Life Care Center Of Andover
Inspection history, citations, penalties and survey trends for this long-term care facility in Andover, Kansas.
- Location
- 621 W 21st, Andover, Kansas 67002
- CMS Provider Number
- 175157
- Inspections on file
- 28
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 3 (3 serious)
Citation history
Health deficiencies cited at Life Care Center Of Andover during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and behavioral issues was subjected to physical and verbal abuse by an LPN, who responded to the resident's aggression with threats, physical restraint, and inappropriate handling. The incident was witnessed by a CNA but not reported until the following day, allowing the LPN to continue providing care to the resident and others without restriction. The facility failed to immediately remove the LPN from resident care after the abuse occurred.
A resident with severe cognitive impairment and a history of aggressive behaviors became agitated and physically aggressive toward a nurse, who responded by yelling, threatening harm, and using a neck restraint. The incident was witnessed by a CNA who did not report it until the following day. The nurse had not received formal dementia training, and the response did not follow the resident's care plan or facility policy, resulting in immediate jeopardy.
A resident with severe cognitive impairment and behavioral issues was subjected to staff-to-resident abuse by an LPN, who responded to the resident's aggression with threats, physical restraint, and inappropriate handling. The incident was witnessed by a CNA, but was not reported to administration until the following day, violating facility policy requiring immediate reporting of suspected abuse and resulting in immediate jeopardy.
A resident with severe cognitive impairment and chronic pain experienced uncontrolled crying, poor oral intake, and visible distress over several days, but staff failed to consistently assess, document, or manage the pain effectively. Despite orders for scheduled and as-needed pain medications, there were lapses in medication administration, inadequate follow-up when pain relief was ineffective, and poor communication among staff and providers. The resident ultimately was found to have an acute fracture after days of ineffective pain relief.
A CNA employed for over a year did not have a documented annual performance evaluation, as required. Administrative staff confirmed the absence of the evaluation and could not provide a policy regarding yearly performance reviews for staff.
Surveyors found that food items were not properly labeled or dated, plates were stored in a manner that could lead to contamination, and cleaning in dining areas was inadequate. Additionally, hazardous chemicals were improperly stored in a dining room cabinet. These actions did not follow the facility's food safety policy and placed residents at risk for food safety concerns.
Several dependent residents did not receive consistent bathing and personal hygiene care as required, with documentation showing missed or irregular bathing opportunities, lack of evidence that care was offered or refused, and observations of poor hygiene. Staff interviews confirmed that scheduled baths were sometimes missed due to staffing issues or resident behaviors, and care plans lacked clear direction or follow-through on resident preferences.
Surveyors found that staff did not consistently elevate the head of the bed during tube feedings and failed to label and date enteral feeding bags for several residents with complex medical needs. Despite care plans and physician orders specifying protocols for safe enteral nutrition, these were not followed, and the facility could not provide a policy on enteral nutrition when requested.
Surveyors found that linen carts and pillows were left uncovered, bedspreads were improperly stored, and medical equipment such as urinary catheter bags and CPAP machines were not maintained in a sanitary manner. Staff failed to perform hand hygiene during wound care, catheter care, and feeding tube procedures, including not changing gloves between tasks. These actions were not in compliance with the facility's infection prevention policy.
Two residents experienced unmet care needs due to the facility's failure to provide appropriate bariatric equipment, ensure access to call lights, and use wheelchair foot pedals as required. One resident with morbid obesity did not have access to a suitable lift or wheelchair, resulting in missed weights and lack of proper bathing and transfers, while another resident with severe cognitive impairment was left without a reachable call light and was transported without foot pedals in place.
Two residents with complex medical and psychosocial needs did not have individualized, person-centered care plans addressing trauma-based care and meaningful activities. One resident with PTSD and severe cognitive impairment lacked trauma-informed interventions in the care plan, while another resident with quadriplegia and severe cognitive impairment had no documented activity participation or person-centered activities, despite staff awareness of his preferences.
Two residents' care plans were not updated to reflect critical changes in their care needs, including one resident's visitation restrictions after an aggressive incident with a family representative and another resident's need for new fall prevention interventions following multiple falls and a hip fracture. Staff and administrative interviews confirmed that these updates were not made, despite facility policy requiring timely care plan revisions by an interdisciplinary team.
A resident with severe cognitive and physical impairments, dependent on staff for ADLs and unable to use a standard push button call light, was not provided with the care plan-specified touch pad call light. Staff confirmed the resident could not operate the available device, and the appropriate equipment was not in place, leaving the resident unable to request assistance.
Two residents at risk for pressure ulcers did not receive proper care when staff failed to set low air-loss mattresses according to actual weight and did not ensure the equipment was plugged in and functioning. One resident's mattress was set at the maximum weight rather than the resident's actual weight, while another resident's mattress was found unplugged and nonfunctional. Staff checks were inconsistent and did not always follow manufacturer or facility guidelines, resulting in inadequate pressure ulcer prevention.
A resident with severe cognitive impairment and spastic quadriplegic cerebral palsy was not provided with prescribed contracture prevention devices or a restorative nursing program, despite care plan directives. Observations showed the resident's hands were tightly clenched without palm grippers, and staff interviews indicated confusion about responsibility for applying these devices. Documentation did not reflect that the required interventions were implemented or monitored.
