Parkview Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Osborne, Kansas.
- Location
- 811 N 1st St, Osborne, Kansas 67473
- CMS Provider Number
- 175409
- Inspections on file
- 16
- Latest survey
- September 3, 2025
- Citations (last 12 mo.)
- 38
Citation history
Health deficiencies cited at Parkview Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not employ a full-time Certified Dietary Manager for 43 residents receiving meals from the kitchen. The staff member acting as Dietary Manager had not completed the required certification course, contrary to facility policy requiring supervision by a certified dietary manager or equivalent.
Surveyors identified multiple failures in food storage, preparation, and serving practices, including staff not using required beard and mustache covers, unclean fans and shelving, uncovered and unlabeled food items, use of expired sanitizing strips, improper thermometer sanitation, and direct hand contact with eating surfaces of utensils.
The facility did not submit accurate PBJ staffing data to CMS, resulting in reports of low weekend nurse staffing and missing 24-hour licensed nurse coverage, despite internal records showing adequate staffing. The facility also lacked a policy for PBJ submission, and the process was managed by corporate staff with administrative nurse review.
The facility's QAA program did not identify or address numerous deficiencies, including failures in resident dignity, proper documentation, care planning, incident reporting, staff background checks, nurse staffing, medication management, food service, and environmental sanitation. Despite expectations for department heads to report concerns and conduct mock surveys, the facility lacked effective action plans, resulting in widespread unaddressed issues affecting most residents.
A licensed nurse was found to have pre-set multiple resident-labeled medication cups in the medication cart, contrary to facility policy and professional standards. This practice was acknowledged by the nurse and confirmed as inappropriate by administrative staff, as medications are required to be prepared and administered only when the resident is ready to receive them.
Staff did not activate a motion detector floor alarm for a resident requiring supervision, as outlined in the care plan, and failed to keep hazardous chemicals locked in the laundry room. These actions resulted in an environment that was not free from accident hazards, placing residents at risk.
Surveyors found that expired medications, including Docusate sodium, Aspirin, Vitamin B12, and Ibuprofen, were not disposed of as required. A nurse confirmed the expired drugs should have been removed, and an administrative nurse stated that both the night shift and nurses administering medications are responsible for checking and disposing of expired items. Facility policy requires routine inspection and destruction of outdated medications, but these procedures were not consistently followed.
The facility did not offer, obtain informed declination, or document physician contraindication for pneumococcal vaccinations, including PVC20, for several residents. Medical records lacked evidence of consent or refusal, and none of the sampled residents had been offered or received the vaccine since admission, despite facility policy requiring assessment and documentation in line with CDC guidelines.
Staff administered a blood sugar test and insulin injection to a resident at a dining room table in view of others, and failed to cover another resident's urinary drainage bag, violating privacy and dignity standards as outlined in facility policy.
The facility did not provide required Medicare notices, including the ABN and NOMNC forms, to three residents or their representatives when skilled services ended. This failure meant that the residents or their representatives were not properly informed about potential financial liability for services not covered by Medicare, as confirmed by administrative staff and record review.
A resident with severe cognitive impairment and a history of falls was placed in a wheelchair with a Lap Buddy restraint without a physician's order, assessment, or care plan documentation. Staff used the device to prevent the resident from standing and falling, but the required medical documentation and justification for restraint use were not present.
A Housekeeping Supervisor was employed without a documented background check, as confirmed by administrative staff and the employee herself. The facility lacked both the required background check documentation and a policy on background checks.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not provide required bed hold notifications to two residents during emergency hospital transfers and failed to notify the LTCO of three resident discharges. Documentation and staff interviews confirmed that neither the residents nor their representatives received information about the bed-hold policy, and the ombudsman was not informed of the discharges, contrary to facility policy.
A resident with a history of UTIs and multiple comorbidities was receiving daily prophylactic antibiotics per ongoing physician orders, but the care plan was not updated to reflect this intervention. The care plan addressed incontinence and skin care but omitted the resident's UTI history and antibiotic use, and there was no documented physician rationale for the continued medication. The facility also could not provide a policy on care plan revisions.
A resident with multiple chronic conditions received long-term prophylactic antibiotics without documented physician review or rationale, and the consultant pharmacist failed to identify or report this ongoing use during monthly drug regimen reviews. The care plan lacked documentation of UTI history or antibiotic prophylaxis, and pharmacy reviews did not address the prolonged antibiotic therapy.
