Logan Manor Community Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in Logan, Kansas.
- Location
- 415 N Washington St, Logan, Kansas 67646
- CMS Provider Number
- 175480
- Inspections on file
- 14
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Logan Manor Community Health Services during CMS and state inspections, most recent first.
Surveyors found that food items in multiple kitchenettes and a pantry were not labeled or dated, and daily temperature logs for dishwashers were not maintained. Administrative staff confirmed that these practices did not align with facility policies requiring proper labeling, dating, and documentation for food safety and sanitation.
The facility did not ensure RN coverage for at least eight consecutive hours each day, as required, on multiple occasions. Staffing records and schedules confirmed repeated days without an RN present, and administrative staff acknowledged the ongoing difficulty in maintaining RN staffing levels.
Staff did not date an opened insulin pen and failed to remove an expired bottle of stock medication from the medication cart. A nurse and administrative staff confirmed that medications should be dated and expired items discarded, in accordance with facility policy.
A resident's blood sugar was checked by a nurse in a common dining area, and the result was announced aloud in front of other residents and staff, violating the facility's policy on privacy and dignity.
A resident with anxiety, dementia, and major depressive disorder received PRN Ativan cream for agitation without a 14-day stop date or documented physician rationale for ongoing use. Staff administered the medication in response to agitation, but the order and medical record lacked required documentation, contrary to facility policy.
A resident with impaired mobility and multiple diagnoses experienced a fall while being loaded into a facility van without foot pedals on her wheelchair, resulting in minor injuries. The facility did not complete an investigation or root cause analysis of the incident, despite policy requirements and staff acknowledgment that these steps were not taken.
The facility did not provide a resident with written information about the bed-hold policy when transferred to the hospital, and failed to complete a required recapitulation in the discharge summary for another resident discharged home. Both deficiencies were confirmed through record review and staff interviews, with missing documentation and notifications as required by facility policy.
Three residents experienced falls due to the facility's failure to provide adequate supervision, ensure the use of required safety devices such as alarms and wheelchair foot pedals, and complete required fall risk assessments and investigations. In each case, staff did not follow individualized care plans or facility policy, resulting in preventable accidents and injuries.
A resident with anxiety, dementia, and major depressive disorder received PRN Ativan cream without a 14-day stop date or specified duration, as required by policy. The Consultant Pharmacist did not identify or report the missing stop date or rationale for continued use during monthly drug regimen reviews, and administrative staff confirmed the oversight. Facility policies requiring periodic reassessment and documentation for such medications were not followed.
The facility did not accurately submit direct care staffing information through PBJ, as required, resulting in reported gaps in licensed nurse coverage that did not reflect actual staffing. The issue was attributed to incomplete documentation of agency nurse hours, despite facility policy requiring all staffing, including agency and contract staff, to be reported.
A resident with cognitive impairment and a history of confusion was able to exit the facility unsupervised on two occasions by using unlocked doors, despite being identified as a fall risk. The care plan did not include interventions for wandering or elopement, and staff were unaware of the resident's absence until after the events. The facility's elopement policy was not followed for this individual prior to the incidents.
Failure to Properly Label, Date, and Store Food Items and Maintain Dishwasher Temperature Logs
Penalty
Summary
Surveyors observed that the facility failed to store food according to professional food service safety standards in two kitchenettes and one pantry room. Multiple food items, including potato salad, chicken patties, pancakes, vegetable beef soup, cranberries, strawberry yogurt, shredded American cheese, sliced Swiss cheese, chicken tenders, and diced chicken, were found in refrigerators and were not labeled or dated. Additionally, the facility did not maintain daily temperature logs for dishwashers in the kitchenettes since moving into the new facility, as staff believed that the use of low temperature dishwasher detergent eliminated the need for temperature documentation. Administrative staff confirmed these findings and acknowledged that food items should be labeled and dated before refrigeration or freezing. The facility's own policies required all products to be labeled with the date received and for food to be rotated appropriately, as well as for dishwashing and food storage practices to meet sanitary standards. However, these procedures were not followed, resulting in the cited deficiencies.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for at least eight consecutive hours a day, seven days a week, as required by regulation and the facility's own policy. Payroll Based Journal (PBJ) records and nursing schedules documented multiple days across several months when there was no RN present in the building for the required duration. Administrative staff confirmed these absences and attributed the issue to difficulty in recruiting RNs due to the facility's rural location. The deficiency affected all residents in the facility, which had a census of 32, and was identified through interviews and record reviews, including a sample of 12 residents.
