Westview Of Derby Rehabilitation & Health Care Cen
Inspection history, citations, penalties and survey trends for this long-term care facility in Derby, Kansas.
- Location
- 445 N Westview Dr, Derby, Kansas 67037
- CMS Provider Number
- 175218
- Inspections on file
- 25
- Latest survey
- September 16, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Westview Of Derby Rehabilitation & Health Care Cen during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of constipation was not properly monitored for bowel movements, resulting in extended periods without a bowel movement or treatment. Staff failed to consistently document or respond to the lack of bowel movements, and follow-up after administering laxatives was incomplete. The facility lacked a policy for monitoring and preventing constipation, and staff interviews revealed inconsistent practices in documentation and follow-up.
A resident with severe cognitive impairment, a history of frequent falls, and significant mobility needs was left unattended and experienced a fall resulting in a femur fracture. Following this incident, the facility did not implement or document any new interventions to prevent further falls, and staff reported that fall interventions were inadequate and not consistently reviewed or updated according to facility policy.
Staff did not consistently test and record dish machine water temperatures, with numerous undocumented checks and missing logs. Dietary staff gave inconsistent information about temperature monitoring, and the facility's policy did not address this requirement.
The facility did not complete a thorough facility-wide assessment to determine specific staffing levels, gather resident input, or develop contingency plans for non-emergency events, resulting in a lack of clear resource planning for all residents.
A resident's protected health information (PHI), including medications, date of birth, allergy information, and code status, was left visible on an unlocked laptop atop a medication cart in a common area. The cart was unattended by staff, and the PHI was accessible to anyone passing by. Staff interviews confirmed the expectation that such information should be secured and not left open.
Several dependent residents did not consistently receive scheduled showers or baths as required by their care plans, with documentation gaps and missed opportunities for personal hygiene. Some residents reported feeling dirty and neglected, and observations confirmed poor hygiene and grooming. Staff interviews revealed that missed baths were sometimes due to staffing shortages or lack of proper documentation, despite facility policy requiring regular bathing and documentation of refusals.
Surveyors found that the facility did not provide consistent, resident-directed activities on weekends, with Sundays limited to televised church services, movies, and news, and no staff-led or interactive engagement. Residents reported boredom and lack of alternatives for those unable to attend outings, and staff confirmed there was no assigned responsibility or documentation for weekend activities.
Surveyors found that hazardous areas, including an unlocked oxygen storage room, unsecured cleaning chemicals, and exposed electrical panels, were accessible to cognitively impaired and mobile residents. Additionally, a resident with severe cognitive impairment and a history of falls did not have required fall prevention interventions, such as gripper strips, in place. Staff were unclear about responsibilities for ensuring interventions were implemented, and the facility could not provide a policy on environmental safety.
Staff failed to consistently reconcile and document controlled substance counts between shifts, as required by facility policy. Reviews of inventory count sheets showed missing signatures from both oncoming and off-going staff on multiple occasions. Interviews with CMAs and LNs revealed uncertainty about the process when signatures were missing, and the required reconciliation was not always completed, increasing the risk of medication misappropriation or diversion.
The facility did not ensure that monthly drug regimen reviews by the consultant pharmacist were properly reviewed and addressed by physicians for multiple residents, including those with dementia, depression, and severe cognitive impairment. In several cases, recommendations for gradual dose reduction, clarification of medication orders, and reeducation on analgesic dosages were not acted upon, and required documentation was missing due to process failures and changes in pharmacy providers.
A resident's oxygen and nebulizer tubing were not stored in a sanitary manner, and a nurse performed tracheostomy care for a resident on Enhanced Barrier Precautions using only gloves, without the required gown and mask. Facility staff were uncertain about training on EBP protocols, despite signage and policy requirements for infection prevention.
Two residents with significant cognitive and physical impairments were not provided with reasonable accommodations as required by their care plans. One resident's call light was left out of reach, preventing her from calling for assistance, while another was pushed in a wheelchair without foot pedals, causing her feet to slide on the floor. Staff interviews confirmed these actions were not in line with facility expectations or policies.
