Kansas Soldiers Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Dodge, Kansas.
- Location
- 200 Custer, Unit 98, Fort Dodge, Kansas 67801
- CMS Provider Number
- 175513
- Inspections on file
- 19
- Latest survey
- September 2, 2025
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Kansas Soldiers Home during CMS and state inspections, most recent first.
The facility did not provide proper care for pressure ulcers and failed to prevent new ulcers from developing. Surveyors found that a resident did not receive consistent assessment, monitoring, or treatment for pressure ulcers, and that preventive measures were not adequately implemented for those at risk.
Surveyors observed that dietary staff failed to consistently follow proper hand hygiene and glove use during food preparation and serving. Staff were seen discarding soiled gloves into uncovered trash cans, donning new gloves without hand washing, and handling multiple food items and equipment with the same gloves, contrary to facility policy. These actions resulted in unsanitary food handling conditions.
The facility did not ensure that kitchen garbage and refuse were properly maintained and disposed of, as observed when trash cans inside lacked lids and outside bins were found with lids open. Staff were unable to account for the missing or open lids, which was not in accordance with the facility's waste disposal policy requiring sealed containers.
The facility did not consistently implement an infection prevention and control program, failing to use Enhanced Barrier Precautions for residents with catheters, wounds, or artificial openings. Staff were observed providing catheter care without required PPE or aseptic technique, and there was no signage or accessible PPE in resident areas. Administrative nurses were unaware of updated CMS requirements, and infection tracking was not performed in real time. The facility also lacked a water management program and policy to prevent Legionella.
The facility did not implement an effective antibiotic stewardship program, failing to track and trend antibiotic use for several residents who received antibiotics for urinary tract infections. Nursing staff confirmed that antibiotic use was not consistently documented or reviewed for appropriateness, and the infection control policy did not address these deficiencies.
The facility did not complete annual performance evaluations for five CNAs employed for over a year, as shown by employee file reviews and staff interviews. No signed evaluations were found for these CNAs, and the facility could not provide a policy on annual evaluations, despite an expectation for full compliance.
Staff failed to administer medications according to professional standards, with multiple residents receiving late medications and staff not verifying orders using the electronic MAR. Nursing staff acknowledged overdue medications and the absence of a liberalized medication pass policy, while administrative staff confirmed expectations for timely administration were not met.
A medication error rate of 52.94% was identified when a certified medication aide administered multiple scheduled medications to a resident significantly later than the prescribed time, based on incorrect training about what constitutes a late dose. The facility did not have a liberalized medication pass policy, and the nurse confirmed that medications were expected to be given on time.
A resident with major depressive disorder and intact cognition was prescribed a daily antidepressant without a documented informed consent form. Staff interviews confirmed the absence of the required consent, and the facility could not provide a policy on informed consent for psychotropic medications.
A resident with COPD and atrial fibrillation, who was cognitively intact but had impaired mobility, was required to wear a seatbelt on a motorized wheelchair that he could not independently release. Staff and documentation failed to assess or address the seatbelt as a restraint, and no care plan or physician order was in place. The resident reported he was told to wear the seatbelt without being given a choice, and staff confirmed no safety assessment or documentation existed for seatbelt use.
A resident with depression and anxiety was routinely administered antipsychotic and antidepressant medications without documented evidence of behaviors warranting antipsychotic use, unsuccessful nonpharmacological interventions, or a risk versus benefit analysis. Staff and pharmacy consultant interviews confirmed the lack of appropriate diagnosis and documentation, and the facility could not provide a policy on psychotropic medication use.
A resident with depression, anxiety, and pain continued to receive Celebrex despite a consultant pharmacist's recommendation to consider discontinuation due to elevated creatinine and low hemoglobin. The physician declined the recommendation without providing a rationale, and staff interviews revealed uncertainty about documentation requirements for pharmacy recommendations, contrary to facility policy.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that the facility did not consistently follow established protocols for pressure ulcer prevention and care, resulting in inadequate interventions for residents with existing ulcers and insufficient preventive actions for those at risk.
