Phillips County Retirement Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Phillipsburg, Kansas.
- Location
- 1300 State Street, Phillipsburg, Kansas 67661
- CMS Provider Number
- 17E658
- Inspections on file
- 16
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Phillips County Retirement Center during CMS and state inspections, most recent first.
A resident with dementia, behavioral symptoms, impaired cognition, and osteoporosis experienced multiple falls, including falls with major injury and a hip fracture requiring surgery. The facility repeatedly failed to complete root cause analyses after these falls, did not finish required dementia and falls CAAs, and delayed implementing individualized interventions such as assisted transfers, toileting schedules, frequent checks, and environmental modifications. Many fall investigations were missing or incomplete, and staff on the floor lacked access to the care plan and did not independently develop fall-prevention measures, relying instead on a CNA and an RN to determine and communicate interventions, sometimes weeks after the events.
Surveyors found that the facility did not provide RN coverage for at least eight continuous hours daily and did not employ a full-time RN as DON. Review of posted staffing sheets and PBJ data showed numerous days with no RN hours recorded, despite a facility policy stating an RN would be employed for at least eight consecutive hours, seven days a week. Administrative staff confirmed there had been no RN in the DON role for an extended period, that the current DON is an LPN enrolled in an RN program, and that the DON job description did not require an active RN license.
The facility failed to implement core elements of an antibiotic stewardship program within its infection prevention and control system for a census of 29 residents, including a sample of 12. The Infection Control Log for a one-year period lacked documentation of organism identification, duration of prescribed antibiotics, and the infections treated, and this information could not be produced when requested. The Infection Preventionist, an administrative nurse, stated she only tracked which residents were on antibiotics in the EMR and was unable to provide tracking and trending data, noting that floor nurses were not completing the infection tracking documents. These practices did not conform to the facility’s Infection Preventionist policy, which required effective management of the infection prevention program using evidence-based practices and compliance with CMS and state regulations.
The facility failed to designate a staff member with the required qualifications and certification to serve as the Infection Preventionist for its infection prevention and control program, despite having 29 residents. An administrative nurse was identified by administration as the IP and had completed continuing education on Enhanced Barrier Precautions and antibiotic stewardship surveillance, but she confirmed she did not hold an Infection Preventionist certificate. Although the facility maintained an antibiotic administration and stewardship policy, there was no evidence that a properly certified IP was responsible for overseeing the infection prevention and control program.
Surveyors found that the facility failed to complete required Care Area Assessments (CAAs) for four residents whose annual MDS assessments triggered multiple areas, including ADL functional/rehab potential, cognitive loss/dementia, communication, urinary incontinence and indwelling catheter, behavioral symptoms, mood, falls, nutritional status, dehydration/fluid maintenance, dental care, pressure ulcer/injury, physical restraints, psychotropic drug use, and pain. An administrative nurse acknowledged that these CAAs were missed and stated she was still learning how to complete MDS assessments, despite a facility policy committing to accurate, timely, and complete MDS assessments.
The facility failed to accurately complete MDS assessments for several residents by coding bedrails as physical restraints used daily, even though the bedrails did not restrict residents’ mobility and were not actually used as restraints. An administrative nurse reported that she routinely marked bedrails as restraints on the MDS whenever a bed had rails installed, regardless of actual use or effect on mobility. This practice conflicted with the facility’s own policy committing to accurate, timely, and complete MDS assessments.
Surveyors observed an RN using a hallway medication cart to prepare medications, then walking away into resident rooms while leaving the cart unlocked and unattended, with the lock not engaged and the cart out of staff visual range. The RN acknowledged that both the cart and computer monitor should be locked whenever unattended, and an administrative nurse confirmed this expectation. This practice did not comply with the facility’s Medication Labeling and Storage policy, which requires all medications to be stored in a secure, locked location accessible only to designated staff.
Surveyors found that respiratory devices, including a CPAP mask and several nebulizer masks, were left on bedside surfaces or in personal items without sanitary containers, contrary to facility expectations for cleaning, drying, and bagging labeled respiratory equipment. Staff were also observed mishandling soiled laundry by carrying unbagged items against their uniforms instead of using appropriate transport methods. In addition, a CNA provided care to a resident with a urinary catheter while handling a urine-filled graduated cylinder wearing only gloves, despite EBP signage and training indicating that gown and gloves were required. Although the facility had policies for respiratory care and laundry, it could not provide a policy for Enhanced Barrier Precautions.
A dependent resident with severe cognitive impairment and multiple diagnoses, including Alzheimer’s disease and dementia, was observed seated in a Broda chair in a TV area wearing only a hospital gown and a sheet, which she lifted, exposing her incontinence brief to two male peers. Staff, including a CNA, an LPN, and an administrative nurse, acknowledged that residents should be fully dressed or completely covered before leaving their rooms and that incontinence briefs should never be exposed in common areas. The facility’s Resident Rights Policy states that residents are entitled to a dignified existence and that all staff must protect these rights, but this was not upheld in this incident.