A resident with severe cognitive impairment and multiple medical conditions was inappropriately charged for services that should have been covered by Medicaid/Medicare due to incorrect billing codes and admission status errors. The facility failed to prevent multiple unauthorized withdrawals from the resident's personal bank account and could not provide a policy on resident personal funds when requested.
A resident who transitioned from Medicare Part A to custodial care was not given the required SNF ABN form 10055, as confirmed by record review and staff interview. The responsible staff member reported never having issued the form and lacked training on the process, resulting in the resident not being informed about potential financial liability for services not covered by Medicare.
A resident with multiple medical conditions and impaired mobility did not receive required pressure ulcer prevention interventions, including the use of heel protectors and offloading of heels while in bed. Staff also failed to monitor and correctly set the resident's low air loss mattress according to her weight, and there was a lack of staff knowledge regarding mattress settings. These failures were not in accordance with the care plan and physician orders.
A resident requiring hemodialysis did not have consistent monitoring and documentation of their dialysis shunt for bruit, thrill, and dressing. Although care plans and physician orders required this monitoring, staff interviews revealed a lack of clear documentation procedures and uncertainty about monitoring on non-dialysis days. The facility's policy did not address access site monitoring, leading to inconsistent practices.
A resident with severe cognitive impairment and multiple medical conditions was prescribed Diclofenac Sodium External Gel for pain, but the physician's order did not specify the dosage amount. Despite a consultant pharmacist's recommendation to clarify the order, the facility did not document any follow-up, and the medication continued to be administered without a defined dosage. Nursing staff confirmed that all medication orders should include dosage and application site, but the facility could not provide a relevant policy when asked.
Surveyors found that a medication cart contained an opened, undated insulin pen. A nurse confirmed that insulin pens should be labeled when removed from refrigeration, and an administrative nurse stated that all opened pens should be dated and labeled. The facility could not provide a medication storage policy, resulting in a failure to properly label medications.
A resident who required two-person assistance for mechanical lift transfers sustained a fractured kneecap when a staff member operated the lift alone, contrary to the care plan and facility expectations. The incident occurred when the staff member, described as impatient, did not wait for a second staff member, resulting in the resident's legs striking a metal object during the transfer. Facility staff interviews confirmed that two-person assistance is required for mechanical lift use, but the policy lacked specific guidance on safe operation.
A cognitively impaired resident at risk for elopement was able to leave the facility unsupervised due to a CNA's failure to verify the source of a WanderGuard alarm. The resident was found 90 feet from the facility, heading toward a busy 4-lane road. The incident revealed lapses in the facility's supervision and monitoring procedures.
The facility failed to provide adequate bathing services for three residents, resulting in significant periods without proper hygiene. One resident went without a shower for up to 15 days, another for 29 days, and a third received only one shower in 57 days. Staff interviews and records revealed inconsistencies in following bathing schedules and a lack of proper documentation.
The facility failed to suspend an alleged perpetrator in response to an abuse allegation, allowing the CNA to work a night shift before suspension. This action was against the facility's policy, which mandates immediate suspension pending investigation.
Failure to Monitor and Respond to Resident Constipation
Penalty
Summary
The facility failed to adequately monitor and respond to a resident's lack of bowel movements, despite the resident having a history of severe cognitive impairment, incontinence, and a diagnosis of constipation. The resident's care plan directed staff to monitor for constipation and administer laxatives as needed if no bowel movement occurred in three days. However, electronic medical records showed that the resident went up to nine consecutive days without a bowel movement or treatment, and up to eight consecutive days on another occasion, with no medication given for constipation and no assessment documented during these periods. Documentation of bowel movements and follow-up after administration of laxatives was incomplete or missing. Interviews with staff revealed inconsistencies in monitoring and documentation practices. Certified Medication Aides and Licensed Nurses stated that bowel movements were supposed to be tracked and that nurses should assess and notify providers if a resident went three days without a bowel movement. However, the administrative nurse acknowledged that Certified Nurse Aides did not always document bowel movements in the EMR, and that nurses did not consistently follow up on EMR alerts for missed bowel movements. The facility did not provide a policy addressing the monitoring of residents to prevent constipation.
