Smoky Hill Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Salina, Kansas.
- Location
- 1007 Johnstown Avenue, Salina, Kansas 67401
- CMS Provider Number
- 175185
- Inspections on file
- 37
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at Smoky Hill Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia and diabetes experienced a marked decline in function, including increased weakness, inability to ambulate, decreased ability to feed herself, lethargy, and frequent urination. Staff documentation over two days showed missing food and fluid intake records, escalating assistance needs for transfers and ambulation, and notes of excessive weakness, but no complete vital signs or blood glucose checks were obtained despite an order for PRN glucose monitoring and a care plan identifying hyperglycemia risk. Nursing staff focused on a presumed UTI, requested and started an antibiotic without a documented urine specimen, and did not consider or assess for hyperglycemia or dehydration. The resident was later sent to the ED with a cold, pale, non-blanchable foot and was found to be obtunded with a blood glucose of 1020 mg/dL and significant lab abnormalities, and the failure to properly assess and respond to her change in condition was cited as neglect and immediate jeopardy.
A resident with COPD, respiratory failure, CHF, and atrial fibrillation, who required continuous O2 and nighttime Bi-Pap per recent hospital discharge orders, returned to the facility without being placed on Bi-Pap despite the facility having told the hospital that a functional Bi-Pap was available. Staff later discovered the in-house Bi-Pap was nonfunctional and, after being told a replacement would arrive that evening, the resident remained without Bi-Pap overnight. An ABG drawn at the facility showed markedly elevated CO2, and the resident was readmitted to the hospital with acute hypercapnic respiratory failure and mucous plugging. Interviews confirmed nursing "dropped the ball" in ensuring Bi-Pap availability and use, and the facility could not provide a relevant respiratory care policy.
Several residents who were dependent on staff for ADL assistance did not receive regular bathing as required by their care plans, resulting in poor hygiene, soiled clothing, and strong odors. Staff interviews revealed challenges in completing scheduled baths, especially on shifts staffed by agency personnel who reportedly refused to perform bathing duties. Documentation confirmed infrequent bathing for these residents, contrary to facility policy.
A resident with significant physical and cognitive impairments was left in a hallway for an extended period with a leaking colostomy bag, resulting in soiled clothing and a foul odor. Multiple staff members passed by without providing assistance, despite care plan directives for regular colostomy care and hygiene. The resident was unable to communicate his needs or move himself, and staff interviews confirmed the lapse in timely care.
Surveyors found extensive unsanitary conditions in the kitchen, including dirty floors, food splatters on walls and equipment, contaminated utensils, and unclean storage areas. Staff confirmed the lack of cleaning and failure to follow the facility's sanitation policy, resulting in all meals being prepared and served in an environment that did not meet professional standards.
A deficiency was found when a section of mopboard in the dining room was detached from the wall and partially lying on the floor, creating unsanitary and unhomelike conditions for residents who dined there. Maintenance staff were aware of the issue and had attempted to block access with a table, but the problem persisted.
Staff did not securely store medications or dispose of expired drugs as required. Expired aspirin, biotin, magnesium chloride, and folic acid were found in medication carts and the medication room. A nurse treatment cart was left unlocked and unattended with medications accessible, and staff confirmed these practices were not in line with facility policy.
Two residents with incontinence and significant care needs were repeatedly left exposed in their briefs and visible from the hallway due to staff failing to provide adequate privacy and assistance. Staff did not consistently cover the residents, ensure call lights were within reach, or position them safely for meals, resulting in compromised dignity and privacy in violation of facility policy.
Two residents were not given the required CMS Form 10055 Advanced Beneficiary Notice when skilled services were ending, and instead received an incorrect form that did not meet regulatory requirements. The facility also could not provide a Medicare beneficiary policy when requested, and staff reported discontinuing the correct form based on corporate direction.
A resident with chronic kidney disease and other comorbidities was placed on a physician-ordered fluid restriction, but the care plan was not updated to reflect this order. Staff were not consistently aware of the restriction, and fluid intake was not being monitored or documented as required, resulting in the resident having unrestricted access to fluids at the bedside.
Two residents with significant medical and functional needs did not receive adequate ADL support, including assistance with positioning, hygiene, and meal setup. Both were left in undignified or unsafe conditions, such as being exposed or unable to reach their call light, and staff failed to ensure privacy or provide timely help. Care plans and facility policies lacked necessary detail or were not provided when requested.
A resident with an indwelling urinary catheter and significant medical needs was observed on multiple occasions with catheter tubing resting on the floor while seated in a wheelchair, contrary to facility policy and the resident's care plan. This failure was confirmed by an administrative nurse, who stated staff were expected to keep tubing off the floor.
