Family Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wichita, Kansas.
- Location
- 639 S Maize Court, Wichita, Kansas 67209
- CMS Provider Number
- 175501
- Inspections on file
- 18
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Family Health & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found multiple sanitation and maintenance deficiencies in several kitchens serving 66 residents, including emergency water cases stored directly on the floor, an oven with heavy burnt residue, and a refrigerator containing an employee lunch bag with resident food. In two kitchens, undated prepared and frozen food items were observed despite dietary staff acknowledging all food should be dated. Additional findings included broken cupboards and missing drawers, heavily scratched cutting boards, bent muffin tins with cooked-on residue, dirty freezer shelves with food and liquid spills, and a dirty shelf under a steamer table. A broken laundry basket containing clean kitchen towels was stored on the floor. These conditions conflicted with facility policy and administrative expectations for clean, well-maintained kitchens and properly labeled food.
A resident with allergic rhinitis, anxiety disorder, and dementia, but intact cognition and no mobility impairment, was observed keeping Fluticasone propionate nasal spray at bedside and self-administering it as needed rather than on a set schedule. The EMR and care plan did not document authorization for self-administration, and the required self-administration assessment tool was not completed, despite facility policy requiring an interdisciplinary competency assessment before allowing medications to be kept in a resident’s room.
A resident with intact cognition but dependent on staff for toileting, dressing, and transfers, and with diagnoses including IBS, HTN, chronic respiratory failure, and urinary retention, had a Falls CAA triggered due to impaired balance, restricted mobility, medication use, need for transfer assistance, and presence of a urinary catheter, with identified risks for falls, injury, pain, and skin breakdown. Despite this, the only documented care plan focus addressed activities, with interventions limited to assisting the resident to and from activities and providing daily education about available activities, and no additional focuses, goals, or interventions were developed for the resident’s clinical and fall-related needs. Nursing staff reported that comprehensive care plans are expected within 21 days of admission, and an administrative nurse acknowledged not realizing that the resident’s comprehensive care plan had not been completed after the resident moved from the skilled unit to the LTC side.
A resident with MS and severe cognitive impairment, who was dependent on staff for oral hygiene, did not consistently receive ordered and care-planned oral care. The care plan and provider orders required staff to assist with toothbrushing twice daily, and dental consults documented poor oral hygiene with heavy food debris and severe gum inflammation, along with instructions to remind and assist with brushing. Surveyors observed morning care without any oral care offered, and the resident’s toothbrush and toothpaste were found dry. The resident’s representative reported ongoing concerns about lack of oral care, an LN admitted signing off oral care without performing it, and a CNA stated she forgot to provide oral care that day, despite acknowledging the resident could not brush independently.
A resident with dementia, chronic constipation, and orders for daily and PRN laxatives went nine days without a documented BM. During this period, ordered Enulose doses were missed on several days because the resident was sleeping, PRN Milk of Magnesia was never given, and there was no documentation of bowel or abdominal assessments. Staff relied on limited electronic bowel documentation and printed reports, and although a standing bowel protocol and assessment requirements were in place for residents approaching three days without a BM, there was no evidence these were initiated or documented for this resident.
A resident with a gastrostomy tube, severely impaired cognition, and total dependence for ADLs had a physician’s order for a daily bolus of Nutrent 2.0 with 100 ml free water flushes before and after each feeding. An LN instead flushed only 50 ml of water before and after administering Zofran via the tube and did not provide the ordered 100 ml flush before the tube feeding, then flushed only 50 ml after the feeding, later acknowledging she misread the order. This failure to follow the ordered water flush regimen occurred despite the care plan directing staff to follow the physician’s orders and an enteral feeding policy addressing order entry and administration.
The facility failed to properly maintain and dispose of outside garbage and refuse. Surveyors observed two outdoor garbage receptacles, including one dumpster with its lid left open, multiple torn garbage bags behind it, and gloves, food, medical supplies, and other trash scattered on the ground. Dietary staff stated that dumpster lids were supposed to remain closed and that no garbage should be on the ground, and administrative staff acknowledged the dumpster was small but still expected staff to keep lids closed and prevent trash accumulation. The facility’s policy required outside dumpsters and surrounding refuse areas to be kept clean, sanitary, and well maintained to prevent nuisance, pest attraction, or contamination risk.
