Derby Health & Rehabilitation, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Derby, Kansas.
- Location
- 731 Klein Circle, Derby, Kansas 67037
- CMS Provider Number
- 175514
- Inspections on file
- 19
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Derby Health & Rehabilitation, Llc during CMS and state inspections, most recent first.
Surveyors found that the facility did not provide required written notifications of transfer or notify the LTCO when three residents were transferred to the hospital, including one who later returned and two who did not. Staff reported that they notified representatives of hospital transfers by phone and documented progress notes, but did not complete written transfer notices and were unfamiliar with this requirement. Review of LTCO discharge notification emails over a one-year period showed that these hospital transfers were not reported. The facility’s policy required written notice with reasons, effective date, receiving location, LTCO and State Agency contacts, and appeal rights, but did not specifically address written notification or LTCO reporting for hospital transfers.
A resident with hypotension and intact cognition was started on an antihypotensive medication, with care plan directions to monitor blood pressure and pulse and to assess for side effects and effectiveness. After the resident reported low blood pressure and symptoms of dizziness and lightheadedness, a provider ordered orthostatic blood pressures twice daily for three days, including lying, sitting, and standing measurements, with results to be sent via EMR message. The EMAR showed that on multiple days only single blood pressure readings were documented, required orthostatic positions were missing, and some ordered evening orthostatic sets were not recorded at all, with one complete set documented only in a nurse’s note due to EMR entry issues. Staff interviews confirmed that CNAs usually obtained vitals, nurses later entered them, orthostatic technique varied, and required EMR messages with results could not be located, and no policy on orthostatic blood pressures was provided.
Staff failed to maintain hands-on stabilization of two residents during full body mechanical lift transfers, leaving them unsupported while the lift was in operation. In both cases, one staff member released physical contact to perform other tasks, contrary to facility expectations that require continuous hands-on support for resident safety. The facility's policy did not provide clear instructions on maintaining resident contact or proper lift positioning.
The facility failed to ensure hazardous chemicals were stored safely, placing five cognitively impaired and independently mobile residents at risk for injury. An unlocked housekeeping closet was found containing hazardous items such as fiberglass resin, tile sealer, ant killer, and ant and roach killer, all stored on a waist-high shelf. Staff confirmed that housekeeping closets should be locked when not supervised.
The facility failed to store, prepare, and serve food in a sanitary manner, with undated and improperly stored food items, and staff not adhering to hand hygiene protocols. Observations revealed unclean kitchen equipment and non-compliance with the facility's cleaning schedule, placing residents at risk for food-borne illness.
The facility failed to provide three residents with the correct CMS Skilled Nursing Facility Advanced Beneficiary Notices (ABN) Form 10055, instead giving them the CMS-R-131 form. This error prevented the residents from making informed decisions about their skilled services and potential financial liabilities.
The facility failed to protect residents from abuse when multiple residents' controlled medications were misappropriated. An LN received and signed for the medications, which later went missing. Despite a search and investigation, the medications and narcotic count sheets were not found, affecting three residents and placing them at risk for further abuse and impaired care.
The facility failed to provide proper G-tube care for a resident with multiple medical conditions by not administering the required 45 ml water flush before a nutritional feeding, as per the physician's orders. This lapse was confirmed by a consultant and was contrary to the facility's Enteral Nutrition policy, placing the resident at risk for complications.
The facility failed to ensure a Consultant Pharmacist identified and reported a resident's blood pressure medication administered outside physician-ordered parameters, placing the resident at risk for unnecessary medications and related complications. Despite multiple instances of incorrect administration, the pharmacist's review did not note these irregularities, and the physician was not notified.
The facility failed to follow physician-ordered parameters for administering midodrine to a resident, resulting in the administration of the medication multiple times when the resident's systolic blood pressure exceeded the specified threshold. This failure placed the resident at risk for unnecessary medications and related complications.