Failure to Maintain Sanitary Food Preparation and Handling Practices
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the kitchen, specifically in the preparation and serving of food. During a kitchen tour, three barrel-type trash cans were found without lids, and staff were unable to locate one of the missing lids. Dietary staff were seen discarding soiled gloves into an uncovered trash can and then donning new gloves without washing their hands. Additionally, staff were observed handling multiple food items and kitchen equipment with the same pair of gloves, including touching plates, bread, and containers, without changing gloves or washing hands in between tasks. The Certified Dietary Manager confirmed that staff are expected to provide food in a safe and healthy environment and that annual food handling training is provided. The facility's hand washing policy requires frequent hand washing, especially after handling soiled equipment and during food preparation, to prevent cross-contamination. However, observations revealed that staff did not consistently follow these procedures, resulting in unsanitary food handling practices.
Improper Disposal and Maintenance of Kitchen Garbage and Refuse
Penalty
Summary
The facility failed to properly maintain and dispose of kitchen garbage and refuse, as observed during two separate inspections. During a kitchen tour, three barrel-type trash cans were found without lids, and staff were only able to locate lids for two of them. Additionally, an inspection of the outside garbage bins revealed that two out of eight bins had their lids open, despite calm weather conditions. The Certified Dietary Manager was unable to provide a reason for the open lids at the time of observation. According to the facility's waste disposal policy, all garbage is to be disposed of daily and placed in sealed containers outside the premises.
Failure to Implement Infection Control Program and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain a consistent infection prevention and control program, as evidenced by the lack of implementation of Enhanced Barrier Precautions (EBP) for residents with indwelling catheters, wounds, and surgical artificial openings. Observations revealed that staff did not use required personal protective equipment (PPE) such as gowns during high-contact care, and there was no signage or accessible PPE in or around the rooms of affected residents. Staff members, including a CNA, were unaware of EBP requirements and did not follow aseptic technique when providing catheter care, such as cleaning the outlet tube with an alcohol wipe after emptying the drainage bag. Administrative nurses confirmed they were not aware of the updated CMS directive for EBP and acknowledged that infection control logs were not completed or reviewed in a timely manner to track and trend infections as they occurred. Additionally, the facility did not have a documented water management program to mitigate the risk of Legionella and other waterborne pathogens, nor did it have a policy addressing the prevention of Legionella. The infection control program documentation was incomplete, lacking evidence of surveillance systems to identify and track infections in real time. The facility's failure to implement these infection control measures and maintain proper documentation had the potential to contribute to the spread of infections among residents, particularly those with indwelling devices or wounds.
Failure to Monitor and Document Antibiotic Use
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program that included an antibiotic stewardship program with protocols for antibiotic use and a system to monitor antibiotic use. Review of facility records showed that, out of a census of 51 residents and a sample of 15, seven residents received antibiotics during the review period. However, the infection control surveillance log did not document tracking or trending of antibiotic use for residents with recurrent urinary tract infections who received gentamycin bladder irrigations or for those who received amoxicillin for urinary tract infection. The log lacked documentation for these cases, and the administrative nurse confirmed that antibiotic use was not consistently tracked or trended, and that the July log was incomplete. Interviews with administrative nursing staff revealed that antibiotics were prescribed by physicians, but the facility did not conduct formal reviews or audits to determine the appropriateness or effectiveness of antibiotic use. The administrative nurse stated that documentation was typically completed at the end of each month and not tracked daily. Additionally, the facility's infection control policy did not address the identified areas of concern related to antibiotic stewardship and monitoring.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for five Certified Nurse Aides (CNAs) who had been employed for over 12 months, as identified through interviews and review of employee files. The review of records showed that none of the five CNAs had a performance evaluation signed by management within the required 12-month period. During an interview, administrative staff confirmed the expectation for 100 percent compliance with annual evaluations, but the facility was unable to provide a policy regarding annual performance evaluations. The census at the time was 51 residents, and the lack of evaluations was observed for CNAs with varying lengths of employment, some dating back several years.
Failure to Administer Medications According to Professional Standards
Penalty
Summary
The facility failed to ensure that medication administration services met professional standards of quality. Observations revealed that a Certified Medication Aide (CMA) prepared medications for residents without verifying orders using the electronic Medication Administration Record (MAR). Multiple residents' names were highlighted in pink on the computer screen, indicating overdue medications. When questioned, the CMA did not provide an explanation and walked away. A Licensed Nurse (LN) confirmed that 14 residents had overdue medications scheduled for 07:30 AM, and acknowledged that the facility did not have a liberalized medication pass policy. The LN stated that it was difficult to administer medications on time to independent residents and that staff did not have time to locate them for timely administration. Further observations showed that another CMA administered 07:30 AM scheduled medications to a resident at 09:52 AM, resulting in 18 oral and one inhaled medication being given late, with the resident declining a nasal spray. Interviews with administrative nursing staff confirmed that medications were expected to be administered on time and that the facility did not have a policy allowing for flexible medication pass times. The facility's policy required adherence to the right drug, dose, time, route, indication, and documentation, but staff training and practice did not align with these standards, as evidenced by the late administration and lack of MAR verification.