A resident with hypertension, DM, severely impaired cognition (BIMS 0), and dependence in most ADLs was receiving multiple psychotropic medications, including an antianxiety agent. The EMR contained an order for lorazepam cream 0.5 mg to be applied every eight hours and PRN for dementia, but the order did not include the required 14-day stop date or any specified duration, and there was no physician rationale documented for extended PRN use. Staff interviews indicated that nurses were expected to notify physicians that PRN lorazepam required a stop date and that the DON was a second check for orders, yet this did not occur, and the facility was unable to provide its unnecessary psychotropic drug policy when requested.
The facility failed to complete a thorough facility-wide assessment to determine necessary resources for competent resident care during routine operations and emergencies. The self-assessment did not specify required staffing levels by unit, shift, or discipline (RN, LPN/LVN, CMA, CNA), nor did it incorporate resident acuity or census. It lacked complete resident condition reports, omitted documentation of staff competencies and skill sets needed for the resident population, and did not fully list contractual agreements for lab, radiology, therapy, hospital, transportation, lawn care, or snow removal services. An administrator acknowledged missing staffing breakdowns, uncompleted required sections, and unchecked competencies such as Safety and Missing Resident for all staff, despite a facility policy stating the assessment should guide staffing, competencies, and resource needs, including third-party contracts, for both day-to-day operations and emergencies.
A resident with paraplegia was left unsupervised outside by a CNA, resulting in the resident being found unresponsive with a high body temperature. The facility failed to follow the resident's care plan, which required supervision and assistance, and did not conduct a thorough investigation into the incident.
The facility did not employ a full-time RN as the Director of Nursing (DON) and failed to provide RN coverage for eight consecutive hours daily, as required by their policies. This deficiency was identified through a review of the 2023 nursing schedule, which showed more than 50 instances of inadequate RN coverage. Administrative Staff A confirmed the lack of a full-time DON and consistent RN coverage, citing challenges in securing RNs, which placed 31 residents at risk for inadequate care.
The facility failed to implement a water management program to address Legionella and other waterborne pathogens, placing residents at risk. Maintenance staff confirmed the absence of routine checks, and administrative staff lacked records of water monitoring. The facility's policy required risk assessments and control measures, but these were not followed, exposing residents to potential infection.
The facility failed to ensure a safe environment by leaving a chemical bottle in an unlocked cabinet in a kitchenette, risking the safety of 12 cognitively impaired, independently mobile residents. A LN confirmed the cabinet should be locked and moved the bottle to a secure location. An Administrative Nurse expected chemicals to be stored in locked cabinets, but the facility lacked a chemical storage policy.
A resident with paraplegia was found unresponsive outside in a wheelchair, showing signs of distress. Staff intervened, but the facility failed to report the incident to the State Agency or conduct an investigation. The resident was later observed outside again, unable to re-enter the facility independently, highlighting ongoing neglect issues.
A resident with paraplegia was found unresponsive outside in a wheelchair, with no means to contact the facility for help. The incident occurred when a CNA left the resident outside and went off shift without informing incoming staff. The facility failed to conduct a thorough investigation, as required by their policy, placing the resident at risk for ongoing neglect.
A resident with stasis ulcers on her shins did not have an updated care plan addressing her skin integrity needs. Despite having conditions like weakness, neuropathy, and localized edema, the care plan lacked instructions for wound care. Observations showed that staff were unaware of the treatment for the ulcers, and the administrative nurse admitted the care plan was not updated as required by facility policy. This oversight risked the resident's quality of care due to uncommunicated needs.
A facility failed to ensure a physician responded to a pharmacist's recommendation for a stop date on a resident's PRN lorazepam, risking unnecessary psychotropic side effects. The resident, with anxiety and hypertension, continued receiving the medication without a specified stop date, contrary to facility policy requiring a 14-day limit for PRN psychotropic drugs.
A facility failed to ensure a 14-day stop date or specified duration for a resident's PRN antianxiety medication, lorazepam. The resident, with anxiety and hypertension, received lorazepam for sleep and behavior issues, but the physician's order lacked a stop date. Observations confirmed the medication was administered without a stop date, contrary to the facility's policy requiring a 14-day stop date for PRN psychotropic medications.
A facility failed to label a resident's insulin flex pen with the date opened and discard date, as observed on a treatment cart. This was confirmed by an administrative nurse, who stated that nurses are required to date flex pens upon opening and discard expired medications. The facility's policy requires medications to be stored securely and labeled for single-resident use to prevent cross-contamination. This oversight placed the resident at risk for ineffective medication.
