Grand Plains Skilled Nursing By Americare
Inspection history, citations, penalties and survey trends for this long-term care facility in Pratt, Kansas.
- Location
- 331 Ne State Road 61, Pratt, Kansas 67124
- CMS Provider Number
- 175566
- Inspections on file
- 16
- Latest survey
- October 1, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Grand Plains Skilled Nursing By Americare during CMS and state inspections, most recent first.
A resident with dementia and a history of wandering entered another resident's room and struck a cognitively and physically impaired resident in the head, causing visible injury. The incident occurred despite prior documentation of the resident's behavioral risks and care plan interventions. Staff responded after hearing yelling, and the injured resident's wife reported previous incidents of the same resident entering the room. The event was not reported to the State Agency as required by policy.
A resident with dementia and a history of wandering and behavioral symptoms struck another resident and the resident's wife. Despite being placed on one-on-one observation, the resident continued to enter other residents' rooms, creating ongoing risk for further abuse. The facility's interventions did not effectively prevent additional opportunities for harm before the resident was transferred to a behavioral health unit.
A resident entered another resident's room and attempted to strike both the resident and his wife, resulting in a red mark and later bruising on the resident's face. Staff and administrative personnel were notified, and EMS and law enforcement responded, but the required report to the State Agency was not made within the mandated timeframe, in violation of facility policy.
Surveyors found that kitchen staff failed to properly store, label, and date multiple food items, including ham, chicken products, tater tots, and French fries, and also kept expired lemon juice in storage. The Kitchen Manager acknowledged these practices were not in line with facility policy, resulting in unsanitary food storage and preparation conditions.
Staff did not consistently use required gowns and gloves during high-contact care for residents on Enhanced Barrier Precautions, despite clear signage and available supplies. Observations included CNAs and a nurse providing care such as toileting, catheter care, and tube feeding without appropriate PPE, and a CNA failing to change gloves after perineal care before touching other surfaces. Staff acknowledged either lack of education or failure to follow established protocols.
The facility did not ensure proper maintenance and monitoring of the dishwasher's sanitizing equipment, as staff lacked chlorine test strips to verify sanitizer levels and did not keep written logs of daily tests. The kitchen manager was unaware of the absence of test strips, and the facility could not provide a policy for maintaining equipment.
A resident who was dependent on staff for care and had an indwelling urinary catheter was repeatedly observed with the catheter drainage bag exposed to public view through an uncovered window, without a privacy cover. Staff interviews confirmed that privacy covers were expected, and facility policy required protection of resident dignity and privacy.
During an inspection, four dumpsters were found with open lids and one missing a lid, leaving trash cans uncovered. The Kitchen Manager was unaware of the requirement to keep trash covered, and administrative staff noted the dumpsters were city property. The facility also lacked a policy for garbage and refuse handling, resulting in unsanitary conditions that could attract pests.
Failure to Prevent Resident-to-Resident Abuse Resulting in Harm
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition and a history of wandering and physical behavioral symptoms entered another resident's room and struck that resident, who was cognitively and physically impaired, in the head. The incident took place in the early morning hours, and staff responded after hearing yelling. The resident's wife, who was present, reported that the aggressor had hit her and attempted to hit her husband. The injured resident was found with a red area on the left side of his forehead, and staff documented the event in the electronic health record and witness statements. Prior to the incident, the resident who initiated the altercation had documented behaviors including wandering, rejection of care, and physical symptoms directed toward others. The care plan for this resident included interventions such as staff developing rapport, anticipating needs, and monitoring for signs of discomfort or distress. Despite these interventions, the resident was able to enter another resident's room multiple times, as reported by the injured resident's wife, who had previously redirected the resident out of the room on several occasions without incident. On the day of the event, the resident's wife was unable to prevent the physical altercation, resulting in harm to both herself and her husband. The facility's investigation included multiple staff and administrative witness statements, some of which noted visible injuries to the resident, while others did not observe marks or bruising. Staff interviews confirmed that the protocol for suspected resident-to-resident abuse was to separate the residents, ensure safety, notify the nurse, and document the incident. However, the administrative staff acknowledged that the incident was not reported to the State Agency as required by facility policy. The deficiency was cited at a scope and severity of G, indicating actual harm and fear or anxiety for the resident involved.
