Pittsburg Care And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburg, Kansas.
- Location
- 1005 E Centennial Drive, Pittsburg, Kansas 66762
- CMS Provider Number
- 175208
- Inspections on file
- 20
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Pittsburg Care And Rehab during CMS and state inspections, most recent first.
The facility failed to fully implement its Legionella water management program as required by its infection prevention and control policy. Maintenance staff reported that only a single Legionella test of kitchen water had been conducted, which was negative, but there was no documentation of a facility water system map, no flow diagram of water distribution, and no identification of dead-end water areas where water could stagnate. This was inconsistent with the facility’s written policy that required waterborne microorganism control measures to follow CDC, HICPAC, FDA, and state and local health department recommendations.
A resident with dementia, severe cognitive impairment, and multiple psychiatric diagnoses had care-plan and physician orders requiring that staff sit and assist with every meal and snack due to weight loss. During observation, a CNA stood beside the resident’s Broda chair while attempting to assist with breakfast instead of sitting at eye level as specified. Staff interviews with a CMA and an LN confirmed that staff are expected to sit next to residents and engage them during meals, showing that the resident was not provided mealtime assistance in a manner consistent with her care plan or with dignified care practices.
Surveyors found that the facility did not include the required estimated daily rate for continued services on CMS-10055 SNF Advance Beneficiary Notices of Non-coverage for two residents whose Medicare Part A skilled stays ended and who remained for custodial care. The nurse responsible for issuing ABNs and administrative staff reported they had been instructed not to list the daily rate due to fluctuating prices, resulting in ABNs that lacked cost information despite facility policy outlining the need to inform Medicare beneficiaries about potential non-coverage and associated financial liability.
Surveyors found that PHI was not kept confidential when two unattended medication carts in separate hallways were left with unlocked laptop screens displaying a resident’s medications, DOB, allergy information, and code status, visible to anyone passing by and without nursing staff in view. Nursing staff and an administrative nurse acknowledged that carts should be locked and laptop screens closed or cleared when unattended, and facility policy required safeguarding all resident records to protect confidentiality.
Surveyors identified that two residents with dementia, depression, and anxiety were receiving daily antipsychotic medications without documented physician rationale or risk–benefit analysis for their continued use with non-approved indications. Each resident’s MDS showed severely impaired cognition and ongoing psychotropic use, while their care plans only directed staff to administer medications as ordered. Physician orders specified olanzapine for behaviors or a psychotic disorder, but the EMRs lacked documentation of multiple unsuccessful nonpharmacological interventions and risk–benefit considerations, and the available psychoactive medication consent forms did not contain the required physician justification, contrary to facility policy on psychotropic drug use.
A resident with dementia, major depressive disorder, anxiety, and bipolar disorder was admitted to hospice, but the facility failed to complete a required Significant Change MDS at the time of hospice admission. The resident had severely impaired cognition per prior MDS and CAA documentation and was receiving daily antipsychotic medication. The care plan only reflected hospice-provided extra bathing and did not include other hospice services, despite physician orders for hospice to evaluate and treat. Administrative nurses acknowledged that while a significant change MDS had been completed earlier for a different health status change, no new significant change MDS was done when hospice services began, contrary to the facility’s MDS transmission policy.
A resident with cardiomyopathy, COPD, depressive disorder, muscle weakness, and chronic joint and low back pain experienced frequent severe pain rated at 10/10 despite being on scheduled hydrocodone and topical diclofenac. The MDS and pain assessment documented frequent severe pain and scheduled opioid use, but there was no active PRN order for breakthrough pain, and the care plan lacked specific nonpharmacological pain interventions or an assessment of the resident’s acceptable pain level. Staff reported the resident continued to have significant pain in multiple joints, sometimes nonverbal but evident through facial expressions and decreased appetite, and an RN confirmed that orders and the care plan did not include PRN pain medication or nonpharmacological strategies, despite ongoing reports of severe pain.
Surveyors found that the facility did not fully integrate hospice services into the care plans for two residents receiving hospice care. Both residents had severe cognitive impairment and multiple psychiatric diagnoses, with documentation confirming hospice admission and physician orders for hospice evaluation and treatment. One resident’s care plan referenced hospice involvement and comfort measures but did not specify hospice services, while the other resident’s care plan only noted extra bathing by hospice. Staff reported that details of hospice services were kept in a separate hospice book and acknowledged that not all hospice services were reflected in the care plans, despite facility policy addressing hospice service provision and coordination.