Failure to Provide Written Transfer Notices and LTCO Notification for Hospital Transfers
Penalty
Summary
Surveyors identified that the facility failed to provide required written notifications of transfer for three residents who experienced facility-initiated transfers to the hospital, and also failed to notify the State Long Term Care Ombudsman (LTCO) of these transfers/discharges. The census was 61 residents, with a sample of 15, including three residents reviewed for hospitalization. One resident was admitted to the facility, transferred to the hospital, and later readmitted, while two other residents were admitted, transferred to the hospital, and did not return. When surveyors requested documentation, the facility was unable to provide written notifications of transfer for any of these hospital transfers. Review of LTCO notification emails for discharges over a one-year period showed that these hospital transfers were not included. During observations and interviews, one of the residents was seen sitting in a wheelchair at a dining room table eating breakfast. A consultant stated that the facility did not do written notifications of transfers. A licensed nurse reported that when a resident transferred to the hospital, she notified the resident’s representative by phone but did not complete a written notification of transfer. The social services staff member stated that she called families about bed holds and documented a progress note but did not complete written notifications of transfer and did not know what they were. She also stated she completed ombudsman reports on discharges, including hospital transfers, but that residents were only included if they were discharged after hospital admission, and she usually reviewed the list to ensure hospital transfers were included. The facility’s Admission, Transfer, and Discharge Policy required a 30-day advanced written notice, except in emergencies, including the reason for transfer/discharge, effective date, receiving location, LTCO contact, State Agency contact, and appeal rights, but the policy did not address written notification of hospital transfers or LTCO notification of transfers.
Failure to Complete and Document Ordered Orthostatic Blood Pressures
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document physician-ordered orthostatic blood pressures for a resident being evaluated for dizziness and lightheadedness. The resident had diagnoses of anxiety and hypotension and an admission MDS BIMS score of 14, indicating intact cognition. The care plan documented use of an antihypotensive medication for hypotension, with directions to monitor and document side effects and effectiveness, and to verify blood pressure and pulse prior to administering the medication. Following a progress note documenting low blood pressure and the resident’s report that their blood pressure had always been low, the provider ordered orthostatic blood pressures twice daily for three days, with lying, sitting, and standing measurements and instructions to send the results via EMR message. The EMR contained the order starting on 02/28/26. Despite this order, the EMAR showed incomplete and missing orthostatic blood pressure documentation. On 02/28/26, only a single blood pressure reading was recorded without the required lying, sitting, and standing values, and there was no documentation for the evening orthostatic set. On 03/01/26, the morning orthostatic entry was marked as not applicable, and the evening entry required reference to a nurse’s note because the system would not allow entry of the readings in the designated fields; the nurse’s note documented all three positions. On 03/02/26, again only a single blood pressure reading was recorded, with no orthostatic breakdown, and no evening orthostatic documentation. Staff interviews revealed that CNAs typically obtained vital signs and nurses later entered them into the computer, that one CMA only checked vitals before certain heart medications and not for this resident, and that one nurse preferred to perform orthostatic measurements herself due to concerns about CNAs’ technique. The administrative nurse stated that orthostatic results should be entered into the EMR and messaged to the provider, but staff were unable to locate these messages. No policy regarding orthostatic blood pressures was provided.
Failure to Maintain Resident Safety During Mechanical Lift Transfers
Penalty
Summary
Staff failed to ensure an environment free from accident hazards during full body mechanical lift transfers for two residents. In both observed incidents, one staff member operated the lift controls while the second staff member, who was responsible for maintaining hands-on stabilization of the resident, released physical contact and attended to other tasks. Specifically, during a transfer from a recliner to a wheelchair, the second staff member let go of the resident to walk around the lift and stand behind the wheelchair, leaving the resident in a raised and unsupported position. In another instance, during a transfer from a wheelchair to a bed, the second staff member let go of the resident to open a bathroom door and move the wheelchair, again leaving the resident unsupported while the lift was in operation. Interviews with the involved staff confirmed that they would not have performed the lift tasks differently and acknowledged releasing physical control of the residents during the transfers. Licensed nursing staff and administrative personnel stated that proper procedure requires two staff members: one to operate the lift and the other to maintain hands-on contact with the resident at all times for safety. Additionally, the facility's mechanical lift policy lacked specific guidance on maintaining resident contact and proper positioning of the lift legs during transfers.