Staff did not provide timely incontinence care to a resident with dementia, resulting in a bladder incontinence episode in the dining room, and failed to ensure proper catheter bag positioning for another resident with severe cognitive impairment and an indwelling catheter. These actions were inconsistent with facility policies and placed residents at risk for negative outcomes.
Two residents did not receive safe and appropriate respiratory care when their physician-ordered oxygen and CPAP equipment was not used or stored as directed. One resident with COPD and dementia was often observed without her nasal cannula in place and left it unbagged, while another resident on hospice had his CPAP mask left unsanitarily in the windowsill. Staff confirmed these practices did not follow facility policy for respiratory equipment storage.
A resident with PTSD and severe cognitive impairment did not have individualized, trigger-specific interventions in their care plan to prevent re-traumatization. Staff were unaware of the resident's PTSD diagnosis and related care needs, and the trauma-informed care assessment had not been updated since admission, contrary to facility policy.
Two residents using low air-loss mattresses did not receive safety assessments that addressed the specific risks of bed rail use with these mattresses. Both residents' records lacked documentation of risk assessments, informed consent, and education about potential hazards, despite facility policy requiring these steps. Staff interviews revealed uncertainty about proper assessment procedures, and observations showed improper equipment use and lack of resident or representative education.
A resident with PTSD, cognitive impairment, anxiety, dementia, and depression did not receive individualized, trauma-informed care as required. The care plan lacked trigger-specific interventions, and staff were unaware of the resident's PTSD diagnosis or effective strategies to prevent re-traumatization. The last trauma assessment was outdated, and the facility did not follow its own policy for regular evaluation and care planning.
The facility did not maintain or retain required daily nurse staffing data for the mandated period, with missing documentation for multiple dates, incomplete resident census records, and absent nursing hour totals. Administrative and front desk staff shared responsibility for posting and storing these records, but gaps in documentation were identified.
A resident with severe cognitive and physical impairments fell from their bed while receiving incontinence care, resulting in a scalp laceration requiring 13 staples. The CNA providing care was informed that the resident required only one-person assistance, contrary to the care plan's directive for one to two staff members. This lack of adherence to the care plan and facility policies on safety and supervision led to the preventable accident.
A resident with multiple diagnoses, including multiple sclerosis and paraplegia, fell and fractured her pelvis when a CNA attempted to transfer her alone using a mechanical lift, contrary to the facility's policy requiring two staff members for such transfers.
Failure to Protect Resident from Staff-to-Resident Abuse and Delay in Restricting Perpetrator Access
Penalty
Summary
A deficiency occurred when a licensed nurse engaged in staff-to-resident abuse involving a resident with severe cognitive impairment, traumatic brain injury, and a history of aggressive behaviors. The incident began when the resident exhibited escalating combative and aggressive behaviors, including grabbing the nurse's genitals and using obscene language. In response, the nurse yelled at the resident, grabbed his arm, threatened physical harm, and stated he would lock the resident in his room. The nurse further reported using a restraint technique involving grabbing the resident around the neck, which he described as a 'scare tactic.' A certified nurse aide witnessed the abuse but failed to report the incident to administrative staff until the following day. During this time, the nurse continued to have unrestricted access to the resident and other residents on the locked memory care unit. The facility did not immediately remove the nurse from resident care or restrict his access to vulnerable residents following the incident, contrary to facility policy and expectations for immediate response to allegations of abuse. The resident involved had a documented history of severe cognitive impairment, behavioral disturbances, and required specific interventions for agitation and aggression. Despite these known risk factors and care plan instructions for de-escalation, the nurse's actions escalated the situation and resulted in physical and verbal abuse. The facility's failure to act promptly to protect the resident and others from further potential abuse constituted a significant deficiency.
Removal Plan
- The Social Service Director/Designee interviewed all current in-house residents who were alert and oriented with an assessed BIMS score of 12 or higher to determine if they had experienced or witnessed misappropriation.
- The Regional Director of Clinical Services educated the Director of Nursing and the Executive Director on the incident of reportable event management and record review.
- The Director of Nursing/Designee reviewed behavior notes, progress notes, psychosocial notes, health status notes, event notes, and plan of care for all residents in the prior 14 days to audit for potential abuse-related events not previously investigated.
- The Director of Nursing/Designee initiated staff education on reporting of suspected Abuse, Neglect, and Exploitation, including misappropriation. Nursing Staff employees would have education provided prior to their next scheduled shift.
- The Director of Nursing/Designee initiated staff education on incident and reporting event management for interdisciplinary team (IDT), including Executive Director, Director of Nursing, Assistant Director of Nursing, Director of Rehabilitation, Social Service Director, Business Office Manager, Health Information Management, Activity Director, Dietary Manager, Infection Prevention, MDS Coordinator, and Admission. IDT would have education provided prior to working their next scheduled shift.
- The Director of Nursing/Designee would randomly ask five staff members what to do if Abuse, Neglect, or Exploitation (ANE), including injuries of unknown origin, was suspected five times weekly for four weeks, three times weekly for four weeks, and then randomly thereafter.