The facility failed to maintain sanitary conditions in the therapy room, with unlabeled and expired food items found in the refrigerator and freezer, and a rusted, dirty microwave. Interviews confirmed the use of kitchen equipment for resident rehabilitation, but policies for food storage and equipment cleaning were not followed, risking foodborne illness.
A resident with chronic back pain and osteoarthritis requested positioning rails to aid in movement and alleviate pain. Despite communicating this need to multiple staff members, the request was not addressed promptly. The facility's policy required an assessment for such devices, which was delayed, impacting the resident's pain management and independence.
A facility failed to accurately document the administration of opioid medication for a resident with chronic pain in their MDS assessments. Despite receiving Fentanyl every 72 hours as per physician's orders, the MDS inaccurately indicated no opioid use. This discrepancy was confirmed by an administrative nurse, highlighting a failure in accurate assessment and documentation.
A resident with Huntington's disease and severe cognitive impairment experienced multiple falls due to the facility's failure to maintain nonskid strips in the bathroom. Observations showed worn and non-adhered strips, and staff interviews revealed frequent ambulation without assistance. The facility lacked a policy for inspecting nonskid strips, contributing to the deficiency.
A resident with a diagnosis of constipation did not receive necessary PRN medications for constipation over several periods, despite having physician's orders and a facility protocol in place. The staff failed to administer the medications or document any refusal by the resident, leading to the resident going without a bowel movement for several days on multiple occasions.
Failure to Implement Comprehensive Legionella Water Management Program
Penalty
Summary
The facility failed to implement a comprehensive water management program for Legionella disease as part of its infection prevention and control program for a census of 60 residents. During an observation and interview, the maintenance staff reported that the facility relied on a single Legionella testing kit performed on kitchen water in late December, which showed no Legionella detected. However, the maintenance staff verified there was no documentation of a map showing the facility’s incoming water source, no flow diagram of the facility’s water distribution system, and no identification of dead-end water areas where water could stagnate. The facility’s written Water Management, Legionella Testing policy, dated October 2022, stated that approaches to controlling waterborne microorganisms, including water systems decontamination, would be consistent with CDC, HICPAC, FDA, and state and local health department requirements, but the lack of these key documents demonstrated the policy was not fully implemented. No specific residents, their medical histories, or clinical conditions at the time of the deficiency were described in the report.
Failure to Provide Dignified, Care-Plan-Compliant Mealtime Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect, dignity, and appropriate care during mealtimes. The resident had diagnoses including dementia, major depressive disorder, anxiety, and bipolar disorder, with documentation of severely impaired cognition on the MDS and CAA, and daily antipsychotic use. The resident’s care plan and physician orders specified that staff were to provide set-up assistance to supervision with one staff, that someone must sit and assist her with every meal and snacks three times a day due to weight loss, and that she was to be assisted with meal intake at every meal. Despite these documented needs and interventions, observation showed that during breakfast the resident was seated in a Broda chair at the dining room table while a CNA stood next to her attempting to assist with the meal, rather than sitting next to her as required. Subsequent interviews with a CMA and a licensed nurse confirmed that nursing staff should be seated next to residents when assisting with meals, at eye level, and engaging them in conversation. These observations and staff statements demonstrate that the resident was not assisted in the manner specified in her care plan and orders, and that staff did not follow the expected practice for dignified, respectful mealtime assistance.
Failure to Include Estimated Daily Rate on SNF ABN Notices
Penalty
Summary
The facility failed to properly complete CMS-10055 Skilled Nursing Facility (SNF) Advance Beneficiary Notices of Non-coverage (ABNs) by omitting the estimated daily rate for continued services when Medicare Part A coverage ended. Record review showed that one resident’s Medicare Part A episode ran from 01/08/26 to 02/09/26, after which the resident remained in the facility for custodial care. The ABN issued on 02/09/26 did not include a daily rate for services. Another resident’s Medicare Part A episode ran from 08/25/25 to 11/07/25, and this resident also remained in the facility for custodial care. The ABN issued on 11/05/25 likewise lacked a daily rate for services. During interviews, the administrative nurse responsible for issuing ABNs at the time of discharge from skilled therapy stated that she had been instructed by the regional manager not to include the daily rate for services on the ABN due to fluctuations in the rate. Administrative staff also confirmed that the facility did not include the rate for services on ABN notices because the rate changed. The facility’s Beneficiary Notices policy, last approved in 07/2025, documented that Medicare beneficiaries have the right to have Medicare determine coverage for skilled services and described both expedited and standard appeals processes, including the need to inform beneficiaries of possible non-coverage and potential cost shifting from the SNF to the beneficiary, but the ABNs reviewed did not contain the required cost information.
