Rolling Hills Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Topeka, Kansas.
- Location
- 2400 Sw Urish Road, Topeka, Kansas 66614
- CMS Provider Number
- 175165
- Inspections on file
- 23
- Latest survey
- September 16, 2025
- Citations (last 12 mo.)
- 28 (2 serious)
Citation history
Health deficiencies cited at Rolling Hills Health Center during CMS and state inspections, most recent first.
The facility did not ensure RN coverage for at least eight consecutive hours each day on multiple occasions, as confirmed by missing schedule and payroll documentation and staff interviews. This failure occurred despite facility policy requiring such coverage for all residents.
Surveyors found unsanitary conditions in the kitchen and food storage areas, including uncovered food in a dirty microwave, dusty refrigerator vents, unprotected napkins, sticky dessert sauce bottles, and gnats on bread. Dietary staff confirmed expectations for cleaning were not met, and facility policy required sanitary handling and storage of food and equipment.
Staff failed to follow infection control protocols by allowing a resident's urinary catheter bag to rest on the floor and by not properly storing or replacing nasal cannulas for two residents after they came into contact with unclean surfaces. These actions were not in line with facility policies for catheter and oxygen equipment management.
The facility did not provide direct, interactive activities based on resident preferences during weekends. Activity calendars listed repetitive activities, but staff and resident interviews revealed that scheduled activities were often not conducted, with only movies or television provided instead. Activities staff were generally not present on weekends, and direct care staff reported being too busy to lead activities, leaving residents with only independent options like puzzles and games.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report highlights that the environment did not meet required safety standards.
A resident with severe cognitive impairment and a history of falls did not have their care plan updated with new interventions after experiencing two separate falls. Despite assessments and investigations following each incident, no additional fall prevention strategies were documented or implemented in the care plan, contrary to facility policy and staff statements.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures to avoid new ulcers were not consistently implemented. Observations and record reviews showed lapses in assessment, monitoring, and treatment, with necessary interventions not applied as required.
A resident with a suprapubic urinary catheter and multiple comorbidities was observed on several occasions with their catheter collection bag lying directly on the floor, despite care plans and facility policy requiring the bag to be secured in a privacy bag and kept off the floor. Staff interviews confirmed these requirements, but the deficiency persisted, resulting in unsanitary catheter care.
A resident with PTSD, bipolar disorder, and schizoaffective disorder did not have trauma-based triggers identified or individualized interventions implemented in the care plan. Although assessments documented the resident experienced nightmares and avoided trauma reminders, the care plan only included general monitoring and support. Facility staff were unclear about responsibilities for PTSD assessment and care planning, resulting in a lack of trauma-informed, personalized care.
The facility did not submit complete and accurate RN staffing information to CMS, with payroll records missing for several days when no RN hours were reported, despite policy requiring daily RN coverage.
A resident with multiple medical conditions and a care plan requiring mechanical lift assistance for transfers was injured when two CNAs, after the resident declined both the lift and a gait belt, attempted to reposition her by lifting under her arms during a shower transfer. This improper technique resulted in a humerus fracture, as confirmed by hospital evaluation.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for at least eight consecutive hours a day, seven days a week, as required. Review of the nursing schedules for April through September 2024 revealed that on six specific dates, there was no verifiable or auditable evidence of RN coverage for the required duration. Administrative staff were unable to provide payroll documentation to confirm RN presence on those days. Interviews with administrative staff indicated that ensuring RN coverage, particularly on weekends, was a persistent challenge. The facility's own policy required sufficient nursing staff, including RN coverage for at least eight consecutive hours every 24 hours, but this standard was not met on the identified dates for a census of 44 residents.