The facility failed to protect a resident and other vulnerable residents during an abuse investigation. The resident reported pain caused by a CNA, but the incident was not immediately reported or investigated according to policy. The CNA continued to work without corrective actions, and administrative staff failed to communicate and report the allegation properly.
The facility failed to ensure accurate reconciliation of controlled substances, with multiple missing signatures on narcotic reconciliation sign-off sheets. Staff confirmed that the sheets should be signed after narcotic counts and key exchanges between shifts, but this was not consistently done. The facility did not provide a policy for controlled medication reconciliation, placing residents at risk of medication misappropriation and diversion.
The facility failed to ensure timely administration of medications and proper insulin pen priming, resulting in a medication error rate of 46.15%. A CMA administered medications outside the allowable timeframe, and an LN did not prime an insulin pen before administration.
The facility failed to ensure safe and secure storage of medications and biologicals, with observations showing unlocked medication refrigerators and carts, and improper maintenance of a refrigerator. Staff interviews confirmed that these storage units should be locked when not in use.
The facility failed to follow consistent infection control standards, including proper signage for EBP, storage of oxygen tubing, indwelling catheter care, laundry handling, and disinfection of shared equipment. Staff did not adhere to hand hygiene protocols, and multiple instances of non-compliance with infection control policies were observed.
The facility failed to ensure that three CNAs had the required 12 hours of in-service education, including dementia management training. The provided training lacked specific directions for staff on interventions and methods of approach for residents with dementia, placing residents at risk for inadequate care.
A resident with multiple medical conditions reported that a CNA hurt her leg during a shower, causing severe pain. The facility failed to report the allegation to the administrator and the State Agency immediately, as required by policy, placing the resident at risk for ongoing abuse or neglect.
The facility failed to implement fall interventions for a resident with quadriplegia, epilepsy, and other conditions, as directed by her care plan. Observations revealed that her bed was not positioned next to the wall, and the fall mat was not in place, putting her at risk of falls. Staff interviews confirmed that the fall precautions were not consistently followed.
The facility failed to follow standards of practice for indwelling catheter care for a resident with severe cognitive impairment and multiple medical diagnoses. Observations revealed the resident's catheter bag was repeatedly found on the floor, and a licensed nurse did not adhere to proper hand hygiene protocols during catheter care. The facility did not provide a policy related to urinary catheter care when requested.
The facility failed to monitor a resident's dialysis access site daily and did not obtain communication from the dialysis center regarding the resident's treatment. The resident had an arteriovenous fistula and required daily assessments, which were not consistently documented, placing the resident at risk of complications.
A resident with multiple diagnoses, including dementia and edema, did not receive a physician-ordered PRN dose of bumetanide despite significant weight gains. This failure to follow the physician's parameters and the facility's medication administration policy was confirmed through record reviews, observations, and staff interviews.
Unsanitary Food Storage and Poor Kitchen Maintenance
Penalty
Summary
Surveyors identified that the facility failed to maintain sanitary food storage and kitchen conditions across four kitchens serving 66 residents. In the main hall food storage room, several cases of emergency water were stored directly on the floor, and dietary staff reported the water had been kept there for a few months. In one house kitchen, the oven contained a large amount of burnt dark residue on the bottom, and the refrigerator held a staff member’s lunch bag stored with resident food items. In two house kitchens, surveyors observed undated containers and bags of food, including cut-up apples with cinnamon, hash browns, and frozen biscuits, and dietary staff acknowledged that all items should have been labeled with dates. Further observations on subsequent days showed multiple areas of disrepair and unclean conditions in the kitchens. Broken cupboards, missing drawers, and very scratched cutting boards were noted, along with muffin bakery tins that were bent and had cooked-on dark black/brown residue. The bottom shelf of a freezer in one kitchen was dirty with drops of food and liquids, and a shelf under a steamer table was dirty with baked-on food and dust. A broken laundry basket labeled for kitchen towels was stored on the floor in a storage area between two houses and contained clean kitchen towels. Administrative staff stated an expectation that kitchen equipment be clean and in good repair, that food be labeled with dates, and that items not be stored on the floor, which contrasted with the conditions observed. The facility’s policy required that food be prepared and served using methods designed to be free of injurious organisms and substances and that the kitchen and equipment be kept clean, neat, orderly, and well maintained.