- The results of the above audits would be submitted to Quality Assurance and Performance Improvement (QAPI) Committee for further review and/or action, as well as any trends identified.
Staff-to-Resident Abuse and Delayed Reporting of Incident
Penalty
Summary
A resident with severe cognitive impairment, traumatic brain injury, and a history of aggressive behaviors exhibited escalating agitation and aggression, including yelling, cursing, and physical aggression toward staff. During an incident, the resident grabbed a licensed nurse's genitals and used obscene language. In response, the nurse yelled at the resident, grabbed his arm, threatened physical harm, and stated he would lock the resident in his room. The nurse also reported using a restraint technique involving grabbing the resident around the neck to prevent further aggressive behaviors. This interaction was witnessed by a certified nurse aide, who did not report the abuse to administrative staff until the following day. The resident's care plan instructed staff to intervene calmly before agitation escalated, to guide the resident away from distress, and to reapproach if the resident became aggressive. Staff were also directed to expect frequent use of profanity and to encourage appropriate language. Despite these care plan instructions, the nurse's actions during the incident included physical and verbal abuse, as well as the use of an unauthorized restraint technique. The nurse had not received formal dementia training since being hired, although he had attended a staff meeting that included behavioral management topics. The facility's policy required immediate reporting of any witnessed or alleged abuse, but the certified nurse aide who witnessed the event delayed reporting until her next shift. The facility's investigation confirmed the incident and noted the delay in reporting. The nurse involved was suspended and later terminated. The failure to protect the resident from staff-to-resident abuse and to ensure timely reporting of abuse constituted a deficiency and resulted in immediate jeopardy for the resident.
Removal Plan
- The Social Service Director/Designee interviewed all current in-house residents who were alert and oriented with an assessed BIMS score of 12 or higher to determine if they had experienced or witnessed misappropriation. No additional concerns were noted during the interviews.
- The Regional Director of Clinical Services educated the Director of Nursing and the Executive Director on the incident of reportable event management and record review.
- The Director of Nursing/Designee reviewed behavior notes, progress notes, psychosocial notes, health status notes, event notes, and plan of care for all residents in the prior 14 days to audit for potential abuse-related events not previously investigated.
- The Director of Nursing/Designee initiated staff education on reporting of suspected Abuse, Neglect, and Exploitation, including misappropriation. Nursing Staff employees would have education provided prior to their next scheduled shift.
- The Director of Nursing/Designee initiated staff education on incident and reporting event management for interdisciplinary team (IDT), including Executive Director, Director of Nursing, Assistant Director of Nursing, Director of Rehabilitation, Social Service Director, Business Office Manager, Health Information Management, Activity Director, Dietary Manager, Infection Prevention, MDS Coordinator, and Admission. IDT would have education provided prior to working their next scheduled shift.
- The Director of Nursing/Designee would randomly ask five staff members what to do if ANE, including injuries of unknown origin, was suspected five times weekly for four weeks, three times weekly for four weeks, and then randomly thereafter.
- The results of the above audits would be submitted to Quality Assurance and Performance Improvement (QAPI) Committee for further review and or action, as well as any trends identified.
Failure to Immediately Report Staff-to-Resident Abuse
Penalty
Summary
A deficiency occurred when a severely cognitively impaired resident with a history of traumatic brain injury and behavioral issues exhibited escalating combative and aggressive behaviors. During an incident, the resident grabbed a licensed nurse's genitals and used obscene language. In response, the nurse yelled at the resident, grabbed his arm, threatened physical harm, and stated he would lock the resident in his room. The nurse also reported using a restraint technique involving grabbing the resident around the neck to prevent further aggression. A certified nurse aide witnessed this staff-to-resident abuse. Despite witnessing the incident, the certified nurse aide did not immediately report the abuse to administrative staff as required by facility policy. Instead, the incident was reported the following day when the aide returned for her next shift. This delay in reporting meant that the facility administrator was not promptly informed of the abuse, which is a violation of the facility's abuse prevention policy that mandates immediate reporting of all alleged or suspected abuse. The failure to ensure immediate reporting of the abuse placed the resident in immediate jeopardy. The facility's own documentation and staff interviews confirmed that the incident was not reported in a timely manner, and that the required notification to administrative staff was delayed until the next day. This lapse in procedure directly contributed to the deficiency cited by surveyors.
Removal Plan
- The Social Service Director/Designee interviewed all current in-house residents who were alert and oriented with an assessed BIMS score of 12 or higher to determine if they had experienced or witnessed misappropriation. No additional concerns were noted during the interviews.
- The Regional Director of Clinical Services educated the Director of Nursing and the Executive Director on the incident of reportable event management and record review.
- The Director of Nursing/Designee reviewed behavior notes, progress notes, psychosocial notes, health status notes, event notes, and plan of care for all residents in the prior 14 days to audit for potential abuse-related events not previously investigated.
- The Director of Nursing/Designee initiated staff education on reporting of suspected Abuse, Neglect, and Exploitation, including misappropriation. Nursing Staff employees would have education provided prior to their next scheduled shift.