High Medication Error Rate Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required. During the survey, 35 medication administration opportunities were observed, resulting in 22 errors and a calculated error rate of 52.94 percent. One resident's July Medication Administration Record/Treatment Administration Record showed 18 oral medications, two nasal sprays, and one inhaled medication scheduled for administration at 07:30 AM. Observation revealed that a Certified Medication Aide administered the 07:30 AM medications at 09:52 AM, outside the one-hour window before or after the scheduled time, resulting in 18 late oral medications and one late inhaled medication; the resident declined the nasal spray. The Certified Medication Aide reported being trained by another aide who instructed that medications were only considered late after 10:00 AM. The Administrative Nurse confirmed the scheduled time and stated there was no liberalized medication pass policy in place. Facility policy requires medications to be administered at the right time, among other standards.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain an informed consent form for a psychotropic medication prescribed to a resident diagnosed with major depressive disorder. The resident, who demonstrated intact cognition as evidenced by BIMS scores of 15 and 14 on recent assessments, was receiving bupropion HCl daily for depression. Documentation in the resident's care plan and assessment area noted the use of antidepressant medication and the need to monitor for adverse effects, but there was no evidence of a signed informed consent for the psychotropic medication in the resident's electronic medical record. Observations confirmed the resident's daily activities and use of assistive devices, while interviews with facility staff revealed that only two other residents had consent forms on file for psychotropic medications. The administrative nurse acknowledged the absence of an informed consent for this resident, and a consultant confirmed that all psychotropic medications should have consent forms, noting that the necessary form had been sent to the administrative nurse previously. The facility was unable to provide a policy on informed consent for psychotropic medications.
Failure to Assess and Document Use of Wheelchair Seatbelt as Physical Restraint
Penalty
Summary
Staff failed to ensure an environment free from physical restraints for a resident who used a motorized wheelchair with a seatbelt. The resident, who had diagnoses including COPD and atrial fibrillation and demonstrated intact cognition, was observed wearing a seatbelt that he could not independently release. Documentation in the electronic health record, care plan, and physician orders did not address the use of the seatbelt, nor was there evidence of an assessment of the resident's ability to release it. Staff interviews confirmed that the resident was required to wear the seatbelt, was unable to remove it on his own, and that no seatbelt safety assessment or care plan was in place for any resident. The resident reported he was told he had to wear the seatbelt and did not have a choice in the matter. Observations showed the seatbelt remained engaged for extended periods, and staff were responsible for applying and releasing it. Staff also indicated that not all residents required seatbelts and that it was policy for residents using electric wheelchairs to wear them, but there was no clear process for evaluating whether a seatbelt constituted a restraint. The facility's policy required a practitioner's order for a restraint, but no such order or documentation was present for the seatbelt. The lack of assessment, documentation, and resident choice led to the use of a physical restraint without proper justification or oversight.
Failure to Document Indication and Rationale for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medication, specifically an antipsychotic, had an appropriate clinical indication or a documented physician rationale for its continued use. The resident had diagnoses of depression and anxiety, with cognitive impairment documented over time. Despite the use of antipsychotic and antidepressant medications, there was no evidence in the medical record of behaviors that would warrant antipsychotic use, nor was there documentation of unsuccessful nonpharmacological interventions or a risk versus benefit analysis for the continued use of the antipsychotic. The resident's care plan included general instructions for monitoring and consulting with the pharmacy and physician, but lacked specific documentation of attempts at gradual dose reduction or alternative therapies. Review of the medication regimen and pharmacy consultant notes did not identify a clear diagnosis or justification for the antipsychotic medication, and staff interviews confirmed uncertainty regarding the appropriateness of the diagnosis for the medication. The facility was unable to provide a policy on psychotropic medication use. These actions and omissions resulted in the resident being at risk for adverse effects associated with unnecessary psychotropic medication use.