A facility failed to coordinate hospice care for a resident with Alzheimer's, aphasia, and dementia, leading to a lack of a comprehensive care plan. The resident's care plan did not include hospice services, and there was no communication book or external document related to hospice care. An administrative nurse confirmed the absence of hospice information in the facility's records, despite the facility's policy requiring a coordinated plan of care.
The facility did not obtain signed consent for flu vaccinations for three residents, as their medical records lacked evidence of being offered the vaccine. Despite sending out consent forms annually, the facility did not follow up on unreturned forms, leading to some residents not receiving vaccinations. Administrative Nurse D acknowledged the difficulty in contacting some residents' representatives. The facility's policy required offering vaccinations on admission and annually, with documentation of immunization status.
Failure to Perform Resident-Centered Post-Fall Analysis and Timely Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to conduct resident-centered post-fall analyses and to implement timely, appropriate fall-prevention interventions for a cognitively impaired resident with multiple falls and serious injuries. The resident had dementia, anxiety, and osteoporosis, with documented memory problems, moderately impaired cognition, behavioral symptoms, rejection of care, and wandering. MDS assessments showed the resident required assistance with transfers and walking, self-propelled in a wheelchair, and had multiple falls, including falls with major injury. Despite these risk factors, the Cognitive Loss/Dementia and Falls Care Area Assessments triggered on 10/07/25 were not completed, and the care plan, while listing numerous generic fall-risk interventions, did not consistently reflect individualized analysis of why specific falls occurred. Across numerous documented falls, the facility’s fall investigations were incomplete or missing, and root cause analyses were not performed. For a fall on 08/05/24, the post-fall evaluation noted a non-injury fall, but the investigation lacked an RCA, and only a general intervention to place grip strips in front of recliners was documented. The facility could not provide any fall investigations or interventions for falls on 10/04/24, 11/01/24, and 12/23/24. For other falls on 10/03/24, 11/02/24, 12/22/24, and 12/28/24, investigations were provided but did not identify causal factors, and interventions such as assistance with gait belt and walker, toileting after evening meal, 15-minute checks, use of a recliner in the commons area, and placement in a low bed were initiated 18–22 days after the falls. A fall report dated 01/03/25 documented a fall with minor injury, but the progress notes contained no corresponding entry, and the fall report again lacked an RCA. The resident experienced a series of significant events related to falls and injuries that were not linked to timely, resident-specific analysis. After a non-injury fall on 12/23/24, the resident later reported increased pelvic, hip, and lower back pain, leading to x-rays that revealed a right greater trochanteric fracture. The resident was initially returned from the ED with non-surgical management orders, but the next day had another unwitnessed fall with right leg shortening and rotation, and was sent back to the ED where the fracture was found to be worse, further fractured, and dislocated, ultimately requiring surgery. A later fall on 02/12/25 resulted in left leg pain and outward rotation and was classified as a fall with major injury, yet the associated investigation again lacked an RCA. Additional falls on 07/10/25, 09/23/25, 10/25/25, 12/05/25, 12/14/25, and 01/08/26 were documented in post-fall evaluations, but the report does not describe completed, detailed causal analyses for these events. Facility processes and staff practices contributed to the deficiency. Floor nurses and CNAs reported they did not have access to the electronic care plan and relied on Administrative Staff C and Administrative Nurse D to determine and communicate fall interventions, often via shift report or an intervention book. Staff stated they did not create or implement their own fall-prevention interventions, and that the care plan book was often kept in an office, limiting access. Administrative Nurse D acknowledged that fall investigations were incomplete or missing, lacked root cause analysis, and that the facility did not have a fall packet to guide staff documentation. She also stated that IDT meetings to review falls and develop interventions were not consistently held within 24–48 hours and were now held only when possible due to scheduling conflicts. Administrative Staff C, a CNA, reported she was in charge of care plan interventions for falls, could revise care plans without DON approval, and that residents could go two to four weeks between a fall and the development of a new intervention, further demonstrating the lack of timely, resident-centered analysis and intervention after falls. The facility’s own Fall Prevention Protocol 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. However, the pattern of missing or incomplete fall investigations, absence of root cause analyses, delayed implementation of interventions, and limited staff access to and involvement in care planning for falls shows that this protocol was not followed for this resident. The repeated falls, including those resulting in major injuries and surgery, occurred in the context of these systemic failures in post-fall assessment and individualized intervention planning.