A resident with chronic kidney disease, hypertension, and other comorbidities was not properly monitored for a physician-ordered fluid restriction. The care plan did not include the restriction, staff were unaware or unable to recall the specific order, and fluid intake was not documented as required. The resident had access to fluids beyond the prescribed limit, and facility policy for fluid restriction was not followed.
A resident with significant care needs and moderately impaired cognition was admitted to hospice, but the facility did not include essential hospice service details—such as visit frequency, medications, equipment, and contact information—in the care plan. Staff confirmed this information was missing from the facility's documentation, despite policy requiring a coordinated plan of care with the hospice provider.
A resident with a urinary catheter was observed when a CNA allowed the catheter drainage bag and tubing to come into contact with the floor during wheelchair transport. Despite facility policy and care plan instructions to keep catheter equipment off the floor, staff did not immediately change out the contaminated items, resulting in a failure to follow infection control protocols.
Three residents were not offered or did not have documentation of being offered the pneumococcal PCV20 vaccine, as required by CDC guidance. In each case, either only a previous Prevnar 13 dose was recorded with no further documentation, or there was no record of pneumococcal vaccination information at all. An administrative nurse was unaware of the updated CDC recommendations, and facility policy requiring adherence to current CDC guidance was not followed.
A resident admitted for rehabilitation after a hip replacement did not receive appropriate pain management due to the facility's failure to obtain prescribed oxycodone and incorrect entry of acetaminophen orders. The resident experienced significant pain and distress, as the staff administered ineffective Norco instead. This impacted the resident's ability to participate in rehabilitation and affected her well-being.
A resident experienced significant medication errors when the facility failed to obtain prescribed as-needed pain medication following a hip replacement. The resident's acetaminophen was incorrectly entered as needed instead of scheduled, and oxycodone was not provided, leading to unalleviated pain and impaired rehabilitation participation.
A resident with a history of hemiplegia and stroke was neglected by staff, leading to a severe injury. The resident was left without a call light, preventing him from calling for help. After being left to eat breakfast lying flat, the resident attempted to communicate his need for assistance by showing a ball of feces to a CMA, who failed to help. The resident fell from the bed, hitting his head, resulting in a severe brain injury. Staff delayed in providing assistance and failed to offer comfort measures, placing the resident in immediate jeopardy.
A resident on antiplatelet therapy fell from bed, hitting his head, and did not receive adequate post-fall care. Staff failed to perform a thorough assessment, including a neurological exam, and left the resident on the floor while preparing his bed. The resident showed signs of distress and potential injury throughout the day, but staff did not conduct proper assessments or closely monitor his condition. The resident was later found lethargic and vomiting, leading to a hospital transfer where he was diagnosed with a severe brain injury and subsequently died.
A resident with significant medical conditions and a high fall risk was left without adequate supervision and safety measures, leading to a fall and fatal injury. Staff failed to ensure the resident's call light was within reach and did not perform necessary assessments or provide timely care, resulting in the resident's death from a hemorrhagic brain bleed.
A resident with severe cognitive impairment and a high fall risk fell from a wheelchair, sustaining a broken nose and head laceration, due to inadequate supervision and intervention by staff. Despite being redirected verbally, the resident's repeated unsafe behavior of leaning forward was not sufficiently addressed, leading to the fall.