A resident with multiple chronic conditions was administered Nitrofurantoin daily for UTI prophylaxis over several months without documented physician review or rationale. The care plan did not indicate a history of UTIs or need for prophylactic antibiotics, and staff could not provide required documentation of antibiotic use review, resulting in the resident receiving unnecessary medication.
A resident receiving hospice care, who was dependent on staff and had severe cognitive impairment, did not have a care plan that included key hospice information such as contact numbers, visit schedules, and details about supplies and medications. Staff confirmed the absence of this information, despite facility policy requiring coordinated care planning with the hospice provider.
The facility did not maintain proper documentation of the Medical Director's attendance at a required QA&A committee meeting, as the signature was missing from the attendance roster. Staff reported the Medical Director was present, but no signed record was available, and the facility could not provide a QA&A policy.
The facility did not post required daily nurse staffing information for several days, as confirmed by administrative staff and direct observation. The missing postings included details such as the facility name, date, census, and actual hours worked by RNs, LPNs/LVNs, and CNAs, in violation of facility policy.
Lack of Certified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time Certified Dietary Manager for 43 residents who receive their meals from the kitchen. During an observation, the staff member identified as the Dietary Manager stated she was still in the process of completing the Certified Dietary Manager course and had not yet obtained certification. The facility's policy requires support staff to work under the supervision of a registered dietitian nutritionist (RDN), certified dietary manager, or director of food and nutrition services, with delegation of tasks based on competency and scope of practice. At the time of the survey, the individual acting as Dietary Manager did not meet the certification requirements outlined in facility policy.
Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to maintain sanitary conditions in the storage, preparation, and serving of food for 43 residents. Observations included dietary staff with facial hair not wearing beard or mustache covers, and a fan above the microwave area with excessive grey/black lint on the blades and screens, blowing toward the steam table. The dining room refrigerator/freezer contained two uncovered and undated containers of chocolate ice cream. Additionally, a fan near the three-compartment sink was also found with excessive lint, and the lower shelving throughout the kitchen was unclean with food debris and dark particles. The Hydrion QT-40 chemical sanitizing strips used for monitoring sanitizer strength were expired. Further deficiencies were observed in food handling practices. A dietary staff member checked food temperatures without sanitizing the thermometer between foods, and another staff member sorted clean spoons from a dishwasher rack by touching the eating surfaces with bare hands. These actions were verified by dietary staff, who acknowledged that proper procedures were not followed, including the need for beard and mustache covers, labeling and covering food items, cleaning fans and shelving, sanitizing thermometers, and avoiding direct contact with eating surfaces of utensils.
Failure to Submit Accurate PBJ Staffing Data
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information through Payroll Based Journaling (PBJ) as required by CMS. Although CMS PBJ reports for two consecutive fiscal quarters indicated excessively low weekend nurse staffing and a lack of 24-hour licensed nursing coverage on specific dates, a review of the facility's own nursing schedules and coverage records for those periods showed that adequate staffing and licensed nurse coverage were actually maintained. The discrepancy arose because the PBJ data submitted did not accurately reflect the facility's actual staffing levels. Additionally, the facility did not have a policy in place related to PBJ submission, and the process involved corporate staff submitting the data with review by the administrative nurse.
QAA Program Fails to Identify and Address Multiple Facility Deficiencies
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) program failed to identify and address multiple issues affecting 33 out of 44 residents. Deficiencies included failure to treat two residents with dignity, improper completion of beneficiary notices for three residents, and lack of physician orders, assessments, and updated care plans for a resident's use of a lap buddy. The facility did not provide documentation of a background check for a staff member prior to employment, failed to report a resident's fall with fracture and another resident's injury to the State Survey Agency, and did not provide required notifications or bed hold policies to residents or their representatives during transfers and discharges. Additionally, care plans were not revised for appropriate use of prophylactic antibiotics, and safety measures such as floor motion detectors and secure chemical storage were not consistently implemented. Further deficiencies included not ensuring a Registered Nurse was on duty for the required hours, failure to post nurse staffing information, and the pharmacy consultant not reporting the physician's rationale for continued antibiotic use. The facility also failed to ensure drugs and biologicals were not expired, did not employ sufficient staff with appropriate competencies in food and nutrition services, and did not maintain a clean and sanitary kitchen environment. Hospice services information was not integrated into care plans, and the medical director did not sign in on quarterly QAA meetings. Despite department heads being expected to bring concerns to QAA meetings and conducting mock surveys, the facility did not develop or implement effective plans of action to address these issues, as evidenced by the multiple deficiencies cited.