Failure to Maintain Required RN Coverage and Full-Time RN DON
Penalty
Summary
The deficiency involves the facility’s failure to provide required RN coverage for at least eight continuous hours daily and to employ a full-time RN as the DON. Surveyors observed the posted daily staffing sheets on three separate days and found no RN hours documented. Review of the facility’s Payroll Based Journal (PBJ) staffing data for FY Q4 2025 showed multiple dates across July, August, and September with no recorded RN hours. The facility’s own undated Registered Nurse policy stated that an RN would be employed for at least eight consecutive hours, seven days per week, but the documented staffing patterns did not reflect this requirement. Administrative staff confirmed that the facility had not had an RN serving in the DON role since 2023 and that the individual currently functioning as DON was an LPN enrolled in an RN program, with an anticipated completion date in the future. Administrative staff also confirmed the accuracy of the PBJ report for dates with no RN coverage and declined to review those dates with the survey team. They reported that the facility did not provide skilled services, stating those were provided by a neighboring hospital, and that the facility was actively but unsuccessfully recruiting RNs. The job description for the DON provided to surveyors did not specify that the DON must hold an active, unencumbered RN license, further evidencing the lack of a full-time RN in the DON role as required.
Failure to Implement Core Elements of Antibiotic Stewardship
Penalty
Summary
The facility failed to develop and implement the core elements of an antibiotic stewardship program as part of its infection prevention and control program for its 29 residents, 12 of whom were included in the sample. Review of the Infection Control Log for tracking and trending infections from March 2025 through February 2026 showed no documentation of organism identification, duration of prescribed antibiotics, or the specific infections being treated, and the facility was unable to provide this information when requested. The Infection Preventionist, who was also an administrative nurse, reported that she only tracked which residents were taking antibiotics in the EMR and confirmed she could not provide tracking and trending data for antibiotic use. She stated that floor nurses were expected to open the infection document for tracking but were not completing the form, leaving her with only records of antibiotics that residents had taken for infections, without the additional required details. This practice did not align with the facility’s Infection Preventionist policy, which assigned responsibility for effective direction, management, and operation of the infection prevention program, including use of evidence-based practices and compliance with CMS and state regulatory requirements. No additional resident-specific medical histories or conditions at the time of the deficiency were provided in the report.
Lack of Qualified Infection Preventionist for Infection Control Program
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) with the required training and certification to be responsible for the Infection Prevention and Control Program for a census of 29 residents. During the entrance conference, an administrative staff member identified an administrative nurse as the facility’s IP, stating she was a licensed nurse who had been completing continuing education in infection prevention. Documentation provided by the facility showed that this nurse had completed education on Enhanced Barrier Precautions and implementation of an antibiotic stewardship surveillance plan. In a subsequent interview, the administrative nurse confirmed she had been performing IP duties and participating in continuing education but acknowledged she did not hold an Infection Preventionist certificate, and that the facility’s plan was for her to take the course and obtain the certificate. The facility also had an undated antibiotic administration policy describing appropriate use and stewardship of antibiotics, but there was no evidence that a properly qualified and certified IP had been designated to oversee the infection prevention and control program.
Failure to Complete Required CAAs for Multiple Residents’ Annual MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to complete required Care Area Assessments (CAAs) for multiple residents whose comprehensive Minimum Data Set (MDS) assessments triggered these areas. The facility had a census of 29 residents with 12 residents sampled, and record review showed that four residents’ annual MDS assessments had triggered multiple CAAs that were not completed. One resident’s annual MDS dated 09/28/25 triggered CAAs for ADL Functional/Rehabilitation Potential, urinary incontinence and indwelling catheter, falls, nutritional status, dehydration/fluid maintenance, dental care, pressure ulcer/injury, and psychotropic drug use, but none of these CAAs were completed. Another resident’s annual MDS dated 10/07/25 triggered CAAs for cognitive loss/dementia, communication, urinary incontinence and indwelling catheter, behavioral symptoms, falls, pressure ulcer/injury, psychotropic drug use, and pain, which were also not completed. A third resident’s annual MDS dated 08/25/25 triggered CAAs for ADL Functional/Rehabilitation Potential, urinary incontinence and indwelling catheter, nutritional status, pressure ulcer/injury, physical restraints, and pain, but these CAAs were not completed. A fourth resident’s annual MDS dated 04/16/25 triggered CAAs for cognitive loss/dementia, communication, urinary incontinence and indwelling catheter, mood state, falls, nutritional status, dental care, pressure ulcer/injury, psychotropic drug use, and pain, and these CAAs were likewise not completed. During an interview on 03/10/26 at 4:06 PM, an administrative nurse acknowledged that the CAAs for these residents were missed, stated that the CAAs should be filled out to more accurately trigger care plan interventions, and noted she was still learning how to complete MDS assessments. The facility’s undated MDS Accuracy Audits policy documented a commitment to ensuring the accuracy, timeliness, and completeness of all MDS assessments.