Failure to Prevent Further Resident-to-Resident Abuse After Initial Incident
Penalty
Summary
The facility failed to initiate adequate protective actions to prevent further resident-to-resident abuse after an incident in which a resident with moderately impaired cognition and a history of wandering and behavioral symptoms entered another resident's room and struck both the resident and the resident's wife. The resident who committed the abuse had documented diagnoses including unspecified dementia and had previously exhibited wandering and physical behavioral symptoms directed towards others. Despite being placed on one-on-one observation following the incident, the resident continued to wander into other residents' rooms, creating ongoing potential for harm. Facility records and interviews revealed that the resident's care plan identified risks such as invading others' space and disruptions in common areas, but the interventions implemented did not prevent further opportunities for abuse. The facility's policy required removal of the accused resident from contact with others and supervision by staff until assessment and treatment options were determined. However, documentation showed that one-on-one observation was inconsistently provided, with the resident's wife at times assuming this role, and the resident continued to have access to other residents' rooms until eventual transfer to a behavioral health unit.
Failure to Timely Report Resident-to-Resident Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the State Agency as required by regulation. On the morning of the incident, staff heard yelling and found one resident in another resident's room, where the intruding resident was observed attempting to strike the other resident and his wife. The wife reported being struck, and the resident who was the target of the aggression was found with a red mark on his forehead, with later reports of facial bruising. Multiple staff witness statements confirmed the aggressive behavior, and the nurse on duty notified administrative staff, EMS, and law enforcement. However, the incident was not reported to the State Agency within the required timeframe. The facility's policy required notification of the State Agency within 24 hours of such incidents, or within two hours if the incident met the definition of a crime or resulted in serious bodily injury. Despite these requirements and the presence of physical evidence of injury, administrative staff did not report the incident to the State Agency. Interviews confirmed that the administrative staff was aware of the reporting requirements but failed to comply, resulting in a deficiency related to the timely reporting of suspected abuse.
Failure to Store and Label Food Items Properly in Kitchen and Storage Areas
Penalty
Summary
Surveyors observed multiple instances of improper food storage and labeling practices in the facility's main kitchen, refrigerator, and dry food storage areas during an initial tour with the Kitchen Manager. Specifically, they found an unsealed and undated bag of ham open to air in the walk-in freezer, as well as undated and unlabeled bags of chicken patties, chicken nuggets, tater tots, and French fries. Additionally, eight bottles of lemon juice were found to be expired. The Kitchen Manager confirmed that staff are expected to label and date opened food items and acknowledged that the observed issues with undated, unlabeled, and unsealed items were unacceptable. The facility's own policy requires all foods stored in the refrigerator or freezer to be covered, labeled, and dated, and to be rotated using a first-in, first-out system. These failures resulted in the facility not storing, preparing, and serving food in a sanitary manner, which could potentially lead to food-borne illness among residents.
Failure to Adhere to Enhanced Barrier Precautions and Proper PPE Use
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions (EBP) protocols during the care of residents identified as requiring these infection control measures. Multiple observations revealed that Certified Nurse Aides (CNAs) and a Licensed Nurse (LN) did not wear gowns as instructed by signage on residents' doors when providing close contact care, such as toileting, catheter care, and PEG tube feeding. Staff members admitted to not being educated on the need for gowns during certain procedures or acknowledged that they should have worn the appropriate personal protective equipment (PPE) but did not do so. Supplies for PPE were available in hallway closets, and signage was present, but staff did not consistently adhere to the protocols outlined in the facility's EBP policy. Additionally, improper hand hygiene and glove use were observed during resident care. For example, a CNA was seen cleaning a resident's perineal area and then touching the resident's head, pillow, blanket, and oxygen tubing without changing gloves. The CNA confirmed awareness of the correct procedure but failed to implement it. These lapses in infection control practices occurred despite the facility's policy requiring targeted gown and glove use during high-contact care activities for residents at risk of multidrug-resistant organism transmission.
Failure to Maintain Dishwasher Sanitizing Equipment and Monitoring
Penalty
Summary
The facility failed to ensure the availability and proper maintenance of essential equipment in the kitchen, specifically related to the dishwasher's sanitizing function. During observation, the kitchen manager was found making sanitizer water that registered at 50 parts per million, but was unable to provide chlorine test strips to verify the chlorine level in the dishwasher. Interviews revealed that dietary staff were expected to test the sanitizer level daily, but there was no written log documenting these tests, and staff were trusted to perform them as expected. The kitchen manager was unaware of how long the kitchen staff had been without chlorine testing strips, and staff had not reported this issue. Additionally, the facility was unable to provide a policy related to maintaining properly functioning equipment, and failed to maintain mechanical equipment in safe operating condition. No specific residents were directly mentioned as being affected in the report, and no relevant medical history or resident condition was provided.
