Baldwin Healthcare & Rehab Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Baldwin City, Kansas.
- Location
- 1223 Orchard Lane, Baldwin City, Kansas 66006
- CMS Provider Number
- 175338
- Inspections on file
- 19
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Baldwin Healthcare & Rehab Center, Llc during CMS and state inspections, most recent first.
Staff pre‑poured medications for 11 residents into medication cups that were stored in a medication cart drawer and labeled only with residents’ initials, without identifying the medications, doses, or administration instructions. A CMA acknowledged that facility policy required medications to be popped from bubble packs immediately before administration and not set up early, and an administrative nurse confirmed that medications were not to be prepared until a resident was ready to take them. This practice did not comply with the facility’s medication storage policy, which required proper labeling and storage of all medications and biologicals.
A resident with multiple medical conditions, including memory impairment and expressive aphasia, was assessed by a consultant who made a comment perceived as disrespectful, suggesting the resident might be 'playing opossum.' This comment, made in the presence of the resident's family, was reported by staff and acknowledged by the consultant as not malicious. The facility's policy on resident dignity was not upheld, resulting in a deficiency in maintaining the resident's dignity and quality of life.
The facility failed to secure hazardous cleaning chemicals, leaving them accessible to seven cognitively impaired, independently mobile residents. An inspection revealed an unlocked closet in an unattended shower room containing bleach and other cleaning products with warnings. Staff interviews confirmed that chemicals should be locked up, aligning with the facility's policy, but this protocol was not followed, posing a risk for accidents.
The facility failed to follow infection control standards, with oxygen equipment improperly stored and a lack of enhanced barrier precautions for residents needing wound care and dialysis. Observations showed oxygen tubing on floors and furniture without clean storage, and wound care procedures lacked proper glove changes and hand hygiene. Mechanical lifts were not sanitized after use, and staff interviews confirmed non-compliance with protocols, risking resident safety.
The facility failed to maintain a dignified care environment for three residents. A grievance form was improperly displayed, and two residents with urinary catheters lacked privacy covers, exposing their urine collection bags to public view. Staff interviews confirmed the need for privacy measures, which were not followed, violating the facility's dignity policy.
A resident with multiple medical conditions was pushed in a wheelchair without foot pedals, leading to her foot dragging on the floor. Staff interviews confirmed that foot pedals should be used, aligning with the facility's policy to accommodate resident needs.
A facility failed to include essential dialysis information in a resident's baseline care plan, despite the resident's chronic kidney disease and dependency on staff for daily activities. The care plan omitted details about the dialysis provider, schedule, and times, leading to a lack of pre- and post-dialysis assessments and communication with the dialysis provider. Staff interviews revealed confusion and lack of access to the care plan, highlighting a deficiency in meeting professional standards of quality care.
A resident with end-stage renal disease and type 2 diabetes mellitus required dialysis treatment, but the facility failed to update the care plan with necessary details such as the dialysis clinic's location, schedule, and contact information. Staff interviews confirmed the absence of this information, which is crucial for coordinating care. The facility's policy requires comprehensive care plans to include specialized services, but this was not followed, placing the resident at risk for complications.
A facility failed to provide adequate dialysis care for a resident with chronic kidney disease, pulmonary edema, and heart failure. The resident's care plan required monitoring and communication with the dialysis provider, but the facility did not obtain necessary communication or assess pre- and post-dialysis status. Documentation was lacking for several dialysis sessions, and the resident experienced complications with the access site, leading to incomplete dialysis sessions and refusal of treatment by the provider.
A resident with hypertension and other medical conditions was administered an anti-hypertensive beta-blocker outside the physician-ordered parameters on multiple occasions without notifying the physician. The facility's policy required documentation and physician notification when medication parameters were not met, but this was not followed, increasing the risk of unnecessary medication and side effects.
A facility failed to attempt a gradual dose reduction (GDR) for a resident's antipsychotic medication, despite the resident having a diagnosis of dementia and receiving Risperidone for major depressive disorder with psychosis. The facility's policy required GDRs unless clinically contraindicated, but no attempts were made, and the physician did not document justification for not attempting a GDR. The facility relied on the pharmacist to notify the physician if a GDR was due, leading to a lack of evidence for GDR attempts or justification, placing the resident at risk for unnecessary psychotropic medications.