Inaccurate MDS Coding of Bedrails as Physical Restraints
Penalty
Summary
Surveyors found that the facility failed to ensure accurate completion of MDS assessments for five residents regarding the use of bedrails as restraints. For these residents, multiple Quarterly MDS assessments documented that bedrails were used as physical restraints on a daily basis during the look-back periods. Specifically, the MDS assessments dated 01/20/25, 11/25/25, 01/16/26, 02/15/26, and 12/20/25 each indicated daily use of bedrails as physical restraints. However, during an interview on 03/10/26 at 4:06 PM, Administrative Nurse D stated she had coded bedrails as restraints on the MDS for all residents whose beds had bedrails installed, regardless of whether the residents actually used the bedrails or whether the bedrails restricted their mobility. Administrative Nurse D further confirmed that, for the identified residents, the bedrails did not restrict mobility and therefore did not meet the definition of a restraint, despite being coded as such on the MDS. She also stated that her expectation was that MDS assessments accurately reflect each resident’s status. The facility’s undated “Minimum Data Set (MDS) Accuracy Audits” policy documented that the facility was committed to ensuring the accuracy, timeliness, and completeness of all MDS assessments, which contrasted with the inaccurate coding practice described.
Unlocked and Unattended Medication Cart Left Accessible in Hallway
Penalty
Summary
The deficiency involves failure to ensure medications were stored securely in locked compartments accessible only to designated staff. The facility had a census of 29 residents, with one medication room, three medication carts, and one treatment cart. During an observation, a licensed nurse approached a medication cart parked directly outside the nurse's station, prepared medications in a small cup, locked only the computer screen, and then walked away from the cart, which remained unlocked. The cart’s lock was positioned outward, indicating it was not engaged and that the contents were accessible to anyone who attempted to open it. The nurse then entered a resident’s room down the hall, leaving the unlocked cart unattended and out of staff visual range. Upon returning, she logged back into the computer, prepared medications for another resident, again locked the monitor screen, closed the medication drawer, and walked down the hall into another resident’s room, once more leaving the cart unlocked and unsupervised. During interview, the nurse acknowledged that the medication cart and computer monitor should be locked every time they are left unattended. The administrative nurse also stated she expected staff to lock the medication cart before walking away. The facility’s Medication Labeling and Storage policy required all medications to be stored in a secure, locked location accessible only to designated staff.
Infection Control Failures in Respiratory Equipment Storage, PPE Use, and Laundry Handling
Penalty
Summary
Surveyors identified multiple infection prevention and control deficiencies involving respiratory equipment, personal protective equipment (PPE) use, and laundry handling. During an initial walk-through, one resident’s CPAP mask was found lying directly on the bedside table without being stored in a sanitary container. Three other residents’ nebulizer masks were also observed either on bedside tables or hanging over a side table and lying in a magazine rack, all without sanitary containers. Facility nursing leadership later stated that respiratory equipment should be rinsed, laid to dry covered, and then placed in a marked bag labeled with the resident’s name and date when not in use, which was not done in these cases. Surveyors also observed improper handling of dirty laundry and failure to follow Enhanced Barrier Precautions (EBP) PPE requirements. A CNA was seen carrying unbagged dirty laundry close to their uniform down a hallway to a dirty laundry barrel, contrary to the administrative nurse’s expectation that staff move the laundry tub to the resident’s door and avoid carrying dirty laundry next to their clothing. Another CNA was observed holding a graduated cylinder containing dark amber urine while wearing only gloves and no additional PPE, despite the resident having a urinary catheter and signage on the door indicating required PPE for EBP. Staff interviews confirmed that all CNAs had been trained on EBP and that a gown and gloves were expected for personal care of residents with urinary catheters. The facility was unable to provide a policy for EBP when requested, despite having written policies for respiratory care and laundry protocols.
Failure to Maintain Resident Dignity in Common Area
Penalty
Summary
Surveyors identified a deficiency related to resident dignity when a dependent resident with severe cognitive impairment was observed in a common TV area wearing only a green hospital gown with a white sheet over her lap. The resident’s EMR documented diagnoses including Alzheimer’s disease, dementia, aphasia, anxiety, pain, and major depressive disorder, and her most recent MDS showed a BIMS score of 0, indicating severely impaired cognition, and dependence on staff for all ADLs. While seated in a Broda chair in the TV room, the resident moved her hands up and down, raising her sheet and gown so that her white incontinence brief became visible to two male residents seated in the same area. Staff interviews confirmed that this situation was inconsistent with facility expectations and policy. A CNA stated the resident should have been dressed or completely covered and that residents should not be exposed to other residents. A licensed nurse stated residents should not be in the TV room wearing only a gown and sheet and should remain in their rooms until the bath aide was ready for them. An administrative nurse stated facility protocol required residents to be dressed and groomed before leaving their rooms, that residents should be fully dressed when in the TV area, and that incontinence briefs should never be exposed. The facility’s Resident Rights Policy documented that all residents have the right to a dignified existence and that all staff are responsible for protecting those rights, underscoring that the observed exposure of the resident’s incontinence brief in a public area constituted a failure to ensure dignity.