Failure to Document Physician Rationale for Pharmacy Recommendation
Penalty
Summary
The facility failed to act upon a consultant pharmacist's recommendation during the monthly medication regimen review for a resident with diagnoses of depression, anxiety, and pain. The pharmacist identified elevated creatinine levels and low hemoglobin in the resident's laboratory results and recommended considering discontinuation of Celebrex due to potential renal or gastrointestinal involvement. The physician responded to the recommendation by declining to discontinue the medication but did not provide a rationale for this decision, as required by facility policy. Documentation in the resident's electronic health record and care plan confirmed ongoing administration of Celebrex despite the pharmacist's concerns. Interviews with facility staff revealed a lack of understanding regarding the requirement for physicians to document a rationale when not following pharmacy recommendations. The administrative nurse and pharmacy consultant both indicated that a rationale was only necessary for gradual dose reductions of psychotropic medications, not for other pharmacy recommendations. The facility's drug regimen review policy, however, required an appropriate response from physicians concerning previous drug regimen review recommendations or drug irregularities, which was not met in this case.
Latest citations in Kansas
Surveyors identified unsanitary food storage and preparation conditions, including food debris in a reach-in freezer, an unknown spilled liquid in a reach-in refrigerator, missing two-inch air gap on an ice machine drain, dirty carts used for clean dishes, and a steamtable shelf with built-up food debris. A dietary staff member acknowledged these areas needed cleaning, and it was determined the facility lacked a cleaning schedule or policy for kitchen cleanliness.
The facility failed to complete and analyze Care Area Assessments (CAAs) for multiple residents after Admission, Annual, and Significant Change MDS assessments triggered areas such as cognition, mood/behavior, functional status, urinary incontinence/indwelling catheter, nutrition, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, and visual function. Instead of documenting individualized analysis of underlying causes and contributing factors, an LPN reported she had stopped writing CAA notes and relied mainly on check-off worksheets and the fact that triggers appeared in the MDS CAA section. No facility policy on CAAs was provided to surveyors, and the CAAs consistently lacked required analytical documentation for residents with diverse and significant clinical needs.
A resident with dementia, severe cognitive impairment, and an indwelling urinary catheter was repeatedly observed sitting in common areas with his catheter drainage bag resting on his lower leg, visibly filled with dark amber urine and lacking a privacy cover, despite a care plan directing staff to cover the drainage bag. CNAs reported that the bag often slid down from the resident’s thigh, that they did not use catheter dignity bags on their hall, and that they simply moved the bag back up when it slid down. An administrative nurse stated she had not considered the use of dignity bags on the memory care unit, even though the facility’s resident rights policy affirms each resident’s right to a dignified existence, privacy, and confidentiality.
Two residents with documented cognitive ability to participate in care planning were not invited to any care plan meetings, and their EMRs lacked evidence of care plan conferences, invitations, or Interdisciplinary Care Conference assessments. Administrative staff stated that invitations should be mailed or hand-delivered and uploaded to the EMR, and that an Interdisciplinary Care Conference note should be completed, but none of this documentation existed for these residents, contrary to facility policy and federal requirements for resident and/or representative participation in care planning.
A resident with C-diff and CHF, newly admitted and with a baseline care plan that did not address call light use, was repeatedly found without access to a call light. Surveyors observed the resident yelling for help with her room door closed and later noted the call light on the floor under the bed and again on the floor while the resident sat in a recliner and stated she wanted to return to bed but could not do so independently. Staff reported using a binder clip to attach the call light to the resident’s clothing because the cord lacked a clip, acknowledged the resident sometimes threw the call light to the floor, and stated that call lights should be kept within residents’ reach. An administrative nurse confirmed the expectation that call lights be accessible at all times and was unsure about the use of a binder clip, and no facility policy on call lights was provided.
Surveyors found that a resident’s bathroom and handwashing area were not maintained in a safe, sanitary, and comfortable condition, including a loose baseboard with black substance behind it, a cracked toilet seat, and an empty, improperly mounted hand soap dispenser. Maintenance staff confirmed these conditions, noted that the soap dispenser was nonfunctional, and reported that although a QR code system existed for reporting maintenance issues, these problems had not been reported. Maintenance staff also stated there were no facility policies for maintenance repair in resident rooms and no policy provided for ensuring a safe, homelike environment.
