Orchard Gardens
Inspection history, citations, penalties and survey trends for this long-term care facility in Wichita, Kansas.
- Location
- 1600 S Woodlawn Blvd, Wichita, Kansas 67218
- CMS Provider Number
- 175452
- Inspections on file
- 30
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Orchard Gardens during CMS and state inspections, most recent first.
A resident with intact cognition but extensive ADL dependence and morbid obesity, who relied on staff for wheelchair mobility, was propelled down a hallway slope by a CNA in a wheelchair without foot pedals, causing the resident’s right foot to drop under the chair and resulting in a right femoral neck fracture. The care plan noted the need for a Hoyer lift and that the resident could self-propel with foot pedals stored on the back of the wheelchair, but it did not specify non–weight-bearing limb status, did not address the fracture, and lacked clear interventions for safe wheelchair locomotion. Video evidence showed no foot pedals in use and contradicted nursing notes that described the resident self-propelling and catching her ankle on a foot pedal, and administrative staff reported there was no MDS nurse to update care plans and no incident report or witness statements completed.
A resident with schizoaffective disorder and borderline intellectual functioning, who had intact cognition and verbal behaviors toward others, was issued an involuntary discharge notice after behaviors that allegedly endangered others, including actions posing a serious fire risk. The facility did not develop a comprehensive care plan, did not obtain a physician discharge order, and did not complete a discharge summary with a recapitulation of the stay or documented medication reconciliation, even though the resident was discharged home with medications. The involuntary discharge notice omitted required elements, including instructions on how to file an appeal, identification of who at the facility would assist with an appeal, the Ombudsman’s name and email, and contact information for state protection and advocacy agencies for individuals with developmental disabilities and mental disorders.
A resident with suspected adrenal insufficiency, hypothyroidism, myxedema, prior stroke with one-sided impairment, visual changes, and multiple identified care needs (including mobility, incontinence, falls, nutrition, pressure injury risk, and psychotropic drug use) did not have a comprehensive, person-centered care plan. The MDS and CAAs documented that these areas would be addressed, and the resident had active orders for levothyroxine, trazodone, methadone, and continuous oxygen, yet the written care plan only noted the resident’s wish to remain in the facility and full-code status, with no specific interventions or measurable objectives. Staff reported that an offsite MDS nurse initiated care plans and the IDT was expected to update them, but acknowledged that updates had not been maintained, resulting in a care plan that did not reflect the resident’s actual care needs.
Two residents did not consistently receive ordered medications as prescribed, including thyroid replacement for a resident with hypothyroidism and myxedema and alprazolam for a resident with anxiety and bipolar disorder. MAR review showed multiple missed doses of levothyroxine without hold orders or documented reasons, despite the resident reporting prior hospitalizations for severe hypothyroidism and stating that staff sometimes gave the medication incorrectly or not at all. Another resident had multiple missed doses of alprazolam over several days, with EMAR notes indicating medication unavailability, pharmacy issues, and awaiting prescriptions, and several entries lacking reasons for non‑administration. Staff interviews revealed that CMAs and nurses were expected to administer medications per orders, use the emergency kit or contact the pharmacy when medications were not available, and document all administrations or omissions, but actual MAR and EMAR documentation was incomplete and inconsistent with these expectations.
A kitchen was found to have live and dead roaches in multiple areas, including behind refrigerators, under counters, and in storage, along with uncovered garbage cans. Dietary staff reported the pest issue had persisted for about six months, and administrative staff confirmed the ongoing problem despite regular pest control visits. These unsanitary conditions placed residents at risk for foodborne illness.
The facility did not ensure shower rooms and smoking areas were kept clean and free of mildew or unknown substances, with observations of black/brown stains, cigarette smoke odor, ashes, and water damage in two shower rooms, as well as numerous cigarette butts littering the entryway and courtyard. The entryway lacked a cigarette receptacle, and the exhaust fan in one shower room was not working, contrary to facility policy for maintaining a sanitary and homelike environment.