PRN Lorazepam Order Lacked Required Stop Date and Rationale
Penalty
Summary
The deficiency involves the facility’s failure to ensure an as-needed psychotropic medication order for a resident included a required 14-day stop date or a specified duration with physician rationale for extended use. The resident had diagnoses of hypertension and diabetes mellitus and a BIMS score of zero, indicating severely impaired cognition, and required substantial to maximal assistance with all ADLs except eating. The MDS documented that the resident received an antidepressant, hypnotic, and antianxiety medication during the observation period. The Psychotropic Use CAA noted no adverse reactions to antidepressant treatment, and the care plan included goals for the resident to be free from medication side effects and symptoms related to black box warnings, with pharmacist consultation and education for the DPOA and the resident. Despite these care plan elements, the EMR orders showed lorazepam cream 0.5 mg to be applied every eight hours and as needed for dementia without a 14-day stop date or any specified duration. The EMR also lacked a physician’s rationale for the extended as-needed use of lorazepam. Nursing staff interviews confirmed that nurses taking orders were expected to inform physicians that as-needed lorazepam required a stop date and that the DON served as a second check for all orders. Administrative staff stated the facility’s policy was to follow regulations for as-needed psychotropic medications, but the facility did not provide an unnecessary psychotropic drug policy when requested by surveyors.
Incomplete Facility-Wide Assessment of Staffing, Competencies, and Resources
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough, facility-wide assessment to determine the resources necessary to care for residents competently during routine operations and emergencies. With a census of 29 residents and a sample of 12 residents, surveyors reviewed an undated Long-Term Care Self-Assessment provided by administrative staff. The assessment did not identify specific staffing levels needed for each unit, nor did it specify the number of RNs, LPNs/LVNs, CMAs, and CNAs required based on unit, resident acuity, and census. It also lacked staffing levels for each shift, including evenings and weekends. The assessment did not fully document resident condition reports or any extenuating circumstances that would make those condition reports unusual. The assessment further failed to document staff competencies and skill sets necessary to provide the level and types of care needed for the facility’s resident population. It did not fully document contractual agreements with outside providers for services such as laboratory, radiology, therapy, hospital, or transportation, and it omitted contracts for lawn care and snow removal. Administrative staff reported that the assessment was reviewed annually, most recently on a specific date, and acknowledged that the facility did not have a vision or mission statement. The administrative staff member stated he was unaware that certain sections of the assessment (orange boxes) were required to be completed, confirmed that the staffing breakdown per unit was missing, and verified that unchecked competencies (including Safety and Missing Resident for all staff) indicated those staff were not responsible for those competencies. The facility’s own Facility Assessment Policy stated that the assessment was to be the foundation for determining staffing levels, competencies, and resources, and was to address resident care needs, staff competencies, and third-party contracts during normal operations and emergencies, but the completed assessment did not meet these requirements.
Neglect of Resident Leading to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure a resident, identified as R14, remained free from neglect, which placed him in immediate jeopardy. R14, who had diagnoses of paraplegia, spinal stenosis, and muscle weakness, required extensive assistance with activities of daily living and used a wheelchair for mobility. On a particular day, a Certified Nurse Aide (CNA) assisted R14 into the courtyard and left him there without any means to contact the facility or return inside. R14 was found unresponsive outside several hours later, with a dangerously high body temperature and elevated pulse, indicating severe neglect in supervision and care. R14's care plan required staff to assist him with all activities of daily living and to provide supervision, especially when he was outside. However, the facility failed to adhere to this plan. The CNA who assisted R14 outside did not inform the oncoming staff that R14 was outside, leading to a lack of supervision for over three hours. During this time, R14 was exposed to conditions that led to his unresponsiveness and required emergency medical intervention. The facility's failure to conduct a thorough investigation into the incident further compounded the deficiency. There was no evidence of a facility investigation, witness statements, or analysis of causative factors related to the event. This lack of documentation and follow-up indicates a significant oversight in the facility's procedures for handling such incidents, as outlined in their Abuse, Neglect, and Exploitation policy.
Removal Plan
- The facility will no longer employ the nurse on duty.
- The facility will train all current staff and will train all future employees including the agency staff on outdoor safety and neglect.
- The facility provided re-training on the Abuse, Neglect, and Exploitation Policy.
- The facility created a procedure specific to the incident that all staff were trained on.
- The administration will monitor outdoor safety on an ongoing basis.
- Staff will ensure residents outside receive adequate visual checks and adequate hydration.
Failure to Provide Full-Time DON and RN Coverage
Penalty
Summary
The facility failed to comply with regulatory requirements by not employing a full-time Registered Nurse (RN) as the Director of Nursing (DON) and not providing RN coverage for eight consecutive hours a day, seven days a week. The facility had a census of 31 residents, and the deficiency was identified through observation, record review, and interviews. A review of the nursing schedule from January to December 2023 revealed that there was no RN coverage for eight consecutive hours on more than 50 occasions. Administrative Staff A confirmed the absence of a full-time RN as DON and the lack of consistent RN coverage, citing difficulties in securing an RN except occasionally from an agency. The facility's policies required a full-time DON and RN coverage for eight consecutive hours daily, which were not met, placing the residents at risk for inadequate care.