Failure to Assess Resident for Self-Administration of Nasal Spray Kept at Bedside
Penalty
Summary
The facility failed to ensure a resident was assessed for the ability to safely self-administer a prescribed Fluticasone propionate nasal spray before allowing the medication to be kept at bedside. The resident’s EMR documented diagnoses of allergic rhinitis, anxiety disorder, and unspecified dementia, with annual and quarterly MDS assessments showing a BIMS score of 13, indicating intact cognition, and no impairment in upper or lower extremities. The Psychotropic Drug Use CAA indicated his medications were managed and overseen by the nurse and physician team, and his care plan did not document that he kept the nasal spray at his bedside. The physician’s order specified daily use of Fluticasone propionate nasal suspension for allergic rhinitis, but the Assessment tab lacked the facility’s Self-Administration of Medication/Treatment Data Collection Tool for this medication. During observation, the resident was seen seated in a recliner with a bottle of Fluticasone propionate nasal spray on the dresser directly in front of him, and he stated he administered the nasal spray himself when he felt “stopped up,” rather than on a set schedule. A subsequent observation again found the nasal spray on his dresser. Facility staff, including a licensed nurse and an administrative nurse, confirmed that if a resident had medication in the room, an assessment for self-administration should have been completed, and that no such assessment existed for this resident’s nasal spray. The facility’s self-administration policy stated that resident competency must be assessed by the interdisciplinary team prior to allowing self-administration and that such assessments should be performed annually and after significant changes of condition, but this process was not followed for the resident’s nasal spray.
Failure to Develop Comprehensive Care Plan for High-Risk Resident
Penalty
Summary
Surveyors identified that the facility failed to develop a comprehensive care plan for a resident with multiple medical conditions, including irritable bowel syndrome, hypertension, chronic respiratory failure, and urinary retention. The resident’s admission MDS documented a BIMS score of 14, indicating intact cognition, and showed that she was dependent on staff for toileting, dressing, and transfers, and had experienced one non-injury fall. A Falls Care Area Assessment dated 12/18/25 triggered due to impaired balance with transitions and transfers and the resident’s need for assistance with ADLs. The CAA identified contributing factors such as restricted mobility, medication use, need for assistance with transfers, and the presence of a urinary catheter, and listed risk factors including falls, injuries from falls, pain, and skin breakdown. The CAA stated that a care plan would be reviewed to assist in preventing falls and injuries related to falls. Despite these identified needs and risks, the resident’s care plan contained only one Focus related to activities, initiated on 12/08/25, with interventions limited to assisting the resident to and from activities and educating her daily about available activities. The care plan lacked additional Focus areas, goals, or interventions addressing the resident’s fall risk, impaired balance, dependence in ADLs, catheter care, or other clinical needs. During interviews, nursing staff, including a licensed nurse and administrative nurses, stated that the comprehensive care plan was expected to be completed within 21 days of admission, and one administrative nurse acknowledged she had not realized the resident’s comprehensive care plan had not been developed after the resident moved from the skilled unit to the long-term care side. The facility’s policy on Care Plan Revisions described a care planning process that should include assessment, goal setting, interventions, referrals, evaluation, and revision of care, which was not carried out for this resident.
Failure to Provide Ordered and Care-Planned Oral Hygiene Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary staff assistance with oral hygiene for a resident with multiple sclerosis and severe cognitive impairment. The resident’s MDS documented dependence on staff for oral hygiene, and the care plan directed that he required supervision and partial/moderate assistance with eating and moderate assistance for oral hygiene, with staff to encourage and/or assist with oral care in the morning and evening. Physician orders required staff to offer to brush the resident’s teeth twice daily, every shift. Dental consultant summaries documented that the resident had missing lower right teeth, heavy food debris, moderate to severe gum inflammation, and poor oral hygiene, while remaining cooperative with cleanings. The dentist left written directions for staff to remind and/or assist the resident with brushing twice daily, focusing on the gumline. Surveyor observations and interviews showed that these ordered and care-planned oral care interventions were not consistently carried out. During morning care, staff assisted the resident but did not offer oral care, and later observation revealed the resident’s toothbrush and toothpaste were present but dry. The resident’s representative reported concerns that staff were not performing oral care as they should and stated she had raised these concerns at a recent care plan meeting. A licensed nurse acknowledged that he did not personally provide oral care but signed it off on the treatment record and then followed up with aides, while a CNA reported she usually did the resident’s oral care after breakfast but had forgotten to do it that day, confirming the resident could not brush his own teeth. The facility’s oral health care policy required oral care twice daily for every resident, but this was not followed for this resident.
