Lincoln Park Manor Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lincoln, Kansas.
- Location
- 922 N 5th St, Lincoln, Kansas 67455
- CMS Provider Number
- 175419
- Inspections on file
- 14
- Latest survey
- September 8, 2025
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Lincoln Park Manor Inc during CMS and state inspections, most recent first.
The facility did not ensure that the director of food and nutrition services had the required certification as a CDM, as both the dietary manager and administrator were still in the process of obtaining certification. The registered dietician visited only twice a month, and the facility's policy requiring specific qualifications for this role was not met.
Staff did not consistently follow Enhanced Barrier Precautions or proper hand hygiene during wound care for two residents with pressure ulcers, including not wearing gowns, not changing gloves at appropriate times, and not performing hand hygiene between glove changes. Additionally, a resident's oxygen and nebulizer equipment was not properly stored when not in use, contrary to facility policy.
The consultant pharmacist did not provide the required monthly drug regimen review, resulting in missed communication of medication recommendations for several residents, including those prescribed antipsychotic and antidepressant medications. As a result, necessary recommendations for gradual dose reduction or physician rationale were not relayed to prescribers, and medication irregularities were not addressed in a timely manner.
Surveyors found that medication carts were left unlocked and unattended, insulin pens were not labeled or dated when opened, and expired medications were present in both medication carts and the emergency medication kit. Staff confirmed these deficiencies, which were not in accordance with facility policy requiring secure storage and proper labeling of all medications.
A resident with COPD and moderately impaired cognition was allowed to keep and self-administer an inhaler at bedside without a physician's order or documented assessment of self-administration ability. The resident's care plan required staff to administer medications, and facility policy mandated an IDT assessment and order before permitting self-administration, but these were not completed.
Staff left a resident's electronic medical record open and visible on a medication cart laptop, failing to secure protected health information. A CMA and a nurse both confirmed that screens and carts should be locked when unattended, in accordance with facility policy.
The facility did not ensure proper management and documentation of psychotropic medications for several residents, including missing stop dates for PRN antianxiety medication, lack of appropriate indications and risk/benefit documentation for antipsychotic use, and failure to obtain or document physician responses to pharmacist recommendations for gradual dose reduction of antidepressants. Required policies for psychotropic and antipsychotic medication use were not provided when requested.
Two residents with complex medical needs did not have their care plans updated after significant changes in condition, including hospital readmission and the need for Enhanced Barrier Precautions. Staff were not provided with current guidance on required care interventions or PPE use, leading to care being delivered without appropriate infection control measures and without reflecting the residents' increased need for assistance.
A resident with COPD and other conditions did not have their oxygen tubing, cannula, and nebulizer mask stored in a sanitary manner as required by facility policy. Staff left these respiratory devices unbagged and exposed in the resident's room, despite being aware of the need to keep them bagged when not in use.
Two residents receiving hospice care did not have their care plans updated to include specific details about hospice services, such as the frequency of visits, supplies, medications, and equipment provided by hospice. Although hospice documentation was present in the medical records and staff confirmed regular hospice involvement, the care plans lacked this essential information, resulting in incomplete coordination of care as required by facility policy.
Unqualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the director of food and nutrition services possessed the required qualifications, specifically the certification as a certified dietary manager (CDM). Observations and interviews revealed that the current dietary manager and the administrator were both enrolled in classes to obtain CDM certification but had not yet completed them. The facility's policy required the director of food and nutrition services to be a CDM, a certified food service manager, be nationally certified in food service management and safety, have an associate's degree in food service management or hospitality, or have two or more years of experience in the position along with a completed course in food safety and management. At the time of the survey, these requirements were not met, and the registered dietician was only present twice a month, though available by phone.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols during wound care for two residents. In one instance, two licensed nurses provided wound care to a resident with a Stage 2 pressure ulcer without following EBP guidelines, such as wearing gowns and changing gloves at appropriate times. The care plan for this resident did not include specific instructions for EBP or the required personal protective equipment (PPE), and a certified nurse aide was unaware that EBP was necessary for this resident. The resident had multiple diagnoses, including Alzheimer's disease, COPD, hemiparesis, and was dependent on staff for all activities of daily living. In another case, wound care for a resident with a Stage 4 pressure ulcer was performed without the use of protective gowns, and hand hygiene was not consistently performed between glove changes or after glove removal. One nurse applied clean gloves without performing hand hygiene, failed to don a gown, and did not sanitize hands after removing gloves or handling trash. The facility's policies required the use of gowns and gloves for high-contact care activities and specified hand hygiene before and after glove use, but these protocols were not followed during the observed care. Additionally, the facility failed to ensure that a resident's nasal cannula and nebulizer mask were properly stored when not in use, which could contribute to infection risk. The facility's own policies on EBP and hand hygiene were not adhered to during these care activities, as evidenced by staff statements and direct observation.