Failure to Implement Post-Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement an intervention to prevent further falls after a resident experienced a fall resulting in a serious injury. The resident had multiple diagnoses, including severe cognitive impairment, a nonunion femur fracture, muscle weakness, anxiety, and a history of frequent falls. The resident required extensive assistance for transfers and mobility, including the use of a mechanical lift and wheelchair. Despite being identified as high risk for falls and having several care plan interventions in place, after a significant fall in which the resident was left unattended in the dining room and sustained a femur fracture, the facility did not document or implement any new intervention to prevent further falls. Staff interviews revealed that interventions following falls were not consistently chosen by direct care staff and that the interventions in place were considered inadequate by some staff members. Additionally, there was a lack of documentation for previous fall investigations, and the process for reviewing and updating interventions was not consistently followed. The facility's policy required completion of an occurrence report, root cause determination, and implementation of interventions after each fall, but these steps were not fully carried out in this case.
Failure to Document Dish Machine Water Temperatures
Penalty
Summary
The facility failed to ensure that staff members properly tested and recorded dish machine water temperatures, as evidenced by 34 undocumented temperature checks out of 84 opportunities in February and eight undocumented checks in March. During the initial tour, it was observed that the Dish Machine Log for March was not available in the kitchen, and staff provided inconsistent information regarding the location and posting of the log. Dietary staff confirmed that dish machine water temperatures should be checked at least daily, but documentation was lacking. Additionally, the facility's Food Storage policy did not address dish machine water temperatures.
Incomplete Facility-Wide Assessment for Resource and Staffing Needs
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment provided by the administrative nurse was last updated on 08/12/24 and did not specify required staffing levels for each unit, including the number of RNs, LPNs/LVNs, CMAs, and CNAs needed based on patient acuity and census. Additionally, the assessment did not address staffing requirements for all shifts, such as evenings and weekends. The assessment also lacked documentation of input from residents and their representatives in its formulation. Furthermore, it did not include contingency plans for events that could impact resident care but do not require activation of the facility's emergency plan. These deficiencies were identified through observations, interviews, and record reviews, and affected all 69 residents in the facility.
Resident PHI Left Visible on Unattended Medication Cart
Penalty
Summary
A medication cart was observed parked in a hallway with a laptop computer on top, displaying a resident's protected health information (PHI) on the screen. The information visible included the resident's medications, date of birth, allergy information, and code status. At the time of observation, no nursing staff were present to monitor the cart or the computer, making the PHI accessible to anyone passing by. A Certified Medication Aide (CMA) later confirmed that she had left the cart unattended for a short period and acknowledged that the computer should not have been left open with PHI visible. Interviews with facility staff, including a Licensed Nurse and an Administrative Nurse, confirmed that the expectation was for the laptop to be closed or locked when unattended, and that PHI should not be accessible to unauthorized individuals. The facility's policy on electronic medical records specifies that only authorized personnel should have access and that efforts should be made to limit the disclosure of PHI to the minimum necessary. The failure to secure the laptop resulted in a breach of the resident's privacy regarding their PHI.