A resident with chronic pain and depression, who was cognitively intact and required ADL assistance, was involved in a verbal altercation with a maintenance staff member that included yelling and profanities. Multiple witnesses confirmed the exchange, and the incident was not documented in the resident's health record. The facility's policy against abuse was not followed, resulting in the resident experiencing verbal mistreatment.
Surveyors identified multiple deficiencies in food storage and handling, including uncovered, undated, and unsealed food items in both refrigerated and dry storage, as well as the use of uncleanable cutting boards. Dietary staff confirmed that these practices did not meet facility policy, placing residents at risk for foodborne illness.
The facility did not complete required annual performance evaluations for five CNAs employed for over a year, as shown by missing signed evaluations in their files and confirmed by administrative staff. Facility policy requires annual reviews and links in-service training to these evaluations.
Five CNAs did not receive the required 12 hours of annual in-service training or education on mandated topics such as dementia care and abuse prevention. Training records were incomplete and outdated, and administrative staff could not provide documentation to show compliance with facility policy.
Staff did not consistently follow infection control protocols, including leaving clean clothes uncovered in a dusty laundry area, failing to use required PPE such as gowns and gloves during care for residents with tube feedings or wounds, and neglecting proper hand hygiene during peri-care and dressing changes. Interviews revealed staff were unaware of EBP protocols and correct procedures, and maintenance staff did not recognize environmental risks in the laundry area.
Multiple deficiencies were observed in the facility's environment, including damaged walls, missing tiles, broken furniture, makeshift window coverings, and built-up dirt in resident rooms and common areas. Staff interviews confirmed that maintenance issues were reported but not consistently addressed, and the facility lacked a policy for ensuring a homelike environment.
Multiple residents were found with prohibited items such as lighters, cigarettes, vape supplies, unsecured medications, alcohol, firecrackers, and a pocketknife in their rooms, including one resident with an oxygen cannula and another with a nebulizer. Hazardous chemicals and a mouse trap were also found unsecured in an unlocked cupboard. Staff interviews confirmed these items were not allowed per facility policy, and that staff were expected to confiscate such contraband when found.
A resident with multiple mental health diagnoses and on high-risk psychotropic medications did not receive a required PASARR Level 2 evaluation, despite documentation indicating the need for further assessment. Staff interviews revealed confusion about responsibility for PASARR compliance, and the necessary evaluation was not found in the EHR. Facility policy addressed CARE assessments but did not specify procedures for obtaining a Level 2 PASARR screening.
A resident with cognitive and physical care needs did not have their bathing preferences and required assistance accurately reflected in their care plan. The care plan lacked specific guidance for staff, and documentation showed the resident received fewer baths than scheduled, with no refusals recorded. Interviews and observations confirmed the resident's requests for baths were not addressed, and staff did not consistently document offers or refusals as required by facility policy.
Three residents with cognitive and physical impairments did not receive necessary assistance with ADLs, including bathing, eating, and personal hygiene. One resident received fewer showers than scheduled and requested, another was not assisted with eating despite care plan requirements, and a third did not receive full assistance with shaving due to lack of equipment and staff follow-through.
Two residents were not given the required CMS-10055 SNF Advanced Beneficiary Notice (ABN) when their Medicare Part A benefits ended before the 100-day limit, leaving them uninformed about their options and potential financial responsibility for continued skilled services. This was confirmed by an administrative nurse, and the facility's policy requiring ABN issuance was not followed.
Two residents were found to have beds in unsafe and inoperable conditions, including a broken bed frame and a bed with exposed wiring and a malfunctioning remote. Maintenance staff confirmed the deficiencies, and no policy on bed safety or maintenance was provided.
Surveyors found that trash bags were left on the ground next to an uncovered portable dumpster, and doors were left open on a stationary dumpster. Dietary staff were unaware of the requirement to keep all trash covered, which is contrary to facility policy stating dumpsters must be kept closed and free of litter.
