Medicalodges Iola
Inspection history, citations, penalties and survey trends for this long-term care facility in Iola, Kansas.
- Location
- 600 E Garfield Street, Iola, Kansas 66749
- CMS Provider Number
- 175226
- Inspections on file
- 21
- Latest survey
- August 12, 2025
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Medicalodges Iola during CMS and state inspections, most recent first.
Annual performance evaluations were not completed for five CNAs and CMAs who had been employed for over a year, despite facility policy requiring formal, written evaluations for all staff. Administrative staff confirmed that these evaluations were not conducted as required.
Surveyors identified unsanitary conditions in the kitchens, including dirty equipment, food debris, sticky floors, and improper hand hygiene by dietary staff. Staff interviews confirmed a lack of regular cleaning schedules and inconsistent adherence to facility policies for cleaning and sanitation.
The facility did not have a certified Infection Preventionist (IP) overseeing the infection prevention and control program. After the previous certified IP left, the current staff member assigned as IP was not certified, contrary to facility policy requiring certification for this role.
A Certified Medication Aide did not complete the required 12 hours of annual education, and administrative staff confirmed the absence of a facility policy on education. The aide verified not having completed the mandatory training, and no policy was provided by the facility.
Residents were not fully informed about their health status, care, and treatments. The facility did not provide adequate communication to ensure that residents understood their medical conditions and the care or treatments being administered.
Multiple areas of the facility, including a resident's room and the dining area, were found to be unclean and in disrepair, with sticky food debris, missing floor tiles creating unmarked tripping hazards, and damaged door frames and doors. Staff interviews confirmed that these issues persisted for weeks without adequate cleaning or safety measures, contrary to facility policy.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
Two residents had inaccurate Minimum Data Set (MDS) assessments, including errors in documenting fall history and medication use. One resident’s MDS failed to record all recent falls, including one with injury, while another’s MDS incorrectly listed anticoagulant use instead of antiplatelet therapy. Staff confirmed these inaccuracies, which resulted in the residents’ care needs not being properly identified.
Two residents did not have complete care plans addressing their specific needs: one with trigeminal neuralgia lacked non-pharmacological pain interventions in the care plan despite documented pain and medication orders, and another with respiratory failure did not have care plan instructions for oxygen use, even though oxygen therapy was ordered and administered.
A resident with severe cognitive impairment and an indwelling Foley catheter was transferred using a full body lift, during which staff attached the catheter drainage bag above bladder level, contrary to care plan instructions and standard practice. Staff interviews confirmed knowledge of proper catheter bag positioning, but this was not followed during the transfer. The facility did not provide a catheter care policy when requested.
A resident with trigeminal neuralgia did not receive scheduled doses of carbamazepine and lidocaine viscous solution due to a failure to reorder medications in a timely manner, resulting in increased pain and observed facial grimacing. The care plan lacked non-pharmacological interventions, and the facility's pain management policy was not fully implemented.
Staff failed to maintain resident dignity and privacy by transporting a resident through common areas in a shower chair with exposed buttocks and by entering the rooms of three residents without knocking, introducing themselves, or waiting for acknowledgment. Staff interviews confirmed awareness of proper protocols, and facility policy emphasized residents' rights to dignity and privacy.
A resident reported being roughly handled by a CNA, causing dizziness, nausea, and difficulty breathing due to improper bed positioning and lack of oxygen. Despite activating her call light and yelling for help, she did not receive assistance for hours. The incident was not immediately reported to administrative staff, allowing the CNA to continue her shift, placing other residents at risk.
A resident reported that a CNA was rough during a transfer, causing dizziness and difficulty breathing. The resident's call for help was ignored, and the CNA responded rudely. The incident was not reported to administrative staff immediately, allowing the CNA to continue working for eight more hours, putting other residents at risk.
A resident experienced abuse and neglect when a CNA was rough during a transfer, causing dizziness and difficulty breathing. The resident's call light was ignored for hours, and staff failed to report the incident immediately, allowing the CNA to continue working and potentially placing other residents at risk.
A cognitively impaired resident with a history of elopement risk exited the facility unnoticed due to a deactivated door alarm. The resident was found outside by a visitor, highlighting lapses in supervision and safety protocols.