Failure to Assess Change in Condition and Evaluate for Hyperglycemia in Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a resident’s significant change in condition, resulting in neglect. The resident had diagnoses including diabetes mellitus with circulatory complications, dementia with severe cognitive impairment, hyperlipidemia, and a cognitive communication deficit, and resided on a secure unit. Her care plan identified her as at risk for hyperglycemia and directed staff to observe, document, and report signs and symptoms such as increased thirst, frequent urination, fatigue, and other indicators. Laboratory data showed an elevated HbA1c placing her at risk for diabetes, and the MAR included an order for PRN blood glucose monitoring with instructions to notify the provider if blood sugar was below 70 mg/dL or above 400 mg/dL. In the days leading up to the event, documentation showed a decline in the resident’s functional status and intake that was not fully assessed. On one day, EMR task documentation lacked information on the amount of food consumed at breakfast and lunch, noted that she required staff assistance for eating and transfers, and showed she did not ambulate or required total staff assistance for ambulation, with no fluid intake documented. The following day, documentation again lacked food intake for breakfast and lunch, showed she required extensive assistance from two staff for transfers and ambulation, and still lacked fluid intake documentation. A health status note recorded that she had excessive weakness, could no longer ambulate independently or with assistance, and required two staff to pivot her from chair to wheelchair, but the EMR did not contain a complete set of vital signs or any blood glucose value associated with this change. Later that same day, staff faxed the physician reporting that the resident had shakes, was more sleepy, not as awake as usual, and had frequent urination, and requested an antibiotic for a presumed UTI, noting unsuccessful attempts to obtain a urine specimen, including straight catheterization, though the EMR lacked documentation of these attempts. The physician ordered Macrobid, and a health status note documented administration of the first dose and continued weakness and cognitive decline, with the resident non-verbal and requiring staff to feed her. Again, the EMR lacked a complete set of vital signs and a blood glucose measurement despite documentation that vital signs were within normal limits. Early the next morning, staff reported the resident’s foot was cold and colorless; the nurse found it pale, cold, and non-blanchable, notified the on-call physician, and the resident was sent to the emergency department. In the ED, she was obtunded, with a point-of-care glucose reading “HI” and a laboratory glucose of 1020 mg/dL, along with a sodium level of 158 mEq/L and urine showing very high glucose but negative for bacteria and nitrites. Interviews with facility staff revealed that they believed the resident had a UTI, did not obtain or document complete vital signs, did not perform blood glucose checks, and did not consider hyperglycemia or dehydration as potential causes of her symptoms, despite her diagnosis and risk factors. The facility’s own Acute Condition Changes Protocol required comprehensive assessment and data collection, including vital signs and evaluation of possible causes, which were not carried out. This failure to assess and respond to the resident’s change in condition, including failure to consider and evaluate for hyperglycemia or dehydration, was determined to be neglect and placed the resident in immediate jeopardy.
Removal Plan
- Upon change of condition of any resident, Smoky Hill Nurses will complete a Change of Condition Form and notify the resident physician immediately.
- Any resident with a diabetes diagnosis will be assessed for hypo/hyperglycemia and labs as ordered by the physician.
- Nursing staff will be in-serviced on hypo/hyperglycemia and other conditions (frequent urination, lethargy, weakness, inability to ambulate, inability to feed self) as associated with diabetes.
- All residents with diabetes will be assessed for signs and symptoms of dehydration or hypo/hyperglycemia or any other changes associated with diabetes.
- The facility will monitor changes in condition 7 days a week and 5 days a week for 3 weeks.
Failure to Provide Functional Bi-Pap and Required Respiratory Support
Penalty
Summary
The deficiency involves the facility’s failure to provide required respiratory care and equipment for a resident with significant pulmonary and cardiac comorbidities. The resident had diagnoses including COPD, respiratory failure, CHF, and atrial fibrillation, required continuous oxygen, and needed extensive assistance with ADLs. The resident’s care plan documented the need for oxygen at all times and monitoring for signs and symptoms of respiratory distress. Following a hospitalization for hypercapnia and pneumonia, the hospital discharge instructions specified that the resident was to receive 3 L of oxygen continuously and use Bi-Pap at night. Upon discharge from the hospital, the resident’s primary care physician documented that the resident was supposed to be on Bi-Pap when he returned to the facility and that the facility had told the hospital they had a functioning Bi-Pap available. However, the physician noted that as of the time of his dictation, the resident had not been placed on Bi-Pap and that the facility would need to see if they could acquire one. The physician also documented that an ABG was needed to evaluate CO2 retention and that, if the facility could not obtain a Bi-Pap in a timely manner and the resident’s CO2 continued to rise, he would likely need to return to the emergency room. A subsequent health status note recorded that an ABG drawn at the facility showed a CO2 level of 85, and the resident was sent to the emergency room. Hospital records from the readmission documented that the resident presented with elevated CO2 and was diagnosed with mucous plugging, left pleural effusion, acute hypercapnic respiratory failure, and decreased responsiveness. The hospital noted that the resident had been discharged two days earlier with orders for Bi-Pap ventilation and that the hospital had kept him an extra day so the facility could arrange Bi-Pap, but for some reason he did not have access to a Bi-Pap machine after return. A pulmonology consult documented recurrent acute hypercapnic respiratory failure requiring Bi-Pap and noted that the resident’s mentation was already improving with Bi-Pap. Facility staff interviews revealed that the facility had informed the hospital they had an in-house Bi-Pap, but when staff attempted to set it up, they could not program the settings and were later told by the equipment company that the machine was no longer functional. Staff stated a replacement Bi-Pap was expected that evening, but one nurse reported she did not know until the next morning that the new machine had not been delivered and that the resident had been without Bi-Pap overnight. The facility was unable to provide a Respiratory Care Policy applicable to this practice.