- The Director of Nursing/Designee initiated staff education on incident and reporting event management for interdisciplinary team (IDT), including Executive Director, Director of Nursing, Assistant Director of Nursing, Director of Rehabilitation, Social Service Director, Business Office Manager, Health Information Management, Activity Director, Dietary Manager, Infection Prevention, MDS Coordinator, and Admission. IDT would have education provided prior to working their next scheduled shift.
- The Director of Nursing/Designee would randomly ask five staff members what to do if ANE, including injuries of unknown origin, was suspected five times weekly for four weeks, three times weekly for four weeks, and then randomly thereafter.
- The results of the above audits would be submitted to Quality Assurance and Performance Improvement (QAPI) Committee for further review and or action, as well as any trends identified.
Failure to Assess and Manage Severe Pain in Cognitively Impaired Resident
Penalty
Summary
The facility failed to adequately assess and manage pain for a resident with severe cognitive impairment, chronic pain, and significant physical limitations. The resident had a history of osteoarthritis, hemiparesis, and chronic pain, and was dependent on staff for all activities of daily living. Despite care plan directives to evaluate pain interventions, provide both pharmacological and non-pharmacological pain relief, and notify the physician if interventions were ineffective, staff did not consistently follow these protocols. Documentation showed that the resident experienced episodes of uncontrolled crying, poor oral intake, and visible distress over several days, but there was a lack of follow-up assessment or timely action to address ongoing pain. The resident's medication orders included both scheduled and as-needed acetaminophen and hydrocodone-acetaminophen for pain management. However, when as-needed acetaminophen was found to be ineffective, there was no evidence that alternative pain management strategies were implemented or that the physician was promptly notified. Additionally, there was a lapse in the availability of the resident's scheduled hydrocodone-acetaminophen due to a delay in obtaining a new prescription, further contributing to inadequate pain control. Communication between nurses, physicians, and other healthcare providers regarding the resident's pain was insufficient, as critical information was not consistently documented in the electronic health record or the Team Health Book. Staff interviews revealed that while some aides reported the resident's pain to nurses, and nurses were aware of increased pain, documentation and follow-up actions were inconsistent or lacking. The resident's pain assessments on the treatment administration record often indicated no pain, despite clear behavioral signs and staff observations of distress. Ultimately, the resident was found to have an acute, displaced fracture of the left humerus, which had not been identified on earlier X-rays, and had experienced ineffective pain relief for six days prior to the diagnosis. The facility's failure to assess, document, and manage the resident's pain according to professional standards and the care plan resulted in prolonged suffering and placed the resident at risk for further decline.
Failure to Complete Yearly Performance Evaluation for CNA
Penalty
Summary
The facility failed to complete a yearly performance evaluation for one of five Certified Nurse Aides (CNA) reviewed, despite the CNA being employed for over 12 months. Record review showed that CNA O, hired on 06/13/23, did not have a documented yearly performance evaluation available upon request. Administrative staff confirmed that department directors are responsible for completing these evaluations, with assistance from the human resources department in tracking them, but were unable to locate the required documentation for CNA O. Additionally, the facility did not provide a policy regarding yearly performance reviews for staff. This deficiency was identified during a review of personnel records and staff interviews, with a facility census of 96 residents and a sample of 20 residents included in the review.
Deficient Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
Surveyors identified multiple failures in the facility's dietary services related to food storage, preparation, and meal service. During an inspection of the kitchen, four large plastic bins containing various cereals were found without dates indicating when they were opened. Additionally, plates were stored facing upward on a mobile counter without any barrier to prevent contamination of the eating surfaces. In the main dining room, trash and food debris were observed under the ice machine and condiment counter, indicating inadequate cleaning practices. Further inspection of the 500 hall dining room revealed a bottle of drain cleaner stored in a cabinet under the sink, despite the product's warning label indicating it was hazardous and should be kept out of reach of children. Dietary staff confirmed that all food items were expected to be labeled and dated, and that plates and utensils should be stored downward to prevent contamination. The facility's Food Safety policy required safe and sanitary practices for food storage, preparation, and service, and specified that the kitchen should be maintained in a sanitary manner.
Failure to Provide Consistent Bathing and ADL Care to Dependent Residents
Penalty
Summary
The facility failed to provide consistent bathing and personal hygiene care to several dependent residents, as evidenced by gaps in documentation, resident interviews, and staff statements. One resident with multiple medical conditions, including a pressure ulcer, congestive heart failure, and functional limitations, was dependent on staff for all ADLs, including bathing. Documentation showed irregular intervals between baths, with some periods exceeding a week without evidence of bathing being offered or refused. The resident confirmed that sometimes more than a week would pass between baths, attributing this to staff shortages and her need for more assistance. Staff interviews corroborated that scheduled baths were sometimes missed due to staffing issues, and the care plan lacked clear direction on the resident's preferred bathing schedule. Another resident with diabetes, morbid obesity, and mental health diagnoses was also dependent on staff for all ADLs and was at risk for skin breakdown. Review of records over an 86-day period revealed only a few documented bathing opportunities, with many days marked as 'not applicable' and no evidence of refusals. The resident reported not having a bath in almost a month, and observations noted poor hygiene. Staff confirmed the resident often refused care, but there was no consistent documentation of offers or refusals, and the care plan directed staff to make multiple attempts and involve the nurse if care was refused. Additional residents, including one with hypertensive heart disease and another with spastic quadriplegic cerebral palsy, were also found to have inconsistent bathing care. Documentation for one resident showed no evidence of bathing or refusals over several months, despite a care plan specifying twice-weekly baths. Staff interviews indicated that a hospice aide provided some care, but facility staff were also responsible for offering baths. For the resident with cerebral palsy, records showed only a handful of baths over an 82-day period, with no evidence of refusals, and observations noted poor hygiene. In all cases, the facility's policy required consistent ADL care based on resident needs and preferences, but this was not consistently provided or documented.