Failure to Maintain Sanitary Food Storage and Equipment Cleaning
Penalty
Summary
Surveyors observed multiple failures to maintain sanitary conditions in the facility's kitchen and food storage areas. During an inspection, a microwave oven was found with a bowl of uncovered green beans inside, along with old food debris spattered on the interior surfaces. The walk-in refrigerator unit had built-up dust and debris covering the blower vents. In the dry food storage area, unboxed packages of napkins were resting directly against the storage room wall without a protective barrier, and several syrup-based dessert sauce bottles had syrup residue caked on their lids while being stored on racks. Additionally, gnats were seen flying and landing on bread packages in the dry food storage room. Dietary staff confirmed that staff were expected to clean equipment and wipe down containers after use, and that kitchen staff were responsible for cleaning all surfaces after each meal service. The facility's policy required all food to be labeled and dated, and for cooking equipment to be maintained in a sanitary environment and stored to prevent contamination. These observations and staff statements indicated that the facility failed to follow its own policies and professional standards for food storage and equipment cleaning.
Failure to Maintain Proper Infection Control for Catheter and Oxygen Equipment
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for three residents. One resident's urinary catheter collection bag was observed lying flat on the floor with visible urine in the bag and tubing, rather than being properly hung on the bed frame with a privacy bag. The same resident's catheter bag was later observed correctly hung, but the initial failure to keep the bag off the floor was not in accordance with facility policy, which requires cleansing or replacement if the bag or tubing contacts the floor. Additionally, two residents' nasal cannulas (NC) were not properly stored when not in use. One resident's NC tubing was found hanging over a walker railing without a storage bag, and another resident's NC was found lying on the floor. An administrative nurse picked up the NC from the floor and handed it back to the resident for use without replacing it, contrary to facility policy that requires replacement if oxygen equipment contacts the floor. These lapses in infection control practices were confirmed by the facility's infection preventionist and were not consistent with the facility's written policies.
Failure to Provide Direct, Interactive Activities on Weekends
Penalty
Summary
The facility failed to provide direct, interactive activities based on resident preferences during weekends for its census of 44 residents, as identified through observation, record review, and interviews. Activity calendars for several months showed repetitive scheduling of movies, games, social hours, puzzles, and a specific game on weekends. However, the Resident Council reported that these activities were often not conducted, with the activities coordinator only occasionally present on weekends. When the coordinator was absent, nursing care staff did not complete the scheduled activities, instead resorting to playing movies or television shows, and not engaging in staff-led activities. Residents reported frequent boredom on weekends due to the lack of interactive programming. Staff interviews confirmed that scheduled weekend activities were often not completed, as activities staff typically worked only Monday through Friday. Direct care staff, including CNAs and LNs, stated they were too busy with resident care to facilitate activities, and only provided materials like puzzles and games for residents to use independently. The facility's Activities Programming policy required activities to meet residents' needs and interests, but this was not consistently implemented on weekends, resulting in a lack of direct, interactive engagement for residents during those times.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions by staff or details about the residents involved are not provided in the report.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to revise the care plan for a resident with Alzheimer's disease, dementia with behavioral disturbance, and agitation after the resident experienced two falls. The resident had severely impaired cognition, required a wheelchair for mobility, and needed substantial to total assistance with activities of daily living. Despite being identified as at risk for falls due to poor cognition, incontinence, impaired mobility, and medication use, the care plan was not updated with new interventions following unwitnessed and witnessed falls. After the first fall, which occurred when the resident attempted to replace her shoe without locking the wheelchair brakes, no new interventions were added to the care plan. Similarly, after a second fall in the dining room, where the resident missed the wheelchair while attempting to sit, the care plan remained unchanged. Staff interviews confirmed that the facility's process required assessment and implementation of new interventions after each fall, with subsequent care plan revision. However, documentation and care plan review showed that no new fall prevention strategies were added after either incident. The facility's policy required ongoing updates to the care plan as residents' needs changed, but this was not followed in the resident's case, resulting in a lack of updated interventions after multiple falls.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that necessary interventions to prevent skin breakdown were not consistently applied, and existing pressure ulcers were not managed according to established protocols.