Failure to Provide Consistent Bathing and ADL Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide consistent bathing and assistance with activities of daily living (ADLs) for several residents who were dependent on staff for personal care. Multiple residents, including those with intact cognition and those with severe cognitive impairment, did not receive scheduled showers or baths as documented in their care plans and medical records. For example, one resident with muscle weakness and depression was documented as requiring staff assistance for bathing but had only one recorded shower over a 61-day period, with no evidence of being offered or refusing care during that time. The resident reported feeling dirty and neglected due to missed baths. Another resident with chronic medical conditions, including COPD, morbid obesity, and diabetes, was dependent on two staff for ADLs and had a history of moisture-associated skin damage. This resident had no documented bathing opportunities for over a month, and reported feeling unclean, with staff providing only peri-care and not assisting with full bathing or showering. Similarly, a resident with hemiplegia and other significant health issues did not consistently receive bathing twice weekly as per her care plan, and reported not having a shower for 15 days, noting that showers were missed when staff were short. Additionally, a resident with vascular dementia and multiple comorbidities, who required substantial to maximum assistance for bathing and grooming, had no documentation of showers given over nearly two months. Observations noted poor grooming and hygiene, with matted and tangled hair. Staff interviews confirmed that while policies required offering showers twice weekly and documenting refusals, there were lapses in both the provision and documentation of care, particularly when staffing was insufficient or when residents refused care. The facility's own policy required individualized care based on assessment and care plans, but this was not consistently followed for the residents reviewed.
Lack of Resident-Directed Activities on Weekends
Penalty
Summary
The facility failed to provide resident-directed, interactive activities based on resident preferences during weekends. Review of activity calendars for three consecutive months showed that Sundays only included church services via television or internet, movies in the afternoon, and the evening news, with no staff-led or engaging activities. Resident Council feedback confirmed that activities were rarely provided on weekends, with Sundays being particularly inactive. While outings sometimes occurred on Saturdays, not all residents could participate due to limited transportation, and no alternative activities were offered for those unable to attend. Staff interviews revealed that weekend activities were expected to be completed by staff, but there was no assignment of specific staff to lead activities, and no documentation of which activities were provided or which residents attended. An activity basket with puzzles, coloring pages, and games was available, but there was no evidence of consistent or interactive engagement. The facility was unable to provide a policy related to activities when requested. These findings indicate a lack of consistent, resident-centered activities on weekends, as directly observed and reported.
Failure to Secure Hazardous Areas and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to secure areas containing hazardous materials and potential accident hazards, leaving them accessible to seven cognitively impaired and independently mobile residents in a secured unit. During a walkthrough, surveyors observed an unlocked supplemental oxygen storage room containing 46 fully charged oxygen cylinders, a propped-open shower room with unsecured bleach wipes and disinfectant, an unsecured closet with a gallon of floor cleaner, and two unlocked utility closets with exposed electrical panels labeled as high voltage. Staff acknowledged that these areas should have been locked and that residents should not have access to such hazards. The facility was unable to provide a policy related to environmental safety when requested. Additionally, the facility failed to implement and maintain fall prevention interventions for a resident with a history of falls, severe cognitive impairment, muscle weakness, COPD, and hypertension. The resident required substantial to maximum staff assistance for transfers and had experienced multiple falls, some resulting in injuries such as skin tears and bruising. The care plan included interventions such as ensuring the resident wore gripper socks, keeping the call light and personal items within reach, and using gripper strips on the floor next to the bed. However, on inspection, gripper strips were not in place, and staff interviews revealed uncertainty about who was responsible for ensuring interventions were implemented. The facility's fall management policy outlined the need for an interdisciplinary approach to fall prevention, but documentation and staff interviews indicated lapses in following and updating care plans and interventions. The lack of environmental safety measures and failure to consistently implement fall prevention strategies placed residents, particularly those with cognitive impairment and mobility, at risk for preventable injuries and accidents.
Failure to Reconcile and Document Controlled Substance Counts Between Shifts
Penalty
Summary
The facility failed to ensure that controlled substances were properly accounted for and reconciled between shifts, as required by their policy. A review of the Shift Change Controlled Substance Inventory Count Sheets for multiple months revealed missing signatures from both oncoming and off-going nurses on several dates. Certified Medication Aides (CMAs) and Licensed Nurses (LNs) confirmed that the process required both parties to count the medication cards and pills and sign the count sheet at each shift change. However, there was a lack of clarity among staff regarding the procedure to follow when signatures were missing, and the required reconciliation was not consistently completed. The facility's policy mandated that all controlled substances be counted every shift, with both the oncoming and off-going nurse or CMA responsible for verifying and signing the count. Despite this, documentation showed repeated failures to obtain the necessary signatures, indicating that the reconciliation process was not reliably followed. This deficiency was identified through observation, record review, and staff interviews, and it placed residents at risk for misappropriation or diversion of controlled substances.