Failure to Provide Regular Bathing and Hygiene Care
Penalty
Summary
The facility failed to provide bathing care according to residents' care plans and preferences for four residents who were dependent on staff for activities of daily living. Observations revealed that multiple residents had greasy, matted hair, strong body odors, and soiled clothing, indicating a lack of regular bathing and hygiene care. One resident had not received a bath in 39 days, another had only two baths in 34 days since admission, and others had similarly infrequent bathing documented. Residents expressed feeling dirty, unclean, and neglected, with one stating that bathing did not seem to be a priority in their care. Staff interviews confirmed difficulties in completing scheduled baths, particularly on the evening shift, which was staffed entirely by agency personnel who reportedly refused to perform bathing duties. Documentation reviewed supported the lack of regular bathing for the affected residents. The facility's own policy required regular bathing to promote cleanliness and comfort, but this was not followed, resulting in the observed deficiencies.
Failure to Maintain Resident Dignity and Hygiene Due to Unaddressed Colostomy Leak
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis, major depressive disorder, and cognitive communication deficit was observed sitting in a hallway in a wheelchair for approximately 45 minutes with a visibly leaking colostomy bag. The resident's t-shirt and sweatpants were soiled with a brown liquid substance consistent with bowel movement, and there was a foul odor present. Multiple staff members walked past the resident during this time without providing assistance or addressing the resident's hygiene needs. The resident was unable to move himself or communicate his needs effectively due to his medical conditions. The resident's care plan documented the need for staff to provide care to the colostomy site every shift and as needed, and to ensure the resident was clean, well-groomed, and appropriately dressed. Despite these directives, staff failed to recognize and respond to the resident's condition in a timely and dignified manner. Staff interviews confirmed that the resident was left in the hallway as a reminder to get him into bed after breakfast, but his hygiene needs were not addressed during the observed period. Facility policy required the provision of a safe, clean, and comfortable environment with person-centered care, which was not upheld in this instance.
Widespread Kitchen Sanitation Failures Compromise Food Safety
Penalty
Summary
Surveyors observed widespread unsanitary conditions in the facility's kitchen, affecting the preparation, storage, and serving of meals for all 61 residents. During the initial kitchen tour, dried dirt, food splatters, and debris were found throughout the kitchen, including on the tiled floors, dishwashing area walls, and food serving areas. Clean dish carts and utensils were contaminated with food debris, and equipment such as microwaves, ovens, and refrigerators contained old, dried, and burned food residues. The food storage bins, can opener, and food scales were also found to be dirty and covered in food debris or grease. Trash cans were greasy and uncovered, and the dried food storage area was littered with packets and onion skins. Additionally, kitchen vents lacked covers, exposing air filters, and the walk-in refrigerator had food debris on the floor and door. Interviews with dietary and administrative staff confirmed the uncleanliness of the kitchen, with staff attributing the lack of cleaning to the evening shift and acknowledging the unsanitary conditions. The facility's own sanitation policy requires all kitchen and dining areas, equipment, and utensils to be kept clean and in good repair, but these standards were not met. The failure to maintain sanitary conditions in the kitchen placed all residents at risk for food-borne illnesses, as all meals were prepared and served from this environment.
Dining Room Environmental Deficiency Due to Damaged Mopboard
Penalty
Summary
A deficiency was identified when approximately 2-3 feet of mopboard at the west end of the dining room was observed coming away from the wall, with about 6 inches of it lying on the floor. Maintenance staff confirmed awareness of the issue and stated that a table had been placed in front of the damaged area, but it had been moved. The facility was in the process of replacing all mopboards, and staff were expected to report environmental issues through the TELS system. The facility's policy required the maintenance supervisor to ensure the building and equipment were maintained in a safe and operable manner. The failure to promptly repair the mopboard resulted in unsanitary and unhomelike conditions for residents dining in the main dining room.
Failure to Secure and Timely Dispose of Medications
Penalty
Summary
Facility staff failed to store medications securely and did not dispose of expired medications in a timely manner. Observations included a nurse treatment cart containing an expired bottle of aspirin and an undated insulin pen, as well as a medication cart with an expired bottle of biotin. Additionally, the medication room contained expired stock medications, including magnesium chloride and multiple bottles of folic acid. These expired medications were confirmed by licensed staff and had not been removed or disposed of as required by facility policy. Further, a nurse treatment cart on one hall was found unlocked and unattended, with warfarin, insulin pens, and other medications accessible for at least two minutes without licensed staff present. Staff interviews confirmed that medication carts should be locked when not in use and that expired medications should be removed and disposed of according to policy. The facility's own policy requires that discontinued or outdated drugs be destroyed or returned to the pharmacy and that all medication storage areas be locked when not in use.