A cognitively impaired resident at high risk for elopement was allowed to exit the facility unsupervised, despite having a WanderGuard alarm. The alarm was turned off without checking which resident triggered it, and the resident was not noticed missing until three hours later. The resident was found and returned by law enforcement after being outside for five and a half hours.
Failure to Prevent Wheelchair Fall Due to Missing Foot Pedals and Inadequate Supervision
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision and equipment use for a wheelchair-dependent resident, resulting in a right femur fracture. The resident had intact cognition with a BIMS score of 15 and was dependent on staff for most ADLs, including transfers, toileting, showers, and wheelchair mobility. The care plan documented that the resident had an ADL self-care deficit, required a Hoyer lift for transfers, had limited physical mobility related to morbid obesity, and could self-propel in a wheelchair, with foot pedals to be kept in a bag on the back of the wheelchair when not in use and staff to monitor safety on an ongoing basis. However, the care plan lacked specific mention of the right femur fracture, did not specify which limb was non-weight-bearing, and did not include clear interventions directing staff regarding the use of foot pedals for locomotion. On the date of the incident, camera footage showed a CNA propelling the resident in a wheelchair down a hallway slope without foot pedals attached, with the resident’s legs extended and not supported. As the wheelchair moved down the incline, the resident’s right foot dropped to the floor, became entangled under the wheelchair, and the resident fell to the floor, later confirmed by mobile X-ray and hospital records as a displaced right femoral neck fracture. The resident reported that the CNA pushed the wheelchair too fast and that no foot pedals were in place when her right foot went under the chair. Nursing notes contained conflicting descriptions of the event, including references to the resident self-propelling and the right ankle catching on a foot pedal, which were inconsistent with the video evidence of no foot pedals in use. Administrative staff acknowledged that the camera footage contradicted the nursing note about foot pedal use, that there was no MDS nurse to update care plans, and that no incident report, witness statements, or staff education were completed for this incident.
Failure to Complete Discharge Recapitulation and Provide Complete Involuntary Discharge Notice
Penalty
Summary
The deficiency involves the facility’s failure to complete a discharge summary with a recapitulation of the resident’s stay, including medication reconciliation, and failure to issue a fully compliant involuntary discharge notice. The resident had schizoaffective disorder and borderline intellectual functioning, with an admission MDS showing intact cognition (BIMS 15), no depression, and verbal behaviors toward others. The MDS indicated no plans for discharge and that the resident planned to remain at the facility. A Cognitive Loss/Dementia CAA identified potential for altered cognitive patterns related to schizoaffective disorder and noted verbal behaviors, but the electronic health record lacked evidence that a comprehensive care plan was developed for this resident. An involuntary discharge notice was issued, citing that the safety of individuals in the facility was endangered due to the resident’s behaviors, including an incident in which the resident engaged in actions that posed an immediate and serious risk of fire requiring staff intervention. The notice referenced ongoing explosive, aggressive, and unsafe behaviors and specified a discharge date 30 days from the notice, as well as discharge locations and appeal rights. However, the notice did not include information on how to file an appeal or identify who in the facility would assist the resident with the appeal. It also omitted the Ombudsman’s name and email contact information, and lacked contact information for the State Agency responsible for protection and advocacy for individuals with developmental disabilities and for individuals with a mental disorder. The resident’s physician orders did not contain a discharge order, and there was no recapitulation of the resident’s stay or documented medication reconciliation at the time of discharge, despite facility policy requiring a discharge summary that includes a recapitulation of the stay. Progress notes documented that the resident was to receive an involuntary discharge and be discharged with 30 days of medications, and that the family was educated to call 911 if aggression occurred. Another progress note documented that the resident was discharged home with family with medications and belongings, and a subsequent note indicated the family returned seeking clarification on how to administer the medications. During interviews, staff and a consultant confirmed that administrative staff prepared discharge paperwork, that no narcotics were sent with residents, and that no recapitulation or medication list could be produced for what was sent with the resident at discharge, confirming the lack of required discharge documentation and complete notice content.