Multiple residents were affected by inaccurate MDS assessments, including a resident with dementia and an indwelling catheter who was miscoded as always incontinent of urine and independent in ADLs despite staff and EMR documentation showing long-term catheter use and total dependence for dressing and wheelchair positioning. Another resident with a history of stroke was incorrectly coded as having a restraint, even though bed grab bars were used as enablers to assist with repositioning and did not limit voluntary movement. A resident with diabetes and unsteadiness experienced two documented falls that were not captured on the MDS, and another resident with diabetes, depression, CAD, and CKD was actively receiving hospice services per EMR, social services, and staff interviews, yet hospice was not coded on the MDS. The consultant MDS nurse confirmed these were significant coding errors not in accordance with the RAI User’s Manual.
A resident with C. diff and CHF was admitted, and while a baseline care plan documenting contact precautions was created, the resident later reported not knowing what a baseline care plan was. The resident was also found yelling for help with her call light on the floor under the bed. Nursing staff stated that baseline care plans are started on the day of admission and reviewed with residents, but also indicated that residents and families are not given written copies. An administrative nurse claimed a 48-hour interdisciplinary care conference had been completed, yet no corresponding documentation existed in the EMR, and explanations about who was responsible and why it was missing were inconsistent. No facility policy for baseline care plans was provided.
A resident with dementia and severe cognitive impairment was inaccurately assessed and care planned as needing only setup or independent assistance with dressing, despite actually requiring total staff assistance. The EMR lacked clear ADL documentation, and the ADL CAA did not trigger, leading to inaccurate MDS entries and a care plan that did not match the resident’s functional status. Surveyors observed the resident sitting in a wheelchair wearing dirty, food-stained pants and being taken to the dining room without a clothing change, with the soiled pants not changed until later when two CNAs provided total assistance. Staff, including CNAs, an LN, and an administrative nurse, acknowledged that the resident needed total help with dressing and should always be in clean clothing, revealing a failure to provide appropriate ADL support and maintain clean attire.
A resident with dementia and severe cognitive impairment was transported multiple times in a wheelchair without staff ensuring that his feet remained safely on the foot pedals. Although assessments inaccurately documented that he was independent with walking using a walker and/or wheelchair, his care plan did not instruct staff on proper use of wheelchair foot pedals. During observed transports by CNAs, the resident’s shoed feet repeatedly fell off the pedals and skimmed the floor between them. Staff acknowledged that his feet did not stay on the pedals and that the pedals were not effectively adjusted, and nursing leadership confirmed expectations that feet should remain on the pedals during transport. No wheelchair safety policy was provided.
Unsanitary Kitchen Conditions and Lack of Cleaning Policy
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions when surveyors observed multiple cleanliness and equipment issues in the kitchen. During an initial kitchen tour on 04/27/26 at 08:57 AM, the three-door reach-in freezer was found with food debris on the bottom shelf, and the three-door reach-in refrigerator had an unknown spilled liquid on the bottom shelf. The drain to the ice machine did not have the required two-inch air gap. Two black two-tiered plastic carts used to store clean dishes had food debris on the bottom tier, and the bottom shelf of the steamtable, which was used to store plate covers, had a buildup of food debris. On 04/28/26 at 01:57 PM, a dietary staff member confirmed these areas required cleaning, and it was identified that the facility did not have a cleaning schedule or a policy regarding kitchen cleanliness. No specific residents, medical histories, or clinical conditions were mentioned in the report in relation to this deficiency.
Failure to Complete and Analyze Care Area Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive Care Area Assessments (CAAs) with analysis of underlying causes, contributing factors, and risk factors for multiple residents following MDS assessments. Record review showed that numerous residents had Admission, Annual, or Significant Change MDS assessments that triggered CAAs in areas such as mood/behavior, cognitive loss/dementia, functional abilities, communication, urinary incontinence/indwelling catheter, nutritional status, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, visual function, and psychosocial well-being. For each of these triggered areas, the corresponding CAAs lacked analysis of the findings. This pattern was identified for residents with a wide range of clinical issues, including dementia, incontinence, falls, pressure ulcers, nutritional concerns, psychotropic medication use, pain, and functional decline. During an interview, a licensed nurse reported that she had stopped writing CAA notes the previous year after being told to do so by someone she could not identify. She stated that she did not write anything on the triggered CAAs and that, at times, she would document risk concerns only on a main check-off worksheet, relying on the fact that the triggers were already reflected in the MDS CAA section. The facility did not provide a policy regarding CAAs when requested. These findings demonstrate that the facility did not ensure that comprehensive assessments were fully completed as required when residents were first admitted and periodically thereafter.