Failure to Adhere to Professional Standards in Medication Preparation
Penalty
Summary
The facility failed to meet professional standards of quality in medication administration. During an observation of the medication cart on the long-term care unit, four handwritten, resident-labeled medication cups containing various medications were found pre-set in the top drawer. A licensed nurse admitted to pre-setting these medications and acknowledged awareness that this practice was not permitted. The facility's policy requires medications to be administered by licensed staff as ordered and in accordance with professional standards to prevent contamination or infection. An administrative nurse confirmed that medications should not be pre-set before the resident is ready to take them.
Failure to Activate Resident Alarm and Secure Hazardous Chemicals
Penalty
Summary
Staff failed to ensure a safe environment free from accident hazards by not activating a motion detector floor alarm for a resident with macular degeneration and a history of pain, who required supervision and assistance with transfers and ambulation. The resident's care plan specifically instructed staff to ensure the motion alarm was on whenever the resident was in his room. However, observations revealed the alarm was not activated while the resident was present, and staff confirmed the alarm should have been on according to the care plan. Additionally, chemicals including disinfectants, laundry bleach, lime scale remover, and detergent were found unsecured in an unlocked laundry room on the dementia unit. Labels on these chemicals indicated they could cause harm if ingested, inhaled, or if they came into contact with skin or eyes. Staff and consultants verified that these chemicals should have been stored in a locked room, as required by facility policy, to prevent resident access and minimize accident hazards.
Expired Medications Not Disposed of Timely
Penalty
Summary
Surveyors observed that the facility failed to dispose of expired medications in a timely manner. During an inspection of the East medication room, several expired stock medications were found, including Docusate sodium, Aspirin, Vitamin B12, and Ibuprofen, all past their respective expiration dates. A licensed nurse confirmed that these expired drugs should have been disposed of, and an administrative nurse stated that the night shift is responsible for checking the medication cart for expired medications, with each nurse administering medications also expected to check and dispose of expired items. The facility's policy requires that all medications be stored according to manufacturer recommendations and that medication rooms are routinely inspected for discontinued, outdated, defective, or deteriorated medications. The policy also specifies that such medications are to be destroyed in accordance with the facility's procedures. Despite these policies, expired medications remained in the medication room, indicating that the required checks and disposals were not consistently performed.
Failure to Offer and Document Pneumococcal Vaccinations per CDC Guidelines
Penalty
Summary
The facility failed to offer, obtain informed declination, or secure physician-documented contraindication for pneumococcal vaccinations, including the PVC20, for five sampled residents. Review of the clinical medical records for these residents showed no evidence that the residents or their representatives received or signed a consent to receive or decline the pneumococcal vaccine. Additionally, none of the five residents had been offered or received the pneumococcal vaccine since their admission to the facility, as confirmed by their electronic health records. An administrative nurse confirmed that immunization status is assessed upon admission and that the Web IZ portal is used to check prior immunizations. The nurse also stated that consent forms are provided to residents or their representatives for signature. However, she acknowledged that due to workload and issues with insurance coverage for the vaccine, she had not completed the process for some residents. The facility's policy requires offering pneumococcal immunization in accordance with CDC guidelines, assessment upon admission, and documentation of consent or refusal, but these steps were not followed for the sampled residents.
Failure to Maintain Resident Dignity During Care Procedures
Penalty
Summary
Staff failed to maintain and enhance resident dignity and respect by administering a finger stick blood sugar test and an insulin injection to a resident at the dining room table, in full view of other residents and visitors. During the observation, a licensed nurse performed these procedures while two other residents and two staff were seated at the same table, and seven additional residents were present in the dining room. Additionally, staff did not place a privacy bag on another resident's urinary drainage bag, leaving it exposed. These actions were verified by a nurse consultant, who confirmed that such procedures should not be conducted in public areas and that privacy should be maintained. The facility's own policy requires staff to protect and promote residents' rights, treat each resident with respect and dignity, and maintain privacy during care and procedures.
