Emporia Presbyterian Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Emporia, Kansas.
- Location
- 2300 Industrial Road, Emporia, Kansas 66801
- CMS Provider Number
- 175304
- Inspections on file
- 19
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Emporia Presbyterian Manor during CMS and state inspections, most recent first.
Surveyors found multiple unsanitary food storage and handling practices in the kitchen, including uncovered utensils and butter on counters, refrigerated and frozen foods lacking open/use-by dates, and improperly stored spices and dishes. Dietary staff were observed working without required hair coverings, failing to change gloves or perform hand hygiene between tasks during pureed meal preparation, reusing a cloth placed on a soiled counter over a blender cap, and wiping a food thermometer with a paper towel instead of sanitizing it between uses. Another staff member carried a plate to a resident with thumbs on the eating surface. These practices conflicted with the facility’s stated expectations for HACCP-based food handling, labeling, and sanitation.
Two residents were not cared for in a manner that protected their dignity. One resident had a blood glucose test performed at a dining room table in view of other residents, a visitor, and staff, and was repeatedly observed in the dining area wearing thin, see-through pants with an undergarment visible. Another resident with paraparesis, contractures, dysphagia, and dependence for most ADLs, but needing supervision and touching assistance for eating, was assisted with eating by a CNA who stood at the resident’s side rather than sitting next to him, despite facility expectations that staff sit and converse with residents during meal assistance. These practices conflicted with facility policies requiring respect for resident dignity and person-centered care.
A resident with dementia, muscle weakness, repeated falls, and dependence on staff for toileting and eating assistance was observed seated in a Broda chair with the TV on while the pancake call light was placed on the bed, out of reach, despite the care plan instructing the resident to use the call light for assistance. A CNA acknowledged the call light was not accessible and repositioned it within reach, and both an LN and an administrative nurse stated that call lights should always be within residents’ reach, consistent with the facility’s call light policy.
Surveyors observed a medication cart parked in a hall with a laptop left unlocked and unattended by a CMA, displaying a resident's PHI including medications, date of birth, allergies, and code status, visible to anyone passing by. Staff interviews confirmed that facility policy requires medication carts to be locked and laptop screens to be closed or hidden when out of staff’s line of sight, and that staff had been in-serviced on these confidentiality expectations.
A resident with cognitive impairment, neuropathy, and multiple mobility and sensory deficits used an electric lift recliner brought in by family, but the facility did not complete any assessment of the resident’s ability to safely use the chair despite documented fall risk and need for supervision with transfers, and the resident later slid from the elevated recliner and sustained a skin tear. Another resident with a history of repeated falls and a prior fracture experienced a fall with visible injuries and was sent to the ER, yet the EMR showed that required post-fall neurological checks were either not completed or documented with vital signs from days before the fall, inconsistent with the facility’s neurological assessment policy.
A resident with DM receiving daily insulin and oral diabetes medications had multiple blood glucose readings significantly above the ordered parameter over several months, with values repeatedly exceeding the threshold that required provider notification. The care plan and physician orders directed staff to monitor blood sugars twice daily and notify the provider when levels were outside specified limits, yet the EMR progress notes contained no documentation of such notifications for the elevated readings. Review of monthly Drug Regimen Reviews over the same period showed that the consulting pharmacist did not identify these out-of-range blood sugars or the lack of documented monitoring, despite facility policy requiring the pharmacist to complete monthly reviews and identify medications without proper monitoring.
A resident with DM, morbid obesity, and prior stroke, receiving daily insulin and oral diabetes meds, had multiple blood glucose readings significantly above ordered parameters over several months. The care plan and physician orders required staff to notify the provider for values above a specified threshold, but progress notes contained no documentation of such notifications. A CMA reported using informal notification thresholds that did not match the provider’s orders, and an administrative nurse described notification practices based on symptoms and faxing, with expected documentation of provider contact. The facility’s written notification parameters assigned licensed nursing staff responsibility for contacting the PCP when clinical problems arose, but this was not carried out or documented for this resident’s repeated hyperglycemic readings.
A resident with hypokalemia, dementia, and multiple comorbidities who was receiving a diuretic had a new order for potassium 40 mEq PO three times daily for three days after low potassium was identified. The nurse entered the potassium order in a pending status, so it never populated to the MAR and the medical records nurse’s second check did not detect the problem. As a result, the ordered potassium doses were not administered, and there was no contemporaneous documentation that the physician was notified when the medication was not given, contrary to the facility’s medication error policy.