The facility did not post daily nurse staffing data as required. During a tour, it was found that the posted data was outdated, showing a date from several days prior. Administrative Nurse D explained that the staffing coordinator and charge nurse were responsible for posting the data, but the weekend sheets were not properly displayed. The facility's policy required staffing information to be readily available and updated at the beginning of each shift, which was not followed.
Improper Pre‑Pouring and Labeling of Medications in Medication Carts
Penalty
Summary
The deficiency involves improper storage and preparation of medications and biologicals when staff set up medications early for 11 residents and placed them into unlabeled medication cups in a medication cart. On 04/13/26 at 07:42 AM, surveyors observed medication carts outside the dining room containing 11 medication cups marked only with residents’ initials, stored in the top left-hand drawer of the cart. These cups contained medications but did not include the names of the medications, their doses, or administration instructions, contrary to requirements that drugs and biologicals be labeled in accordance with accepted professional principles. A CMA stated that facility policy required medications to be popped from bubble packs immediately before administration and not placed into cups before the resident was ready to take them. An administrative nurse later confirmed that medications should not be set up early and that staff had been educated to prepare medications only when the resident was ready to receive them. The facility’s written Medication Storage policy documented that all medications would be stored in medication carts or rooms according to manufacturer recommendations to ensure proper sanitation, temperature, light, moisture control, segregation, and security, which was not followed in this instance. No specific medical histories or clinical conditions of the 11 residents whose medications were pre-poured into cups are described in the report.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain an environment that treated a resident with respect and dignity, which placed the resident at risk for impaired dignity. The resident, who was admitted following a cerebral vascular accident, had multiple diagnoses including rhabdomyolysis, bacteremia, urinary tract infection, and hypertension. The resident's medical records indicated short-term and long-term memory impairment, expressive aphasia, and occasional bladder incontinence. The care plan directed staff to ensure a safe environment and monitor the resident for discomfort or distress. However, during an assessment by a consultant, the resident was less responsive, and the consultant made a comment suggesting the resident might be 'playing opossum,' which was perceived as disrespectful by the resident's representative. The consultant's comment was made during an assessment when the resident was not responding to verbal and tactile stimuli. The resident's family was present but did not respond to the comment. The consultant later acknowledged the comment but stated it was not made with malicious intent. The facility's policy on promoting and maintaining resident dignity emphasizes treating residents with respect and avoiding discussions that may be overheard. Despite this policy, the consultant's comment was reported by staff, and the administrative staff acknowledged the incident. The facility's failure to adhere to its dignity policy resulted in a deficiency in maintaining the resident's dignity and quality of life.
Failure to Secure Hazardous Chemicals
Penalty
Summary
The facility failed to secure hazardous cleaning chemicals in a safe, locked area, which placed seven cognitively impaired, independently mobile residents at risk for preventable accidents. During an inspection of the facility's south hall, an unattended shower room was found with its entry door propped open. Inside, an unlocked closet contained a full-gallon bottle of bleach, purple disinfectant wipes, and several cleaning spray cans, all of which had warnings indicating they were hazardous to humans and should be kept out of reach of children. Despite a sign on the closet door instructing that it should be locked at all times, it was left unsecured until an unidentified staff member locked it. Interviews with facility staff, including a Certified Nurses Aid (CNA), a Licensed Nurse, and an Administrative Nurse, confirmed that hazardous cleaning chemicals should always be supervised or locked up when not in use to prevent exposure to residents. The facility's policy on Cleaning and Disinfection of Resident-Care Equipment, dated March 2020, also indicated that all approved cleaning materials should be stored safely to prevent chemical exposure. However, the failure to adhere to these protocols resulted in the chemicals being accessible to residents, thereby creating a risk for accidents.