Failure to Address Consultant Pharmacist Recommendations and Medication Order Irregularities
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed adequate monthly drug regimen reviews and that physicians reviewed and addressed the consultant pharmacist's (CP) recommendations for several residents. For one resident with dementia, depression, and anxiety, the medical record showed ongoing use of antipsychotic, antianxiety, and antidepressant medications without evidence of a gradual dose reduction (GDR) or documentation that a GDR was clinically contraindicated. The monthly medication review (MMR) for this resident indicated a 14-day stop date was required for as-needed antipsychotic medication, but the physician did not review and sign the MMR until several months later. Additionally, the facility was unable to provide MMRs for certain months, and administrative staff acknowledged that the process for addressing MMRs was incomplete. Another resident with a history of stroke, muscle weakness, and severe cognitive impairment had a physician's order for topical Diclofenac gel that lacked a specified dosage and site of application. The CP identified this irregularity and recommended clarification, but there was no documented response from the facility or evidence that the order was updated. Nursing staff and administration confirmed that all medication orders should include dosage and application site, and that pharmacy recommendations should be acted upon, but this was not done in this case. Additional deficiencies were identified for two other residents receiving psychotropic medications. For one resident with depression and multiple comorbidities, the facility could not provide evidence that the CP's recommendations regarding antidepressant and analgesic medications were reviewed or addressed by the physician. For another resident with severe cognitive impairment and depression, the facility was unable to produce documentation of the MMR or evidence that the physician addressed the CP's recommendations for antidepressant medication. In both cases, administrative staff stated that records were missing due to changes in pharmacy providers and acknowledged a breakdown in the process for handling CP recommendations.
Failure to Maintain Sanitary Storage of Respiratory Equipment and Proper PPE Use During Tracheostomy Care
Penalty
Summary
The facility failed to maintain sanitary storage of respiratory equipment and did not ensure proper use of personal protective equipment (PPE) during tracheostomy care. During a facility walk-through, one resident's oxygen tubing and cannula were found wrapped over a walker, and nebulizer tubing was left on a side table, both not stored in a sanitary manner. Additionally, a licensed nurse performed tracheostomy care for a resident on Enhanced Barrier Precautions (EBP) but only donned sterile gloves, omitting the required gown and mask. The nurse stated he was unaware that additional PPE was necessary beyond gloves. Administrative staff confirmed that respiratory equipment not in use should be bagged and that there are signs on doors for residents on EBP, but there was uncertainty about whether staff had been adequately trained on EBP protocols. The facility's own infection prevention and control policy emphasizes maintaining a safe and sanitary environment to prevent the transmission of communicable diseases, but these practices were not followed, resulting in the identified deficiencies.
Failure to Accommodate Resident Needs: Inaccessible Call Light and Missing Wheelchair Foot Pedals
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents, resulting in deficiencies related to resident safety and care. For one resident with a history of heart failure, hemiparesis following a stroke, muscle weakness, neurogenic bladder, major depressive disorder, and dementia, the call light was observed to be out of reach while the resident was asleep in bed. The resident's care plan specifically required that the call light be within reach and that staff encourage its use for assistance. Interviews with staff confirmed that call lights should always be accessible to residents, but the facility did not provide a policy on accommodations of needs. Another resident, diagnosed with acute respiratory failure, bipolar disorder, unsteadiness of feet, and catatonic disorder, was observed being pushed in a wheelchair without foot pedals on two separate occasions. The resident's feet were seen sliding on the floor as staff pushed the wheelchair. The care plan indicated the resident was at risk for falls due to impaired balance and poor safety awareness, and staff interviews confirmed that foot pedals should be used, especially for cognitively impaired residents, to prevent falls during transport. The facility's fall prevention policy required the implementation of preventative interventions to ensure resident safety, but this was not followed in the observed cases. The lack of accessible call lights and the absence of wheelchair foot pedals during transport represented failures to accommodate the residents' needs as outlined in their care plans and facility policy.