Surveyors found that insulin pens for a resident were not properly labeled when opened, in violation of professional standards and facility policy. On review of the med cart, one Lantus insulin pen lacked any opened or expiration date, and a second pen had an illegible, smeared date. Nursing staff, including an LPN and an administrative nurse, acknowledged that insulin pens are required to be labeled and dated when opened. The facility’s medication storage policy required medications to be labeled for individual residents and handled per manufacturer or supplier recommendations, and external guidance cited in the report specified that opened, unrefrigerated insulin pens are only usable for a limited number of days before they must be discarded.
A resident with intact cognition and poor dentition, including broken, decayed, and missing teeth, was care planned to receive assistance with oral care and dental appointments as needed, but assessments failed to document dental problems or pain. After an initial dental visit identified extensive caries and recommended fillings and extractions by an oral surgeon, and a later hygienist exam noted ongoing mouth pain and inflammation requiring further dental evaluation, no documented follow-up dental appointment or rationale for lack of follow-up was found in the medical record. The resident reported tooth pain and difficulty eating, and staff confirmed the absence of documentation despite a facility policy requiring timely dental referrals, documentation of refusals, and recording of interventions while awaiting dental services.
Surveyors found that a resident’s record lacked documentation that the Pneumococcal Conjugate Vaccine (PCV20) was offered, administered, or declined, despite prior pneumococcal vaccines being recorded. The facility’s policy required admission nurses to determine and document immunization history and obtain signed consent or declination forms for vaccines, but the required PCV20 consent/declination and related documentation were not present in the resident’s chart, and an administrative nurse reported that stored forms had been lost due to flooding.
A resident with a history of hemiplegia and neuromuscular bladder dysfunction experienced a deficiency in care when the facility failed to notify the physician about missed monthly catheter changes and a significant change in condition. Despite staff awareness of swelling and redness in the resident's genital area, timely assessment and documentation were not conducted, leading to an emergency medical transport for further evaluation.
A resident with a high fall risk experienced multiple falls within a short period, but the facility failed to conduct thorough assessments or implement new interventions. The facility also did not notify the resident's family or physician after the incidents, contrary to their policy. This lack of appropriate response and communication led the resident's family to remove them from the facility.
The facility failed to ensure the required members, including the infection preventionist, attended the QAA Committee meetings at least quarterly. The facility's QAPI Meeting Attendance Sheets lacked evidence of the infection preventionist's attendance on multiple dates. An administrative nurse confirmed the absence of the infection preventionist and that the facility had not employed one at the times of the meetings. This placed residents at risk of decreased quality of care.
The facility failed to ensure reconciliation of controlled medications was completed consistently and per industry standards. Missing signatures on the Eight Hour Verification Controlled Substance Count sheets indicated that required narcotic counts were not properly documented at shift changes. Staff members acknowledged the necessity of signing off on the narcotic counts, and the Administrative Nurse confirmed awareness of the issue. The facility's policy mandates a physical inventory of controlled medications at each shift change, but this procedure was not followed, placing residents at risk of medication misappropriation and diversion.
The facility failed to provide complete Medicare Advance Beneficiary Notice (ABN) Forms 10055 to two residents, omitting estimated costs and documentation of chosen options, leading to uninformed decisions about skilled services.
The facility failed to provide a clean, comfortable, and homelike environment for a resident, resulting in a persistent and overwhelming urine odor in the resident's room. Despite multiple cleanings and staff awareness, the odor persisted due to the resident's independent management of his urinary catheter, which often resulted in spills on the carpet. The clinical record lacked interventions to address the issue.