Failure to Maintain Dignity and Privacy for Resident with Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to a dignified existence by not maintaining privacy for his urinary catheter drainage bag as directed in his care plan. The resident had diagnoses including bladder calculus and dementia, with a BIMS score of one indicating severe cognitive impairment, and was dependent on staff for toileting hygiene with an indwelling urinary catheter and constant urinary incontinence. His care plan, revised 03/23/26, instructed staff to cover his drainage bag with a privacy cover. However, during observations on 04/27/26, the resident was seen sitting in his wheelchair at his room doorway and later in the dining room with his catheter drainage bag resting on his lower left leg, supported by his shoe, containing dark amber urine and visible to visitors and other residents, without a privacy cover. Staff interviews confirmed that the catheter drainage bag frequently slid from the resident’s left thigh down to his lower leg and that staff did not consistently reposition it or use dignity/privacy bags. One CNA stated he had never placed a dignity bag on the resident’s drainage bag, and another CNA reported that staff on their hall did not utilize catheter dignity bags, instead just moving the bag back up when it slid down. An administrative nurse acknowledged she had not considered staff use of dignity bags for urinary catheters on the memory care unit. The facility’s Resident Rights policy, approved 12/2024, stated that each resident has the right to a dignified existence including privacy and confidentiality, which was not followed in this case.
Failure to Involve Cognitively Able Residents in Care Plan Meetings
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were given the opportunity to participate in the development and implementation of their person-centered plans of care. For one resident with a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognition, the electronic medical record showed an admission MDS and a Significant Change MDS, but there was no documentation of any care plan meeting in the prior four months. This resident reported not being invited to any care plan meeting. For a second resident with a BIMS score of 14, indicating intact cognition, the electronic medical record contained an admission MDS and a Quarterly MDS, but there was no documentation of a care plan meeting in the prior two months. This resident also reported not being invited to any care plan meeting. Administrative staff reported that residents and/or family members were supposed to be mailed or hand-delivered invitations to attend care planning meetings and that a copy of the invitation should be uploaded into the EMR. They further stated that an Interdisciplinary Care Conference assessment should be completed in the EMR during the care plan meeting. However, the administrative nurse confirmed that there was no documentation of invitations, Interdisciplinary Care Conference assessments, or completed care plan meetings for the two residents. The facility’s care planning policy stated that social services should attend care plan meetings and that the team presents information to the resident and/or representative about progress toward care plan goals, and referenced federal law requiring resident and/or representative participation in care plan meetings to the extent possible, but this process was not carried out or documented for the two residents identified.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach and to reasonably accommodate the resident’s needs and preferences. The resident had documented diagnoses of C-diff and CHF, and her baseline care plan dated 04/23/26 directed staff to evaluate for changes in level of consciousness but did not include any direction regarding call light use or accessibility. On 04/28/26 at 08:06 AM, surveyors observed the resident’s room door closed while she yelled loudly for help several times. When a licensed nurse entered the room, the resident was lying on her left side in bed, stated she wanted to get up, and reported she could not find her call light. The call light was observed on the floor under her bed. Later that morning, a CNA attached the call light to the resident’s shirt using a black and silver binder clip because the call light cord did not have its own clip. On 04/29/26 at 12:15 PM, the resident was seated in a recliner with the call light again lying on the floor out of her reach; she reported she wanted to go to bed and could not get herself back into bed. Staff interviews revealed that the CNA used the binder clip to keep the call light attached to the resident, and the licensed nurse stated staff should make sure the call light is clipped to the resident’s clothes and reported that the resident would throw her call light on the floor. An administrative nurse stated she expected staff to ensure all residents always have their call lights in reach and was unsure about using a binder clip to hold a call light in place. The facility did not provide a policy regarding call lights.