Unnecessary Charges to Resident's Personal Funds Due to Billing Errors
Penalty
Summary
The facility failed to prevent unnecessary charges to a resident's personal bank account, resulting in multiple inappropriate withdrawals. The resident, who had diagnoses including COPD, senile degeneration of the brain, and dementia with severe cognitive impairment, was admitted for hospice services and was eligible for Medicaid/Medicare coverage. Despite this, the facility's records showed that the resident's bank account was charged several times for services that should have been covered by Medicaid/Medicare, with amounts ranging from $215.27 to $2,494.73. The resident's representative reported these unauthorized transactions to the state agency and provided the facility with documentation of the resident's Medicaid/Medicare eligibility. Interviews with facility staff revealed that the resident's billing code was set up incorrectly, which led to the inappropriate charges. Staff acknowledged that the resident was admitted under both hospice pay and private pay, which may have contributed to the billing errors. Additionally, the facility was unable to provide a policy related to resident personal funds when requested. This series of actions and inactions resulted in the resident being inappropriately charged for services that should have been covered by public insurance programs.
Failure to Provide SNF ABN Notification at End of Medicare Part A Coverage
Penalty
Summary
The facility failed to issue the required CMS Skilled Nursing Facility Advance Beneficiary Notification (SNF ABN) form 10055 to a resident whose Medicare Part A episode ended, despite the resident remaining in the facility for custodial care. Review of the electronic medical record confirmed the resident's Medicare Part A coverage period and subsequent stay, but no evidence was provided that the SNF ABN was given. An interview with a social services staff member revealed that she had never provided the SNF ABN to residents ending Medicare Part A coverage and had not been trained to do so. The facility's own policy states that the SNF ABN is intended to inform patients about potential financial responsibility for services not covered by Medicare, but this process was not followed in this case. The failure to provide the required notification meant that the resident was not given the necessary information to make informed decisions regarding their care and financial obligations at the end of their Medicare Part A coverage.
Failure to Implement Pressure Ulcer Prevention Interventions and Monitor Support Surfaces
Penalty
Summary
A deficiency was identified when staff failed to provide appropriate pressure ulcer prevention and care for a resident with multiple medical conditions, including heart failure, hemiparesis following a stroke, muscle weakness, hypertension, neurogenic bladder, major depressive disorder, and dementia. The resident was assessed as having severely impaired cognition and required assistance with mobility and repositioning. Despite care plan instructions and physician orders for heel protectors and offloading of heels while in bed, staff did not ensure these interventions were implemented. Observations revealed that the resident was lying in bed with her heels directly on the mattress, without heel protectors or offloading, contrary to physician orders and the care plan. Additionally, the low air loss mattress, intended to reduce pressure and prevent ulcers, was set at 350 pounds, which did not correspond to the resident's actual weight of 116 pounds. Staff interviews indicated a lack of knowledge regarding the correct mattress settings and monitoring procedures, and there was no documentation in the care plan for staff to monitor the mattress settings as required by manufacturer recommendations. The facility's policy required individualized plans to address pressure injury prevention, including the use of mechanical support surfaces and regular monitoring. However, the failure to apply heel protectors, offload the resident's heels, and monitor the low air loss mattress as specified in the care plan and physician orders placed the resident at increased risk for developing pressure ulcers.
Failure to Consistently Monitor and Document Dialysis Shunt Care
Penalty
Summary
The facility failed to consistently monitor and document a resident's dialysis shunt for bruit, thrill, and dressing as required. The resident, who had diagnoses including diabetes mellitus, hypertension, end-stage renal disease, and a fractured shoulder, required hemodialysis three times a week. The care plan and physician's orders specified that nursing staff should monitor the shunt's bruit and thrill and obtain vital signs before and after dialysis. However, the electronic medical record lacked clear documentation or direction for daily monitoring of the shunt's dressing, bruit, and thrill. Observations and staff interviews revealed that there was no designated place for nurses to document daily monitoring of the shunt, and it was unclear whether monitoring occurred or was recorded on non-dialysis days. The facility's dialysis communication policy did not address access site monitoring, and administrative staff were unsure about the documentation process. This resulted in inconsistent monitoring and documentation practices for the resident's dialysis access site.