Unsanitary Food Storage and Handling Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen, placing residents at risk for food-borne illness. During an initial kitchen tour, surveyors observed an uncovered plastic tub of metal spoons on a counter in the dining area at the kitchen entrance and five uncovered blocks of butter in a metal container on the counter. Inside the refrigerator, bowls of spaghetti, milk, cottage cheese, and yogurt were covered with plastic wrap but lacked any open or use-by dates. In the freezer, five cups of pudding, a piece of pie, two packages of shredded cheese, two sheet pans of Jello, and seven sausage links were not labeled or dated. On the spice rack, an open package of brown sugar had no opened-on date, and multiple spice containers (including turmeric, crushed red pepper flakes, and curry powder) had various open and use-by dates, with at least one container of turmeric showing conflicting or unclear dating. A table in the kitchen held six stacks of plates that were not inverted, and a container on the counter held cake decorating gels and colored sugar with open and use-by dates noted, indicating that multiple opened food items were stored in the kitchen. Further observations showed multiple breaches in staff food-handling and hygiene practices. One dietary staff member wore a ball cap without a hair net while in the kitchen. During preparation of pureed foods, the same staff member did not change gloves or perform hand hygiene between tasks or when gloved hands contacted new locations or unclean environments. This staff member also placed a cloth over the blender cap, then repeatedly set the cloth on a counter that had clean and dirty utensils and food debris, and reused the same cloth over multiple blending cycles for the entire pureed meal preparation. The same staff member failed to properly sanitize a food thermometer, using only a paper towel to wipe it off between checking temperatures on three different pureed food items. Another dietary staff member carried a plate of food to a resident with thumbs placed on the eating surface of the plate. Facility leadership and the dietary manager later described expectations for hand hygiene, glove use, hair covering, plate handling, labeling and dating of food, and cleaning and sanitizing of equipment and surfaces, which contrasted with the practices observed by surveyors.
Failure to Maintain Resident Dignity During Blood Glucose Testing, Clothing, and Meal Assistance
Penalty
Summary
The deficiency involves failures to protect and promote resident dignity for two residents. One resident was observed seated at a dining room table while a licensed nurse obtained a blood glucose reading from the resident’s finger in the presence of other residents, a visitor, and staff. On another occasion, the same resident was observed wearing thin, see-through pink pants in the dining room, with her brief visible through the material. She was seen wearing the same see-through pants again the following morning at breakfast, with her brief still visible. The administrative nurse later verified that blood sugar checks should not be done at the dining room table and that the resident should not have been wearing see-through pants due to dignity concerns. The facility’s Residents Dignity policy stated that residents would be treated with respect and dignity and cared for in a manner that promotes maintenance and enhancement of quality of life. The second resident had diagnoses including paraparesis, major depressive disorder, dysphagia, contractures, and polyneuropathy, with documented impairments of both upper and lower body and dependence on staff for all ADLs except eating, for which supervision and touching assistance were required. The resident’s care plan included setup assistance with adaptive equipment, supervision and partial assistance with meals, half portions for weight loss, and mechanical soft diet consistency. During observation, a CNA stood at the resident’s right side and assisted him with eating a bite of bacon rather than sitting next to him. Subsequent staff interviews revealed inconsistent understanding among nursing staff about proper positioning when assisting residents with eating, despite prior in-servicing that staff should sit in a chair and converse with the resident they are assisting. The facility’s Resident Rights and Responsibilities policy documented that residents would be treated with respect and dignity in an environment that promotes maintenance or enhancement of quality of life.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences by not ensuring the resident’s call light was within reach. The facility had a census of 51 residents with a sample of 14, including one resident with diagnoses of hypertension, dementia, unsteadiness on feet, muscle weakness, and repeated falls. The admission MDS documented a BIMS score of four, indicating severely impaired cognition, and showed the resident was dependent on staff for toileting and required supervision or touching assistance with eating. A Falls CAA identified the resident as at risk for falls due to a history of falls, impaired mobility, weakness, dementia, a urinary catheter, and the need for assistance with transfers and mobility. The care plan documented that the resident had been instructed to use the call light for assistance and was dependent on one or two staff for toileting throughout the day to manage bowel incontinence. During observation, the resident was seen sitting in a Broda chair in his room with the TV on, while his pancake call light was lying in the middle of his bed, out of his reach, preventing him from calling for assistance. A CNA confirmed at the time of observation that the call light was out of reach and stated it should be placed where the resident could reach and use it, then moved the call light to the bedside table within reach. Subsequent interviews with an LN and an administrative nurse confirmed that residents’ call lights should always be within reach and that it was every staff member’s duty to ensure this. The facility’s Call Light System policy documented that a call button or pull cord would be located next to each bed and in each resident’s bathroom, underscoring that the observed placement of the call light did not comply with facility expectations and practice.