Failure to Provide Privacy Cover for Indwelling Catheter Bag
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of neuromuscular bladder, who was dependent on staff for all care, was observed multiple times with an indwelling urinary catheter drainage bag that lacked a privacy cover. The drainage bag was positioned facing a window with open blinds, making it visible to staff, the public, and individuals outside the facility. These observations occurred on several occasions, and the lack of a privacy cover was consistently noted. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that the expectation was for all indwelling catheter drainage bags to have privacy covers. The facility's policy on promoting and maintaining resident dignity also required that residents be treated with respect and that their privacy be protected. The failure to provide a privacy cover for the catheter drainage bag resulted in a lack of privacy and dignity for the resident.
Improper Garbage Disposal and Unsanitary Dumpster Conditions
Penalty
Summary
The facility failed to properly maintain and dispose of garbage and refuse in a sanitary manner, as observed during an inspection of the outside trash dumpsters. Four dumpsters were found with lids in the open position, and one dumpster was missing its lid entirely, resulting in trash cans not being completely covered. The Kitchen Manager stated she was unaware of the requirement to keep trash covered, and administrative staff indicated that the dumpsters belonged to the city. Additionally, the facility did not have a policy in place regarding the handling and disposal of garbage and refuse. These actions and inactions led to unsanitary conditions that could attract pests.
Latest citations in Kansas
Surveyors identified unsanitary food storage and preparation conditions, including food debris in a reach-in freezer, an unknown spilled liquid in a reach-in refrigerator, missing two-inch air gap on an ice machine drain, dirty carts used for clean dishes, and a steamtable shelf with built-up food debris. A dietary staff member acknowledged these areas needed cleaning, and it was determined the facility lacked a cleaning schedule or policy for kitchen cleanliness.
The facility failed to complete and analyze Care Area Assessments (CAAs) for multiple residents after Admission, Annual, and Significant Change MDS assessments triggered areas such as cognition, mood/behavior, functional status, urinary incontinence/indwelling catheter, nutrition, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, and visual function. Instead of documenting individualized analysis of underlying causes and contributing factors, an LPN reported she had stopped writing CAA notes and relied mainly on check-off worksheets and the fact that triggers appeared in the MDS CAA section. No facility policy on CAAs was provided to surveyors, and the CAAs consistently lacked required analytical documentation for residents with diverse and significant clinical needs.
A resident with dementia, severe cognitive impairment, and an indwelling urinary catheter was repeatedly observed sitting in common areas with his catheter drainage bag resting on his lower leg, visibly filled with dark amber urine and lacking a privacy cover, despite a care plan directing staff to cover the drainage bag. CNAs reported that the bag often slid down from the resident’s thigh, that they did not use catheter dignity bags on their hall, and that they simply moved the bag back up when it slid down. An administrative nurse stated she had not considered the use of dignity bags on the memory care unit, even though the facility’s resident rights policy affirms each resident’s right to a dignified existence, privacy, and confidentiality.
Two residents with documented cognitive ability to participate in care planning were not invited to any care plan meetings, and their EMRs lacked evidence of care plan conferences, invitations, or Interdisciplinary Care Conference assessments. Administrative staff stated that invitations should be mailed or hand-delivered and uploaded to the EMR, and that an Interdisciplinary Care Conference note should be completed, but none of this documentation existed for these residents, contrary to facility policy and federal requirements for resident and/or representative participation in care planning.
A resident with C-diff and CHF, newly admitted and with a baseline care plan that did not address call light use, was repeatedly found without access to a call light. Surveyors observed the resident yelling for help with her room door closed and later noted the call light on the floor under the bed and again on the floor while the resident sat in a recliner and stated she wanted to return to bed but could not do so independently. Staff reported using a binder clip to attach the call light to the resident’s clothing because the cord lacked a clip, acknowledged the resident sometimes threw the call light to the floor, and stated that call lights should be kept within residents’ reach. An administrative nurse confirmed the expectation that call lights be accessible at all times and was unsure about the use of a binder clip, and no facility policy on call lights was provided.