Failure to Protect PHI on Unattended Medication Carts
Penalty
Summary
Surveyors identified a failure to maintain confidentiality of residents' protected health information (PHI) related to unsecured medication carts with visible electronic records. With a facility census of 60 residents and a sample of 15, observations showed a medication cart parked in the east hallway with a laptop on top, the screen unlocked and displaying a resident’s PHI, including medications, date of birth, allergy information, and code status. This screen was visible to anyone passing by, and no nursing staff were in view of the cart at the time of the observation. A similar observation was made in the west hallway, where another medication cart was parked with an unlocked laptop displaying a resident’s medications, date of birth, allergy information, and code status, again with no nursing staff present. Licensed nurses interviewed stated that the medication cart should be locked and the laptop screen cleared or closed when staff walk away, and an administrative nurse confirmed the expectation that laptop screens be closed or resident information cleared when staff are not working at the cart. The facility’s Confidentiality and Privacy of Information policy, last approved in 10/2025, documented that all resident information would be treated confidentially and that resident records of all types would be safeguarded to protect confidentiality.
Lack of Physician Rationale for Antipsychotic Use in Residents With Dementia
Penalty
Summary
Surveyors found that the facility failed to ensure appropriate indications and physician documentation for the continued use of antipsychotic medications in two residents with dementia. One resident had diagnoses of dementia, depression, and anxiety, with a Quarterly MDS showing severely impaired cognition and documentation of daily antipsychotic, antidepressant, anticonvulsant, and opioid use. The resident’s CAA noted daily antipsychotic use for dementia, and the care plan intervention was limited to administering medications as ordered. A physician order directed Zyprexa 5 mg twice daily via PEG tube or by mouth for combative behavior, hitting, and scratching. However, the clinical record lacked physician documentation of the risk versus benefit for this antipsychotic use with a non-approved indication in a resident with dementia, and the facility could not provide such documentation upon request. The only available consent form for psychoactive medication therapy did not include the required physician rationale or documentation of multiple unsuccessful nonpharmacological interventions. A second resident, also with diagnoses of dementia, depression, and anxiety and severely impaired cognition on the Quarterly MDS, was receiving hospice services and had received antipsychotic, antidepressant, antianxiety, and opioid medications. The CAA documented daily antipsychotic use for dementia, and the care plan intervention again only directed staff to administer medications as ordered. A physician order prescribed olanzapine 5 mg by mouth at bedtime for a psychotic disorder. Similar to the first resident, the clinical record for this resident lacked physician documentation of risk versus benefit for antipsychotic use with a non-approved indication in a resident with dementia, and the facility was unable to provide this documentation when requested. The consent form for psychoactive medication therapy for this resident also lacked the physician documentation supporting continued use with a non-approved indication, despite the facility’s policy stating that psychotropic drugs would only be used when necessary to treat specific indicated and effective conditions and not for staff discipline or convenience.
Failure to Complete Significant Change MDS Upon Hospice Admission
Penalty
Summary
The facility failed to identify a significant change in condition and complete a comprehensive Significant Change MDS when a resident was admitted to hospice services. The resident had documented diagnoses of dementia, major depressive disorder, anxiety, and bipolar disorder. A Significant MDS dated 12/28/25 showed a BIMS score of 99 with a staff interview indicating severely impaired cognition, and a Cognitive Loss/Dementia CAA dated 01/02/26 documented dementia and daily antipsychotic use. The care plan included an intervention for hospice to provide extra bathing on Mondays and Thursdays but lacked documentation of other hospice services. Physician orders dated 01/21/26 directed hospice of the family's choice to evaluate and treat, and the resident was observed seated in a Broda chair at the dining room table while a CNA attempted to assist with breakfast. Administrative staff interviews revealed that the required Significant Change MDS was not completed at the time of the resident's admission to hospice. One administrative nurse stated she had completed a significant change MDS prior to the resident's hospice admission and acknowledged she should have completed another significant MDS after hospice admission. Another administrative nurse confirmed that the significant change MDS was not completed when the resident was admitted to hospice, clarifying that the earlier significant change MDS had been done for a prior significant change in health status. The facility's policy on Electronic Transmission of the MDS, effective 10/2025, stated that MDS assessments, including significant change assessments, would be transmitted per state and federal guidelines, but this was not followed for the hospice admission event.