Failure to Protect Resident PHI on Unattended Medication Cart Laptop
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's protected health information (PHI) when a medication cart laptop was left unlocked and unattended in a hallway. During observation, a medication cart was parked against the wall in A hall with a laptop on top. The Certified Medication Aide (CMA) assigned to the cart walked away into a resident's room, leaving the computer screen unlocked and open. The screen displayed a specific resident's PHI, including the resident's medications, date of birth, allergy information, and code status, making this information visible to anyone passing by the cart. Interviews with staff confirmed that this practice was inconsistent with facility policy and expectations. The CMA stated she had stepped away from the cart to help a resident and acknowledged that the policy required locking the medication cart and pushing the hide button on the laptop. A Licensed Nurse stated that medication carts should be locked and the laptop screen either closed or hidden when out of staff's visual range. An Administrative Nurse stated the policy was to lock the cart and either close the laptop or use the hide screen button, and that staff had been in-serviced on these requirements. The facility's Confidentiality policy documented that confidentiality must be maintained for all health information, including electronic, and that a breach occurs when information can be intercepted by unauthorized persons and connected to a specific individual.
Failure to Assess Lift Chair Use and Complete Post-Fall Neurological Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision and assessment to prevent accidents. One resident with diabetes, restless leg syndrome, peripheral neuropathy, impaired vision and hearing, morbid obesity, pain, and documented moderate cognitive impairment used an electric lift recliner brought in by family. The resident’s care plan and CAAs identified fall risk factors and need for supervision with mobility and transfers, and fall risk assessments showed the resident was at risk for falls. However, the electronic health record contained no assessment for the resident’s use of the electric lift chair, despite its arrival months earlier and the resident’s cognitive and physical limitations. The same resident later experienced a fall from the electric lift recliner when she raised the chair to a high position and slid forward out of it. Staff responded to yelling and found the resident on the floor with the recliner fully elevated. The resident reported attempting to get out of the recliner and raising it too far, which caused her to slide out of the chair. An assessment identified a skin tear to the back of the resident’s hand. Administrative nursing staff later confirmed that the facility had not completed an electric lift chair assessment when the chair was brought in, and that such an assessment should have been completed at that time, annually, and with any change in condition, as part of the facility’s fall risk identification and intervention process. Another resident with diagnoses including repeated falls, right arm fracture, anxiety, difficulty walking, and muscle weakness had a history of falls, including a fall with major injury. The resident’s falls CAA and care plan documented risk factors such as prior falls with fracture, incontinence, impaired vision, impaired mobility, and medication use, and directed that the resident be instructed to use the call light for assistance. After a fall in the resident’s room that resulted in visible injuries and transfer to the emergency room, the neurological assessment documentation in the EMR showed multiple required checks either missing or populated with vital signs time-stamped from dates prior to the fall. Several 15‑minute, 30‑minute, 60‑minute, and shift neurological checks were not completed or lacked completion times, and some entries used vital signs recorded days before the fall, contrary to the facility’s neurological assessment policy that required a structured series of timely neurological screenings after a head injury.
Failure of Monthly Drug Regimen Review to Address Out-of-Range Blood Glucose Levels
Penalty
Summary
Surveyors identified a deficiency in the facility’s monthly drug regimen review process related to a resident with diabetes mellitus who received daily insulin and oral diabetes medications. The resident’s admission MDS documented intact cognition and confirmed a diagnosis of diabetes with daily insulin injections, and the care plan directed staff to monitor and document side effects and effectiveness of diabetes medications. An intervention added to the care plan instructed staff to check fasting blood sugars as ordered and to notify the provider for readings less than 60 mg/dl or greater than 350 mg/dl. Physician orders also required blood glucose monitoring twice daily with a directive to call the physician if levels were below 60 mg/dl or above 350 mg/dl. Record review of the resident’s EMR from July 2025 through February 2026 showed multiple blood glucose readings above 350 mg/dl, including values ranging from the mid-350s to as high as 596 mg/dl on numerous dates. The progress notes lacked documentation that the provider was notified of these out-of-range blood glucose levels as required by the physician’s order and care plan parameters. Additionally, review of the Drug Regimen Reviews from August 2025 to February 2026 showed no documentation that the consulting pharmacist identified these elevated blood sugars as being out of range or as a monitoring concern, despite facility policy stating the pharmacist will complete a monthly drug regimen review and identify medications without proper monitoring. An administrative nurse stated she expected the pharmacist to recognize when a medication was outside ordered parameters and notify the facility.