Unsafe Storage of Hazardous Chemicals
Penalty
Summary
The facility failed to ensure hazardous chemicals were stored safely, placing five cognitively impaired and independently mobile residents at risk for injury. During an observation in the 300-household area, an unlocked housekeeping closet was found containing hazardous items such as fiberglass resin, tile sealer, ant killer, and ant and roach killer, all stored on a waist-high shelf. These items had instructions to keep out of reach of children. A Certified Nurse Aide verified the findings, and an Administrative Nurse confirmed that staff should ensure housekeeping closets are locked when not supervised. The facility's Chemical Storage policy stated that all hazardous chemicals should be stored in a locked area or used under supervision.
Failure to Maintain Sanitary Food Storage and Service Practices
Penalty
Summary
The facility failed to store, prepare, and serve food in a sanitary manner for residents in two of four kitchens and dining rooms. Observations revealed undated and improperly stored food items in the 100-household kitchen freezer, including a bag of chicken tenders and a box of hamburger patties with a torn plastic bag. Additionally, Certified Nurse Aide (CNA) M was observed serving food to residents without washing or sanitizing his hands after touching his face, hair, and clothing, which occurred in both the 300-household dining room and the 200-household dining room. The facility's cleaning schedule was not adhered to, as evidenced by dried crumbs on toasters and dried food spills on oven doors in the 100 and 300 household kitchens, despite staff initialing the cleaning schedule as completed for certain tasks. Dietary Staff BB confirmed the findings of undated and improperly stored food items, as well as the unclean state of the ovens and toasters. The facility's policies on food preparation, sanitation, and food storage were not followed, as staff failed to perform hand hygiene after touching their face, hair, or clothing, and did not properly label or cover food items. These deficiencies placed residents at risk for food-borne illness due to the lack of adherence to professional standards for food storage, preparation, and service.
Failure to Provide Correct Medicare ABN Form
Penalty
Summary
The facility failed to provide three residents, or their representatives, with the correct Centers for Medicare and Medicaid (CMS) Skilled Nursing Facility Advanced Beneficiary Notices (ABN) Form 10055. Instead, the residents received the CMS-R-131 form, which is not the appropriate form for informing beneficiaries about potential non-coverage of future skilled therapy services. This error was identified through a review of the records for residents R8, R11, and R160, whose skilled services ended on different dates. The incorrect form did not provide the necessary information for the residents to make informed decisions about their skilled services and potential financial liabilities. Interviews with facility staff, including Social Services and a consultant, confirmed that the CMS-R-131 form was mistakenly provided to the residents instead of the required Form 10055. The facility's policy on Medicare Denial Notices, dated March 13, 2024, mandates that residents be informed about services not covered under Medicare and provided with the correct ABN form to decide whether to appeal a decision to terminate Medicare care and services. The failure to provide the correct form placed the residents at risk of making uninformed decisions regarding their skilled services and financial responsibilities.
Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to ensure residents remained free from abuse when multiple residents' medications were misappropriated. The incident involved the disappearance of three narcotic cards containing controlled medications, including oxycodone and hydrocodone-acetaminophen, which were delivered to the facility and signed for by a Licensed Nurse (LN). The medications were intended for three residents, and the loss was discovered when an Administrative Nurse noted that one resident's entire card of oxycodone was missing. Despite a thorough search of the medication carts and the shred box, the medications and narcotic count sheets could not be located. The LN responsible for receiving the medications was contacted and initially stated she might have accidentally placed them in the shred box, but no evidence was found to support this claim. The LN later provided a witness statement and a urine sample after returning to the facility from out of town. The facility's investigation revealed that the misappropriation affected three residents, with a total of 62 tablets of controlled medications missing. The facility contacted the police department and gathered statements from staff members. Observations of the medication carts in various houses within the facility confirmed that narcotic medications were stored in locked metal boxes affixed to the carts, which were also locked when not in use. The facility's policy on Abuse, Neglect, and Exploitation emphasized the prohibition of mistreatment, neglect, and abuse of residents, including the misappropriation of elder property. However, the facility failed to adhere to this policy, resulting in the misappropriation of medications and placing residents at risk for further abuse and impaired care related to missing or stolen medications.