Failure to Complete Annual Performance Evaluations for CNAs and CMAs
Penalty
Summary
The facility failed to complete annual performance evaluations for five Certified Nurse Aides (CNAs) and Certified Medication Aides (CMAs) who had been employed for more than 12 months. Personnel records reviewed showed that these evaluations had not been conducted within the required timeframe, as outlined in the facility's Employee Handbook, which mandates formal, written evaluations for all full and part-time employees. During an interview, administrative staff confirmed awareness of the requirement but acknowledged that the evaluations were not completed for the selected staff members.
Unsanitary Food Storage and Preparation Conditions Identified
Penalty
Summary
Surveyors observed multiple unsanitary conditions in the facility's kitchens, including dried food debris on the automated dishwasher, food particles and storage bags on top of the ice maker, and dirty, dusty fans blowing into food preparation and dish cleaning areas. The kitchen floors were found to be sticky, slick, and littered with food items and trash, while trash cans and counters were visibly dirty. Seven plastic cutting boards were deeply grooved and marked, and three large baking sheets had baked-on grease and cut marks, all of which were acknowledged by the Dietary Manager as unsanitary and in need of replacement. Additionally, a broken tile was noted around a clean-out drain by the stove, and clean dishes were exposed to air from a dirty fan. Staff interviews revealed a lack of regular cleaning schedules for key equipment such as the automated dishwasher, and inconsistent cleaning practices throughout the kitchen. Dietary staff were observed failing to perform hand hygiene or wear gloves when handling resident cups and food, and continued food preparation without proper sanitation. Facility policies required routine cleaning and disinfection, as well as adherence to written cleaning schedules and staff training, but these were not followed as evidenced by the ongoing unsanitary conditions and staff admissions regarding lapses in cleaning and hand hygiene.
Lack of Certified Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) was trained and certified in infection prevention and control, as required by their own policy and regulatory standards. At the time of the survey, the facility had a census of 43 residents. Interviews with administrative staff revealed that the previous certified IP left the facility on 06/01/25, and the current staff member identified as the IP was not certified in infection control. The facility's Infection Control Surveillance policy, dated 11/2023, specifies that the IP is responsible for monitoring compliance with infection prevention and control standards, but this requirement was not met due to the lack of a certified IP.
Failure to Ensure Mandatory CNA Education Requirements Met
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) completed the mandatory 12 hours of education required within a 12-month period. Review of personnel and training records showed that a Certified Medication Aide (CMA) had not completed any of the required education hours in the last year. During interviews, administrative staff confirmed that there was no facility policy related to education and that the facility relied solely on regulations. The CMA also verified not having completed the mandatory education during the specified period. No policy was provided by the facility regarding staff education requirements.
Failure to Inform Residents of Health Status and Treatments
Penalty
Summary
Residents were not fully informed about their health status, care, and treatments. The facility failed to ensure that residents received adequate information and understanding regarding their medical conditions and the care or treatments being provided. This lack of communication resulted in residents not having the necessary knowledge to make informed decisions about their care. The deficiency was identified through observations and interviews, which revealed that residents did not consistently receive explanations or updates about their health status or the treatments they were receiving.
Failure to Maintain Safe and Clean Environment Creates Tripping Hazards and Discomfort
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations of uncleanliness and physical hazards throughout the building. One resident's fall mat and room floor were found to have sticky food particles and debris, and the mat was described as filthy by a licensed nurse. The dining room floor was missing 44 tiles, creating a tripping hazard that was not marked with any warning signs or barriers. Additionally, door frames and doors in several hallways were observed to have bubbled, chipped, and missing paint, with some doors showing veneer separation. These issues were present in multiple areas, including the 100, 300, and 400 halls. Staff interviews revealed that the missing dining room tiles had been removed three weeks prior due to a plumbing issue, but no temporary safety measures were put in place. Maintenance staff acknowledged ongoing issues with door frame and door repairs, including monthly repainting and attempts to re-glue bubbling laminate. Administrative staff confirmed that floors should be cleaned daily and that maintenance should be notified immediately for repairs, but these practices were not consistently followed. The facility's own policy states that residents have the right to dignity, respect, and proper living arrangements, which were not upheld in these instances.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, resulting in documentation errors regarding their clinical status and care needs. For one resident with Parkinson’s disease and dementia, the Significant Change MDS incorrectly recorded the number and type of falls, documenting only one non-injury fall when records showed two falls, one of which resulted in a minor injury. Observations confirmed the resident’s high level of dependency and fall risk, and staff interviews acknowledged the MDS inaccuracy. The facility’s own documentation and staff statements confirmed that the MDS did not accurately reflect the resident’s fall history as required by the Resident Assessment Instrument (RAI) manual. For another resident with dementia, the Quarterly MDS inaccurately indicated that the resident received an anticoagulant during the assessment period, when in fact the resident was only receiving an antiplatelet medication (aspirin). The resident’s cognitive status was also documented inconsistently between assessments. Staff interviews confirmed the MDS error, and facility policy required accurate and timely completion of the MDS. These inaccuracies in the MDS assessments placed the residents at risk for impaired care due to unidentified or misidentified care needs.