Failure to Ensure Safe Administration and Management of Enteral Nutrition
Penalty
Summary
Surveyors identified that the facility failed to ensure safe administration and management of enteral nutrition for four residents who were receiving tube feedings. Observations revealed that residents were repeatedly found lying flat or with insufficient elevation of the head of the bed while tube feedings were being administered, despite care plans and physician orders specifying that the head of the bed should be elevated to at least 30 or 45 degrees during and after feedings. This practice was not followed consistently, as evidenced by multiple instances where residents were observed in a flat or inadequately elevated position while their enteral feeding pumps were running. Additionally, the facility did not ensure that enteral feeding bags were properly labeled and dated. On several occasions, surveyors observed unlabeled and undated feeding bags containing unknown supplements being administered to residents. Staff interviews confirmed that the expectation was for all enteral feeding bags to be labeled with the date and time of administration to ensure consistent and safe nutrition delivery, but this was not consistently practiced. The facility also failed to provide a policy related to enteral nutrition when requested by surveyors. The residents involved had significant medical conditions, including severe cognitive impairment, dysphagia, quadriplegia, end-stage renal failure, and a history of aspiration or pressure ulcers. Despite these vulnerabilities and the presence of care plans and physician orders outlining specific protocols for enteral feeding, the facility did not adhere to these protocols, resulting in a deficiency related to the safe provision of enteral nutrition.
Infection Control Lapses in Linen Handling, Equipment Storage, and Hand Hygiene
Penalty
Summary
Surveyors identified multiple infection control deficiencies during their review and observation of the facility. Uncovered linen carts and pillows were found in various locations, including a shower room and on top of linen carts, and bedspreads were stored inappropriately in a shower room marked with a 'Do Not Use' sign. Additionally, a resident's urinary catheter bag was observed dragging on the floor beneath a wheelchair during lunchtime, and another resident's CPAP machine was not stored in a sanitary manner. There were also issues with the storage of a nasal cannula and the positioning of a urine collection bag, which was not kept below the level of the bladder as required. Staff failed to consistently perform hand hygiene during critical care procedures. During wound care, administrative nurses and a licensed nurse entered a resident's room without performing hand hygiene, and one nurse failed to change gloves or sanitize hands between wound sites. Similar lapses were observed during catheter care and feeding tube dressing changes, where hand hygiene was not performed between glove changes. During medication administration via feeding tube, a nurse did not change gloves or perform hand hygiene after adjusting the resident's pillow, gown, and brief, and before administering water flushes and medication. These failures were in direct violation of the facility's infection prevention policy and placed residents at risk for infection.
Failure to Provide Adequate Equipment and Accommodations for Resident Needs
Penalty
Summary
The facility failed to ensure adequate bariatric equipment was available to meet the needs and preferences of a resident with morbid obesity. The resident, who weighed over 700 pounds and was dependent on staff for most activities of daily living, did not have access to a mechanical lift or wheelchair that could accommodate his weight. As a result, staff were unable to obtain required monthly weights, and there was no evidence of bathing or transfers occurring for several months, with no documentation of refusals. When movement was necessary, such as during an emergency, staff had to call Emergency Medical Response to move the resident using a gurney, as the facility lacked appropriate equipment. The facility also did not provide a policy regarding accommodation of needs for such residents. Another deficiency involved a resident with severe cognitive impairment who required a wheelchair for mobility. Observations revealed that the resident's call light was repeatedly clipped to the wall and not within reach, and the resident was transported in the wheelchair without foot pedals in place. Staff interviews confirmed that call lights should be within reach and foot pedals should be used when pushing residents in wheelchairs, but these practices were not followed. The facility did not provide policies related to the use of foot pedals or call lights. These failures resulted in unmet care needs for both residents, including the inability to obtain weights, lack of appropriate bathing and transfer support, and increased vulnerability due to lack of access to call lights and proper wheelchair equipment. The report documents that these practices placed the residents at risk for impaired quality of life and health complications related to unmet needs.