Failure to Implement Bowel Protocol for Resident With Prolonged Constipation
Penalty
Summary
The deficiency involves the facility’s failure to identify and implement appropriate interventions for a resident who went nine days without a documented bowel movement despite existing bowel management orders and a bowel protocol. The resident had dementia with severely impaired cognition, required maximal assistance with transfers and toileting, and was frequently incontinent of bowel. The care plan identified chronic constipation and directed staff to administer medications as ordered and monitor for signs of constipation, including no bowel movement for two days when administering narcotics. Physician orders included daily Enulose for constipation and PRN Milk of Magnesia. Record review showed the resident had a small bowel movement on 02/02/26 and then no documented bowel movement from 02/03/26 through 02/11/26, with the next medium bowel movement recorded on 02/12/26. The February MAR indicated Enulose was not administered on three days because the resident was sleeping, and the PRN Milk of Magnesia was not administered at all during the month. Progress notes from 02/02/26 through 02/12/26 lacked evidence that any bowel or abdominal assessments were conducted during the nine-day period without a documented bowel movement. Staff interviews revealed that CNAs and CMAs documented incontinence and bowel movements in separate tasks, and the CMA relied on a dashboard that only displayed 24–48 hours of bowel records, with charge nurses responsible for printing a three-day bowel report. Nursing staff reported there was a standing bowel protocol to be initiated when a resident had no bowel movement for three days, and that nurses were responsible for abdominal assessments and documentation in the EMR. The facility’s bowel and bladder management policy required licensed nurses to review bowel reports each shift, assess residents approaching three days without a bowel movement, and follow a stepwise bowel protocol, but there was no documentation that these assessments or protocol steps were implemented for this resident during the nine-day period without a documented bowel movement.
Failure to Follow Physician’s Orders for Tube Feeding Water Flushes
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for water flushes before and after medication administration and tube feeding for a resident with a gastrostomy tube. The resident had an artificial opening of the gastrointestinal tract, severely impaired cognition, required total staff assistance with ADLs, and received tube feedings. The resident’s care plan directed staff to provide tube feeding and water flushes per the physician’s order. The physician’s order specified administration of one 250 ml carton of Nutrent 2.0 daily at 10:00 AM, with 100 ml of free water to be flushed through the tube before and after each bolus feeding. During an observation, a licensed nurse donned gloves, placed a catheter tip syringe into the resident’s feeding tube, and administered 50 ml of free water, followed by Zofran dissolved in 15 ml of water, then 250 ml of Nutrent supplement, and finally flushed with 50 ml of water. The nurse confirmed she had flushed the tube with 50 ml of water before and after the Zofran administration and 0 ml before the tube feeding, instead of the ordered 100 ml before and 100 ml after the bolus feeding. The nurse stated she had read the order incorrectly. An administrative nurse later stated her expectation that staff verify the order, position the resident properly, and flush with water per the physician’s order when providing medications and supplements via tube. The facility’s enteral tube feeding policy indicated that bolus supplementation orders would be encoded into the computer under the medication order entry program and handled as unit-dose medications.
Improper Maintenance and Disposal of Outside Garbage and Refuse
Penalty
Summary
The facility failed to properly maintain and dispose of kitchen garbage and refuse in accordance with its policy. With a reported census of 66 residents, surveyors observed two outside garbage receptacles, one on the east side and one on the west side of the building. The dumpster outside of the [NAME] House had a lid open on one side, and several garbage bags with holes in them were found behind the dumpster, with gloves, food, and other medical supplies visible. Additional garbage was observed on the ground on the side of the dumpster. Dietary staff confirmed that dumpster lids were expected to remain closed and that garbage should not be on the ground around the dumpsters. Administrative staff acknowledged that the dumpster in question was small and that she expected staff to keep the lids closed and prevent garbage from accumulating on the ground. The facility’s written Disposal of Garbage and Refuse Policy required that all outside dumpsters and surrounding refuse storage areas be maintained in a clean, sanitary, and well‑maintained condition to prevent nuisance, pest attraction, or potential contamination risk.