Failure to Develop Comprehensive, Person-Centered Care Plan for Medically Complex Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and interventions for a resident with multiple complex medical conditions. The resident’s EMR documented diagnoses including suspected adrenal insufficiency, hypothyroidism, myxedema, and a prior cerebral infarction, with associated right-sided impairment, use of a walker, and need for supervision or touching assistance with care. The admission MDS and multiple Care Area Assessments (CAAs) identified issues in visual function, functional abilities (self-care and mobility), urinary incontinence/indwelling catheter, falls, nutritional status, pressure ulcer/injury, and psychotropic drug use, and each CAA stated these areas would be addressed in the care plan. Despite this, the resident’s care plan dated 08/12/25 only documented that the resident wished to stay in the facility and was a full code, and lacked any additional information or specific interventions related to the identified care areas. The resident had active physician orders for levothyroxine for myxedema, trazodone for insomnia, methadone for pain, and continuous oxygen at two liters, but these treatments and related care needs were not reflected in a comprehensive care plan. Staff interviews showed that a CMA stated staff should follow the care plan to care for residents, while an LN reported she did not enter information into the care plan. An administrative nurse explained that an offsite MDS nurse started the care plan and the interdisciplinary team was supposed to add to it as needed, but acknowledged the team had not kept up with updating the care plan. Another administrative nurse stated it was her expectation that care plans reflect the resident’s care and be started and updated as needed. These findings demonstrated that, contrary to the facility’s policy requiring a comprehensive, person-centered care plan with measurable objectives and timetables for each resident, the resident’s care plan was incomplete and did not address the resident’s identified physical, psychosocial, and functional needs.
Failure to Administer and Document Ordered Medications for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, resulting in ordered medications not being administered as prescribed for two residents. One resident with diagnoses including hypothyroidism, myxedema, and prior cerebral infarction had an order for levothyroxine 200 mcg daily starting in early November, later changed to 137.5 mcg daily in January. Review of the Medication Administration Record (MAR) showed multiple dates in November when the 200 mcg levothyroxine dose was not given, with no corresponding order to hold the medication and no documented reason for omission. The resident, who was cognitively intact, reported multiple hospitalizations for hypothyroidism, including a coma prior to admission and an ICU stay with a 10‑day hospitalization in November, and stated that staff had not been giving thyroid medications correctly, sometimes administering them after meals with other medications or not at all. Staff interviews revealed inconsistent practices and documentation related to medication administration and availability. A Certified Medication Aide (CMA) stated that she did not give the thyroid medication because she believed the night shift nurse had already administered it between 5:00 AM and 6:00 AM, and also described that when medications were not available, staff would look for them and mark them as not given with a specific reason in a note. However, the MAR for the resident with hypothyroidism lacked documentation of reasons for the missed levothyroxine doses. A Licensed Nurse (LN) stated that if a CMA reported a medication could not be found, she would search for it, contact the pharmacy, use the emergency medication kit if needed, and document the reason on the MAR, emphasizing that the MAR should never be left blank and that all medications should be given and documented as ordered. For the second resident, who had anxiety and bipolar disorder and was cognitively intact, physician orders required alprazolam 0.5 mg every morning and at bedtime for anxiety. The MAR documented nine missed doses over several consecutive days. EMAR administration notes showed repeated notations that the pharmacy was notified, that the medication was not on hand, that the pharmacy reported no prescription on file, and that staff were awaiting a prescription and delivery. On several occasions, the EMAR lacked documentation explaining why alprazolam was not administered. The resident reported that staff missed several doses of his alprazolam. Facility policy on administering medications stated that medications were to be administered in accordance with prescriber orders, in a safe and timely manner, and that administration times should be based on resident need and benefit rather than staff convenience, but the documented omissions and incomplete MAR entries for both residents showed that medications were not consistently administered or documented as ordered.