Failure to Implement Water Management Program for Legionella
Penalty
Summary
The facility failed to implement a comprehensive water management program to address the risk of Legionella and other waterborne pathogens, which placed residents at risk for infectious diseases. During an observation, Maintenance Staff U confirmed the absence of routine water management checks and noted that the 300 hall was not in use, with no regular flushing of water in unoccupied rooms. Administrative Staff A acknowledged that while the city conducted monthly water checks, there were no records available, and the facility lacked a system to monitor standing water and mitigate the risk of Legionella. The facility's Legionella Surveillance policy outlined the need for Legionella risk assessments, identification of potential growth areas, and implementation of control measures. However, the facility did not adhere to these standards, as evidenced by the lack of regular inspections, microbiological monitoring, temperature checks, and flushing. The policy also required documentation of all monitoring activities and the appointment of a responsible person for the water system, which was not fulfilled. This failure to implement a water management program exposed residents to the risk of contracting Legionella pneumonia.
Chemical Storage Deficiency in Kitchenette
Penalty
Summary
The facility failed to ensure an environment free from accident hazards when staff left a gallon chemical bottle in an unlocked bottom cabinet in one of three kitchenettes. This incident placed 12 cognitively impaired, independently mobile residents at risk for preventable accidents or injuries. During an observation, a plastic gallon bottle of Attack Enzyme odor digester, drain opener, and maintainer was found in an unlocked cabinet underneath the sink in a kitchenette located off the family dining room. The label on the bottle warned to keep it out of reach of children, avoid contact with eyes, and noted it may cause skin irritation. A Licensed Nurse verified the finding and acknowledged that the cabinet should be locked, subsequently moving the bottle to a locked housekeeping closet. An Administrative Nurse later stated that staff were expected to store chemicals in a locked cabinet. The facility did not provide a chemical storage policy upon request, highlighting a lapse in ensuring a safe environment for residents.
Failure to Report Neglect Incident
Penalty
Summary
The facility failed to report an incident of neglect involving a resident, identified as R14, to the State Agency as required. R14, who had diagnoses including paraplegia, spinal stenosis, and muscle weakness, required extensive assistance with activities of daily living and used a wheelchair for mobility. On a particular day, R14 was found outside unresponsive in his wheelchair, with no shirt on, and showing signs of distress such as drooling and minimal responsiveness. Staff intervened by cooling him down and calling EMS, who later transported him for further care. However, the facility did not conduct an investigation into the incident, nor did they report it to the State Agency, as evidenced by the lack of documentation in R14's electronic health record. Further observations revealed that R14 was again outside on the front patio, unable to re-enter the facility on his own. Administrative Staff B had to assist him inside, and it was noted that R14 was unaware of how to use his walkie-talkie, which was meant for communication. Administrative Staff A later confirmed that a CNA had let R14 outside as she went off duty, and the oncoming staff did not check on him. The facility's policy required the Nursing Home Administrator to report such incidents, but this was not done, placing R14 at risk for ongoing neglect.
Failure to Investigate Neglect Incident
Penalty
Summary
The facility failed to thoroughly investigate an incident of neglect involving a resident with paraplegia, spinal stenosis, and muscle weakness, who required extensive assistance with activities of daily living and used a wheelchair for mobility. The resident was found outside unresponsive in his wheelchair, with no means to contact the facility for assistance. The incident occurred when a CNA took the resident outside and went off shift without informing the incoming staff, leaving the resident unattended. The resident's care plan required staff to assist with all activities of daily living and to monitor for signs of immobility, skin breakdown, and fall-related injuries. However, the facility did not conduct a written investigation or gather witness statements and causative factors related to the event. The facility's policy mandates that all allegations of neglect be thoroughly investigated, including a root cause analysis and review by the Quality Assurance Performance Improvement Committee. Despite the policy, the facility was unable to provide evidence of an investigation into the incident. Administrative staff acknowledged that the resident was left outside without any means to contact the facility and that the staff was not informed of the resident's whereabouts. This lack of investigation placed the resident at risk for unidentified and ongoing neglect.
