Advena Living Of Cherryvale
Inspection history, citations, penalties and survey trends for this long-term care facility in Cherryvale, Kansas.
- Location
- 1001 W Main Street, Cherryvale, Kansas 67335
- CMS Provider Number
- 175335
- Inspections on file
- 26
- Latest survey
- September 4, 2025
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Advena Living Of Cherryvale during CMS and state inspections, most recent first.
Surveyors found that the kitchen had unsanitary conditions, including handwashing sinks with brown stains and grime, and a broken, uncovered trash can located near the food preparation area. Dietary staff confirmed the issues and the facility lacked a policy for trash disposal and hand sanitation equipment.
Multiple areas of the facility, including the hallway outside the kitchen and the laundry area, were found with broken tiles, standing water, missing flooring, exposed pipes, unsanitizable surfaces, and exposed electrical components. Staff and maintenance personnel were often unaware of these issues until they were reported, and the process for reporting maintenance concerns was inconsistently followed, resulting in unsafe and unsanitary conditions.
Multiple environmental hazards, including exposed drywall, damaged ceilings, dirty floors, cracked tiles, and live open electrical outlets, were observed in resident rooms and common areas. Staff interviews revealed a lack of awareness and inconsistent use of the maintenance reporting system, resulting in unaddressed hazards and failure to maintain a safe, clean, and homelike environment as required by facility policy.
A resident with multiple chronic conditions was administered several medications together after breakfast, despite orders requiring some to be given before meals and others with or after food. Staff confirmed the medications were not given as prescribed, contributing to a medication error rate of 17%, exceeding the required threshold.
Numerous handrails in a resident hallway were found to be loose and easily moved by hand during a facility tour. Maintenance and administrative staff were unaware of the issue, despite facility policies requiring a safe environment and prompt reporting of damaged equipment.
Several residents were administered psychotropic medications, including antipsychotics and antianxiety drugs, without proper informed consent being obtained or documented prior to the initiation or change of these medications. Facility staff confirmed that required consents were missing, delayed, or incomplete, contrary to facility policy.
A resident with a history of depression, psychotic disturbance, and anxiety, requiring assistance with daily activities, was not consistently included or invited to participate in her care plan meetings. Staff interviews and record reviews confirmed a lack of documentation and notification regarding the resident's involvement in care planning, contrary to facility policy.
A resident with multiple mental health diagnoses was prescribed PRN clonazepam for anxiety and sleeplessness without a required 14-day stop date or physician justification for continued use. Facility staff confirmed the absence of a stop date or rationale, and no policy was provided to support compliance with regulations regarding PRN psychotropic medications.
A resident with Parkinson's disease, CHF, and DM was transferred to the hospital, but the facility did not notify the Ombudsman as required by policy. The electronic medical record lacked documentation of this notification, and staff confirmed the omission.
A deficiency was cited for not providing enough food and fluids to maintain a resident's health, as required. The report indicates that the facility did not meet the necessary standards for nutrition and hydration, but does not include further details about the circumstances or the resident's condition.
A resident in need of pain management did not receive safe and appropriate pain management services, resulting in a deficiency related to the facility's failure to meet the resident's needs.
A resident with a history of stroke, hypertension, and chronic kidney disease continued to receive Xarelto, an anticoagulant flagged by the consultant pharmacist for increased bleeding risk in older adults. The pharmacist recommended considering a switch to Eliquis, but the facility did not obtain a physician response or follow up on this recommendation for over 42 days, and lacked a policy for such follow-up.
Surveyors found that staff did not properly secure medications, leaving delivery boxes containing various drugs and biologicals on the floor of an Environmental Services closet instead of storing them in the medication room or cart as required by facility policy. Interviews confirmed that medications should not have been stored outside designated secure areas.
Unsanitary Kitchen Conditions Due to Improper Trash Disposal and Handwashing Sink Maintenance
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the kitchen, specifically regarding the storage and preparation of food. During an initial kitchen tour, the handwashing sinks were found to have brown stains and grime buildup around both the inner and outer edges. Additionally, a foot-operated trash can had a broken lid, which was found lying on the floor behind the trash can in a pile of used coffee grounds. The open trash can was located adjacent to the food preparation area, next to the steam table and a rack of clean dishes. Dietary staff confirmed that the trash should be contained to ensure food sanitation and prevent contamination. On a follow-up tour, the same uncovered trash can was observed at the handwashing sink in the food preparation area, and staff verified that it was the same broken trash can from the previous day. The facility did not provide a policy addressing trash disposal and hand sanitation equipment in the kitchen. These observations were made while the facility had a census of 26 residents and one main kitchen. No specific residents were directly involved or affected at the time of the deficiency.