Failure to Notify Provider of Critically Elevated Blood Glucose Levels
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and care plan parameters for notifying the provider when a resident’s blood glucose levels were outside the ordered range. A resident with diabetes mellitus, morbid obesity, and a history of stroke had an admission MDS showing intact cognition and daily insulin use, and the care plan directed staff to monitor blood sugars and notify the provider for readings less than 60 mg/dl or greater than 350 mg/dl. Physician orders documented blood glucose monitoring twice daily with instructions to call the doctor if levels were below 60 mg/dl or above 350 mg/dl. Review of the resident’s blood glucose records from July through February showed numerous readings above 350 mg/dl, including multiple values in the 360–400+ mg/dl range and one reading of 596 mg/dl. Despite these elevated readings, the resident’s progress notes lacked documentation of any provider notification for blood glucose levels over 350 mg/dl on the identified dates. During interviews, a CMA reported that CMAs performed the Accu-checks and stated there were no parameters for when to notify the nurse or doctor, adding that she notified the nurse only if blood sugar was under 100 mg/dl or over 185 mg/dl. An administrative nurse stated that nursing staff should notify the physician if the resident was symptomatic and that staff usually faxed the doctor if the blood sugar was over a certain level if the resident was not symptomatic, and that the nurse should document any fax or call and the physician’s response. The facility’s written notification parameters stated that licensed nursing staff are responsible for contacting the primary care provider anytime a resident develops a clinical problem requiring provider intervention, but this was not reflected in the documentation for this resident’s elevated blood glucose levels.
Missed Potassium Therapy Due to Pending Order and Lack of Timely Notification
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident remained free from significant medication errors when ordered potassium for hypokalemia was not administered. The resident had diagnoses including fluid overload, hypokalemia, hypertension, dementia with severely impaired cognition, unsteadiness on feet, muscle weakness, and repeated falls, and was receiving a diuretic. A care area assessment documented the resident was at risk for dehydration related to diuretic use, impaired mobility, a wound, dementia, and constipation, and the care plan identified risk for adverse reactions related to polypharmacy and use of medications with Black Box Warnings. A nurse received an order from a nurse practitioner for potassium 40 mEq by mouth three times a day for three days due to low potassium levels, with instructions to recheck a CMP and magnesium level. The electronic medical record showed the potassium order under discontinued orders and the MAR documented the potassium as “pending confirmation” with a start date and discontinue date, but the clinical record lacked evidence that the potassium doses were administered or rescheduled, and there was no documentation that the physician was notified when the medication was not given as ordered. The order was placed in a pending status by the nurse on duty, and because it remained in pending, it did not appear on the MAR and the medical records nurse’s second check did not identify the issue. The facility’s medication error policy required that residents be free of significant medication errors, that such errors be immediately reported to the physician and DON or designee, documented on an incident tracking report, and tracked for quality assurance purposes, but the documentation showed the potassium doses were missed and not reported at the time they were omitted.
Failure to Properly Label Opened Insulin Pens
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication management practices when they observed that insulin pens for one resident were not properly labeled in accordance with professional standards and facility policy. During observation of the medication cart in the nurse’s room, one Lantus (long-acting insulin) flex pen for Resident 11 was found without any opened date or expiration date, and a second Lantus flex pen for the same resident had a date written on it that had smeared and was illegible. Licensed Nurse G confirmed that nurses are expected to label and date insulin flex pens with the date opened, and Administrative Nurse D also verified that nurses should label and date insulin flex pens when opened. The facility’s Medication Storage policy stated that medications and biologicals are to be stored safely, securely, and properly following manufacturer or supplier recommendations, and that medications are to be labeled for individual residents and stored appropriately. Medlineplus.gov guidance cited in the report stated that an open, unrefrigerated insulin pen can be used within 28 days and must be discarded after that time.