Inadequate Pain Management and Care Planning for Resident With Chronic Severe Pain
Penalty
Summary
The facility failed to provide adequate pain management for a resident with chronic pain in the knees, lower back, and shoulders. The resident had diagnoses including cardiomyopathy, COPD, depressive disorder, need for assistance with personal care, and muscle weakness, and had intact cognition per a recent MDS. The MDS documented that the resident frequently experienced pain at a level of 10 on a 0–10 scale, which occasionally affected sleep, and that the resident was on a scheduled pain medication regimen and received nonpharmacological interventions, with no PRN pain medications. The Pain CAA indicated the resident took an opioid every six hours for low back pain and was to be monitored every shift and as needed for any pain. The care plan documented use of an opioid for chronic joint and lower back pain and directed staff to assess pain type, location, and characteristics before and after administration of PRN medication, and stated that long-acting opioid use was appropriate based on the resident’s history, but it lacked specific directions for nonpharmacological pain interventions. Physician orders included hydrocodone-acetaminophen 10-325 mg every six hours for low back pain, diclofenac gel to the right knee three times daily, and an order to monitor pain every shift related to PRN hydrocodone use, but there was no active PRN order for breakthrough pain. A physician progress note documented the resident reporting pain at level 10 in the right leg and knee, described as achy with pins and needles and worsened by movement, while taking hydrocodone 10 mg every six hours. During surveyor observation, the resident reported significant ongoing pain in joints, knees, shoulders, and lower back despite routine pain medication. A CNA reported the resident did not always verbalize pain but showed signs such as facial expressions and decreased appetite, which she reported to the nurse. A licensed nurse confirmed that physician orders lacked PRN pain medication despite reports of pain at level 10 and that the care plan and orders lacked direction for nonpharmacological pain interventions. An administrative nurse acknowledged the resident was on routine hydrocodone without breakthrough pain medication, had no nonpharmacological interventions in the care plan, and that there had been no assessment of the resident’s acceptable pain level or consultation for ongoing pain, in the context of a facility policy addressing unnecessary medications and appropriate duration based on assessment and therapeutic goals.
Failure to Integrate Hospice Services Into Resident Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate collaboration with hospice providers and to incorporate hospice services into the residents’ care plans. One resident with dementia, depression, anxiety, and severely impaired cognition had documentation in the EMR and MDS indicating she was receiving hospice services, with a nursing note confirming hospice admission. Her care plan referenced consulting with the physician and social services to have hospice care in the facility and included comfort-focused interventions such as oxygen for comfort and pain management. However, the care plan did not clearly outline the specific hospice services being provided, despite her documented hospice status. Another resident with dementia, major depressive disorder, anxiety, bipolar disorder, and severely impaired cognition had an order for hospice of the family’s choice to evaluate and treat and was confirmed by nursing staff to have been admitted to hospice. The care plan for this resident only documented that hospice would provide extra bathing on two specified days and lacked other hospice services. Staff interviews revealed that information about hospice services was kept in a separate hospice-provided book and that not all hospice services were included in residents’ care plans. An administrative nurse acknowledged that the facility only included some, but not all, hospice services on the care plans, contrary to the facility’s hospice program policy that addressed services to be provided and coordination of care.
Unsanitary Food Storage and Equipment Maintenance in Therapy Room
Penalty
Summary
The facility failed to ensure sanitary food storage and maintenance of kitchen equipment in the therapy room, as observed during a survey. Unlabeled and undated hamburger patties were found in the therapy room refrigerator freezer, along with medical devices and cold packs. The refrigerator contained expired almond milk and yogurt, as well as a sack with various foods in undated, unmarked Styrofoam containers. Additionally, an opened container of chicken broth was found without an open date. The microwave in the therapy room was observed to have rusted surfaces and splatters of unidentified substances. Interviews with Maintenance Staff U and Therapy Consultant GG confirmed the unsanitary conditions and the use of kitchen equipment for resident rehabilitation purposes. The facility's policy on foods brought in by family or visitors required perishable foods to be stored in resealable containers with labels, but this was not adhered to. Furthermore, there was no policy for cleaning the microwave, contributing to the unsanitary conditions. The facility's failure to maintain the therapy room refrigerator, freezer, and microwave in a sanitary manner and to ensure food items did not exceed their use-by date posed a risk of foodborne illness among residents.