Infection Control Deficiencies in Oxygen Equipment and Wound Care
Penalty
Summary
The facility failed to adhere to sanitary infection control standards, particularly concerning enhanced barrier precautions, wound care, disinfection of mechanical lifts, and the maintenance of oxygen therapy equipment. Observations revealed that several residents' oxygen tubing and nasal cannulas were improperly stored, often found on the floor, under beds, or on furniture without clean storage bags. Additionally, there was a lack of enhanced barrier precaution signage and personal protective equipment in rooms where residents required such measures for wound care and dialysis. These lapses were noted in multiple residents' rooms, indicating a systemic issue in maintaining infection control protocols. Further deficiencies were observed in the handling of wound care and shared equipment. An administrative nurse failed to use clean barriers for wound care supplies, did not change gloves appropriately, and neglected hand hygiene during the procedure. Similarly, a mechanical lift was not sanitized after use, as required by the facility's infection control policy. Interviews with staff confirmed a lack of adherence to established protocols, including the need for hand hygiene, proper storage of oxygen equipment, and the use of protective gear during high-risk care. These practices placed residents at risk for infectious diseases.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain a dignified care environment for three residents, compromising their dignity and quality of life. During an inspection, a grievance form completed by a resident's representative was found in a clear file box attached to a hallway wall, with the details of the grievance visibly displayed. This incident occurred due to a new kitchen staff member mistakenly placing the form in the wrong box, instead of the locked grievance box in the main hallway. Additionally, two residents were observed with indwelling urinary catheters that lacked privacy covers, exposing the urine in the collection bags to public view. One resident was seen in the dining room with a urinary collection bag without a dignity cover, and another resident was observed at the nurse's station with a catheter bag attached to the handlebars of his electric scooter, also without a privacy cover. Staff interviews confirmed that all indwelling catheters should have privacy bags to maintain resident dignity, and grievance forms should be confidential. The facility's policy on promoting and maintaining resident dignity was not adhered to, resulting in these deficiencies.
Failure to Provide Wheelchair Foot Pedals
Penalty
Summary
The facility failed to ensure that a resident had foot pedals on her wheelchair while being pushed by staff, which left her vulnerable to preventable accidents and injuries. The resident, who had a range of medical conditions including depressive disorder, hypertension, and congestive heart failure, was dependent on staff for wheelchair mobility. Observations on two separate occasions noted that the resident was pushed in her wheelchair without foot pedals, causing her right foot to drag on the floor. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that residents should have foot pedals on their wheelchairs when being pushed by staff. The facility's policy on the accommodation of needs stated that residents should be treated with respect and dignity, and reasonable accommodations should be made for their individual needs and preferences. However, the facility did not adhere to this policy, resulting in the deficiency.
Failure to Include Dialysis Information in Baseline Care Plan
Penalty
Summary
The facility failed to develop a person-centered baseline care plan for a resident, identified as R304, which included critical information about his hemodialysis treatment. R304 had a medical history of chronic kidney disease, pulmonary edema, and heart failure, and was dependent on staff for activities of daily living. Despite these needs, the baseline care plan did not document the dialysis provider, the days of the week, or the times for dialysis, which are essential for coordinating his care. The resident's electronic medical record (EMR) contained physician orders specifying dialysis on Monday, Wednesday, and Friday, with specific times for departure and chair time. However, the facility's records lacked evidence of pre- and post-dialysis assessments, and there was no documentation of communication with the dialysis provider. Additionally, the Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not include a pre-dialysis assessment, and there was no dialysis communication sheet for one of the scheduled dialysis days. Interviews with facility staff revealed a lack of awareness and access to the resident's care plan, with some staff unsure if dialysis information was included. The facility's policy required a baseline care plan to include necessary instructions for effective and person-centered care, but this was not adhered to, placing the resident at risk of impaired care due to uncommunicated care needs.
Failure to Update Dialysis Care Plan
Penalty
Summary
The facility failed to update the comprehensive care plan for a resident, identified as R51, to include necessary information regarding dialysis treatment. R51, who has end-stage renal disease and type 2 diabetes mellitus, requires dialysis treatment. The care plan did not provide staff with directions on the location, days, times, chair time, and contact number for the dialysis clinic, which are crucial for coordinating care and ensuring the resident's needs are met. Observations and interviews revealed that the care plan lacked specific instructions for staff regarding the dialysis schedule and communication with the dialysis clinic. Although the resident's electronic medical record contained some information about the dialysis schedule, it was not reflected in the care plan. Staff members, including a Certified Nurse Aide and a Licensed Nurse, acknowledged the absence of this critical information in the care plan, which should have been updated by the Administrative Nurse responsible for care plans. The facility's policy on comprehensive care plans mandates that a person-centered care plan be developed within seven days after the completion of the comprehensive MDS assessment. This care plan should describe any specialized services required to maintain the resident's well-being. However, the facility did not adhere to this policy, as R51's care plan was not updated to include essential details about the dialysis treatment, placing the resident at risk for complications due to uncommunicated care needs.