Failure to Properly Label and Remove Expired Medications
Penalty
Summary
Staff failed to properly label and store medications and biologicals as required by facility policy and professional standards. During an observation of the medication room refrigerator, an opened insulin glargine pen belonging to a resident was found without an open date or discard date. Additionally, a medication cart inspection revealed a bottle of Thera High Potency Vitamin Dietary Supplement that had expired, yet remained in use. The bottle had been dated when placed in the cart, but the expiration date had passed. Licensed nursing staff confirmed that insulin pens are to be dated when opened and expired medications are to be discarded. Administrative staff also verified that medications should be removed once expired and that insulin pens require both an open date and an expiration date. Facility policies on medication administration and pharmacy services require all drugs and biologicals to be labeled according to accepted professional principles, including expiration dates, and to be stored and administered safely.
Failure to Protect Resident Dignity During Blood Glucose Testing
Penalty
Summary
A deficiency occurred when a licensed nurse checked a resident's blood sugar using a glucometer in a common dining area, rather than in a private setting. The nurse announced the resident's blood sugar result aloud in the presence of other residents who were seated at the dining table and in adjacent hallways. This action was observed by surveyors and was later confirmed by administrative staff to be contrary to facility policy, which requires such procedures to be conducted in private to protect residents' dignity, privacy, and confidentiality. The facility's policy specifically states that residents have the right to a dignified existence and privacy, which was not upheld in this instance.
Failure to Specify Duration and Rationale for PRN Antianxiety Medication
Penalty
Summary
The facility failed to ensure that a resident's as-needed (PRN) antianxiety medication, Ativan (lorazepam) cream, had a 14-day stop date or a specified duration with a physician's rationale for ongoing use. The resident, who had diagnoses of anxiety, dementia, and major depressive disorder, was noted to have severely impaired cognition and required extensive assistance with activities of daily living. The care plan indicated the resident received antianxiety medication and mental health consults, but the physician's order for Ativan cream lacked a stop date or documented rationale for continued PRN use. Observations showed the resident exhibiting agitation and resistance to redirection, leading to the administration of Ativan cream by staff. Review of the electronic medical record confirmed the absence of a specified duration or physician rationale for the extended use of the PRN medication. Administrative staff verified that the required stop date or justification for continued use was not obtained, which was inconsistent with the facility's policy on antipsychotic medication use that requires periodic reassessment and documentation.
Failure to Investigate and Analyze Resident Fall Incident
Penalty
Summary
The facility failed to complete an investigation, including a root cause analysis, after a resident experienced a fall while being loaded into a facility van. The resident, who had diagnoses of hypertension, transient ischemic attack, and chronic kidney disease, was documented as having impaired mobility and required substantial staff assistance for transfers and ambulation. On the day of the incident, the resident was being assisted by a licensed nurse and the activity director, but did not have foot pedals on her wheelchair, which made it more difficult to push her. As the staff attempted to pull the resident up the ramp, she slid forward out of the wheelchair and onto the ramp, resulting in two small skin tears on her left elbow. The incident was documented in the nurse's note, and the resident was treated for her injuries. Despite the fall and resulting injury, the electronic medical record lacked documentation that an investigation or root cause analysis was completed for the incident. Interviews with staff confirmed that a full investigation was not conducted, and administrative staff acknowledged the absence of a root cause analysis. The facility's policy required that investigations begin immediately and include a root cause analysis, but this was not followed in this case. The failure to investigate the fall and analyze its causes constituted a deficiency in responding appropriately to an alleged violation.
Failure to Provide Bed-Hold Policy Notification and Discharge Recapitulation
Penalty
Summary
The facility failed to provide a resident with written information regarding the bed-hold policy when the resident was transferred to the hospital. The resident in question had multiple diagnoses, including congestive heart failure, edema, GERD, and anxiety, and was noted to have moderately impaired cognition and required staff assistance with activities of daily living. During an acute episode involving fever and respiratory distress, the resident was transferred to the hospital, but the clinical record did not contain documentation that the bed-hold policy was provided to the resident or their representative, as required by facility policy. Administrative staff confirmed that there was no evidence of a signed bed-hold policy being given or acknowledged at the time of transfer. Additionally, the facility failed to complete a required recapitulation as part of the comprehensive discharge summary for another resident who was discharged home. This resident had a history of a femur fracture, anxiety, major depressive disorder, and hypertension, and required significant staff assistance with daily care. The care plan included arrangements for community resources and home health services upon discharge. However, review of the electronic medical record revealed that a discharge summary, including a recapitulation of the resident's stay, was not completed as required by facility policy. Administrative staff were unable to locate the required documentation. Both deficiencies were identified through record review and staff interviews, which confirmed the absence of required documentation and notifications related to resident needs, appeal rights, and bed-hold policies. The facility's own policies specify the need for written information and documentation in these situations, but these procedures were not followed in the cases reviewed.