Failure to Update Care Plan for Resident with Stasis Ulcers
Penalty
Summary
The facility failed to review and revise the care plan for a resident with stasis ulcers on her shins, which are open wounds caused by circulation problems in the leg veins. The resident's electronic medical record documented diagnoses of weakness, neuropathy, and localized edema. The resident had a Brief Interview of Mental Status score indicating moderately impaired cognition and required partial to moderate staff assistance with most activities of daily living. Despite these conditions, the care plan, last revised on 05/01/24, did not include a section on skin integrity or instructions for caring for the resident's bilateral lower legs. Observations and interviews revealed that the licensed nurse was unaware of the appearance or treatment of the resident's ulcers, as the resident received wound care at the hospital. The administrative nurse confirmed the absence of a skin integrity section in the care plan and acknowledged responsibility for updating it. The facility's policy stated that changes in a resident's condition require updates to the care plan, but this was not done for the resident's venous ulcers. This oversight placed the resident at risk for decreased quality of care due to uncommunicated care needs.
Failure to Implement Pharmacist's Recommendation for PRN Medication Stop Date
Penalty
Summary
The facility failed to ensure that a physician acknowledged and responded to a Consultant Pharmacist's recommendation regarding a stop date for a resident's PRN antianxiety medication. The resident, identified as R19, had diagnoses of anxiety and hypertension and was receiving lorazepam, an antianxiety medication, without a specified stop date. The Consultant Pharmacist recommended a 14-day stop date for the medication, but the clinical record lacked evidence of a physician's response to this recommendation. This oversight placed the resident at risk for unintended effects related to psychotropic drug medications. Observations and interviews revealed that the resident continued to receive lorazepam PRN without a stop date, and the facility's policy required a 14-day stop date for PRN psychotropic medications. The Administrative Nurse confirmed that the pharmacist's recommendations were sent to the physician, but there was no response regarding the duration or rationale for the continued use of the medication. The facility's policy also required an assessment and documentation of the resident's response to the medication before extending its use, which was not adhered to in this case.
Failure to Ensure Stop Date for PRN Antianxiety Medication
Penalty
Summary
The facility failed to ensure a 14-day stop date or a specified duration with rationale for a resident's ongoing as-needed (PRN) antianxiety medication, lorazepam. The resident, identified as R19, had diagnoses of anxiety and hypertension and was noted to have moderately impaired cognition. The resident's care plan indicated the use of lorazepam for trouble sleeping and behavior problems, with a specific dosage at bedtime and an additional dose allowed during the night. However, the physician's order for lorazepam lacked a stop date, and there was no documented rationale for the extended use of the PRN medication. Observations and interviews confirmed that the resident received lorazepam PRN without a stop date, which was verified by the administrative nurse. The facility's policy on psychotropic drug use required a 14-day stop date for PRN psychotropic medications, with an assessment and documented rationale for continued use if necessary. The absence of a stop date or specified duration for R19's lorazepam placed the resident at risk for adverse psychotropic medication side effects.
Failure to Label Insulin Pen
Penalty
Summary
The facility failed to appropriately store medications by not labeling a resident's insulin flex pen with the date it was opened and the discard date. During an observation of the treatment cart, it was found that the Basaglar flex pen for a resident lacked these essential labels. This oversight was confirmed by Administrative Nurse D, who acknowledged that nurses are required to date the flex pens upon opening and discard expired insulin and medications. The facility's Medication Storage and Labeling policy mandates that medications and biologicals be stored in secured, clean, and sanitary conditions, with insulin pens clearly labeled for single-resident use to prevent cross-contamination. The failure to label and date the insulin pen placed the resident at risk for receiving ineffective medication.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to ensure a coordinated plan of care for a resident receiving hospice services, which placed the resident at risk for inappropriate end-of-life care. The resident, who had diagnoses of Alzheimer's disease, aphasia, and dementia, was admitted to the facility and received hospice treatment. However, the resident's nursing care plan lacked information regarding hospice services and evidence of coordination between the hospice and the facility. The facility did not maintain a communication book or external document related to the resident's hospice services, and the care plan did not reflect the resident's hospice status. Observations and interviews revealed that the facility had initial hospice admit notes with limited care plan information but lacked a complete plan of care. An administrative nurse confirmed the absence of hospice information in the facility's electronic health records and acknowledged difficulties in receiving information from the hospice. The facility's hospice program policy required a coordinated comprehensive plan of care involving communication between hospice, the resident, family, and external resources, which was not adhered to in this case.
Failure to Obtain Consent for Influenza Vaccinations
Penalty
Summary
The facility failed to obtain signed consent for influenza immunizations for three residents, identified as R4, R13, and R18, during the flu season. The clinical medical records for these residents lacked evidence that the facility or the residents' representatives received or were offered the current influenza vaccine. Administrative Nurse D confirmed that while the facility sent out consent forms annually, they did not receive all forms back and did not follow up, resulting in some residents not receiving the vaccinations. Additionally, it was noted that some residents' representatives were difficult to contact and did not return the forms. The facility's Immunization Policy, revised in March 2024, stated that all residents would be offered vaccinations on admission and annually, with documentation of each resident's immunization status in their clinical record. The failure to offer or obtain informed declinations for the flu vaccination placed the residents at risk of acquiring, spreading, and experiencing complications from 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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