Surveyors found that a resident’s bathroom and handwashing area were not maintained in a safe, sanitary, and comfortable condition, including a loose baseboard with black substance behind it, a cracked toilet seat, and an empty, improperly mounted hand soap dispenser. Maintenance staff confirmed these conditions, noted that the soap dispenser was nonfunctional, and reported that although a QR code system existed for reporting maintenance issues, these problems had not been reported. Maintenance staff also stated there were no facility policies for maintenance repair in resident rooms and no policy provided for ensuring a safe, homelike environment.
Multiple residents were affected by inaccurate MDS assessments, including a resident with dementia and an indwelling catheter who was miscoded as always incontinent of urine and independent in ADLs despite staff and EMR documentation showing long-term catheter use and total dependence for dressing and wheelchair positioning. Another resident with a history of stroke was incorrectly coded as having a restraint, even though bed grab bars were used as enablers to assist with repositioning and did not limit voluntary movement. A resident with diabetes and unsteadiness experienced two documented falls that were not captured on the MDS, and another resident with diabetes, depression, CAD, and CKD was actively receiving hospice services per EMR, social services, and staff interviews, yet hospice was not coded on the MDS. The consultant MDS nurse confirmed these were significant coding errors not in accordance with the RAI User’s Manual.
A resident with C. diff and CHF was admitted, and while a baseline care plan documenting contact precautions was created, the resident later reported not knowing what a baseline care plan was. The resident was also found yelling for help with her call light on the floor under the bed. Nursing staff stated that baseline care plans are started on the day of admission and reviewed with residents, but also indicated that residents and families are not given written copies. An administrative nurse claimed a 48-hour interdisciplinary care conference had been completed, yet no corresponding documentation existed in the EMR, and explanations about who was responsible and why it was missing were inconsistent. No facility policy for baseline care plans was provided.
A resident with dementia and severe cognitive impairment was inaccurately assessed and care planned as needing only setup or independent assistance with dressing, despite actually requiring total staff assistance. The EMR lacked clear ADL documentation, and the ADL CAA did not trigger, leading to inaccurate MDS entries and a care plan that did not match the resident’s functional status. Surveyors observed the resident sitting in a wheelchair wearing dirty, food-stained pants and being taken to the dining room without a clothing change, with the soiled pants not changed until later when two CNAs provided total assistance. Staff, including CNAs, an LN, and an administrative nurse, acknowledged that the resident needed total help with dressing and should always be in clean clothing, revealing a failure to provide appropriate ADL support and maintain clean attire.
A resident with dementia and severe cognitive impairment was transported multiple times in a wheelchair without staff ensuring that his feet remained safely on the foot pedals. Although assessments inaccurately documented that he was independent with walking using a walker and/or wheelchair, his care plan did not instruct staff on proper use of wheelchair foot pedals. During observed transports by CNAs, the resident’s shoed feet repeatedly fell off the pedals and skimmed the floor between them. Staff acknowledged that his feet did not stay on the pedals and that the pedals were not effectively adjusted, and nursing leadership confirmed expectations that feet should remain on the pedals during transport. No wheelchair safety policy was provided.
Unsanitary Kitchen Conditions and Lack of Cleaning Policy
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions when surveyors observed multiple cleanliness and equipment issues in the kitchen. During an initial kitchen tour on 04/27/26 at 08:57 AM, the three-door reach-in freezer was found with food debris on the bottom shelf, and the three-door reach-in refrigerator had an unknown spilled liquid on the bottom shelf. The drain to the ice machine did not have the required two-inch air gap. Two black two-tiered plastic carts used to store clean dishes had food debris on the bottom tier, and the bottom shelf of the steamtable, which was used to store plate covers, had a buildup of food debris. On 04/28/26 at 01:57 PM, a dietary staff member confirmed these areas required cleaning, and it was identified that the facility did not have a cleaning schedule or a policy regarding kitchen cleanliness. No specific residents, medical histories, or clinical conditions were mentioned in the report in relation to this deficiency.