Failure to Maintain Resident Privacy and Dignity During Personal Care
Penalty
Summary
Staff failed to provide adequate privacy and assistance to two residents who wore incontinent briefs, resulting in their exposure to staff, visitors, and other residents from the hallway. One resident, who had multiple comorbidities including diabetes, morbid obesity, chronic pain, and respiratory failure, was observed on several occasions with her lower body uncovered and her incontinent brief exposed while lying in bed with her leg hanging off the mattress. The resident was dependent on staff for bed mobility, positioning, and use of the call light, which was often not within reach. Staff did not consistently assist with covering the resident or adjusting her bed for meals, leaving her in unsafe positions for eating and drinking, and her privacy was not maintained as required by facility policy. Another resident, with diagnoses including hypertension, stroke, chronic kidney disease, and major depressive disorder, was also observed without adequate privacy. This resident, who required supervision and assistance with mobility and toileting, was seen standing in her room wearing only a blue incontinent brief while staff left the door open, making her visible to those passing in the hallway. The room also had a strong odor of urine, and the resident's clothing was on the floor, indicating a lack of timely assistance with personal hygiene and dressing. Facility policy required staff to promote and protect residents' privacy and dignity, including bodily privacy during personal care. Despite this, staff actions and inactions led to repeated instances where both residents' privacy and dignity were compromised. Administrative staff acknowledged that staff should assist residents to protect their privacy by closing doors and covering them, but these practices were not consistently followed, resulting in the observed deficiencies.
Failure to Provide Required Medicare Liability Notices
Penalty
Summary
The facility failed to provide two residents with a fully completed Advanced Beneficiary Notice (ABN) using the required CMS Form 10055 when skilled services were ending. Instead, the facility issued CMS Form 10124, which is not the appropriate form for this situation. The ABN is intended to inform residents or their representatives about potential Medicare non-coverage for continued skilled therapy services and to provide an estimated cost of those services. The forms given to the residents did include options for the beneficiary to choose whether to receive the therapy and how billing should be handled, but did not meet the regulatory requirement for the specific form and content. Additionally, when requested, the facility was unable to provide a Medicare beneficiary policy. Administrative staff reported that the use of CMS Form 10055 had been discontinued based on corporate direction. This failure to use the correct form and provide the necessary policy documentation resulted in residents not being properly informed about their potential financial liability for services not covered by Medicare.
Failure to Update Care Plan with Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to update a resident's care plan to include a physician-ordered fluid restriction, despite clear documentation in the medical record and physician orders. The resident had multiple diagnoses, including hypertension, chronic kidney disease, and a history of stroke, and was under a fluid restriction of three liters per day as ordered by the physician. The care plan, however, did not reflect this restriction, and staff were not consistently aware of or monitoring the fluid intake as required. The dietary and nursing departments had specific instructions for fluid provision, but these were not incorporated into the care plan, and intake was not being documented for the resident. Observations revealed that the resident had access to a 600-cc jug of ice water at the bedside, contrary to the fluid restriction order. Interviews with staff indicated a lack of awareness regarding the fluid restriction, and the responsible nurse had not documented the resident's fluid intake. The facility's policy required the interdisciplinary team to develop individualized care plans, but this was not followed in the case of the resident with a fluid restriction.
Failure to Provide Adequate ADL Support and Maintain Resident Dignity
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) support for two residents who required staff assistance. One resident had multiple diagnoses including diabetes mellitus, morbid obesity, major depressive disorder, delusional disorder, restless leg syndrome, chronic pain, lymphedema, and chronic respiratory failure. This resident was documented as dependent on staff for bed mobility, transfers, toileting hygiene, bathing, and dressing. Observations revealed that the resident was frequently left in unsafe or undignified positions, such as having a leg hanging off the bed and being exposed from the waist down, with the incontinent brief visible from the hallway. The resident was also left without assistance to adjust the bed for safe eating and drinking, resulting in coughing episodes, and the call light was often out of reach. Staff failed to provide timely assistance with positioning, covering, and meal setup, and the bed controls were found to be nonfunctional without prompt repair. Another resident, with diagnoses including hypertension, stroke, chronic kidney disease, angina, delusional disorder, anxiety disorder, localized edema, and major depressive disorder, was also observed to have unmet ADL needs. This resident was frequently incontinent and required supervision and setup assistance with eating and toileting, as well as a scheduled toileting program. Observations showed the resident remained in bed in soiled clothing, with a strong urine odor in the room, and was left standing in only an incontinent brief while staff and visitors could see into the room. Staff failed to ensure the resident was dressed or covered, and the door was left open, compromising privacy and dignity. The care plan for this resident lacked documentation of a physician-ordered fluid restriction, despite a progress note indicating a three-liter fluid restriction was in place. The facility's policies and care plans were found to be insufficient or lacking in specificity regarding the level of staff assistance required for these residents' functional abilities. The facility failed to provide a policy for activities of daily living support when requested. Additionally, the facility's repositioning policy outlined the need for individualized care plans and consistent repositioning programs, but observations indicated these were not consistently implemented for the residents in question. These failures resulted in ongoing unmet needs for ADL support, lack of privacy, and inadequate assistance with positioning, hygiene, and meal setup.