Failure to Provide Adequate Dialysis Care and Communication
Penalty
Summary
The facility failed to provide adequate dialysis care for Resident 304, who had chronic kidney disease, pulmonary edema, and heart failure, and required hemodialysis. The resident's care plan included monitoring lab work, vital signs, and signs of infection at the access site, as well as ensuring communication with the dialysis provider. However, the facility did not obtain necessary communication from the dialysis center and failed to assess the resident's pre-dialysis and post-dialysis status. The resident's electronic medical record lacked documentation of a post-dialysis assessment on 05/15/24 and a pre-dialysis assessment on 05/20/24. Additionally, the dialysis communication form for 05/20/24 indicated that the resident's condition was poor, with bleeding at the access site, yet there was no evidence of physician notification or a post-assessment. The facility also failed to document a dialysis communication sheet for 05/17/24, and there was no evidence of communication with the dialysis provider. Interviews with facility staff revealed that the resident had received incomplete dialysis sessions due to complications with the access site, and the dialysis provider refused treatment on 05/22/24. The facility's hemodialysis policy required ongoing assessment and communication with the dialysis provider, which was not adhered to, placing the resident at risk of adverse outcomes and physical complications related to dialysis.
Failure to Follow Medication Parameters for Resident
Penalty
Summary
The facility failed to adhere to physician-ordered parameters for administering an anti-hypertensive beta-blocker medication to Resident 50. The resident, who had a medical history of hypertension, dementia, restless leg syndrome, and Parkinson's disease, was dependent on staff for most daily activities and had mild cognitive impairment. The physician's order specified that the medication should be withheld if the resident's systolic blood pressure was less than 110 mmHg or diastolic blood pressure was less than 60 mmHg. However, the medication was administered outside these parameters on multiple occasions without notifying the physician. The facility's policy required staff to document when a medication was held due to ordered parameters and to notify the physician of any changes or missed treatments. Despite this, the medication was given on several dates when the resident's blood pressure readings were outside the specified limits, and there was no documentation of physician notification. This oversight placed the resident at increased risk for unnecessary medication and potential side effects.
Failure to Attempt Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) was attempted or addressed by the physician for a resident's antipsychotic medication. The resident, who had a diagnosis of dementia, was receiving Risperidone for major depressive disorder with psychosis. Despite the facility's policy requiring GDRs and behavioral interventions unless clinically contraindicated, the resident's medication regimen did not include any attempts at GDR during the observation period. The Monthly Medication Review from June 2023 recommended considering a GDR, but the physician marked that a dose reduction would impair the resident's function due to persistent targeted behaviors. The resident's care plan directed staff to consult with the pharmacy and physician to consider a GDR at least quarterly, but the facility relied on the pharmacist to notify the physician if a GDR was due. The facility's records lacked evidence of attempts for a GDR or documented justification for not attempting one. The resident was observed interacting with peers in the dining room, and the administrative nurse confirmed the facility's reliance on the pharmacist for GDR recommendations. This oversight placed the resident at risk for unnecessary psychotropic medications and related complications.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily as required. During an initial tour of the facility, it was observed that the posted daily nurse staffing hour data was outdated, showing the date 06/07/24, despite the tour occurring on 06/11/24. An interview with Administrative Nurse D revealed that the staffing coordinator was responsible for posting the nurse staffing data daily, while the charge nurse was responsible for posting it on weekends. However, it was noted that the weekend staffing sheets were placed behind the sheet from 06/07/24, indicating a lapse in the posting process. The facility's policy, implemented on 12/01/19, required that staffing information be made readily available in a readable format to residents and visitors at any given time, with postings at the beginning of each shift in a prominent place. The facility did not adhere to this policy, resulting in the deficiency.
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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