Failure to Complete and Analyze Care Area Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive Care Area Assessments (CAAs) with analysis of underlying causes, contributing factors, and risk factors for multiple residents following MDS assessments. Record review showed that numerous residents had Admission, Annual, or Significant Change MDS assessments that triggered CAAs in areas such as mood/behavior, cognitive loss/dementia, functional abilities, communication, urinary incontinence/indwelling catheter, nutritional status, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, visual function, and psychosocial well-being. For each of these triggered areas, the corresponding CAAs lacked analysis of the findings. This pattern was identified for residents with a wide range of clinical issues, including dementia, incontinence, falls, pressure ulcers, nutritional concerns, psychotropic medication use, pain, and functional decline. During an interview, a licensed nurse reported that she had stopped writing CAA notes the previous year after being told to do so by someone she could not identify. She stated that she did not write anything on the triggered CAAs and that, at times, she would document risk concerns only on a main check-off worksheet, relying on the fact that the triggers were already reflected in the MDS CAA section. The facility did not provide a policy regarding CAAs when requested. These findings demonstrate that the facility did not ensure that comprehensive assessments were fully completed as required when residents were first admitted and periodically thereafter.
Failure to Maintain Dignity and Privacy for Resident with Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to a dignified existence by not maintaining privacy for his urinary catheter drainage bag as directed in his care plan. The resident had diagnoses including bladder calculus and dementia, with a BIMS score of one indicating severe cognitive impairment, and was dependent on staff for toileting hygiene with an indwelling urinary catheter and constant urinary incontinence. His care plan, revised 03/23/26, instructed staff to cover his drainage bag with a privacy cover. However, during observations on 04/27/26, the resident was seen sitting in his wheelchair at his room doorway and later in the dining room with his catheter drainage bag resting on his lower left leg, supported by his shoe, containing dark amber urine and visible to visitors and other residents, without a privacy cover. Staff interviews confirmed that the catheter drainage bag frequently slid from the resident’s left thigh down to his lower leg and that staff did not consistently reposition it or use dignity/privacy bags. One CNA stated he had never placed a dignity bag on the resident’s drainage bag, and another CNA reported that staff on their hall did not utilize catheter dignity bags, instead just moving the bag back up when it slid down. An administrative nurse acknowledged she had not considered staff use of dignity bags for urinary catheters on the memory care unit. The facility’s Resident Rights policy, approved 12/2024, stated that each resident has the right to a dignified existence including privacy and confidentiality, which was not followed in this case.
Failure to Involve Cognitively Able Residents in Care Plan Meetings
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were given the opportunity to participate in the development and implementation of their person-centered plans of care. For one resident with a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognition, the electronic medical record showed an admission MDS and a Significant Change MDS, but there was no documentation of any care plan meeting in the prior four months. This resident reported not being invited to any care plan meeting. For a second resident with a BIMS score of 14, indicating intact cognition, the electronic medical record contained an admission MDS and a Quarterly MDS, but there was no documentation of a care plan meeting in the prior two months. This resident also reported not being invited to any care plan meeting. Administrative staff reported that residents and/or family members were supposed to be mailed or hand-delivered invitations to attend care planning meetings and that a copy of the invitation should be uploaded into the EMR. They further stated that an Interdisciplinary Care Conference assessment should be completed in the EMR during the care plan meeting. However, the administrative nurse confirmed that there was no documentation of invitations, Interdisciplinary Care Conference assessments, or completed care plan meetings for the two residents. The facility’s care planning policy stated that social services should attend care plan meetings and that the team presents information to the resident and/or representative about progress toward care plan goals, and referenced federal law requiring resident and/or representative participation in care plan meetings to the extent possible, but this process was not carried out or documented for the two residents identified.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach and to reasonably accommodate the resident’s needs and preferences. The resident had documented diagnoses of C-diff and CHF, and her baseline care plan dated 04/23/26 directed staff to evaluate for changes in level of consciousness but did not include any direction regarding call light use or accessibility. On 04/28/26 at 08:06 AM, surveyors observed the resident’s room door closed while she yelled loudly for help several times. When a licensed nurse entered the room, the resident was lying on her left side in bed, stated she wanted to get up, and reported she could not find her call light. The call light was observed on the floor under her bed. Later that morning, a CNA attached the call light to the resident’s shirt using a black and silver binder clip because the call light cord did not have its own clip. On 04/29/26 at 12:15 PM, the resident was seated in a recliner with the call light again lying on the floor out of her reach; she reported she wanted to go to bed and could not get herself back into bed. Staff interviews revealed that the CNA used the binder clip to keep the call light attached to the resident, and the licensed nurse stated staff should make sure the call light is clipped to the resident’s clothes and reported that the resident would throw her call light on the floor. An administrative nurse stated she expected staff to ensure all residents always have their call lights in reach and was unsure about using a binder clip to hold a call light in place. The facility did not provide a policy regarding call lights.