Medication Order Lacked Required Dosage for Topical Pain Medication
Penalty
Summary
A deficiency was identified when a resident with multiple medical diagnoses, including cerebral infarction, muscle weakness, aphasia, chronic kidney disease, and heart failure, was found to have a physician's order for Diclofenac Sodium External Gel that lacked a specified dosage amount. The resident's electronic medical record indicated severe cognitive impairment and a need for substantial to maximal assistance with daily activities. The care plan noted the use of medications with Black Box Warnings and instructed staff to monitor for pain and medication side effects. Despite these precautions, the Diclofenac order did not include the required dosage information. A consultant pharmacist's monthly medication review highlighted the missing dosage and site of application for the Diclofenac order and recommended clarification, but there was no documented response from the facility. Observations confirmed that the medication was administered without a specified dosage, and interviews with nursing staff and administration affirmed that all medication orders should include an accurate dosage and application site. The facility was unable to provide a policy regarding physician's orders when requested.
Failure to Properly Label Opened Insulin Pen in Medication Cart
Penalty
Summary
Surveyors observed that one of three medication carts contained an opened and undated insulin pen. A licensed nurse confirmed that all insulin pens should be labeled once removed from the refrigerator and placed into the medication cart. An administrative nurse also stated that her expectation was for all insulin pens to be dated and labeled upon opening. The facility was unable to provide a policy related to medication storage. These findings indicate that the facility failed to properly label medications as required, specifically with respect to insulin pens in the medication cart. The sample included 18 residents, three medication carts, and one medication room, with a total facility census of 69 residents at the time of the survey.
Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with cerebral palsy, blindness, diabetes mellitus type 2, and restless leg syndrome, who was dependent on staff for transfers and required a mechanical lift with two-person assistance, sustained a fracture to the left patella during a transfer. On the evening of the incident, an unknown staff member operated the mechanical lift alone, contrary to the resident's care plan and facility expectations, which required two staff members for such transfers. The staff member was described as impatient and did not wait for a second staff member to assist. During the transfer, the resident's legs struck a metal object, resulting in a popping sensation and immediate pain. The resident reported the incident to the nurse and requested to be sent to the emergency department, where a non-displaced fracture of the left patella was diagnosed. Interviews with multiple CNAs, a licensed nurse, and an administrative nurse confirmed that facility policy and standard practice required two staff members for mechanical lift transfers to ensure resident safety. The facility's policy on safe lifting and movement of residents lacked specific direction regarding the safe and appropriate use of mechanical lifting devices. The care plan also lacked documentation or intervention related to the injury following the incident.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure a safe and secure environment to prevent the elopement of a cognitively impaired resident identified at risk for elopement. On the specified date, a CNA mistakenly let the resident out the front doors of the building, thinking the resident had an appointment and was leaving to get on the facility transport vehicle. The resident's WanderGuard alarm activated, but the CNA did not check which resident caused the alarm. The facility did not realize the resident was missing until almost 15 minutes later when a staff member driving by saw the resident outside, unsupervised, and notified the facility. The resident was found approximately 90 feet from the facility, heading toward a busy 4-lane road. These failures placed the resident in immediate jeopardy. The resident had a history of paraplegia, cognitive communication deficit, reduced mobility, and chronic pain syndrome. The resident's care plan indicated an elopement risk, wandering behavior, and a desire to leave the facility. The care plan required frequent monitoring by staff and specified that the resident could only go outside with staff supervision. Despite these precautions, the resident was able to leave the facility unsupervised due to the CNA's failure to verify the source of the WanderGuard alarm. Interviews with staff revealed that the CNA who let the resident out was unaware of the resident's elopement risk and did not follow the facility's elopement policy. The facility's investigation confirmed that the WanderGuard alarm functioned correctly, but staff failed to respond appropriately. The facility's policy required all residents to be assessed for elopement risk and have these issues addressed in their care plans, but this was not effectively implemented in this case. The incident highlighted a significant lapse in the facility's supervision and monitoring procedures for residents at risk of elopement.