Failure to Maintain Sanitary Kitchen Conditions Due to Ongoing Roach Infestation
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by the presence of both live and dead roaches in various stages of life throughout the kitchen area, including behind and on the sides of refrigerators and freezers, under the clean dish storage rack, under the meal prep counter, behind doors, and in the dry storage room. Observations also revealed two garbage cans in the kitchen without lids, which staff stated were left uncovered for convenience. Dietary staff confirmed ongoing issues with roaches and reported that the problem had persisted for approximately six months, despite regular pest control visits. Interviews with dietary and administrative staff confirmed awareness of the pest issue, with staff reporting the problem to the Certified Dietary Manager and the administrator being responsible for contacting pest control services. The facility's pest control policy requires an effective program to keep the building free of insects and rodents, but the ongoing presence of roaches indicated a failure to meet this standard. The unsanitary conditions in the kitchen placed residents at risk for foodborne illnesses.
Failure to Maintain Cleanliness and Homelike Environment in Shower Rooms and Smoking Areas
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment in two of three shower rooms and in designated smoking and entryway areas. Observations revealed the presence of mildew or an unknown black/brown substance on the walls of the 400-hall and 200-hall shower rooms, with the 400-hall shower room also exhibiting a strong odor of cigarette smoke and ashes around the toilet. The paint in the 400-hall shower room showed bubbling consistent with water damage, and the exhaust fan in the 200-hall shower room was not operational. These findings were confirmed by facility consultants, who identified the substance in the 400-hall shower room as mildew and noted the similarity of the substance in the 200-hall shower room. Additionally, the exterior entryway and smoking courtyard were observed to be littered with dozens of used cigarette butts. The entryway lacked a cigarette receptacle, while the courtyard had several receptacles present. The facility's policies required a clean and sanitary environment and specified the use of metal containers with self-closing covers in smoking areas, but did not provide further guidance on the disposal of cigarette butts. Staff interviews confirmed that the entryway is a non-smoking area and that expectations were for shower rooms and smoking areas to be kept clean, with maintenance notified of any damage or discoloration.
Resident Exposed to Verbal Abuse by Maintenance Staff
Penalty
Summary
A deficiency occurred when a resident with chronic pain and major depressive disorder, who was cognitively intact and required assistance with activities of daily living, was subjected to verbal abuse and mistreatment by a maintenance staff member. The incident took place in the facility's parking lot, where the resident and the staff member engaged in a verbal argument that included yelling and the exchange of profanities. Multiple witnesses, including other residents and staff, confirmed the altercation and the use of inappropriate language. The facility's investigation documented that the situation was de-escalated by administrative staff who intervened and separated the individuals involved. Despite the occurrence of the incident, there was no documentation of the event in the resident's electronic health record for the relevant period. Witness statements were collected from staff and bystanders, but a statement from the maintenance staff member involved was not obtained. The facility's policy prohibits any form of resident abuse, including verbal abuse and intimidation, but this policy was not upheld in this instance, resulting in the resident being exposed to verbal mistreatment.
Improper Food Storage and Handling Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage, preparation, and serving practices. During an inspection of the kitchen and storage areas, several food items were found uncovered, undated, or unsealed in both the refrigerator and dry storage. Examples included an uncovered and undated tray of chocolate pie dessert, individually portioned cranberry sauces and dressings past their date, staff personal food items without dates, and various bags of cheese, ham, turkey, and breadsticks that were either unsealed, undated, or stored with meat juices at the bottom of containers. Additionally, a box of recalled shakes was found, and several dry storage items such as Oreos, potato chips, cocoa powder, baking powder, and pancake mix were unsealed or past their best-by dates. Two cutting boards were also noted to have deep gashes, making them uncleanable. Interviews with dietary staff confirmed that the observed storage and labeling practices did not meet facility policy, which requires all opened food items to be labeled, dated, and sealed. Staff acknowledged that the presence of undated, unsealed, and improperly stored food items was unacceptable and not in accordance with professional standards or facility policy. These actions and inactions placed residents at risk for foodborne illness due to improper food handling and storage.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for five Certified Nurse Aides (CNAs) who had been employed for more than 12 months. A review of employee files revealed that none of the five CNAs had performance evaluations signed by management, as required by the facility's policy. During an interview, an administrative staff member acknowledged difficulty in producing the requested evaluations and was unaware that annual performance evaluations for CNA staff were required. The facility's policies state that job performance should be reviewed at least annually and that in-service training is based on the outcomes of these reviews.