Failure to Maintain Safe and Sanitary Resident Bathroom Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, functional, sanitary, and comfortable environment in Resident 87’s bathroom and handwashing area. During an environmental tour with Maintenance Staff UU, surveyors observed an approximately four-foot section of loose baseboard to the left of and behind the toilet, with a black substance present on the wall and floor behind the loose baseboard. They also noted an approximately three-inch crack in the toilet seat and an empty hand soap dispenser hanging above the handwashing sink, mounted with exposed lag bolt fasteners. Maintenance Staff UU confirmed these conditions, acknowledged that the soap dispenser did not work, and stated that the toilet seat should be replaced, the bathroom baseboard removed, the black substance tested for mold, and the sheetrock removed and replaced. Further interview with Maintenance Staff UU revealed that the facility had implemented a QR code system for staff and visitors to report maintenance items, but the issues in this resident’s bathroom had not been reported through that system. He also reported that there had been a leak behind the handwashing sink that had flowed into the bathroom area, leading to the sink’s replacement, but he had received no report of the specific deficiencies observed in the bathroom. Additionally, Maintenance Staff UU stated that the facility did not have policies for maintenance repair in residents’ rooms, and the facility did not provide a policy for ensuring a safe, homelike environment.
Inaccurate MDS Coding for ADLs, Restraints, Falls, and Hospice Services
Penalty
Summary
The deficiency involves the facility’s failure to complete accurate Minimum Data Set (MDS) assessments in accordance with the Resident Assessment Instrument (RAI) User’s Manual, resulting in multiple residents’ clinical status not being correctly reflected. For one resident with dementia and severe cognitive impairment, the Significant Change and subsequent Quarterly MDS assessments coded him as always incontinent of bladder and independent with eating and upper body dressing, with use of a walker and wheelchair. However, the electronic medical record showed ongoing indwelling catheter care each shift and no documentation of walker use, wheelchair mobility, or dressing requirements during the review period. Staff interviews revealed that this resident had an indwelling catheter for more than a year, had not walked for several years, and was dependent on staff for all ADLs, including dressing and wheelchair positioning, contradicting the MDS coding. Observations showed the resident slumped in a wheelchair, wearing a hospital gown over clothing, with a visible catheter bag on his lower leg and feet frequently skimming the floor despite foot pedals being present, further indicating dependence and catheter use not accurately captured on the MDS. Another deficiency involved a resident with a history of stroke, hemiplegia, and hemiparesis whose Significant Change MDS coded the use of “other restraint.” During observation, the resident was seen in bed with bilateral grab bars at the head of the bed and her right arm positioned on a pillow. The resident reported using the grab bars to help move and reposition herself in bed. CNAs and administrative nursing staff confirmed that the facility did not use restraints and that the grab bars were used as enablers to assist residents with repositioning and to increase independence. Administrative staff acknowledged that the MDS coding for restraints was inaccurate because the grab bars did not limit the resident’s voluntary movement or access to her body. A further inaccuracy was identified for a resident with diabetes, atrial fibrillation, unsteadiness of feet, and a toe fracture. Both a Significant Change and a Quarterly MDS documented intact cognition, partial/moderate assistance with transfers, no ambulation, and no falls. However, progress notes in the EMR documented two unwitnessed falls during the look-back period, including one where the resident was found on the floor next to the bed with a forehead skin tear and another where the resident was found sitting on a fall mat on the floor with a scratch on the ankle. These documented falls were not reflected on the MDS. In addition, another resident with diabetes, depression, CAD, and chronic kidney disease had a Significant Change MDS that coded no hospice services, while the EMR contained a hospice certification and physician orders initiating hospice services, and social service notes and staff interviews confirmed that hospice services, including bathing by a hospice aide, were being provided during the look-back period. The consultant MDS nurse confirmed that these assessments were inaccurate and not completed in accordance with the RAI User’s Manual, constituting significant errors in coding for urinary status, ADL dependence, restraints, falls, and hospice services. The consultant MDS nurse stated that the resident with the indwelling catheter should have been coded as not rated for urinary continence due to catheter placement rather than as always incontinent, and that his ADL status should not have been coded as independent given his dependence on staff for dressing and wheelchair positioning. For the resident with grab bars, the nurse confirmed that the grab bars were used as enablers and not as restraints, making the restraint coding inaccurate. For the resident with documented falls, the MDS failed to capture falls that occurred within the look-back period, and for the resident receiving hospice services, the MDS did not reflect hospice care that was active during the look-back period. These miscodings met the RAI Manual’s definition of significant error, in which the resident’s overall clinical status is not accurately represented on the assessment and the error has not been corrected by a more recent assessment.