Failure to Prevent Falls and Ensure Safe Environment
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent falls for three residents. One resident with a history of multiple fractures, severe cognitive impairment, and high fall risk was found on the floor in her room after a fall. Her care plan required the use of bed and chair alarms, but at the time of the incident, the alarm was not attached, and staff were unaware of the correct alarm type to use. The resident's environment also had poor lighting during the fall, and her medical record lacked a documented fall risk assessment. Another resident, who was dependent on staff for mobility and transfers and had a history of falls, slipped out of her wheelchair while being loaded into a facility van. Staff failed to ensure the use of foot pedals on the wheelchair, which contributed to the resident sliding forward and falling. The incident resulted in skin tears, and there was no documentation of a completed investigation or root cause analysis for the fall, despite facility policy requiring such actions after every fall. A third resident, with osteoarthritis and a moderate fall risk, experienced a fall when he was lowered to the floor by staff and subsequently dropped himself to the floor again. His care plan did not include new interventions after the fall, and there was no documentation of an investigation or root cause analysis. Staff interviews confirmed that the resident had a history of not using his call light and getting up on his own, which contributed to his fall risk. The facility's fall prevention policy required assessment and care plan review after each fall, which was not consistently followed.
Failure to Identify and Report Missing Stop Date for PRN Antianxiety Medication
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist identified and reported the absence of a 14-day stop date or specified duration for a resident's as-needed (PRN) antianxiety medication, as required by facility policy and federal regulations. The resident in question had diagnoses of anxiety, dementia, and major depressive disorder, with severely impaired cognition and required extensive assistance with activities of daily living. The physician's order for Ativan (lorazepam) cream, to be administered every six hours as needed for anxiety or aggression, did not include a stop date or documented rationale for continued use beyond 14 days. The resident's electronic medical record also lacked evidence of a specified duration or physician justification for the ongoing PRN use of lorazepam. During the monthly drug regimen review, the Consultant Pharmacist did not identify or report the missing stop date or rationale for the extended use of the PRN antianxiety medication to the Director of Nursing, medical director, or physician. Administrative staff confirmed that the facility did not obtain the required 14-day stop date or appropriate rationale for continued use, and that the pharmacist's monthly reviews did not include recommendations regarding this issue. Facility policies required that antipsychotic and antianxiety medications be prescribed for the shortest effective duration and reassessed periodically, but these procedures were not followed in this case.
Failure to Accurately Report Licensed Nurse Staffing in PBJ Submission
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information through Payroll Based Journaling (PBJ) as required. The PBJ report for a specific fiscal quarter indicated that there was no licensed nurse coverage on five dates. However, a review of the facility's licensed nurse payroll data for those dates showed that a licensed nurse was on duty 24 hours a day, seven days a week. Administrative staff confirmed that the discrepancies were likely due to the use of agency nurses whose hours were not properly documented in the PBJ system. The facility's policy required the submission of complete staffing information, including agency and contract staff, but this was not followed, resulting in inaccurate data being reported to CMS.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Lacking Care Plan Interventions
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent a resident from exiting the building unsupervised. The resident had a history of nontraumatic brain dysfunction, dementia, anxiety, depression, and psychotic disorder, and was assessed as having impaired decision-making skills and confusion, despite an MDS score indicating intact cognition. The care plan did not include interventions for wandering or elopement prior to the incident, although it did note the resident was a fall risk and required alarms for bed and chair mobility. On two separate occasions, the resident was able to leave the facility without staff awareness. In the first incident, the resident exited through unlocked double doors in a wheelchair while a maintenance staff member briefly left the room. The resident was later found outside on the sidewalk near a generator and was brought back inside by staff. In the second incident, the resident again exited the building, this time by kicking open a west door, and was found outside on the grass by a CNA taking out the trash. In both cases, the resident was unsupervised outside the facility for a period of time before being located and returned by staff. Observations and staff interviews confirmed that the doors used by the resident did not lock from the inside and that the resident's care plan lacked specific interventions for elopement risk prior to these events. The facility's elopement policy required identification and precautions for residents at risk, but these measures were not implemented for this resident before the incidents occurred.
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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