Failure to Provide Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required annual in-service training, both in terms of content and duration. A review of training records for five CNAs who had been employed for over a year revealed that none had completed the mandated 12 hours of in-service training within the previous 12 months. The only documented training for two CNAs was on Abuse, Neglect, and Exploitation, with no evidence of additional required topics. Further review showed that none of the five CNAs had received in-service training on all required topics, including care for residents with cognitive impairment, dementia management, and abuse prevention, as outlined in the facility's policy. During an interview, administrative staff were unable to provide documentation for the required training and were unaware that the available records were outdated. The facility's policy mandates at least 12 hours of in-service training per year, covering specific topics, but this was not met for the reviewed CNAs.
Failure to Implement and Adhere to Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow established infection prevention and control practices in several areas of the facility. Clean clothes were left uncovered in the laundry folding area, directly beneath exposed insulation and pipes covered with dust, contrary to facility policy requiring personal clothing to be stored in clean, dust-free areas. During observations, there was no Enhanced Barrier Precautions (EBP) signage or precautions outside any resident doors, and staff did not consistently use required personal protective equipment (PPE) such as gowns and gloves when providing care to residents with conditions requiring EBP, including those with tube feedings, open wounds, or catheters. Direct care staff were observed not performing proper hand hygiene or using correct techniques during peri-care and dressing changes. For example, a CNA used the same part of a washcloth for multiple strokes during incontinence care, applied ointment with soiled gloves, and failed to remove gloves and wash hands before re-gloving. Another CNA picked up a dropped glove from the floor and reused it, placed soiled linen directly on the floor, and did not perform hand hygiene after glove removal. A licensed nurse did not perform hand hygiene before applying gloves for a dressing change. These actions were inconsistent with the facility's hand hygiene policy, which requires hand hygiene before and after glove use. Interviews with staff revealed a lack of awareness and understanding of EBP protocols and proper infection control procedures. Staff admitted to not using gowns when required, not posting EBP signage, and not following correct hand hygiene and linen handling practices. Maintenance staff were unaware of the exposed insulation and dust above the laundry area where clean clothes were stored. These deficiencies in infection control practices had the potential to contribute to the spread of infections among residents.
Failure to Maintain a Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's physical environment, including missing thresholds, broken or missing tiles, chipped paint, exposed drywall, and damaged or missing baseboards in resident rooms and common areas. Several rooms had makeshift window coverings such as blankets instead of curtains, broken window blinds, and missing dresser drawers. In one instance, a standing floor fan was missing its front cover, and a room had a strong smell of cigarettes. Built-up dirt was noted on walls and floors, and the activity room had several missing floor tiles, which staff reported had caused tripping incidents. These conditions were directly observed in the rooms of several residents and in common areas. Interviews with staff revealed that maintenance concerns were to be reported through a computer system, and all staff had access to submit work orders. However, some staff acknowledged that issues such as missing curtains and environmental hazards had persisted, and administrative staff were aware of ongoing concerns but had not fully addressed them. The facility did not provide a policy regarding maintaining a homelike environment. These actions and inactions resulted in a failure to promote a sanitary, safe, and homelike environment for residents.