Failure to Provide Timely Dental Follow-Up and Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to provide timely dental care and follow-up for a resident with documented dental problems and pain. The resident’s MDS showed intact cognition and a need for staff assistance with personal and oral hygiene, with no oral or dental issues identified on that assessment. The ADL Care Plan documented that the resident had his own teeth in poor condition, with caries and missing teeth, and required setup to partial assistance with oral care, with dental appointments to be arranged as scheduled, needed, or requested. A CAA for ADLs did not identify or document any signs or symptoms of dental problems or pain despite the resident’s broken, decayed, and missing teeth. Interdisciplinary notes documented that the resident was seen by a dentist for a lost tooth and mouth pain, with findings of extensive gross caries and recommendations for staff to brush the resident’s teeth and for the resident to return for fillings and extractions, with extractions to be done by an oral surgeon. Later, a dental hygienist’s exam at the facility documented pain in the upper mouth, moderate inflammation, and the need for further evaluation by a dentist. The resident reported broken and missing teeth, pain in the upper jaw, and difficulty eating due to tooth pain, and observation confirmed missing, decayed, and broken teeth. The Administrative Nurse verified the prior dental appointment and recommendations but could not find any documentation of a follow-up appointment or reasons why it was not made, and confirmed there was no documentation in the medical record, despite the facility’s dental services policy requiring timely referral, documentation of refusals, and documentation of interventions while awaiting dental services.
Failure to Document PCV20 Offer or Declination for a Resident
Penalty
Summary
The facility failed to offer and administer, or obtain an informed declination for, the Pneumococcal Conjugate Vaccine (PCV20) for one resident in the sample. Record review for Resident 3 showed prior pneumococcal vaccinations (PCV13 on 10/30/15 and PPSV23 on 11/12/04), but the clinical record lacked documentation that PCV20 was offered or declined, lacked documentation of a historical administration of PCV20, and lacked any physician-documented contraindication. According to Administrative Nurse D, the admitting nurse was responsible for ensuring the resident or family signed a consent or declination for immunizations, with the signed form to be uploaded into the resident’s chart; however, Administrative Nurse D was unable to locate the consent or declination for this resident and stated that the room where the forms had been stored had flooded. The facility’s Immunizations-Pneumococcal policy required that, at admission, the nurse determine the resident’s vaccination history through resident, family, or primary care provider information and document it on the immunization record, but this required documentation for PCV20 was not present in the resident’s record. The deficiency was identified during a review of a census of 51 residents, with a sample of 14 residents and five reviewed for immunization status, and was based on the missing documentation and interviews confirming that the required consent/declination and immunization record for PCV20 were not available in the resident’s chart.
Failure to Notify Physician of Catheter Issues and Resident Condition
Penalty
Summary
The facility failed to notify the physician in a timely manner regarding the lack of monthly catheter changes for a resident, identified as R2, over several months. R2, who had a history of hemiplegia, aphasia, and neuromuscular dysfunction of the bladder, required an indwelling catheter. Despite instructions to change the catheter monthly, records showed that the catheter was last changed in April 2024, with refusals documented in May, June, and July. However, the facility did not notify the physician about these refusals until days later, and in some cases, not at all. On August 14, 2024, at 9:00 PM, staff were alerted to swelling and redness in R2's penis and scrotum, but the licensed nurse on duty did not assess or document the condition, nor was the physician notified. The following day, R2's condition worsened, leading to an emergency medical transport for further evaluation and treatment. The facility's policy required immediate notification of the physician for such changes in condition, but this protocol was not followed. Interviews with staff revealed a lack of communication and documentation regarding R2's condition. Several staff members, including CNAs and LNs, were aware of the swelling and discoloration but failed to take appropriate action or notify the physician promptly. This delay in response and failure to adhere to the facility's notification policy contributed to the deficiency, ultimately resulting in R2 requiring emergency medical attention.
Failure to Investigate and Respond to Resident Falls
Penalty
Summary
The facility failed to adequately investigate and respond to multiple falls experienced by a resident, identified as R1, during their stay. R1, who was admitted to the facility with a high risk for falls, experienced four falls within a six-day period. Despite the resident's known fall risk and previous incidents, the facility did not conduct thorough assessments or implement new interventions following falls on two specific occasions. Additionally, the facility did not notify the responsible party or the physician after these incidents, as required by their policy. R1's medical records indicated a diagnosis of dementia and a history of mixed incontinence and dystonia. The resident required supervision for mobility and was identified as a fall risk upon admission. Despite these known risks, the facility's response to R1's falls was inadequate. On two occasions, the facility failed to perform necessary assessments, such as neurological checks, and did not document or implement new interventions to prevent further falls. The lack of communication with R1's family and physician further compounded the issue, as they were not informed of the falls that occurred on two separate days. The facility's policy required staff to assess residents for injuries, conduct vital sign checks, and notify the responsible party and physician after a fall. However, these procedures were not followed in R1's case. The failure to adhere to these protocols resulted in a lack of appropriate care and communication, ultimately leading to the resident's family deciding to remove R1 from the facility due to perceived neglect.