Failure to Timely Provide Positioning Devices for Resident
Penalty
Summary
The facility failed to timely assess and accommodate a resident's request for positioning devices to aid in movement and alleviate back pain. The resident, who had diagnoses including chronic back pain and osteoarthritis, was assessed with normal cognitive function and required supervision with activities of daily living. Despite the resident's ability to communicate his needs, he reported requesting positioning rails multiple times without them being provided. Observations and interviews revealed that the resident expressed his preference for positioning rails to several staff members, but the request was not acted upon until much later. A licensed nurse was unaware of the request until an interview, after which a work order was placed. The facility's policy required staff to assess the appropriateness of such devices, but this was not done in a timely manner, resulting in a delay in addressing the resident's needs for pain management and independence in bed mobility.
Inaccurate MDS Documentation for Opioid Medication
Penalty
Summary
The facility failed to complete accurate Minimum Data Sets (MDS) for a resident, identified as Resident 25, regarding the administration of opioid medications. The resident, who had a diagnosis of chronic pain, was documented in the Annual MDS and Quarterly MDS as not receiving opioid medication, despite evidence to the contrary. The resident's Electronic Medical Record (EMR) and Medication Administration Record (MAR) indicated that she was receiving Fentanyl, an opioid medication, every 72 hours as per physician's orders. This discrepancy was confirmed by Administrative Nurse D, who acknowledged that the MDSs were inaccurately coded during the lookback period of the assessments. The resident's care plan for pain management, revised in April 2024, instructed staff to administer a Fentanyl pain patch for chronic pain, which was consistent with the physician's orders documented in the EMR. However, the MDS assessments failed to reflect the administration of this opioid medication, leading to inaccurate documentation. The facility utilized the Resident Assessment Instrument (RAI) for the completion of MDSs, yet the oversight in coding resulted in the failure to accurately assess the resident's medication regimen.
Failure to Maintain Fall Interventions for Resident with Huntington's Disease
Penalty
Summary
The facility failed to maintain fall interventions for a resident diagnosed with Huntington's disease, major depressive disorder, and anxiety, who was assessed with severe cognitive impairment. The resident had a history of repeated falls, weakness, lack of coordination, and unsteadiness, and was independent for most activities of daily living, using a walker for mobility. Despite these needs, the resident experienced multiple falls, including two non-injury falls and one non-major injury fall since the last assessment. The care plan required nonskid strips in the bathroom and by the recliner, as well as fall mats, to prevent falls. Observations revealed that the nonskid strips in the resident's bathroom were worn and not adhered to the floor, increasing the risk of falls. Interviews with staff indicated that the resident often ambulated without a walker or calling for assistance, and the nonskid strips were frequently compromised due to wetness from the resident's habits. Maintenance staff confirmed the issue with the nonskid strips, and there was no facility policy for their inspection. This lack of maintenance and policy led to the deficiency in ensuring the resident's safety as care planned.
Failure to Administer PRN Medications for Constipation
Penalty
Summary
The facility failed to ensure that a resident remained free from unnecessary medications by not administering as-needed (PRN) medications for constipation. The resident, who had a diagnosis of constipation and was dependent on staff for toileting needs, did not have a bowel movement for several days on multiple occasions. Despite having physician's orders for various laxatives and stool softeners, the staff did not administer these medications or document any refusal by the resident to take them. The facility's bowel management protocol required staff to administer specific medications if a resident did not have a bowel movement for three, four, or five days, but this protocol was not followed. The resident's electronic medical record showed that there were three separate periods where the resident went without a bowel movement for four to six days. During these times, the staff failed to administer PRN medications or document any refusal by the resident to accept bowel management interventions. Interviews with facility staff revealed that the resident would sometimes refuse the ordered PRN medications, but there was no documentation to support this. The facility's protocol also required staff to make a brief nurse's note if a resident refused the protocol, which was not done in this case.
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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