Failure to Provide Required Medicare Coverage and Liability Notices
Penalty
Summary
The facility failed to provide required Medicare notices to three residents or their representatives regarding the end of skilled services and potential financial liability for services not covered by Medicare. Specifically, one resident or their representative did not receive the completed Skilled Nursing Facility Advanced Beneficiary Notice (ABN) form 10055, and two other residents or their representatives did not receive either the ABN form 10055 or the Notice of Medicare Non-Coverage (NOMNC) form 10123. These forms are intended to inform beneficiaries that Medicare may not pay for certain skilled therapy services and to outline their options and potential financial responsibilities. The lack of these notices was confirmed by administrative staff during the survey. The facility's policy required timely issuance of these notices, including hand delivery and proper documentation, to ensure residents and their representatives were aware of Medicare eligibility, coverage, and any changes in charges. The policy also specified that the Business Office Manager or designee was responsible for issuing these notices and that the current CMS-approved versions of the forms must be used. Despite these requirements, the facility did not provide the necessary forms to the affected residents or their representatives when skilled services ended, as verified through record review and staff interviews.
Failure to Obtain Physician Order and Assessment for Use of Lap Buddy Restraint
Penalty
Summary
A resident with diagnoses including dementia without behavioral disturbance, transient ischemic attack, traumatic subdural hematoma, muscle weakness, and unsteadiness was observed using a Lap Buddy device in a wheelchair. The resident's medical record documented severely impaired cognition and a history of multiple falls, with care plans addressing fall risk but lacking any mention of the Lap Buddy. During observation, staff placed the Lap Buddy across the resident's lap to prevent him from standing and falling, as he had previously attempted to ambulate independently. The resident was able to remove the device when prompted by staff, but otherwise it was used to restrict his movement. The facility failed to provide a physician's order, an assessment, or a care plan for the use of the Lap Buddy as a restraint. The resident's electronic medical record did not contain documentation supporting the use of the device, and staff interviews confirmed that the device was used to prevent the resident from standing due to fall risk. The facility's policy requires that restraints only be used with proper medical justification and documentation, which was not present in this case.
Failure to Conduct Background Check for Housekeeping Supervisor
Penalty
Summary
The facility failed to conduct or provide documentation of a background check for the Housekeeping Supervisor, who had been employed since 1979, left, and was rehired in 1991. Review of background check records showed no evidence that a background check was completed for this staff member. Administrative staff confirmed the absence of documentation, attributing it to the long tenure of the employee. The Housekeeping Supervisor was observed working in the facility, and during an interview, confirmed her employment history. Additionally, the facility was unable to provide a policy regarding background checks for staff.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Provide Bed Hold and Ombudsman Notifications During Resident Discharge and Transfer
Penalty
Summary
The facility failed to provide required Bed Hold Notifications to two residents at the time of their emergency transfers to the hospital. In both cases, the residents had significant medical histories, including heart failure, osteoarthritis, pain, Parkinson’s disease, diabetes, depression, and repeated falls. Documentation showed that neither the residents nor their representatives received information about the facility’s bed-hold policy at the time of transfer, as required by the facility’s own policy and federal regulations. Administrative staff confirmed that the notifications were not provided during interviews. Additionally, the facility did not notify the Office of the Long-Term Care Ombudsman (LTCO) of the discharges for three residents. Review of records and staff interviews revealed that the last notification to the ombudsman had been made several months prior, and there was no evidence that the ombudsman was informed of the recent discharges. This was despite the facility’s policy stating that such notifications should be made, either at the time of transfer or via a monthly list. The documentation and interviews indicated that the facility’s processes for both bed-hold notification and ombudsman notification were not followed for the residents involved. The lack of timely and appropriate notifications was confirmed by administrative staff and was not in accordance with the facility’s written policies.
Failure to Revise Care Plan for Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to revise the care plan for a resident with a history of urinary tract infections (UTIs) to include the ongoing use of prophylactic antibiotics. The resident's electronic medical record documented multiple diagnoses, including chronic kidney disease, anxiety disorder, dehydration, hypertension, restlessness, agitation, dementia, and anemia. The resident's Minimum Data Set indicated moderately impaired cognition, occasional incontinence, and the use of several medications, including an antibiotic. The care plan addressed incontinence risk and skin care but did not mention the resident's history of UTIs or the use of prophylactic antibiotics. Physician orders consistently directed staff to administer Nitrofurantoin daily for UTI prevention over several months, with no documented stop date or physician rationale for the ongoing use. The administrative nurse confirmed the care plan should have included the prophylactic antibiotic use for the resident's UTI history. Additionally, the facility was unable to provide a policy regarding care plan timing and revisions when requested.