Failure to Prevent Accident Hazards and Secure Prohibited Items
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, as evidenced by multiple residents possessing prohibited items such as lighters, cigarettes, vape supplies, unsecured medications, alcohol, firecrackers, and a pocketknife in their rooms. Observations revealed that one resident with an oxygen cannula had a lighter and vape supplies in his room and reported vaping there. Another resident had a lighter and cigarettes on her dresser while not present in the room. Additional residents were found with lighters, cigarettes, and in one case, a nebulizer with tubing hooked up next to smoking materials. One resident had unsecured prescription medications on his bedside dresser, and another had a large bottle of vodka, firecrackers, and a pocketknife in his closet, along with medicated chest rub and an albuterol inhaler at bedside. Staff interviews confirmed that these items were not permitted per facility policy, and that staff were expected to confiscate such contraband when found. Further, the facility failed to secure hazardous chemicals in a safe manner. An unlocked cupboard under a workstation sink contained a spring-loaded mouse trap, a full gallon of drain cleaner, a gallon of disinfectant cleaner, and a spray bottle of germicidal cleaner, all labeled as harmful and to be kept out of reach of children. Staff interviews indicated a lack of awareness regarding the presence of these chemicals and the expectation that such items should be locked away. Facility policies required that smoking materials not be kept in residents' possession and that maintenance storage areas be locked to prevent unauthorized access to hazardous chemicals.
Failure to Obtain Required PASARR Level 2 Evaluation
Penalty
Summary
The facility failed to obtain a required PASARR Level 2 evaluation for a resident with multiple significant mental health diagnoses, including suicidal ideations, auditory hallucinations, major depressive disorder, generalized anxiety disorder, schizoaffective disorder, and primary insomnia. The resident's records indicated the use of high-risk antipsychotic, antianxiety, and antidepressant medications, and the care plan documented ongoing behavioral and mood problems. The resident's CARE assessment specifically indicated the need for further evaluation (Level 2), but there was no documentation in the electronic health record that this evaluation had been completed. Interviews with facility staff revealed a lack of clarity regarding responsibility for PASARR compliance, with the administrative staff deferring to the Assistant DON and the business office manager unable to locate the required documentation. The social service designee reported discovering the missing Level 2 evaluation during a chart audit and subsequently submitting paperwork to the state, but this action occurred after the deficiency was identified. The facility's policy outlined responsibilities for completing and submitting CARE assessments but did not address the process for obtaining a PASARR Level 2 screening when recommended.
Failure to Update Care Plan and Honor Bathing Preferences
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident regarding bathing preferences and needs. The resident had multiple diagnoses, including dementia with behavioral disturbances, generalized anxiety disorder, insomnia, and psychotic disorder with hallucinations. Despite being cognitively intact according to the BIMS score, the resident required staff assistance for bathing and expressed a strong preference for the type and frequency of baths. The care plan did not include specific guidance for staff about the resident's bathing preferences, schedule, or required assistance. Documentation in the electronic medical record and bath sheets showed that the resident received only five baths in a 30-day period, instead of the twelve scheduled, and there was no record of the resident refusing any offered baths. Observations and interviews revealed that the resident repeatedly requested baths without receiving a response from staff and needed help with certain aspects of bathing for safety reasons. Staff interviews confirmed that resident preferences should be care planned and that offers and refusals should be documented, but this was not consistently done. The facility's policy required assessments and resident interviews to develop person-centered care plans, but this was not followed in the case of the resident's bathing needs.
Failure to Provide Assistance with ADLs Including Bathing, Eating, and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services and assistance with activities of daily living (ADLs) for three residents, resulting in unmet care needs. One resident with diagnoses including dementia, disorientation, and psychotic disorder had a care plan that lacked specific guidance regarding bathing preferences, such as type, frequency, and time of day. Although the resident was scheduled for showers three times a week, documentation showed only five showers were provided in a 30-day period, instead of the twelve scheduled. The resident reported repeatedly requesting a bath without response from staff, and there was no documentation of refusals. Another resident with severe cognitive impairment and aphasia required set-up and supervision for eating, as documented in the care plan and dietary notes. Observations revealed that the resident was left with food and drink out of reach, with no tray table available, and was not provided the necessary assistance to eat. The resident remained in the same position for extended periods, and staff interviews confirmed that the resident required assistance, which was not consistently provided. A third resident with dementia and Parkinson's disease required maximal assistance with personal hygiene, including shaving. Documentation indicated the resident was dependent on staff for these tasks. Observations showed the resident had significant facial hair and reported wanting a shave but was not allowed to have a razor. Staff interviews confirmed that shaving was only partially performed due to lack of appropriate equipment, and the care plan for personal hygiene was not fully followed. The facility did not provide policies on ADL assistance for these cases.