Failure to Protect Resident After Abuse Allegation
Penalty
Summary
The facility failed to protect Resident 25 and other vulnerable residents during the investigation of an abuse allegation. Resident 25, who had multiple medical diagnoses including acute kidney failure, deep vein thrombosis, congestive heart failure, depression, and dementia, reported that a Certified Nurse Aide (CNA) was rough with her and caused pain by pulling off her wound cover instead of cutting it off. Despite the resident's report and visible distress, the incident was not immediately reported to the administrator, physician, or family, and no protective measures were taken to separate the alleged perpetrator from the resident or other residents under their care. The facility's investigation into the incident was inadequate. The progress notes and grievance form indicated that the resident reported the incident to staff, but the facility did not follow its own policy for handling abuse allegations. The policy required immediate investigation, assessment of the resident's health and safety, and separation of the alleged perpetrator from the resident. However, the CNA continued to work at the facility without any corrective actions or additional training being implemented. Interviews with administrative staff revealed a lack of communication and proper reporting. Administrative Nurse D did not consider the incident as abuse after reviewing camera footage, and Administrative Staff A was not notified of the allegation until the following morning. The facility's failure to follow its abuse reporting policy and protect Resident 25 and other residents from potential harm constitutes a significant deficiency in care and oversight.
Failure to Ensure Accurate Reconciliation of Controlled Substances
Penalty
Summary
The facility failed to ensure accurate reconciliation of controlled substances, placing residents at risk of medication misappropriation and diversion. Observations revealed that the narcotic reconciliation sign-off sheets on the medication cart in [NAME] House lacked signatures on multiple occasions. Specifically, from 03/07/24 to 03/31/24, there were 11 missing signatures out of 152 opportunities, and from 04/01/24 to 04/21/24, there were 16 missing signatures out of 136 opportunities. Certified Medication Aide (CMA) S and Licensed Nurse (LN) G confirmed that the narcotic sign-on and off sheets should be signed after the narcotic count and key exchange between shifts, but this was not consistently done. Administrative Nurse D also stated that the narcotic sign-on and off sheets were expected to be signed by both the off-going and oncoming nursing staff at the end and beginning of each shift. However, the facility did not provide a policy for controlled medication reconciliation, further contributing to the inconsistency. This failure to ensure accurate reconciliation of controlled substances was consistently completed, placing residents at risk of medication misappropriation and diversion.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure the medication error rate did not exceed five percent when staff did not administer scheduled morning medications to a resident within the ordered timeframe. Specifically, a Certified Medication Aide (CMA) administered medications to a resident at 12:20 PM, well beyond the allowable one-hour window before or after the scheduled administration times of 08:00 AM and 06:00 AM to 10:00 AM. The CMA acknowledged being behind schedule and stated that the medications should have been administered on time. Additionally, a Licensed Nurse (LN) failed to prime an insulin pen and needle before administering insulin to another resident. The LN administered 15 units of insulin without priming the pen and needle with two units of insulin, as required by standard practice. The LN admitted to not being aware of the need to prime the insulin pen and needle before administration. The facility's policy on medication administration, last revised on 01/16/24, requires that medications be administered within a one-hour window before or after the scheduled time. Both the CMA and LN failed to adhere to this policy, resulting in a medication error rate of 46.15%. The facility's administration confirmed the expectations for timely medication administration and proper insulin pen priming, which were not met in these instances.