Failure to Maintain Safe and Sanitary Environment in Key Facility Areas
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in several key areas, including the hallway outside the kitchen and the laundry area. Observations revealed multiple broken tiles and standing water in the hallway leading from the kitchen to the outside, which was being tracked into the kitchen. Dietary staff confirmed that water entered the hallway during rain and had to be mopped up to prevent it from entering the kitchen, while the broken tiles prevented proper sanitation. Maintenance staff were unaware of the broken and missing tiles until notified, and acknowledged that the area could not be properly sanitized. Additional observations found missing linoleum flooring behind the nurse's desk, with staff reporting that maintenance concerns should be entered into a computerized notification system, though this was not always done consistently. In the laundry area, there were several unsanitary and unsafe conditions, including an exposed, uncapped sewage pipe between washers, an unsealed and flaking ceiling in the dryer room, and heavily scuffed and chipped paint on walls, door frames, and storage cabinets, exposing wood and making the surfaces unsanitizable. A wall-mounted thermostat was also found without a cover, exposing electrical components. Maintenance staff stated they were unaware of these issues until recently and reiterated that all concerns should be reported through the facility's computerized work order system, but acknowledged that this process was not always followed by staff.
Failure to Maintain Safe and Homelike Environment Due to Unaddressed Environmental Hazards
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in both resident rooms and common areas, as evidenced by multiple observations of environmental hazards and lack of timely maintenance. Surveyors observed dark spots and missing molding with exposed and broken drywall in one resident's room, damaged ceiling areas with exposed sheet rock, and dirty, stained floors. Another resident's room had a large area of exposed drywall and missing paint, with a dirty and sticky floor. The north hallway and rooms had chipped, cracked, and bubbled floor tiles, with some areas exposing the concrete underneath. Additional observations included a significant ceiling and wall crack extending between two rooms, a broken wall tile in the dining room, and multiple open 220-volt electrical outlets in both the dining room and north resident hall, all of which were live with electricity and located close to the ground. Interviews with maintenance and administrative staff revealed a lack of awareness regarding several of these hazards, and a breakdown in the facility's process for reporting and addressing maintenance concerns. Staff were expected to use a computerized maintenance management system (TELS) to report issues, but this was not consistently followed, resulting in unaddressed hazards. Maintenance staff indicated delays in repairs due to waiting for quotes or materials, and some hazards had not been reported or tracked as required by facility policy. Facility policies required a safe, clean, and comfortable environment and prompt maintenance service, but these were not adhered to, leading to the observed deficiencies.
Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a 17% error rate during medication administration. Out of 26 medications observed, four were administered in error. Specifically, a resident with a history of GERD, chronic pain, diabetes, and gastrointestinal issues was prescribed multiple medications with specific administration instructions, such as taking certain medications before meals, on an empty stomach, or with food. During observation, a Certified Medication Aide administered several of these medications together after the resident's breakfast, contrary to the prescribed instructions that required some to be given before meals and others with or after food. The resident also refused one medication, and another was held due to blood pressure readings. Staff interviews confirmed that the medications were not administered according to the physician's orders, with both the medication aide and a licensed nurse acknowledging the error. The nurse further verified that the resident had ongoing issues with vomiting and weight loss, and that the medications were intended to prevent these symptoms when given as ordered. The facility's policy required medications to be administered per the physician's schedule, and the error was confirmed by administrative staff, who noted that certain medications, such as Carafate, should be given separately to avoid interference with absorption.
Loose Handrails in Resident Hallway
Penalty
Summary
The facility failed to provide safe and functional handrails in one of two hallways, as observed during a facility tour when numerous handrails in the north resident hallway were found to be loose and easily moved by hand. Maintenance staff interviewed at the time were unaware of the loose handrails, and administrative staff also stated they were not aware of any such issues in the facility. The facility's policies require staff to maintain a safe environment and to report and repair damaged equipment, but these procedures were not followed, resulting in the deficiency being identified during the survey. The facility had a census of 26 residents at the time of the observation. No specific residents or their medical histories were mentioned in relation to the deficiency.
Failure to Obtain Informed Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were fully informed and provided with informed consent regarding the use of psychotropic medications. Specifically, three residents with diagnoses including schizophrenia, anxiety, bipolar disorder, and depression were administered antipsychotic, antianxiety, and antidepressant medications without proper documentation of informed consent prior to the initiation or change of these medications. In one case, a resident received Seroquel and Zyprexa for schizophrenia and clonazepam for anxiety, but the informed consent for these medications was either delayed or incomplete, with some consents signed months after the medications were started and others missing entirely for as-needed orders. Another resident with anxiety and bipolar disorder was prescribed clonazepam, desvenlafaxine, lamotrigine, and Latuda, but the electronic medical record lacked any documentation of informed consent for these psychotropic and antipsychotic medications. Similarly, a third resident with anxiety and depression was prescribed lorazepam and mirtazapine, yet there was no evidence of informed consent for these medications in the medical record. Interviews with administrative and licensed nursing staff confirmed that facility policy required informed consent to be obtained before starting or changing psychotropic medications, but this was not consistently followed. Observations and record reviews revealed that the facility's own policy mandated obtaining informed consent from residents or their representatives prior to the administration of antipsychotic medications. Despite this, the required consents were either missing, delayed, or incomplete for multiple residents receiving high-risk psychotropic drugs. Staff interviews further verified that the process for obtaining and documenting informed consent was not adhered to as required by facility policy.