Removal Plan
- The facility located R1 and brought him back to the building. A skin assessment was performed by the Director of Nursing, with no issues found. A WanderGuard was found in place and functioning at the time of the event. R1's Physician and Durable Power of Attorney were notified of the event. Elopement evaluation completed and care plan reviewed.
- A headcount of all residents was performed.
- Community review of all residents at risk for elopement was completed by the Director of Nursing and Assistant Director of Nursing. Residents identified as having the potential to be affected were evaluated for elopement risk by the Assistant Director of Nursing.
- Care plan review of residents identified as having the potential to be affected was completed by the Assistant Director of Nursing to verify prevention interventions were in place as indicated.
- Current associates were re-educated by the Assistant Director of Nursing and/or designee on the community Elopement Policy and the community Elopement Evaluation process. Associates who had not completed the required education were required to complete education prior to working their next scheduled shift.
- An ADHOC QAPI meeting was completed with the community interdisciplinary team.
- The facility Medical Director was notified of elopement and further notified of the facility compliance plan.
- Exit doors were evaluated and noted to be functioning without discrepancy. Front door code changed and communicated to the staff.
- Residents identified with a new risk for elopement or change in elopement risk will be reviewed by clinical/interdisciplinary team during routine clinical huddle to verify elopement risk assessment accuracy, provider notification, and preventative measures.
Inadequate Bathing Services for Residents
Penalty
Summary
The facility failed to provide adequate bathing services for three residents, resulting in significant periods without proper hygiene. Resident 1, who had diagnoses of muscle weakness and required assistance with personal care, experienced multiple instances where bathing was delayed for up to 15 days. Despite having a care plan that specified a preference for showers at least twice weekly, the facility's documentation revealed inconsistent bathing schedules and missed showers. Resident 1 expressed confusion about the bathing schedule and reported instances where staff did not assist her in getting a shower even after she requested one upon returning from the hospital. Resident 2, who also had muscle weakness and required substantial assistance for bathing, went without a shower for 29 days and then again for 21 days. The resident reported that she preferred showers twice a week but was only receiving them once a week, despite her son's repeated requests to the nursing staff. The facility's records corroborated these gaps in bathing services, and staff interviews revealed that the lack of a designated bath aide contributed to the inconsistency. Resident 3, diagnosed with muscle weakness and dementia, required moderate assistance for bathing and had a care plan that specified showers twice weekly. However, the facility's records showed that Resident 3 received only one shower in 57 days. The resident's fingernails were observed to be long and dirty, indicating a lack of proper hygiene care. Staff interviews confirmed that bathing schedules were not consistently followed, and refusals were not adequately documented or addressed. The facility lacked a policy for bathing services, contributing to the failure to provide adequate care for these residents.
Failure to Suspend Alleged Perpetrator During Abuse Investigation
Penalty
Summary
The facility failed to suspend an alleged perpetrator in response to an allegation of abuse, neglect, exploitation, or mistreatment, thereby not preventing further potential abuse while an investigation was in progress. The incident involved a resident who was allegedly restrained and dragged to her room and forced to take medication by a CNA and a licensed nurse. The administrative nurse received the report of the allegation on 02/27/24 but allowed the CNA to work the night shift on the same day before suspending both the CNA and the licensed nurse the following day. The facility's policy mandates that any employee alleged to have committed abuse or neglect should be immediately barred from further contact with residents through suspension, pending the outcome of the investigation. However, the administrative nurse confirmed that the CNA worked the night shift on 02/27/24, which was corroborated by the nursing staff schedule and daily assignment sheets. This failure to immediately suspend the alleged perpetrator compromised the safety of the residents during the investigation period.
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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