Failure to Develop Individualized, Person-Centered Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for two residents, resulting in unmet care needs. For one resident with diagnoses including PTSD, cognitive communication deficit, anxiety, dementia, and depression, the care plan did not include person-centered interventions specific to her trauma-based care. The care plan lacked details on triggers, de-escalation strategies, and ways to prevent re-traumatization, despite documentation of her severe cognitive impairment and risk factors such as self-care deficits, falls, and decreased socialization. Staff interviews revealed a lack of awareness regarding the resident's PTSD diagnosis and absence of trauma-informed interventions in the care plan. Another resident with chronic kidney disease, quadriplegia, diabetes, dysphagia, and pressure ulcers was also found to have an incomplete care plan. The plan did not address person-centered activities, despite the resident's severe cognitive impairment and total dependence on staff for daily care. There was no documentation of activity participation, and staff confirmed that the resident enjoyed music and television, which were not reflected in the care plan or provided during observations. The facility's policy required timely, person-centered, and interdisciplinary care planning, but these requirements were not met for the two residents. The lack of individualized interventions and activity planning placed the residents at risk for impaired care and unaddressed psychosocial needs, as evidenced by staff interviews and review of medical records.
Failure to Revise Care Plans for Visitation and Fall Prevention
Penalty
Summary
The facility failed to update and revise the care plans for two residents to reflect their current care needs and safety requirements. For one resident with a history of aphasia, hemiparesis, cerebral infarction, muscle weakness, and depression, the care plan did not include updated visitation requirements following an incident where her family representative was observed acting aggressively towards her. Although the resident expressed a desire for supervised or restricted visitation, and staff and administrative nurses acknowledged that this information should be reflected in the care plan, the necessary updates were not made. The facility's own policy required that care plans be reviewed and revised by an interdisciplinary team with input from the resident and their representative, but this was not followed in this case. Another resident, who had diagnoses including lack of coordination, right hip fracture, dementia, muscle weakness, aphasia, and communication deficits, experienced multiple falls, including one resulting in a right hip fracture. Despite repeated falls and changes in her condition, the care plan was not revised to include new long-term interventions to prevent future falls. Staff interviews confirmed that while some fall interventions were in place, such as keeping the bed in the lowest position and using a floor mat, there were no new interventions added after the most recent incidents. The care plan lacked comprehensive updates to address the resident's ongoing high risk for falls, as required by facility policy. These deficiencies were identified through observations, interviews, and record reviews, and were found to place the residents at risk for impaired care due to uncommunicated or inadequately addressed care needs. The facility's failure to revise and update care plans in a timely and comprehensive manner was contrary to its own policies and placed the affected residents at risk for compromised safety and quality of life.
Failure to Provide Appropriate Call Light Device for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with spastic quadriplegic cerebral palsy, severe cognitive impairment, and significant limitations in range of motion was not provided with an appropriate call light device. The resident's care plan specified the need for a mechanical pad call light to request staff assistance, but observations revealed that only a push button call light was available, which was out of the resident's reach and not operable by the resident due to clenched hands and lack of palm grippers. Staff interviews confirmed that the resident could not use the push button call light, and there was uncertainty among staff regarding who was responsible for assessing residents for appropriate equipment. The resident was dependent on staff for activities of daily living, had a feeding tube, and was at risk for pressure ulcers, as documented in the medical record and care assessments. Despite these needs and the facility's policy to provide appropriate treatment and services to maintain or improve ADL abilities, the required touch pad call light was not provided. This failure resulted in the resident being unable to communicate needs or call for assistance as intended in the care plan.
Failure to Ensure Proper Use and Monitoring of Low Air-Loss Mattresses for Pressure Ulcer Prevention
Penalty
Summary
Staff failed to ensure proper use and monitoring of low air-loss mattresses for two residents at risk for pressure ulcers. For one resident with severe cognitive impairment, end-stage renal failure, and a history of pressure ulcers, the low air-loss mattress was consistently set at the maximum weight setting of 400 lbs, despite the resident's actual weight being 228 lbs. The mattress pump had multiple preset weight options, but staff did not adjust the setting to match the resident's current weight as required by the manufacturer's instructions. Interviews with staff revealed inconsistent understanding of mattress settings, with some staff checking only if the pump was on and the bed inflated, rather than verifying the correct weight setting. Another resident, also with severe cognitive impairment, spastic quadriplegic cerebral palsy, and at risk for pressure ulcers, was found lying on a bed with a low air-loss mattress that was unplugged and not functioning. The resident's care plan indicated the use of a pressure-reducing mattress, but there was no documentation of monitoring the mattress's function. Staff interviews confirmed that checks were limited to ensuring the pump was on and the bed was inflated, without consistent verification of proper function or weight-based settings. The facility's policy required individualized interventions based on comprehensive assessment and risk, including the use of pressure redistribution surfaces. However, the failure to set the mattresses according to residents' weights and to ensure the equipment was plugged in and functioning represented a deviation from both manufacturer guidelines and facility policy. These actions and inactions placed the residents at risk for complications related to skin breakdown and pressure ulcers.