Failure to Provide Required Medicare ABN Notice at Termination of Benefits
Penalty
Summary
The facility failed to provide two residents with the required CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice (ABN) when their Medicare Part A benefits were terminated prior to the exhaustion of the 100-day benefit period. Both residents began receiving Medicare Part A services and, upon discharge from these services, remained in the facility. However, neither resident was given the ABN form, which is necessary to inform them of their right to choose continued skilled services and the associated financial responsibility for services not covered by Medicare. This deficiency was confirmed by an administrative nurse, who acknowledged that the facility did not issue the appropriate SNF ABN notice at the time of Medicare Part A termination. The facility's own policy requires that the ABN be provided to residents or their representatives to enable informed decisions regarding continued skilled services and potential costs, but this procedure was not followed for the two affected residents.
Failure to Maintain Safe and Operable Bed Equipment
Penalty
Summary
The facility failed to ensure that beds used by two residents were maintained in a safe and operable condition. One resident's bed frame was observed to be broken and unable to sit level, with the bed being an older crank style. Another resident's bed had a remote that was stuck under the bed and caught in the frame, with stripped sheathing and unraveled wires, and the bed was resting almost completely on the ground. The resident reported that while the bed could go up and down, the head of the bed could not be raised or lowered. Maintenance staff confirmed the issues with both beds and acknowledged that the conditions were unacceptable. The facility did not provide a policy related to bed safety or maintenance.
Improper Disposal and Storage of Garbage and Refuse
Penalty
Summary
During an inspection, surveyors observed that three bags of trash were left on the ground next to a portable dumpster that did not have a lid, and two doors were open on one of the two stationary dumpsters outside the facility. Dietary staff present at the time stated they were unaware that all trash, including that in portable dumpsters, was required to be covered. The facility's policy, dated January 2024, specifies that outside dumpsters provided by garbage pickup services must be kept closed and free of surrounding litter. These observations indicate that the facility failed to maintain and dispose of garbage and refuse in a sanitary manner, as required by their policy.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
The facility failed to ensure a safe and secure environment to prevent the elopement of a cognitively impaired resident identified at high risk for elopement. On the specified date, the charge nurse allowed the resident to exit the front doors of the building to smoke, not realizing the resident was not permitted to leave unescorted. The resident's WanderGuard alarm activated, but the CNA who turned off the alarm did not check which resident had triggered it. The facility did not realize the resident was missing until three hours later when the certified medication aide could not find the resident to administer medications. The resident was eventually found and returned by local law enforcement after being outside the facility for five and a half hours. The resident had a diagnosis of dementia and was identified as having severely impaired cognition. The care plan indicated the resident was at high risk for elopement and had a WanderGuard in place, which was supposed to be checked each shift. Despite these measures, the resident was able to leave the facility unsupervised. The facility's policy required staff to ensure the placement and function of the WanderGuard each shift and to document its status, but these procedures were not followed effectively. Interviews with staff revealed that there was a lack of understanding and adherence to the facility's elopement and alarm policies. The administrative nurse stated that staff should have known the difference between door alarms and WanderGuard alarms and should not have turned off the alarm without checking its cause. The facility's failure to provide adequate supervision and to respond appropriately to the WanderGuard alarm placed the resident in immediate jeopardy.
Removal Plan
- All staff were re-educated regarding the elopement policy, missing person policy, and resident sign out policy.
- Elopement drills were completed on each shift.
- All residents at risk for elopement received a WanderGuard bracelet and they were checked for function and placement.
- All residents had updated wandering assessments completed.
- The Risk for Elopement Book was reviewed and updated.
- All residents identified as being at risk for elopement had care plans updated as needed.
- Agency staff would be educated on the audible wander alarm sounds prior to working a shift.
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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