Failure to Maintain Catheter Tubing Off the Floor
Penalty
Summary
Staff failed to provide proper urinary catheter care for a resident with a history of cerebral infarction, neuromuscular bladder dysfunction, and an infection related to an indwelling urinary catheter. The resident's care plan required staff to change the catheter as ordered, check for patency and urinary output every shift, observe for pain or discomfort, ensure the catheter tubing was free of kinks, and keep the catheter bag and tubing below the level of the bladder and off the floor. The facility's policy also directed staff to keep the catheter tubing and drainage bag off the floor. Despite these directives, observations on two separate occasions found that the resident's catheter tubing was resting on the floor while the resident was seated in a wheelchair in the dining room. On one occasion, approximately four inches of tubing were on the floor, and on another, about one inch was on the floor. An administrative nurse confirmed that staff were expected to prevent tubing from resting or dragging on the floor, indicating a failure to follow established protocols for catheter care.
Failure to Monitor and Implement Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to monitor and implement a physician-ordered fluid restriction for a resident with multiple comorbidities, including hypertension, chronic kidney disease, angina, and a history of stroke. The physician's order specified a daily fluid restriction of three liters, with detailed instructions for the distribution of fluids by shift and department. However, the resident's care plan did not include the fluid restriction, and staff were not consistently aware of or following the order. Observations revealed that the resident had access to a 600-cc jug of ice water at the bedside, contrary to the restriction, and staff interviews confirmed a lack of awareness and documentation regarding the fluid restriction and intake monitoring. Further review of facility policy indicated that staff were expected to follow specific instructions for fluid restrictions, including removing water pitchers from the room and recording intake. Despite these guidelines, nursing staff had not documented the resident's fluid intake, and the care plan lacked the necessary information about the restriction. The failure to implement and monitor the fluid restriction as ordered placed the resident at risk for complications related to hydration status, particularly given the resident's cardiac and renal conditions.
Failure to Communicate and Document Hospice Services in Resident Care Plan
Penalty
Summary
The facility failed to ensure a communication process between the hospice provider and the facility for a resident who was admitted to hospice care. The resident, who had diagnoses of sarcopenia and a transient ischemic attack and demonstrated moderately impaired cognition, required extensive assistance with most activities of daily living. The care plan documented the need for staff to work cooperatively with the hospice team but did not include specific instructions regarding the services provided by hospice, such as the frequency and type of support visits, supplies, medical equipment, medications covered by hospice, or hospice contact information. Record review and staff interviews confirmed that the care plan lacked essential details about hospice services, and this information was not incorporated into the facility's care plan, even though it was available in the hospice care plan kept at the nurse's station. The facility's policy required a coordinated plan of care between the facility, hospice agency, and resident/family, but this was not reflected in the resident's care plan documentation.
Failure to Maintain Catheter Bag and Tubing Off the Floor
Penalty
Summary
Staff failed to maintain a sanitary environment to prevent the development and transmission of infections when a resident's urinary catheter tubing and drainage bag were allowed to come into contact with the floor. The resident, who had diagnoses of obstructive and reflux uropathy and used a urinary catheter, was observed in a wheelchair when a CNA turned the wheelchair, causing the catheter drainage bag to fall out of its privacy bag and land on the floor. The CNA then placed the drainage bag back into the privacy bag and moved the resident to the dining room, with the catheter tubing still touching the floor. The resident's care plan instructed staff to keep the catheter bag and tubing below the level of the bladder and off the floor, and the facility's policy required that catheter tubing and drainage bags be kept off the floor. The administrative nurse confirmed that staff were expected to change out the catheter drainage bag and tubing if they touched the floor. Despite these instructions and policies, staff did not follow proper infection control procedures during the incident.