Failure to Maintain Safe and Sanitary Resident Bathroom Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, functional, sanitary, and comfortable environment in Resident 87’s bathroom and handwashing area. During an environmental tour with Maintenance Staff UU, surveyors observed an approximately four-foot section of loose baseboard to the left of and behind the toilet, with a black substance present on the wall and floor behind the loose baseboard. They also noted an approximately three-inch crack in the toilet seat and an empty hand soap dispenser hanging above the handwashing sink, mounted with exposed lag bolt fasteners. Maintenance Staff UU confirmed these conditions, acknowledged that the soap dispenser did not work, and stated that the toilet seat should be replaced, the bathroom baseboard removed, the black substance tested for mold, and the sheetrock removed and replaced. Further interview with Maintenance Staff UU revealed that the facility had implemented a QR code system for staff and visitors to report maintenance items, but the issues in this resident’s bathroom had not been reported through that system. He also reported that there had been a leak behind the handwashing sink that had flowed into the bathroom area, leading to the sink’s replacement, but he had received no report of the specific deficiencies observed in the bathroom. Additionally, Maintenance Staff UU stated that the facility did not have policies for maintenance repair in residents’ rooms, and the facility did not provide a policy for ensuring a safe, homelike environment.
Inaccurate MDS Coding for ADLs, Restraints, Falls, and Hospice Services
Penalty
Summary
The deficiency involves the facility’s failure to complete accurate Minimum Data Set (MDS) assessments in accordance with the Resident Assessment Instrument (RAI) User’s Manual, resulting in multiple residents’ clinical status not being correctly reflected. For one resident with dementia and severe cognitive impairment, the Significant Change and subsequent Quarterly MDS assessments coded him as always incontinent of bladder and independent with eating and upper body dressing, with use of a walker and wheelchair. However, the electronic medical record showed ongoing indwelling catheter care each shift and no documentation of walker use, wheelchair mobility, or dressing requirements during the review period. Staff interviews revealed that this resident had an indwelling catheter for more than a year, had not walked for several years, and was dependent on staff for all ADLs, including dressing and wheelchair positioning, contradicting the MDS coding. Observations showed the resident slumped in a wheelchair, wearing a hospital gown over clothing, with a visible catheter bag on his lower leg and feet frequently skimming the floor despite foot pedals being present, further indicating dependence and catheter use not accurately captured on the MDS. Another deficiency involved a resident with a history of stroke, hemiplegia, and hemiparesis whose Significant Change MDS coded the use of “other restraint.” During observation, the resident was seen in bed with bilateral grab bars at the head of the bed and her right arm positioned on a pillow. The resident reported using the grab bars to help move and reposition herself in bed. CNAs and administrative nursing staff confirmed that the facility did not use restraints and that the grab bars were used as enablers to assist residents with repositioning and to increase independence. Administrative staff acknowledged that the MDS coding for restraints was inaccurate because the grab bars did not limit the resident’s voluntary movement or access to her body. A further inaccuracy was identified for a resident with diabetes, atrial fibrillation, unsteadiness of feet, and a toe fracture. Both a Significant Change and a Quarterly MDS documented intact cognition, partial/moderate assistance with transfers, no ambulation, and no falls. However, progress notes in the EMR documented two unwitnessed falls during the look-back period, including one where the resident was found on the floor next to the bed with a forehead skin tear and another where the resident was found sitting on a fall mat on the floor with a scratch on the ankle. These documented falls were not reflected on the MDS. In addition, another resident with diabetes, depression, CAD, and chronic kidney disease had a Significant Change MDS that coded no hospice services, while the EMR contained a hospice certification and physician orders initiating hospice services, and social service notes and staff interviews confirmed that hospice services, including bathing by a hospice aide, were being provided during the look-back period. The consultant MDS nurse confirmed that these assessments were inaccurate and not completed in accordance with the RAI User’s Manual, constituting significant errors in coding for urinary status, ADL dependence, restraints, falls, and hospice services. The consultant MDS nurse stated that the resident with the indwelling catheter should have been coded as not rated for urinary continence due to catheter placement rather than as always incontinent, and that his ADL status should not have been coded as independent given his dependence on staff for dressing and wheelchair positioning. For the resident with grab bars, the nurse confirmed that the grab bars were used as enablers and not as restraints, making the restraint coding inaccurate. For the resident with documented falls, the MDS failed to capture falls that occurred within the look-back period, and for the resident receiving hospice services, the MDS did not reflect hospice care that was active during the look-back period. These miscodings met the RAI Manual’s definition of significant error, in which the resident’s overall clinical status is not accurately represented on the assessment and the error has not been corrected by a more recent assessment.