Failure to Ensure Infection Preventionist Attendance at QAA Meetings
Penalty
Summary
The facility failed to ensure the required members, including the infection preventionist, attended the Quality Assessment and Assurance (QAA) Committee meetings at least quarterly. The facility had a census of 48 residents, and the sample included 13 residents. On multiple dates, the facility's Quarterly Quality Assurance Performance Improvement (QAPI) Meeting Attendance Sheets lacked evidence of the designated infection preventionist's attendance. On 04/15/24, an administrative nurse verified the absence of the infection preventionist's signature on the quarterly meeting sign-in sheets and confirmed that the facility had not employed an infection preventionist at the times of the quarterly meetings. The facility's Quality Assurance Process Improvement Plan (QAPI), revised 01/15/24, documented that the steering committee, comprised of department directors, would oversee the QAPI process and meet monthly to prioritize and monitor plans. However, the facility did not ensure the required participants, including the infection preventionist, attended QAPI/QAA meetings at least quarterly, placing residents at risk of decreased quality of care.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to ensure reconciliation of controlled medications was completed consistently and per industry standards. This deficiency was identified through a review of the April 2024 Eight Hour Verification Controlled Substance Count sheets on various medication carts. Specifically, there were missing signatures for either the on-coming nurse or the off-going nurse on multiple occasions: 13 of 62 opportunities on the locked memory care unit, 4 of 84 opportunities on the nurse's cart, and 12 of 84 opportunities on the medication aide's cart. These missing signatures indicate that the required narcotic counts were not properly documented at shift changes, as confirmed by interviews with staff members, including a Certified Medication Aide and a Licensed Nurse, who acknowledged the necessity of signing off on the narcotic counts at the beginning and end of each shift. The Administrative Nurse also confirmed awareness of the issue and mentioned that a performance improvement project had been initiated to address it, although no controlled medications were reported missing or miscounted at the time of the survey. The facility's Medication Storage-Controlled Meds policy, last revised in October 2021, mandates that a physical inventory of controlled medications be conducted by two licensed/certified staff at each shift change and documented on the Eight Hour Verification Controlled Substances Count form. Additionally, the Director of Nursing or designee is required to routinely audit controlled substances as part of the facility's Quality Assurance and Performance Improvement process. However, the facility failed to adhere to these procedures, placing residents at risk of medication misappropriation and diversion.
Failure to Provide Complete Medicare ABN Forms
Penalty
Summary
The facility failed to provide the required Medicare Advance Beneficiary Notice (ABN) Form 10055, which includes the estimated costs for continued services, to two residents (R32 and R41). The ABN Form 10055 is intended to inform beneficiaries that Medicare may not cover future skilled therapy services and to provide them with options regarding their care. However, the forms given to R32 and R41 lacked the estimated costs and did not document which option the residents or their representatives chose. This oversight placed the residents at risk for making uninformed decisions about their skilled services. Administrative Staff B, who was responsible for providing the CMS Form 10055, confirmed that the forms for R32 and R41 did not include the necessary estimated costs or the chosen options. Administrative Staff B admitted to being unaware of the requirement to provide the estimated costs and acknowledged missing the fact that the residents or their representatives had not selected an option. Additionally, Administrative Staff A verified that the facility lacked documentation showing that the estimated costs were provided on the ABN forms. The facility also did not have a policy regarding beneficiary notification, further contributing to the deficiency.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for a resident (R35). Observations over several days revealed a persistent and overwhelming urine odor in R35's room, which was noticeable even from the hallway. The resident's urinary catheter was not visible, and there were visible wet spots on the bed sheets. Despite multiple cleanings by maintenance staff, the strong urine odor persisted. The clinical record and plan of care for R35 lacked any interventions or documentation regarding efforts to address the urine odor in the room. Interviews with staff indicated that the urine odor was due to R35 emptying his urinary catheter bag himself, often spilling urine on the carpet. Staff noted that R35 was fiercely independent and refused assistance with emptying the catheter bag. The facility did not provide a room cleaning policy upon request. This failure to maintain a clean and homelike environment placed the resident at risk for impaired comfort and dignity.
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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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