Failure to Identify and Report Long-Term Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported the long-term use of prophylactic antibiotics for a resident with multiple chronic conditions, including chronic kidney disease, anxiety disorder, hypertension, dementia, and anemia. The resident's medical record showed ongoing administration of Nitrofurantoin for urinary tract infection (UTI) prophylaxis, with physician orders repeatedly renewed without a documented rationale or review of the continued need for the medication. The care plan did not include a history of UTIs or the use of prophylactic antibiotics, and there was no documentation in the physician's progress notes justifying the ongoing use of Nitrofurantoin. Monthly pharmacy drug regimen reviews failed to mention the resident's prolonged antibiotic use, and administrative staff were unable to provide documentation of a monthly antibiotic log review for the resident. The CP reportedly reviewed antibiotic use only every six months, contrary to the facility's policy and regulatory requirements for monthly drug regimen reviews. This lack of appropriate review and reporting placed the resident at risk for inappropriate medication use.
Failure to Ensure Drug Regimen Free from Unnecessary Antibiotics
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary antibiotics. A resident with multiple diagnoses, including chronic kidney disease, anxiety disorder, hypertension, dementia, and anemia, was prescribed Nitrofurantoin for urinary tract infection (UTI) prophylaxis. The resident’s care plan did not document a history of UTIs or the use of prophylactic antibiotics. Despite this, physician orders continued the daily administration of Nitrofurantoin for several months without a documented rationale or stop date. The electronic medical record lacked evidence of physician review or justification for the ongoing use of the antibiotic. Additionally, the facility was unable to provide documentation of monthly antibiotic use review for the resident, as required by their Antibiotic Stewardship Program Policy. Administrative staff could not locate physician progress notes supporting the continued use of Nitrofurantoin, and the monthly antibiotic log was not provided upon request. These actions and omissions resulted in the resident receiving an antibiotic without documented need or oversight, constituting a failure to ensure the drug regimen was free from unnecessary medications.
Failure to Document and Communicate Hospice Care Details
Penalty
Summary
The facility failed to ensure an effective communication process between the hospice provider and the facility for a resident who was admitted to hospice care. The resident, who had diagnoses including malignant neoplasm of the breast and bones and severe cognitive impairment, was dependent on staff for most activities of daily living. The care plan documented the resident's admission to hospice and included general instructions for staff regarding pain management, family time, and notification of hospice for significant changes. However, the care plan did not include essential information such as the hospice provider's contact number, details about supplies, equipment, and medications to be provided by hospice, or the schedule and nature of hospice staff visits. Record review confirmed the absence of this critical information, and staff interviews verified that the care plan lacked documentation regarding hospice visits, phone numbers, and medical supplies. The facility's policy required coordination of a plan of care with the hospice provider, but this was not reflected in the resident's care plan. As a result, there was no clear documentation of the services hospice would provide or how to contact them, which could impact the resident's care.
QA&A Committee Lacked Required Documentation of Medical Director Attendance
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QA&A) Committee with the required membership in attendance, as evidenced by the absence of the Medical Director's signature on the attendance roster for one of the quarterly meetings. Although the Administrative Nurse stated that the Medical Director was present at the meeting, there was no signed documentation to confirm this. Additionally, when requested, the facility was unable to provide a QA&A policy. These findings were based on a review of the QA&A committee attendance records and staff interviews, and involved a facility with a census of 44 residents and a sample of 12 residents.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted as required, resulting in a deficiency. Observations on three consecutive days revealed that the postings of daily staff nursing hours were not present. The facility had a census of 44 residents, and a sample of 13 residents was included in the review. Administrative staff confirmed that the scheduler was responsible for posting the daily nursing staff hours and verified that the information was not posted on the days of the onsite survey. The facility's policy required daily posting of nurse staffing information, including facility name, current date, resident census, and the total number and actual hours worked by RNs, LPNs/LVNs, and CNAs per 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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