Failure to Provide and Communicate Baseline Care Plan to New Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide a summary of the baseline care plan to a newly admitted resident and to ensure that the baseline care plan process was completed and documented as required. The resident’s EMR documented diagnoses of C. difficile and CHF. The Entry MDS was completed on the admission date, and the admission MDS was noted as in progress with no information available. A baseline care plan dated the day after admission documented contact precautions, including staff use of gowns and masks when changing contaminated linens and proper handling and bagging of soiled linens. However, during an interview several days after admission, the resident reported she did not know what a baseline care plan was, indicating that the plan had not been explained or summarized to her. Further observations and interviews showed additional failures in implementing and communicating the baseline care plan. On one occasion, the resident was heard yelling for help with her room door closed; when a nurse entered, the resident stated she wanted to get up but could not find her call light, which was observed on the floor under the bed. A nurse reported that the baseline care plan was started on the day of admission and that nurses would review it with the resident, but also stated that the charge nurse would not provide a written copy of the baseline care plan to the resident or family. An administrative nurse reported she would review the baseline care plan with the resident and/or family and claimed to have completed a 48-hour interdisciplinary care conference, but there was no opened or completed conference note in the EMR. She gave inconsistent explanations regarding who was responsible and why the conference note was missing. The facility did not provide a policy for baseline care plans.
Failure to Provide Accurate ADL Assessment and Timely Clothing Changes
Penalty
Summary
The facility failed to provide appropriate assistance with activities of daily living (ADLs), specifically dressing and clothing changes, for a resident with severe cognitive impairment. The resident had a diagnosis of dementia and repeated Brief Interview for Mental Status (BIMS) scores of one, indicating severe cognitive impairment. Despite this, both a Significant Change MDS and a Quarterly MDS inaccurately documented that the resident required only setup assistance with lower body dressing. The ADL Care Area Assessment did not trigger, and the resident’s care plan, revised on 03/23/26, inaccurately instructed staff that the resident was independent with dressing. The electronic medical record lacked staff documentation of the resident’s ADL needs, resulting in care instructions that did not reflect the resident’s actual functional status. On the day of observation, the resident was seen sitting in a wheelchair wearing black pants with food crumbs on them in the morning, and later was transported by a CNA to the dining room still wearing the same dirty pants. The pants were not changed until early afternoon, at which time two CNAs provided total assistance to change the dirty pants, and the resident was unable to participate in dressing or undressing. During interviews, the CNAs, a licensed nurse, and an administrative nurse all stated that residents should always be dressed in clean clothing and confirmed that this resident required total staff assistance with dressing. These observations and interviews showed that the resident’s actual need for total assistance with dressing and clothing changes was not accurately reflected in the MDS, care plan, or ADL documentation, and that the facility did not ensure the resident was kept in clean clothing as expected by facility policy for ADL care.
Failure to Maintain Safe Wheelchair Foot Positioning During Resident Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision during wheelchair transport for a resident with dementia. The resident’s EMR documented a diagnosis of dementia and a BIMS score of one on both a Significant Change MDS and a Quarterly MDS, indicating severe cognitive impairment. These MDS assessments inaccurately documented that the resident was independent with walking using a walker and/or wheelchair, and the ADL CAA did not trigger. The resident’s care plan, revised 03/23/26, identified cognitive impairment due to dementia but did not include instructions for staff on the use of wheelchair foot pedals while propelling the resident. On multiple observed occasions, staff propelled the resident in a wheelchair without maintaining his feet safely on the foot pedals. During transport from his room to the dining room, the resident’s left shoed foot fell from the foot pedal and skimmed the floor between the pedals, and later, during transport from the dining room to the shower room, both shoed feet skimmed the floor between the pedals. CNAs reported that the resident’s feet never stayed on the foot pedals and described the pedals as useless because he could not keep his feet on them. A licensed nurse confirmed the resident’s feet did not always remain on the foot pedals when staff propelled him and stated the pedals should be adjusted to better fit his needs. An administrative nurse stated it was the expectation that staff ensure the resident’s feet remained on the foot pedals during transport and that pedals should be lowered if needed. The facility did not provide a policy regarding wheelchair safety.
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