Failure to Offer and Document Pneumococcal PCV20 Vaccinations per CDC Guidance
Penalty
Summary
The facility failed to offer or document the offering of pneumococcal PCV20 immunizations to three residents, as required by current CDC guidance. Specifically, one resident's electronic medical record (EMR) showed receipt of a single Prevnar 13 dose in 2015, but lacked documentation regarding any subsequent offer or refusal of further pneumococcal vaccinations. Another resident's EMR also indicated a single Prevnar 13 dose in 2015, with no documentation of additional offers or refusals. A third resident's EMR lacked any information about pneumococcal vaccination or whether the vaccine was offered or refused. During an interview, an administrative nurse acknowledged being unaware of the CDC guidance related to the PCV20 immunization. The facility's policy stated that all residents would be offered pneumococcal vaccines in accordance with current CDC recommendations, but the records reviewed did not reflect compliance with this policy.
Inadequate Pain Management for Post-Surgical Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who was admitted for rehabilitation following a total hip replacement. The resident was prescribed oxycodone 5 mg as needed and acetaminophen 1000 mg every six hours on a scheduled basis. However, the facility did not obtain the prescribed oxycodone until several days after admission and incorrectly entered the acetaminophen order as 'as needed' in the Electronic Medical Record (EMR), requiring the resident to request the medication. Upon admission, the facility did not attempt to obtain the oxycodone until the following day, and when the local pharmacy did not have it in stock, they did not check with other pharmacies. Instead, the medical director prescribed Norco 5/325 mg, which the resident had previously indicated was ineffective for her pain. Despite the resident's repeated complaints and requests for oxycodone, the staff continued to administer Norco, resulting in the resident experiencing significant pain and distress over the weekend. The resident expressed dissatisfaction with the pain management, stating that the Norco did not alleviate her pain and that she was in tears and unable to sleep due to the pain. The facility's failure to follow the discharge orders and obtain the correct medication led to the resident's pain being inadequately managed, impacting her ability to participate in rehabilitation and affecting her overall well-being.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to obtain the prescribed as-needed pain medication for a resident following a total hip replacement, leading to significant medication errors. The resident, who had diagnoses of postoperative care following joint replacement, anxiety, and depression, was admitted to the facility for a Medicare-covered stay. The resident's care plan required the administration of pain medication per physician orders, but the facility did not follow the discharge orders for acetaminophen to be given on a scheduled basis. Instead, the order was incorrectly entered into the Electronic Medical Record (EMR) as needed, requiring the resident to request the medication. The resident's Medication Administration Record (MAR) showed discrepancies in the administration of pain medications. The resident was prescribed Norco and oxycodone for pain management, but the facility failed to provide the oxycodone as needed, and the acetaminophen was not administered as scheduled. The resident expressed dissatisfaction with the pain management, stating that Norco was ineffective and that she was in tears due to pain, which affected her ability to participate in rehabilitation and sleep. The facility's administrative staff acknowledged the errors, noting that the resident's pain was not adequately managed over the weekend due to issues with obtaining the prescribed oxycodone from a local pharmacy. The facility's Medication Monitoring and Management Policy emphasized the importance of optimizing medication therapy and minimizing adverse consequences, but the facility did not adhere to these guidelines, resulting in the resident experiencing unalleviated pain and psychosocial impairment.
Neglect Leads to Severe Injury in Resident
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in a series of events that led to a severe injury. The resident, who had a history of right-sided hemiplegia, cerebrovascular accident, aphasia, dysphagia, and repeated falls, was left without a call light within reach, preventing him from calling for assistance. On the morning of the incident, a Certified Nurse Aide (CNA) entered the resident's room, patted the resident's brief without gloves, and left without ensuring the call light was accessible. Later, the resident was left to eat breakfast lying flat in bed, which led to food spillage and further discomfort. Throughout the morning, the resident attempted to communicate his need for assistance by showing a ball of feces to a Certified Medication Aid (CMA), who failed to provide help and left the room. The resident, unable to reach his call light or wheelchair, attempted to adjust his bed pad, resulting in a fall from the bed. The resident hit his head on the floor, leading to a severe brain injury. Despite the resident's cries for help, staff delayed in providing immediate assistance and failed to offer comfort measures, such as placing a pillow under his head. The facility's neglect was further evidenced by the lack of proper toileting and incontinent care, as the resident's bed pad and linens were found soaked and covered with feces. The staff's failure to conduct timely neurological assessments and provide necessary care after the fall contributed to the resident's deteriorating condition, which included an acute hemorrhagic brain bleed. The facility's actions and inactions placed the resident in immediate jeopardy, highlighting a significant deficiency in the care provided.