Failure to Maintain Sanitary Catheter Care
Penalty
Summary
A deficiency occurred when staff failed to maintain a resident's indwelling suprapubic urinary catheter in a safe and sanitary manner. The resident had multiple diagnoses, including major depressive disorder, diabetes mellitus, chronic kidney disease, and congestive heart failure, and required substantial to maximal assistance with activities of daily living. The resident's care plan and urinary incontinence assessment specifically instructed staff to monitor the catheter for infection and skin breakdown, ensure the catheter drainage bag and tubing were secured in a privacy bag, and prevent the bag from touching the floor. Despite these instructions, observations on multiple occasions showed the resident's urinary catheter collection bag lying directly on the floor with visible urine in the bag and tubing, rather than being hung on the bedframe as required. Staff interviews confirmed that facility policy required catheter collection bags to be placed in a privacy bag and kept off the floor, and that the system should be maintained in a sanitary manner to prevent infections. The facility's policy also emphasized the importance of maintaining unobstructed urine flow and frequent emptying of the catheter bag. However, the observed failure to follow these procedures resulted in the resident's catheter bag being left on the floor for extended periods, contrary to both the care plan and facility policy.
Failure to Provide Trauma-Informed, Individualized Care for Resident with PTSD
Penalty
Summary
The facility failed to identify trauma-based triggers and implement individualized interventions for a resident diagnosed with post-traumatic stress disorder (PTSD), bipolar disorder, and schizoaffective disorder. The resident's care plan included general monitoring for hallucinations and adverse medication side effects, as well as providing opportunities for the resident to talk about feelings when upset. However, the care plan did not include personalized interventions specifically addressing the resident's PTSD or strategies to prevent re-traumatization, despite documentation in the medical record and assessments indicating the resident experienced nightmares and avoided situations that reminded her of past trauma. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for completing PTSD assessments and updating care plans with trauma-specific information. Staff members were unsure who was responsible for ensuring that the type of trauma and individualized interventions were included in the care plan. The facility's policy required trauma-informed care and screening for trauma experiences, but this was not consistently implemented for the resident in question.
Failure to Submit Complete and Accurate RN Staffing Data
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare & Medicaid Services (CMS) through Payroll Based Journaling (PBJ) for a census of 95 residents. CMS reports for two consecutive quarters indicated that the facility had no Registered Nurse (RN) hours reported for 10 days. While payroll documentation was provided for RN coverage on four of those days, administrative staff were unable to provide payroll documentation for the remaining six days. The facility's policy required a sufficient number of nursing staff, including RN coverage for at least eight consecutive hours every 24 hours, seven days a week. This deficiency was identified through interview and record review.
Failure to Ensure Safe Transfer Results in Resident Fracture
Penalty
Summary
A deficiency occurred when staff failed to ensure an environment free from accident hazards for a resident who required staff assistance and a mechanical lift for safe transfers. The resident, who had multiple diagnoses including pleural effusion, COPD, rheumatoid arthritis, polyosteoarthritis, and osteoporosis, was dependent on staff for transfers, toileting, and mobility. The care plan indicated the need for a Hoyer lift for transfers, but also noted the resident often declined its use, in which case two staff and a gait belt were to be used. On the day of the incident, the resident declined both the Hoyer lift and gait belt, insisting on standing and pivoting for the transfer. During a shower transfer, two CNAs assisted the resident, who requested to be scooted back in the shower chair. The CNAs placed their arms under the resident's arms and attempted to move her back, at which point a popping noise was heard and the resident experienced severe pain in her right upper arm. The CNAs did not use a gait belt during this maneuver, and their arms were misplaced in relation to the resident's arms. The incident resulted in a humerus fracture, confirmed by hospital assessment and subsequent surgery. Staff interviews confirmed that proper transfer techniques were not followed, as staff are trained not to lift residents by or under the arms due to the risk of injury. The care plan and therapy notes specified the use of mechanical lifts or, if refused, a gait belt with two staff. Despite these instructions, the transfer was performed without the required equipment, directly leading to the resident's injury.
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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