applied on several occasions due to its unavailability, and R9 was not on any restorative program. Interviews with staff indicated a lack of awareness and documentation regarding the splint's application, further contributing to the risk of decreased mobility and impaired quality of life for R9.
Failure in Dialysis Communication and Monitoring
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding a resident's health status with each procedure. The resident, who had diagnoses of major depressive disorder, end-stage renal failure, and muscle weakness, required dialysis services three times a week. The facility's records indicated that the resident was not weighed before dialysis appointments on eight occasions, as required by the physician's orders. Additionally, the dialysis communication binder lacked completed communication sheets for several dates, indicating a failure to document and relay necessary health information between the facility and the dialysis center. Interviews with facility staff revealed that it was their responsibility to ensure weights were recorded and communication sheets were filled out. However, the inspection of the dialysis communication binder showed that this was not consistently done. The facility's Hemodialysis policy emphasized the importance of coordinating with the dialysis center to monitor changes in the resident's condition, but this was not adhered to, placing the resident at risk for complications related to end-stage renal failure.
Failure to Conduct Proper Safety Assessment for Bed Rails
Penalty
Summary
The facility failed to ensure that a resident, identified as R37, had a proper safety assessment for the use of side rails, consent for their use, and that the resident and/or responsible party were informed of the risks and benefits associated with side rails. R37's medical records indicated diagnoses of anxiety, congestive heart failure, and Parkinsonism, with a severe cognitive impairment score. The resident required assistance with activities of daily living and had a low air-loss mattress, but there was no documentation of the use of bilateral bed cane-style side rails in the care plan or physician orders. Observations and interviews revealed that the facility did not conduct a safety assessment that considered the risks associated with the low air-loss mattress. Although a Nursing Entrapment Risk Assessment was completed, it failed to identify these risks. Staff inspections of the bed were conducted each shift, but documentation of quarterly inspections was unclear. The facility's policy required an assessment of the resident's environment, medical conditions, functional abilities, and safety risks before implementing bed rails, which was not adhered to in this case.
Failure to Follow Physician Orders and Provide Complete Medication Instructions
Penalty
Summary
The facility failed to ensure that antihypertensive medication was administered according to physician-ordered parameters for a resident with multiple diagnoses, including hypertension and atrial fibrillation. The resident's medication administration record revealed that Torsemide and Carvedilol were given outside the specified parameters on several occasions, despite orders to hold the medication if certain blood pressure or heart rate thresholds were not met. Interviews with administrative nurses confirmed that medications should be administered as ordered, and the facility's policy required specific instructions for medication orders. Additionally, the facility did not provide dosing instructions for Voltaren gel for two residents, one with anxiety and depressive disorder and another with arthritis and Lewy body dementia. The orders for Voltaren gel lacked specific dosage amounts, which was against the facility's medication orders policy. Administrative nurses acknowledged that all medication orders should include dosing instructions and that the consultant pharmacist should have identified the missing information during monthly medication reviews. These deficiencies placed the residents at risk for unnecessary medication use, side effects, and physical complications. The facility's failure to adhere to physician orders and ensure complete medication instructions contributed to these risks, as confirmed by the observations, record reviews, and staff interviews conducted during the survey.
Failure to Ensure CMS-Approved Indication for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that three residents, identified as R28, R31, and R79, had a CMS-approved indication or the required physician documentation for the use of antipsychotic medications without attempts at gradual dose reduction (GDR). For Resident 28, the electronic medical record documented diagnoses of anxiety, depressive disorder, and psychosis, with a BIMS score indicating intact cognition. Despite receiving antipsychotic medication, there was no documentation of a GDR attempt or physician documentation contraindicating a GDR. The facility was unable to provide evidence of the required physician documentation for the continued use of Seroquel. Resident 31's records showed diagnoses of hypertension, delusional disorders, and vascular dementia, with severely impaired cognitive skills. The resident routinely received antipsychotic medication, but no GDR was attempted or documented as clinically contraindicated. The facility lacked a physician's documented clinical rationale for the continued use of Seroquel without a GDR or approved indication for use. Observations noted that the resident displayed no behaviors that would necessitate the continued use of the medication. Resident 79's records indicated diagnoses of hallucinations, anxiety disorder, Lewy body dementia, and Parkinson's disease, with severely impaired cognitive skills. The resident received antipsychotic medications routinely, but no GDR was attempted. The facility failed to provide a physician's documented clinical rationale for the continued use of Seroquel without a GDR or approved indication for use. Observations noted that the resident was pacing with a staff member, and the facility was unable to provide the necessary documentation upon request.
Deficient Communication with Hospice Provider
Penalty
Summary
The facility failed to ensure a proper communication process was implemented between the facility and the hospice provider for a resident receiving hospice services. The resident, identified as R24, had multiple diagnoses including fibromyalgia, arthritis, brain damage, hypertension, epilepsy, anxiety, depressive disorder, and dysphagia. The resident's care plan indicated they were at the end of life and receiving hospice services, but it lacked documentation of communication with nursing staff regarding the specific services, medication, and equipment provided by hospice. This lack of documentation and communication created a risk of missed or delayed services and inadequate end-of-life care for the resident. Observations and interviews revealed that staff were unsure about the location of hospice care plans and whose responsibility it was to update facility care plans with hospice-provided services. A Certified Nursing Aide thought the care plans were in binders at the nurse's desk, while a Licensed Nurse was unsure about the duty of updating care plans. An Administrative Nurse stated that the facility collaborates with hospice through the plan of care, which should include schedules for hospice staff visits and details of equipment and medication provided. However, the facility did not provide a hospice policy, indicating a lack of structured collaboration with the hospice provider.
Failure to Provide Mail Delivery on Saturdays
Penalty
Summary
The facility failed to provide mail delivery services to residents on Saturdays, as identified during a survey with a census of 87 residents and a sample of 20 residents. Observations and interviews revealed that the mail was stored over the weekend at the east nurse's station and distributed the following Monday. The Resident Council reported the absence of mail services on Saturdays, attributing it to the weekend activity staff no longer being available. Activities Staff Z confirmed that she worked only Monday through Friday and that her assistant, who previously handled weekend mail distribution, no longer worked weekends. Certified Nurse's Aid M and Administrative Nurse D both indicated a lack of awareness or responsibility for mail distribution on weekends. The facility's undated mail policy stated that mail should be delivered unopened and within 24 hours of receipt, which was not adhered to on Saturdays.
Resident Abuse Incident Involving CNA
Penalty
Summary
The facility failed to protect a resident from abuse when a Certified Nurse Aide (CNA) attempted to pull a call light from the resident's hands, resulting in the resident being pulled from the bed onto the floor. This incident placed the resident at risk of pain, injury, and ongoing abuse. The resident, who had a history of Parkinson's disease, anxiety, and depression, reported the abuse, stating that the CNA's actions caused him to fall and hurt his back. The resident's medical records indicated intact cognition and required assistance with certain activities of daily living. The care plan included interventions for monitoring pain, anxiety, and depression, as well as ensuring a safe environment with a reachable call light. Despite these measures, the incident occurred, and the resident reported the abuse to multiple staff members, who documented the resident's account of being pulled from the bed and sustaining a back injury. The facility's policy on abuse, neglect, and exploitation lacked a date but stated that protections would be provided for residents' health, welfare, and rights. However, the facility did not ensure the resident remained free from abuse, as evidenced by the CNA's actions. The incident was reported to the police, and the resident consistently described the event to various staff members, corroborating the account of being pulled from the bed and injured.
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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