Failure to Include Resident in Care Plan Development
Penalty
Summary
The facility failed to include a resident or her representative in the development and planning of her care plan. The resident had a history of depression, psychotic disturbance, mood disturbance, and anxiety, and her cognitive status varied from moderate impairment to intact cognition according to her MDS assessments. Documentation showed that the resident required varying levels of assistance with mobility, hygiene, dressing, and eating, and was prescribed antidepressant and opioid medications. While there was evidence of the resident's attendance at care plan meetings on two specific dates, there was no documentation that she was invited to or included in any subsequent care plan meetings. Interviews with the resident and facility staff confirmed that the resident had not been informed or invited to her care plan meetings after the documented dates. Staff responsible for notifying residents and maintaining records were unable to provide documentation of invitations or attendance for recent care plan meetings. The facility's policy stated that residents and their representatives should be encouraged to participate in care planning and that meetings should be scheduled at convenient times for them, but this was not consistently documented or followed in practice.
Failure to Ensure 14-Day Stop Date or Justification for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a 14-day stop date or a physician's justification for continuation was in place for an as-needed (PRN) psychotropic medication prescribed to a resident. The resident, who had diagnoses including schizophrenia, cerebral edema, and adjustment disorder with anxiety, had an order for PRN clonazepam for sleeplessness and anxiety without a specified stop date or documented rationale for use beyond 14 days. Review of the resident's electronic health record and medication administration records confirmed the absence of a stop date or physician justification for the ongoing PRN order, despite facility staff acknowledging that such medications should have a 14-day limit unless otherwise justified. Observations of the resident showed them in various settings within the facility, and interviews with nursing and administrative staff confirmed the lack of compliance with the 14-day stop date requirement for PRN psychotropic medications. The facility was unable to provide a policy regarding 14-day stop dates for psychotropic medications. This deficiency was identified through record review, staff interviews, and direct observation, and it placed the resident at risk of unnecessary psychotropic medication use and related adverse effects.
Failure to Notify Ombudsman of Resident Hospital Transfer
Penalty
Summary
The facility failed to notify the Ombudsman of a resident's transfer to the hospital, as required by facility policy. The resident in question had diagnoses of Parkinson's disease, congestive heart failure, and diabetes mellitus, and was transferred to the hospital as documented in the electronic medical record (EMR). However, the EMR did not contain any documentation that the Ombudsman was notified of this transfer. During an interview, the administrative nurse confirmed that the Ombudsman had not been notified. The facility was unable to provide evidence of such notification, despite a policy stating that the Ombudsman must be informed of all resident transfers or discharges.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Failure to Follow Up on Pharmacist's Anticoagulant Recommendation
Penalty
Summary
The facility failed to acknowledge and/or act on the consultant pharmacist's recommendation regarding the use of an anticoagulant medication for a resident with a history of stroke, hypertension, chronic kidney disease, and moderate cognitive impairment. The pharmacist had identified that the resident was receiving Xarelto, which is listed in the 2019 Beers Criteria as having an increased risk of serious bleeding in adults over 75 years when used long-term. The pharmacist recommended considering discontinuation or replacement of Xarelto with Eliquis and sent this recommendation to the physician for follow-up. Despite this recommendation, there was no evidence in the clinical record that the facility obtained a response from the physician or followed up on the pharmacist's recommendation for over 42 days. The administrative nurse confirmed that the lack of follow-up was an oversight and the facility did not have a policy in place to address follow-up on consultant pharmacist recommendations. This inaction resulted in the resident continuing to receive the medication without documented physician review or response to the identified irregularity.
Improper Storage of Medications in Unsecured Area
Penalty
Summary
Staff failed to ensure proper storage of resident medications, as observed when delivery boxes containing various stock medications were found sitting on the floor in the Environmental Services closet. The medications included A&D Ointment, aspirin, folic acid, probiotic, Voltaren Gel, Allegra, niacin, and Senna-Plus. According to interviews with administrative staff, medications were supposed to be taken directly to the medication room upon delivery and stored either in the medication cart or medication room, not in other locations. The facility's policy, dated 11/20, required all drugs and biologicals to be stored in a safe, secure, and orderly manner. The observed practice of leaving medication boxes in an unsecured area outside the designated medication storage locations was inconsistent with both facility policy and accepted professional principles. This practice was identified during a survey when the facility census was 26 residents across two halls.
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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