Failure to Provide Adequate Post-Fall Care for Resident on Antiplatelet Therapy
Penalty
Summary
The facility failed to provide adequate post-fall treatment for a resident, identified as R1, who was on antiplatelet therapy and had a history of cerebrovascular accident, hemiplegia, and repeated falls. On the morning of the incident, R1 fell from his bed, hitting his head on the floor. Despite being on blood thinners, the staff did not perform a thorough assessment for injuries, including a neurological examination, after the fall. Instead, they left R1 on the floor while they prepared his bed, and when they eventually assisted him back to bed, they did so without using a gait belt or assessing for potential fractures or injuries. Throughout the day, R1 exhibited signs of distress and potential injury, such as yelling in pain and later becoming lethargic and vomiting. However, staff failed to conduct proper neurological assessments or monitor R1's condition closely. The video footage revealed that staff did not enter R1's room for several hours after he was last seen at lunch, during which time R1 showed signs of discomfort and eventually vomited. The documented neurological assessments in R1's electronic medical record were not consistent with the video evidence, indicating that these assessments were not actually performed. The facility's policies on assessing falls and conducting neurological assessments were not followed, as staff did not adequately evaluate R1 for head injuries or other complications following the fall. This lack of appropriate care and monitoring led to R1 being found in a deteriorated state later in the day, ultimately resulting in his transfer to a hospital where he was diagnosed with a severe brain injury and subsequently died.
Failure to Prevent Resident Fall Resulting in Fatal Injury
Penalty
Summary
The facility failed to implement safety interventions to prevent falls for a resident with significant medical conditions, including right-sided hemiplegia, cerebrovascular accident, aphasia, dysphagia, and a history of repeated falls. The resident required substantial assistance for daily activities and was identified as a high fall risk. Despite these needs, the resident was left without a call light within reach, and the bed was not in the lowest position, contributing to a fall that resulted in a fatal injury. On the morning of the incident, the resident was left unattended for extended periods, with staff failing to ensure the call light was accessible or that the resident was positioned safely. The resident attempted to manage personal hygiene needs independently, leading to a fall from the bed. The fall was unwitnessed by staff, and the resident suffered a hemorrhagic brain bleed after hitting his head on the floor. The facility's documentation and video footage revealed that staff did not perform necessary neurological assessments or provide adequate supervision and assistance. The resident was left without proper care and monitoring for several hours after the fall, during which time his condition deteriorated, ultimately leading to his death. The facility's failure to adhere to care plans and safety protocols placed the resident in immediate jeopardy.
Removal Plan
- Re-educate all nursing staff on policies including Quality Care Documentation, Notifying Primary Care Physician (PCP) and Family, Neurological Assessments and Vital Signs, Change in Condition, Gait Belt Use, Falls, Using a Lift, Abuse, Neglect, and Exploitation Recognition and reporting.
- Implement a Quality Assurance and Performance Improvement (QAPI) review of the incidents.
- Conduct one-on-one disciplinary counseling with direct care staff on duty.
- Terminate the involved nurses.
- Complete audits to identify residents at risk and ensure all appropriate actions/interventions are implemented.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and intervention for a resident, identified as R1, who exhibited unsafe behaviors that led to a fall and subsequent injuries. R1, who had a history of cerebrovascular accident, depression, and atrial fibrillation, was documented to have severe cognitive impairment and required significant assistance for daily activities. Despite being identified as a high fall risk, R1 was observed leaning forward in his wheelchair multiple times on the day of the incident, which eventually resulted in him falling headfirst to the floor, causing a broken nose and a head laceration. The incident occurred when a Certified Nurse Aide (CNA) was cleaning the dining hall and momentarily turned away from R1, who then fell. The CNA and a Licensed Nurse (LN) responded to the fall, and R1 was subsequently sent to the hospital for evaluation. The facility's records indicated that R1 had been leaning forward in his wheelchair throughout the morning, and staff had verbally redirected him, but no further interventions were implemented to prevent the fall. The facility's policy on managing falls and fall risk emphasized the need for staff to identify and implement appropriate interventions based on a resident's specific risks. However, in this case, the facility did not adequately supervise or intervene to prevent R1's fall, despite his known high fall risk and repeated unsafe behavior. This lack of supervision and intervention directly contributed to the incident and R1's injuries.
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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