Failure to Administer Required Water Flushes for G-Tube Feeding
Penalty
Summary
The facility failed to provide proper G-tube care for Resident 41, who had a diagnosis of dysphasia, cerebrovascular accident, hemiplegia, and diabetes mellitus. The resident's care plan required the administration of Jevity 1.5 nutritional liquid through the G-tube four times a day, with 45 ml water flushes before and after each feeding. However, on the observed date, a licensed nurse administered the Jevity without the required 45 ml water flush prior to the feeding, contrary to the physician's orders. This failure was confirmed by a consultant who verified that the water flushes should have been administered as per the physician's order. The facility's Enteral Nutrition policy, dated 02/07/2022, outlined the procedure for administering enteral feedings, including the necessity of water flushes to meet hydration needs. Despite this policy, the staff did not follow the prescribed protocol, placing Resident 41 at risk for G-tube related complications. The deficiency was identified through observation, record review, and interviews, highlighting a significant lapse in adhering to the physician's orders and the facility's own policies for enteral nutrition management.
Failure to Identify and Report Medication Administration Errors
Penalty
Summary
The facility failed to ensure the Consultant Pharmacist identified and reported a resident's blood pressure medication administered outside the physician-ordered parameters. The resident, who had diagnoses including end-stage renal disease, atrial fibrillation, and hypocalcemia, was prescribed midodrine with specific instructions to hold the medication if the systolic blood pressure (SBP) was greater than 130. Despite this, the resident's Electronic Medical Record (EMR) documented multiple instances where midodrine was administered even when the SBP exceeded the ordered parameters. The Consultant Pharmacist's review did not note these irregularities, and there was no evidence that the physician was notified of the medication administration errors. This oversight placed the resident at risk for unnecessary medications and related complications. Observations and interviews confirmed that staff were aware of the requirement to hold midodrine if the SBP was greater than 130 but failed to do so on numerous occasions. The Consultant Pharmacist's report for the review period did not address the administration of midodrine outside the ordered parameters, and the facility's policy required the pharmacist to communicate potential or actual problems related to medication therapy to the responsible physician and the director of nursing. The failure to identify and report these medication errors was verified by administrative nurses, highlighting a significant lapse in the facility's medication management and review processes.
Failure to Follow Physician-Ordered Parameters for Blood Pressure Medication
Penalty
Summary
The facility failed to adhere to physician-ordered parameters for administering midodrine, a blood pressure medication, to Resident 47. Despite the physician's order to hold the medication if the systolic blood pressure (SBP) was greater than 130 mm/Hg, the medication was administered multiple times when the resident's SBP exceeded this threshold. Specific instances of this failure were documented in the resident's Electronic Medical Record (EMR), with blood pressure readings ranging from 132/83 mm/Hg to 172/119 mm/Hg on various dates. The Certified Medication Aide (CMA) and Administrative Nurse confirmed that the medication should have been held according to the physician's parameters, but it was not, leading to the administration of unnecessary drugs to the resident. Resident 47 had a history of end-stage renal disease, atrial fibrillation, and hypocalcemia, and was receiving high-risk medications, including antianxiety and opioid medications. The resident's care plan required one or two-person assistance for activities of daily living and documented that the resident received hemodialysis three times a week. Despite these detailed care instructions, the facility's failure to follow the physician's order for midodrine administration placed the resident at risk for unnecessary medications and related complications. The facility's Medication Administration policy required staff to document and follow holding or notification parameters for ordered medications, which was not adhered to in this case.
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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