Failure to Complete Comprehensive Care Plans for Pain and Oxygen Use
Penalty
Summary
The facility failed to complete comprehensive care plans for two residents, resulting in unaddressed care needs. One resident with a diagnosis of trigeminal neuralgia had a care plan that did not include staff instructions for non-pharmacological pain interventions, despite receiving both scheduled and PRN pain medications and reporting pain levels ranging from zero to nine on a one to ten scale. The resident's medical record included physician orders for pain management medications, and staff observed the resident experiencing pain, as evidenced by facial grimacing. The facility's pain management policy required individualized interventions for residents with pain to be documented in the care plan, but this was not done for this resident. Another resident with a diagnosis of respiratory failure and receiving oxygen therapy did not have staff instructions regarding oxygen use included in the care plan. The resident's medical record documented ongoing oxygen use per nasal cannula, as ordered by the physician, and staff observed the resident using oxygen during multiple visits. The facility's policy required the development of a care plan to address each resident's needs, but the omission of oxygen use instructions in the care plan represented a failure to communicate essential care requirements.
Failure to Maintain Proper Catheter Bag Position During Resident Transfer
Penalty
Summary
Staff failed to provide appropriate catheter care for a resident with an indwelling Foley catheter, as observed during a transfer from wheelchair to bed. The resident, who had diagnoses including urinary tract infection, Parkinson's disease, and dementia with severe cognitive impairment, required total assistance and was transferred using a full body lift. During the transfer, staff attached the Foley catheter drainage bag to the sling at the resident's shoulder level, which was above the level of the bladder, contrary to care plan instructions and standard catheter care practices. The bag was later placed level with the bladder and then attached to the bed frame. Interviews with staff confirmed awareness that the catheter drainage bag should remain below the level of the bladder at all times to prevent urine backflow. However, staff admitted to not considering this during the transfer. The facility did not provide a policy for catheter care when requested. This failure to maintain the catheter bag below bladder level during resident transfer constituted a deficiency in providing appropriate catheter care and services.
Failure to Administer Prescribed Pain Medications for Resident with Trigeminal Neuralgia
Penalty
Summary
A resident with a diagnosis of trigeminal neuralgia, a chronic and painful nerve condition, did not receive scheduled pain medications, including carbamazepine and lidocaine viscous solution, as ordered by the physician. The medication administration record showed missed doses over several days, and progress notes indicated that the pharmacy was notified of the need for refills, but the medications were not available or administered during this period. The resident reported increased pain and facial grimacing was observed by staff, with a pain score of nine out of ten documented on the morning following the missed doses. Staff interviews confirmed that the medications were not reordered in a timely manner, resulting in the resident not having access to her prescribed pain management regimen over the weekend. The resident's care plan included pharmacological interventions for pain but lacked direction for non-pharmacological interventions. The facility's pain management policy required individualized treatment plans with both pharmacologic and non-pharmacologic interventions for residents experiencing pain. Despite this, the resident's care plan was incomplete, and the failure to ensure timely medication refills and administration led to unmanaged pain for the resident.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
Staff failed to protect the dignity and privacy of three residents through several observed actions. One resident was transported from his room to the shower room in a shower chair covered only with a white sheet, leaving his buttocks exposed as he was wheeled past the dining area where other residents were present. Staff interviews confirmed that this method of transport was not appropriate or dignified, and that residents were typically moved in their wheelchairs, fully clothed or covered. Additionally, staff repeatedly entered the rooms of three residents without knocking, introducing themselves, or waiting for acknowledgment. Observations showed staff opening closed doors and entering rooms while residents were present, sometimes during interviews, without following proper protocols for privacy and respect. Multiple staff members, including CNAs and nurses, acknowledged in interviews that the expected practice was to knock, introduce themselves, and await acknowledgment before entering a resident's room. The facility's policy also documented residents' rights to dignity, respect, and privacy.