Failure to Ensure Secure Storage of Medications
Penalty
Summary
The facility failed to ensure safe and secure storage of medications and biologicals, which created a risk for adverse medication effects and ineffective medication administration. Observations revealed that the medication refrigerator on the [NAME] House was left unlocked with unsecured insulin for several residents. Additionally, a medication cart on the same house was found unlocked and unattended by nursing staff. The inside of the refrigerator also had a large amount of ice formation at the top, indicating improper maintenance. Interviews with staff confirmed that medication carts and refrigerators should be locked when not in use or when staff are not in direct sight of them. The facility's policy on Medication Storage, last revised on 02/14/24, did not address the storage of medications in the medication carts or medication refrigerators. This lack of adherence to proper storage protocols was acknowledged by both Licensed Nurse H and Administrative Nurse D, who stated that they expected nursing staff to keep these storage units locked when not in use.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure consistent infection control standards were followed in several areas, including enhanced barrier precautions (EBP), storage of oxygen tubing, indwelling catheter care, laundry, and shared equipment. Observations revealed that rooms of residents on EBP lacked the required signage and stored personal protective equipment (PPE) inside the rooms. Additionally, soiled items were found lying directly on the floor in the laundry room, and oxygen tubing was improperly stored in a resident's room without clean storage bags or containers available until the following day. Further deficiencies were noted in the care of a resident with an indwelling catheter, where the urinary catheter bag was repeatedly found lying on the floor, posing a contamination risk. Staff failed to disinfect shared equipment, such as a Hoyer lift, after use, and did not adhere to proper hand hygiene protocols. For instance, a licensed nurse did not change gloves or perform hand hygiene after picking up items from the floor before continuing with catheter care for a resident. Interviews with staff revealed a lack of understanding and adherence to infection control policies. A certified nurse aide and an administrative nurse both acknowledged the importance of proper storage and hygiene practices but admitted that these were not consistently followed. The facility's infection control policy and enhanced barrier precautions guidelines were not effectively implemented, leading to multiple instances of non-compliance and placing residents at risk for complications related to infectious diseases.
Deficiency in CNA Dementia Training
Penalty
Summary
The facility failed to ensure that three Certified Nurse Aides (CNAs) had the required 12 hours of in-service education, including dementia management training. The review of the facility's staffing list revealed that CNAs employed for more than 12 months lacked evidence of dementia in-service training. Specifically, CNA N, hired on 01/19/23, CNA O, hired on 06/16/20, and CNA P, hired on 02/21/22, did not have documented dementia training. The provided in-service training on elopement and communication included slides on dementia but lacked specific directions for staff on interventions and methods of approach for residents with dementia. This deficiency placed residents at risk for inadequate care. Interviews with administrative staff revealed that required in-services were completed electronically, and dementia training was included in the facility's elopement and communication in-services. However, the training lacked comprehensive guidance on providing care to residents with dementia. The facility's policy on required training and in-services documented the need for an effective training program for all staff, including dementia management training. Despite this policy, the facility did not ensure that the reviewed CNA staff received the necessary dementia management training, leading to a deficiency in the quality of care provided to residents.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure staff reported an allegation of staff-to-resident abuse for a resident (R25) to the facility administrator immediately. The resident, who had a history of acute kidney failure, lower extremity deep vein thrombosis, congestive heart failure, depression, and dementia, reported that a Certified Nurse's Aide (CNA) had hurt her leg and was rough with her during a shower. Despite the resident's report of pain and distress, the incident was not reported to the administrator, physician, or family immediately as required by the facility's policy. The facility also failed to report the allegation to the State Agency (SA), placing the resident at risk for unidentified and ongoing abuse or neglect. The resident's Electronic Medical Records (EMR) and Minimum Data Set (MDS) indicated she required assistance with activities of daily living (ADLs) and had a venous ulcer on her lower left extremity. On the night of the incident, the resident reported to nursing staff that the CNA had pulled off her wound cover, causing severe pain and burning sensations. The progress notes and a Resident/Family Concern form documented the resident's complaint, but there was no evidence that the situation was reported to the appropriate authorities immediately. Interviews with administrative staff revealed that the incident was not reported to the SA because the facility reviewed the situation and did not feel it constituted abuse. The facility's policy on Reporting of Abuse, Neglect, and Exploitation (ANE) required all alleged or suspected mistreatment to be reported immediately to the administrator and the SA. The failure to follow this policy resulted in a deficiency, as the resident's allegation of abuse was not handled according to the established procedures, potentially compromising her safety and well-being.