Failure to Provide Contracture Prevention and Restorative Care
Penalty
Summary
A resident with spastic quadriplegic cerebral palsy, severe cognitive impairment, and multiple comorbidities including muscle weakness and a history of pressure ulcers, was not provided with appropriate services and treatment to prevent worsening of contractures in his left hand. The resident's care plan specified the use of palm grips on both hands for four to six hours daily, monitoring of skin integrity, pain, and circulation, and a passive range of motion (ROM) program for the upper extremities. However, there was no documentation in the clinical record, Medication Administration Record (MAR), Treatment Administration Record (TAR), or other documentation systems that the restorative nursing program or application of palm grippers was provided during the review period. Multiple observations over several days showed the resident lying in bed with both hands tightly clenched and no contracture prevention devices in place. The resident's enteral feeding equipment was undated and unlabeled, and personal hygiene concerns were noted, including oily hair and body odor. The resident's call light was also observed to be out of reach. Interviews with nursing and therapy staff revealed uncertainty about responsibility for applying palm grippers and a lack of awareness regarding the resident's need for contracture prevention devices. The facility's own restorative nursing policy required proactive identification, care planning, and monitoring of restorative programs, with nursing assistants trained in restorative techniques. Despite this, the resident did not receive the prescribed interventions to maintain or improve range of motion, and there was no evidence of staff following the care plan or documenting the required restorative care.
Failure to Provide Timely Incontinence and Catheter Care
Penalty
Summary
Facility staff failed to provide timely incontinence care to a resident with dementia, metabolic encephalopathy, and other comorbidities, resulting in a bladder incontinence episode during a lunchtime meal in the dining room. This incident left a puddle of urine on the floor where other residents were eating. The resident was known to be frequently incontinent and required partial to moderate assistance with toileting, but staff did not anticipate or address the resident's needs prior to the meal, despite care plans and policies indicating the need for such interventions. Additionally, staff did not ensure proper management of an indwelling urinary catheter for another resident with severe cognitive impairment, obstructive uropathy, and a history of urinary tract infections. Observations showed that the resident's catheter collection bag was repeatedly placed above the level of the bladder, both in bed and while seated in a wheelchair, with urine pooling in the tubing. Staff interviews confirmed awareness of the requirement to keep the catheter bag below bladder level to prevent infection, but this was not consistently implemented or reinforced with the resident. Facility policies required staff to provide appropriate catheter care, maintain catheter bags below bladder level, and ensure timely toileting and incontinence care to prevent urinary tract infections and maintain resident dignity. However, these standards were not met, as evidenced by direct observations, staff interviews, and review of care plans and assessments.
Failure to Ensure Proper Use and Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not ensuring that physician-ordered respiratory equipment was used and stored as directed. One resident with diagnoses including respiratory failure, COPD, CHF, and dementia was ordered to receive oxygen therapy at three liters per minute via nasal cannula (NC). Despite this, observations showed that the resident frequently did not have the NC in place, with the oxygen concentrator running but the NC left unbagged on the bedside table or bed. Staff interviews confirmed that the resident was often non-compliant with wearing the NC and did not consistently store it in the provided bag when not in use, despite reminders and the presence of a care plan and facility policy requiring proper storage and continuous use of oxygen as ordered. Another resident, who had diagnoses such as hypertensive heart disease, heart failure, diabetes, respiratory failure, obesity, and was on hospice care, was ordered to use a CPAP device while sleeping or napping, with specific instructions for cleaning and storage. Observations revealed that the CPAP mask was left in the windowsill and not stored in a sanitary manner as required. Staff confirmed that the resident was unable to properly store the mask and that all respiratory equipment should be placed in a labeled bag when not in use, in accordance with facility expectations. The facility's own policy on oxygen administration and storage required that respiratory equipment be stored in a bag labeled with the resident's name when not in use. However, both residents' respiratory equipment was found not to be stored appropriately, and in one case, the resident was not receiving oxygen therapy as ordered. These failures were confirmed through direct observation, record review, and staff interviews.
Failure to Identify and Address Trauma Triggers for Resident with PTSD
Penalty
Summary
The facility failed to identify and address trauma-based triggers for a resident diagnosed with post-traumatic stress disorder (PTSD), as well as other conditions including cognitive communication deficit, anxiety, dementia, and depression. The resident's care plan did not include individualized, trigger-specific interventions to prevent re-traumatization, despite documentation of PTSD in the medical record and care assessments. Staff interviews revealed a lack of awareness regarding the resident's PTSD diagnosis and the absence of specific interventions or information about potential triggers in the care plan. The trauma-informed care assessment for the resident had not been updated since admission, and reassessment was only performed upon request, rather than routinely. Observations showed the resident with severely impaired cognition and no documented behaviors during assessment periods. Staff, including CNAs, nurses, and social services, indicated they expected to find information about trauma triggers and interventions in the care plan but confirmed this information was missing. The facility's policy required trauma-informed, culturally competent care, including identification and mitigation of triggers, but this was not implemented for the resident in question.