Failure to Prevent Abuse and Neglect of Resident
Penalty
Summary
The facility failed to prevent the physical abuse and neglect of a resident (R2) by a Certified Nurse Aide (CNA M). On the evening in question, R2 reported that CNA M was rough while assisting her to bed, throwing her into bed by holding her legs and swinging her while in the lift sling. This improper handling caused R2 to experience dizziness, nausea, and difficulty breathing due to the bed being left flat and the lack of supplemental oxygen. Despite activating her call light and yelling for help, R2 did not receive assistance for 3 to 3.5 hours until another CNA (CNA N) arrived for the night shift. When CNA N responded, she found R2 crying and upset, and CNA M yelled at R2 from the hallway, further exacerbating the situation. CNA N reported the incident to Licensed Nurse (LN G), who also failed to report the abuse and neglect to the administrative staff immediately, allowing CNA M to continue her shift for eight more hours, placing other residents at risk for abuse and neglect. R2's medical records indicated she had muscle weakness, anxiety disorder, and chronic obstructive pulmonary disease (COPD), requiring oxygen at night to maintain oxygen saturations above 90 percent. R2 was assessed with intact cognition and required extensive assistance from two staff members for bed mobility and transfers with a full-body lift. The facility's investigation revealed that R2 had been left in a flat position without oxygen, causing her significant distress. Multiple staff members, including CNA N and LN G, witnessed R2's distress and reported the incident, but the reports were not immediately escalated to the administrative staff as required by the facility's policy. The facility's policy for Abuse, Neglect, and Exploitation mandates immediate reporting of any alleged violations involving abuse, neglect, exploitation, or mistreatment to the Administrator or their designated representative. However, this policy was not followed, as evidenced by the delayed reporting and the continued presence of CNA M in the facility. The failure to adhere to the policy and the improper handling of R2 by CNA M resulted in immediate jeopardy for R2 and other residents in the facility.
Removal Plan
- Administrative Staff A and Administrative Nurse D interviewed R2. R2 confirmed the allegations.
- CNA M interviewed by Administrative Staff A and Administrative Nurse D and asked if she had done all the things reported and CNA M responded yes and began crying. CNA M suspended.
- CNA M interviewed by Administrative Staff A regarding the allegations against CNA N to R2.
- The LN completed an assessment.
- Verbal discipline and education given to LN G for not reporting immediately.
- All staff training initiated immediately on reporting allegations of abuse and completed at the start of each shift.
- Written discipline given to LN G.
- QAPI meeting held with the medical director.
- CNA M terminated.
Failure to Report Abuse and Neglect Immediately
Penalty
Summary
The facility failed to report abuse and neglect of a resident immediately. On the evening of 03/21/24, a resident reported that a Certified Nurse Aide (CNA) was rough with her during a transfer from her wheelchair to her bed, causing her to feel dizzy, nauseous, and have difficulty breathing. The resident activated her call light and yelled for help, but the CNA responded by yelling back from the hallway and did not assist her. The resident remained in an uncomfortable and unsafe position without her supplemental oxygen for several hours until another CNA arrived for the night shift and provided the necessary assistance. The incident was reported to a Licensed Nurse (LN) at 10:10 PM, but the LN and the CNA who discovered the resident's distress did not report the abuse and neglect to the administrative staff immediately. The administrator only became aware of the situation the following morning after reading the Report of Concern forms. The CNA involved in the incident continued to work her shift for eight more hours, potentially putting other residents at risk. The resident involved had a medical history of muscle weakness, anxiety disorder, and chronic obstructive pulmonary disease (COPD). She required oxygen at night and extensive assistance from staff for bed mobility and transfers. The facility's failure to report the abuse and neglect immediately allowed the CNA to remain on duty, which placed the resident and potentially other residents in immediate jeopardy.
Removal Plan
- Administrative Staff A and Administrative Nurse D interviewed R2. R2 confirmed the allegations.
- CNA M interviewed by Administrative Staff A and Administrative Nurse D and admitted to the allegations. The facility suspended CNA M.