Failure to Provide Timely Monthly Drug Regimen Review and Communicate Medication Irregularities
Penalty
Summary
The facility's consultant pharmacist failed to provide a monthly Drug Regimen Review (MRR) for February 2025, as required by facility policy and federal guidelines. This omission resulted in the facility and physicians not receiving timely recommendations regarding residents' medication regimens. Specifically, the pharmacist did not communicate recommendations for gradual dose reduction (GDR) or request a physician's rationale and risk versus benefit analysis for certain psychotropic medications prescribed to residents. The absence of the February 2025 MRR meant that medication irregularities were not identified or addressed in a timely manner. For one resident with diagnoses including Alzheimer's disease, hypertension, anxiety, and depression, the medical record showed ongoing use of antipsychotic, antidepressant, and antianxiety medications. The pharmacist's review noted the lack of an allowable diagnosis for the antipsychotic medication and requested a risk versus benefit statement or discontinuation, but this recommendation was not sent to the facility or physician, resulting in no physician response. The resident's care plan required quarterly consultation with pharmacy and physician to consider dosage reduction, but this process was not followed due to the missing review. Another resident with diabetes and major depressive disorder was prescribed sertraline, an antidepressant. The pharmacist had previously recommended a GDR or rationale for continued use, but no physician response was documented. The February 2025 MRR, which reiterated this recommendation, was not sent to the facility until months later, and the physician did not receive it. Facility policy required the consultant pharmacist to review each resident's medication regimen monthly and communicate any irregularities to prescribers and facility leadership, but this was not done for the month in question.
Failure to Secure, Label, and Remove Expired Medications
Penalty
Summary
Surveyors observed multiple instances where the facility failed to ensure the proper labeling, dating, and secure storage of medications and biologicals. On several occasions, medication carts were found unlocked and unattended, and medications such as insulin pens were not labeled with resident names or dates of opening. Additionally, expired medications, including aspirin, Systane eye drops, Dulcolax pills, melatonin, artificial tears, lidocaine jelly, and epinephrine auto-injectors, were found in both medication carts and the emergency medication kit. These findings were verified by various staff members, including a Certified Medication Aide, a Licensed Nurse, and an Administrative Nurse, who acknowledged the presence of expired and unlabeled medications and the failure to secure medication carts as required by facility policy. The facility's policies, dated February 2023, required that all medication storage areas be locked when not in use, that medication labels include the resident's name and expiration date, and that insulin pens be labeled and dated when opened. Despite these policies, staff did not consistently follow procedures for medication security and labeling, resulting in the presence of expired and improperly labeled medications accessible in the facility. No specific residents were identified as directly affected in the report, but the deficiencies were confirmed through direct observation and staff interviews.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including COPD, edema, chronic pain, anxiety, hypertension, and atrial fibrillation, was allowed to keep and self-administer a Breztri inhaler at her bedside without a physician's order or a documented assessment of her ability to safely self-administer medications. The resident's medical record indicated moderately impaired cognition and a care plan that directed staff to administer medications as ordered. The self-administration assessment documented that the resident required assistance for all medications, including inhalants, and there was no order permitting self-administration or bedside storage of the inhaler. During medication administration, a licensed nurse discovered the inhaler was not in its box and found it on the resident's bedside table. The resident self-administered the inhaler in the nurse's presence. Facility policy required an interdisciplinary team assessment and a physician's order before allowing self-administration or bedside storage of medications, but these steps were not completed for this resident.
Failure to Secure Resident Medical Record on Medication Cart Laptop
Penalty
Summary
Facility staff failed to secure and protect the privacy and confidentiality of a resident's medical record. On one occasion, staff left a resident's point of care information open and visible on the electronic medical record system at the medication cart laptop, making the information accessible to unauthorized individuals. A certified medication aide acknowledged that the screen should not be left unlocked with resident information displayed. A licensed nurse confirmed that both the medication cart and the laptop screen should always be locked when unattended, and an administrative nurse stated that nursing staff are expected to lock any screen on the laptop and secure the medication cart when not in direct sight. The facility's policy requires that protected health information not be used or disclosed except as permitted by law.