Failure to Assess and Inform on Bed Rail Risks with Low Air-Loss Mattresses
Penalty
Summary
The facility failed to ensure that two residents, both using low air-loss mattresses, received appropriate safety assessments for the use of bed rails that specifically acknowledged the risks associated with these mattresses. For one resident with multiple medical diagnoses including diabetes, morbid obesity, and schizoaffective disorder, documentation showed dependency on staff for all activities of daily living and a care plan that included bed rails to aid in mobility. However, the assessment did not address the risks posed by the combination of bed rails and a low air-loss mattress, and there was no documentation that the resident or their representative was informed of these specific risks or provided informed consent. For the second resident, who had spastic quadriplegic cerebral palsy, severe cognitive impairment, and was dependent on staff for all ADLs, the care plan also included the use of bed rails. The assessment again lacked consideration of the risks associated with the low air-loss mattress. Observations revealed that the resident was unable to use the bed rails for mobility or transfers, and the low air-loss mattress was found unplugged and not functioning. Staff interviews indicated uncertainty about whether bed rail assessments included evaluation of low air-loss mattresses, and there was no evidence that the risks and benefits were reviewed with the resident's representative as required by facility policy. The facility's policy required that all risks and benefits be reviewed prior to bed rail installation and that ongoing inspections and assessments be conducted. Despite this, both residents' records lacked documentation of risk assessments specific to the use of bed rails with low air-loss mattresses, as well as evidence of informed consent and education regarding potential risks. These omissions resulted in the residents being placed at risk for uninformed decisions and impaired safety related to bed rail use.
Failure to Provide Trauma-Informed Social Services for Resident with PTSD
Penalty
Summary
The facility failed to identify and provide medically related social services to support a resident with a history of posttraumatic stress disorder (PTSD), cognitive communication deficit, anxiety, dementia, and depression. The resident's care plan lacked individualized, trigger-specific interventions to decrease exposure to triggers that could re-traumatize her. Staff interviews revealed that direct care staff were unaware of the resident's PTSD diagnosis and did not have access to information about potential triggers or effective interventions. The last trauma-informed care assessment for the resident was completed several years prior, and social services staff indicated that reassessment would only occur upon request from nursing administration. The care plan did not reflect current needs or strategies to address the resident's trauma history. Observations showed the resident with severely impaired cognition and no documented behaviors during assessment periods, despite frequent yelling out as reported by staff. The facility's policy required trauma-informed care and regular evaluation of interventions, but this was not implemented for the resident. Staff, including CNAs and nurses, expected to find information about the resident's PTSD and appropriate interventions in the care plan but did not. The lack of updated assessment and individualized care planning placed the resident at risk for further decline in emotional and mental well-being.
Failure to Maintain and Retain Daily Nurse Staffing Data
Penalty
Summary
The facility failed to maintain and retain the required daily nurse staffing data for the mandated 18-month period. Record review revealed that posted staffing documentation was missing for 29 specific dates, and on 12 additional dates, the resident census was not recorded. Furthermore, eight dates lacked documentation of the total number of nursing hours. Interviews with administrative staff indicated that responsibility for posting and storing the staffing sheets was shared between the administrative nurse, front desk staff, and medical records staff. The facility's own staffing policy required daily posting and retention of staffing data, in accordance with federal regulations.
Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure an environment free from preventable accidents for a resident, identified as R1, who experienced a fall resulting in a scalp laceration requiring 13 staples. On the day of the incident, a Certified Nurse Aide (CNA) was providing incontinence care for R1 and noticed that the resident was close to the edge of the bed. While attempting to clean the resident, the CNA moved her hand to wipe R1's buttocks, causing R1 to roll off the bed onto the floor. This incident led to R1 being sent to the Emergency Department for evaluation and treatment. R1's medical history included diagnoses of cerebral infarction, quadriplegia, lack of coordination, and generalized muscle weakness. The resident had severe cognitive impairments and was dependent on staff for activities of daily living. R1's care plan indicated that he was totally dependent on one to two staff members for repositioning and turning in bed, and one staff member for incontinence care. However, during the incident, the CNA was informed by another CNA that R1 required only one-person assistance, which contributed to the fall. The facility's investigation revealed that the CNA did not follow the care plan's directive for bed mobility and incontinence care, which required adequate supervision and assistance. The facility's policies on fall management and activities of daily living emphasized the need for appropriate safety measures and supervision to prevent accidents. The failure to adhere to these policies and the care plan resulted in the resident's fall and subsequent injury.
Failure to Ensure Safe Transfer with Mechanical Lift
Penalty
Summary
The facility failed to ensure a resident remained free from accident hazards when a Certified Nurse Aide (CNA) used a mechanical lift by himself to transfer the resident. The resident, who had multiple diagnoses including osteomyelitis, multiple sclerosis, and paraplegia, required substantial to total assistance for all activities of daily living and mobility. The care plan specifically indicated that the resident required the use of a mechanical lift with two staff members for transfers. However, on the day of the incident, the CNA attempted to transfer the resident alone, resulting in the resident falling from the lift and fracturing her pelvis. The incident occurred when the CNA lifted the resident from her electric wheelchair using the mechanical lift, and the resident began to slide from the sling. The CNA attempted to lower the resident to the floor, but she hit her head on the bed frame and then the floor. The resident reported pain in her neck and the back of her head. Subsequent X-rays revealed a non-operable left pubic rami fracture. Witness statements from other CNAs and Licensed Nurses confirmed that the CNA had attempted the transfer alone, contrary to the facility's policy requiring two staff members for such transfers. The facility's policy for the safe use of mechanical lifts, revised in August of the previous year, mandated that two staff members be present during transfers. Despite this policy, the CNA proceeded with the transfer alone, leading to the resident's fall and injury. The facility's failure to adhere to its own safety protocols placed the resident in immediate jeopardy and at risk for significant harm.
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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