- CNA M interviewed by Administrative Staff A regarding the allegations against CNA N to R2.
- The LN completed an assessment.
- Verbal discipline and education given to LN G for not reporting immediately.
- All staff training initiated immediately on reporting allegations of abuse, and completed at the start of each shift.
- Written discipline given to LN G.
- QAPI meeting held with the medical director.
- CNA M terminated.
Failure to Protect Resident from Abuse and Neglect
Penalty
Summary
The facility failed to protect a resident from further abuse and neglect when staff did not immediately notify the administrator of an allegation of abuse. The incident occurred when a Certified Nurse Aide (CNA) was reported to have been rough with the resident during a transfer to bed, causing the resident to experience dizziness, nausea, and difficulty breathing. The resident's call light was not answered for several hours, and when another CNA arrived, the resident was found crying and upset. Despite being informed of the situation, the staff did not report the abuse immediately to the administrator, allowing the CNA to continue working for eight more hours, potentially placing other residents at risk. The resident involved had a medical history that included muscle weakness, anxiety disorder, and chronic obstructive pulmonary disease (COPD). The resident required oxygen and had limited use of her right arm, necessitating total assistance from staff for bed mobility and transfers. On the night of the incident, the resident was left in a flat position without her supplemental oxygen, which exacerbated her symptoms. The resident's oxygen saturation level was documented at 85 percent, significantly lower than her usual levels. The facility's policy required immediate reporting of any allegations of abuse, neglect, or exploitation to the administrator. However, the staff failed to follow this policy, resulting in a delay in addressing the resident's concerns and removing the CNA from duty. The failure to report the incident promptly and the continued presence of the CNA in the facility constituted a serious deficiency in the facility's duty to protect its residents from abuse and neglect.
Removal Plan
- Administrative Staff A and Administrative Nurse D interviewed R2. R2 confirmed the allegations.
- CNA M interviewed by Administrative Staff A and Administrative Nurse D and asked if she had done all the things reported and CNA M responded yes and began crying. CNA M suspended.
- CNA M interviewed by Administrative Staff A regarding the allegations against CNA N to R2.
- The LN completed an assessment.
- Verbal discipline and education given to LN G for not reporting immediately.
- All staff training initiated immediately on reporting allegations of abuse and completed at the start of each shift.
- Written discipline given to LN G.
- QAPI meeting held with the medical director.
- CNA M terminated.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for a cognitively impaired and independently mobile resident identified as an elopement risk. On one occasion, staff deactivated an exit door alarm due to a storm, which led to the resident exiting the facility without staff knowledge. The resident was found outside by a visitor, who then informed the facility staff. The resident had a history of Alzheimer's disease, dementia, and hallucinations, and was assessed with severe cognitive impairment and a high elopement risk level. Despite these known risks, the facility did not ensure that the exit door alarms were functioning, nor did they provide appropriate supervision for the resident, who had previously displayed exit-seeking behaviors. The resident's care plan included interventions such as structured activities, reorientation strategies, and monitoring for wandering patterns. However, these measures were not effectively implemented, as evidenced by the resident's ability to exit the facility unnoticed. Staff members who were present during the incident did not hear any door alarms, and the door that the resident exited from was found to be unlocked and unalarmed. Multiple staff members provided witness statements indicating that they were unaware of the resident's whereabouts until alerted by the visitor. The facility's failure to maintain functioning door alarms and provide adequate supervision placed the resident in immediate jeopardy. The incident highlighted significant lapses in the facility's safety protocols and staff awareness, which ultimately led to the resident's elopement. The facility's policies and procedures for monitoring and preventing elopement were not effectively followed, resulting in a serious deficiency in resident care and safety.
Removal Plan
- The facility immediately placed R1 on one-to-one supervision with staff, after the nurse assessed for injuries when he returned back inside the building.
- A facility wide door check completed by maintenance to ensure all alarmed doors were in proper working order.
- R1's elopement assessment updated, and all other residents has elopement assessment completed and care plan reviewed for accuracy and appropriateness.
- Stop signs placed on hallway exit doors to remind resident to turn around.
- The facility's Elopement book reviewed to ensure accurate content.
- The Administrator, Director of Nursing, and Medical Director held a QAPI (Quality Assurance Performance Improvement) meeting via phone.
- All staff educated on elopement policy and resident incident. Otherwise, employees were suspended pending required in-service.
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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