Failure to Ensure Proper Management and Documentation of Psychotropic Medications
Penalty
Summary
The facility failed to ensure appropriate management and documentation of psychotropic medications for multiple residents. For one resident with diagnoses including vascular dementia, anxiety, bipolar disorder, and major depressive disorder, the physician’s order for PRN Ativan lacked a required stop date, and the medication was administered without issue. The facility did not provide a policy for psychotropic medication use when requested, and the administrative nurse confirmed that the Ativan order should have included a stop date and reassessment by the physician. Another resident with Alzheimer’s disease, anxiety, and depression was prescribed Seroquel for anxiety and agitation, with the dose later increased. The care plan directed staff to consider dosage reduction quarterly, but the physician’s order did not include an appropriate indication or documentation of risk versus benefit for the antipsychotic use. The administrative nurse acknowledged that agitation was not an appropriate diagnosis for Seroquel and that the physician needed to provide ongoing justification for its use. The facility was unable to provide a policy for antipsychotic medication use upon request. A third resident with diabetes and major depressive disorder was prescribed sertraline, with the consultant pharmacist recommending a gradual dose reduction or rationale for continued use. There was no documented physician response to these recommendations, and the administrative nurse confirmed that the physician had not received or responded to the pharmacist’s recommendations. The facility’s pharmacy services policy required monthly medication regimen reviews and communication of recommendations, but the facility did not provide a specific policy for psychotropic drugs.
Failure to Update Care Plans After Significant Change in Condition
Penalty
Summary
The facility failed to ensure that care plans for two residents were updated to reflect their current care needs following significant changes in their conditions. One resident, who had diagnoses including Alzheimer's disease, COPD, hemiparesis, and anxiety, was dependent on staff for all activities of daily living and had a Stage 2 pressure ulcer. Despite being on hospice and requiring Enhanced Barrier Precautions (EBP) due to an open area, the care plan did not include interventions or directions for staff regarding the use of personal protective equipment (PPE) necessary for infection control. Staff interviews revealed a lack of awareness about the resident's EBP status, and care was provided without appropriate PPE, as confirmed by both nursing and administrative staff. Another resident, with diagnoses of paraplegia, hypertension, pressure ulcer, and osteomyelitis, experienced a significant change in condition after a hospital stay and was placed on hospice services. The resident's Minimum Data Set (MDS) indicated increased dependence on staff for activities of daily living, but the care plan was not revised to reflect these changes. The care plan continued to document previous levels of independence and did not address the resident's current needs for assistance, despite the resident now requiring more substantial support and the use of a mechanical lift with two staff members for transfers. Facility policy required that comprehensive, person-centered care plans be developed and updated within specific timeframes following significant changes in a resident's condition, including after hospital readmission and at least quarterly. In both cases, the care plans were not updated as required, resulting in a lack of clear guidance for staff and the potential for delayed or missed care.
Failure to Store Respiratory Equipment in a Sanitary Manner
Penalty
Summary
Staff failed to provide adequate respiratory care and services for a resident diagnosed with COPD, vascular dementia, anxiety, bipolar disorder, and major depressive disorder. The resident had physician orders for supplemental oxygen via nasal cannula and nebulizer treatments, with care plans and facility policy directing that oxygen tubing, cannula, and nebulizer mask be stored in a plastic bag when not in use to prevent infection. However, observations revealed that the resident's oxygen tubing and cannula were left unbagged and draped over a lamp, and the nebulizer mask was left unbagged on a table beside the resident's recliner on multiple occasions. Interviews with staff confirmed awareness of the policy requiring these respiratory devices to be bagged when not in use, and staff acknowledged that bags had been provided for this purpose. Despite this, the resident's preference to drape the tubing over the lamp was noted, and staff did not consistently ensure proper storage as required by facility policy. The facility's infection prevention policy specifically directed staff to keep these items in a plastic bag when not in use, but this was not followed, resulting in a failure to maintain sanitary storage of respiratory equipment.
Failure to Coordinate and Document Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure proper collaboration and communication between hospice providers and facility staff for two residents receiving hospice care. For one resident with Alzheimer's disease, COPD, hemiparesis, and anxiety, the care plan documented receipt of hospice services and provided general instructions for comfort and medication administration. However, it lacked specific details about the hospice services being provided, such as the frequency of support visits, supplies and medical equipment covered by hospice, medications provided, and the hospice provider's contact information. The resident's records confirmed hospice admission, and staff interviews indicated that hospice staff visited regularly, but the care plan was not updated to reflect these arrangements. For another resident with paraplegia, hypertension, a stage 4 pressure ulcer, and osteomyelitis, the care plan noted a terminal prognosis and receipt of hospice services. The plan included directions for comfort measures and collaboration with the hospice team but did not specify which durable medical equipment, supplies, or medications were provided by hospice, nor did it detail the hospice staff involved or the frequency of their visits. Although the resident's electronic medical record contained the hospice plan of care and related documentation, this information was not incorporated into the care plan used by facility staff. Facility policy required coordinated care plans for residents receiving hospice services, including the most recent hospice plan of care and details of care and services provided by both the hospice and the facility. Staff interviews confirmed that care plans should include all relevant hospice information, but this was not consistently done for the residents in question. As a result, the facility did not ensure comprehensive and coordinated care planning for residents on hospice, as required by its own policy.
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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