Failure to Implement Fall Interventions for Resident
Penalty
Summary
The facility failed to provide Resident 42's fall interventions as directed by her care plan, placing her at risk of falls and related injuries. Resident 42 had diagnoses of quadriplegia, epilepsy, a feeding tube, and a transient ischemic attack. She was dependent on staff for all activities of daily living and used a wheelchair for mobility. Her care plan included specific fall interventions such as arranging her bed next to the wall and placing a fall mat next to her bed. However, observations on multiple occasions revealed that these interventions were not in place. The bed was not positioned next to the wall, and the fall mat was either rolled up or not in place next to the bed while Resident 42 was in bed. Interviews with staff members, including a Licensed Nurse, a Certified Nursing Aide, and an Administrative Nurse, confirmed that the fall precautions for Resident 42 were not consistently followed. The staff acknowledged that they were responsible for ensuring the safety of each resident and that the care plans, including fall precautions, were discussed during morning huddles and reports. Despite this, the necessary fall interventions for Resident 42 were not implemented, as evidenced by the observations. The facility's Falls policy emphasized the importance of maintaining a safe environment to minimize accident hazards, but this policy was not adhered to in the case of Resident 42.
Failure to Follow Standards of Practice for Indwelling Catheter Care
Penalty
Summary
The facility failed to follow standards of practice related to indwelling catheter care for a resident with severe cognitive impairment and multiple medical diagnoses, including hemiplegia, hemiparesis, and neurogenic bladder dysfunction. The resident required maximal assistance with activities of daily living and had an indwelling urinary catheter. Observations revealed that the resident's catheter bag was repeatedly found on the floor, which is against the care plan instructions to keep the catheter collection bag below the level of the bladder to prevent contamination. Additionally, a licensed nurse was observed performing catheter care without adhering to proper hand hygiene protocols, including failing to change gloves and wash hands after touching soiled surfaces and items, which further increased the risk of infection for the resident. The resident's care plan indicated the need for urinary catheter care each shift and instructed staff to check the tubing for kinks and ensure the catheter collection bag remained below the level of the bladder. However, multiple observations showed that these instructions were not followed. The facility did not provide a policy related to urinary catheter care when requested, indicating a lack of adherence to established standards of practice. This deficiency placed the resident at risk for catheter-related complications, including urinary tract infections.
Failure to Monitor Dialysis Access Site and Obtain Communication from Dialysis Center
Penalty
Summary
The facility failed to monitor a resident's dialysis access site for complications at least daily and did not obtain communication from the dialysis center regarding the resident's treatment. The resident, who had diagnoses of diabetes mellitus, end-stage renal disease, and dependence on dialysis, required staff assistance with toileting needs and had an arteriovenous fistula in her left upper chest. The care plan specified that the nursing staff should monitor the fistula every shift and communicate with the dialysis provider using a written form for each dialysis visit. However, the facility's records showed that staff only assessed the fistula on dialysis days and did not consistently document these assessments or obtain communication from the dialysis center on multiple occasions. Observations and interviews with staff confirmed these deficiencies. A Certified Nurse Aide mentioned assisting the resident with her dialysis bag, while a Licensed Nurse stated that communication forms should be filled out and returned from the dialysis center, and the fistula should be assessed and documented. However, the Licensed Nurse confirmed that the resident's Electronic Medical Record lacked consistent documentation of the fistula assessments. An Administrative Nurse also stated that the fistula should be assessed every shift for bleeding and infection. The facility's Hemodialysis Policy required daily inspection and documentation of the fistula site, but the facility failed to adhere to this policy, placing the resident at risk of potential adverse outcomes and physical complications related to dialysis.
Failure to Administer PRN Medication as Ordered
Penalty
Summary
The facility failed to follow the physician-ordered parameters related to a resident's as-needed (PRN) bumetanide medication. The resident, who had diagnoses including dementia, osteoarthritis, depression, a left femur fracture, and edema, was supposed to receive an additional dose of bumetanide if her weight increased by more than three pounds. Despite multiple instances of weight gain exceeding this threshold, the PRN medication was not administered. This failure was confirmed through record reviews, observations, and staff interviews, indicating a lapse in adhering to the physician's instructions and the facility's medication administration policy. The resident's care plan included instructions to monitor for weight gain or loss due to the use of bumetanide, a medication with a Black Box Warning. The resident's weight history showed significant weight gains on several occasions, yet the additional PRN dose was not given. Interviews with nursing staff and administrative personnel revealed that the staff were expected to follow the physician's parameters, but this was not done in the resident's case. This oversight placed the resident at increased risk for unnecessary medication and side effects.
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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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