Failure to Provide and Communicate Baseline Care Plan to New Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide a summary of the baseline care plan to a newly admitted resident and to ensure that the baseline care plan process was completed and documented as required. The resident’s EMR documented diagnoses of C. difficile and CHF. The Entry MDS was completed on the admission date, and the admission MDS was noted as in progress with no information available. A baseline care plan dated the day after admission documented contact precautions, including staff use of gowns and masks when changing contaminated linens and proper handling and bagging of soiled linens. However, during an interview several days after admission, the resident reported she did not know what a baseline care plan was, indicating that the plan had not been explained or summarized to her. Further observations and interviews showed additional failures in implementing and communicating the baseline care plan. On one occasion, the resident was heard yelling for help with her room door closed; when a nurse entered, the resident stated she wanted to get up but could not find her call light, which was observed on the floor under the bed. A nurse reported that the baseline care plan was started on the day of admission and that nurses would review it with the resident, but also stated that the charge nurse would not provide a written copy of the baseline care plan to the resident or family. An administrative nurse reported she would review the baseline care plan with the resident and/or family and claimed to have completed a 48-hour interdisciplinary care conference, but there was no opened or completed conference note in the EMR. She gave inconsistent explanations regarding who was responsible and why the conference note was missing. The facility did not provide a policy for baseline care plans.
Failure to Provide Accurate ADL Assessment and Timely Clothing Changes
Penalty
Summary
The facility failed to provide appropriate assistance with activities of daily living (ADLs), specifically dressing and clothing changes, for a resident with severe cognitive impairment. The resident had a diagnosis of dementia and repeated Brief Interview for Mental Status (BIMS) scores of one, indicating severe cognitive impairment. Despite this, both a Significant Change MDS and a Quarterly MDS inaccurately documented that the resident required only setup assistance with lower body dressing. The ADL Care Area Assessment did not trigger, and the resident’s care plan, revised on 03/23/26, inaccurately instructed staff that the resident was independent with dressing. The electronic medical record lacked staff documentation of the resident’s ADL needs, resulting in care instructions that did not reflect the resident’s actual functional status. On the day of observation, the resident was seen sitting in a wheelchair wearing black pants with food crumbs on them in the morning, and later was transported by a CNA to the dining room still wearing the same dirty pants. The pants were not changed until early afternoon, at which time two CNAs provided total assistance to change the dirty pants, and the resident was unable to participate in dressing or undressing. During interviews, the CNAs, a licensed nurse, and an administrative nurse all stated that residents should always be dressed in clean clothing and confirmed that this resident required total staff assistance with dressing. These observations and interviews showed that the resident’s actual need for total assistance with dressing and clothing changes was not accurately reflected in the MDS, care plan, or ADL documentation, and that the facility did not ensure the resident was kept in clean clothing as expected by facility policy for ADL care.
Failure to Maintain Safe Wheelchair Foot Positioning During Resident Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision during wheelchair transport for a resident with dementia. The resident’s EMR documented a diagnosis of dementia and a BIMS score of one on both a Significant Change MDS and a Quarterly MDS, indicating severe cognitive impairment. These MDS assessments inaccurately documented that the resident was independent with walking using a walker and/or wheelchair, and the ADL CAA did not trigger. The resident’s care plan, revised 03/23/26, identified cognitive impairment due to dementia but did not include instructions for staff on the use of wheelchair foot pedals while propelling the resident. On multiple observed occasions, staff propelled the resident in a wheelchair without maintaining his feet safely on the foot pedals. During transport from his room to the dining room, the resident’s left shoed foot fell from the foot pedal and skimmed the floor between the pedals, and later, during transport from the dining room to the shower room, both shoed feet skimmed the floor between the pedals. CNAs reported that the resident’s feet never stayed on the foot pedals and described the pedals as useless because he could not keep his feet on them. A licensed nurse confirmed the resident’s feet did not always remain on the foot pedals when staff propelled him and stated the pedals should be adjusted to better fit his needs. An administrative nurse stated it was the expectation that staff ensure the resident’s feet remained on the foot pedals during transport and that pedals should be lowered if needed. The facility did not provide a policy regarding wheelchair safety.
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