Providence Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Kansas.
- Location
- 8909 Parallel Pky, Kansas City, Kansas 66112
- CMS Provider Number
- 175159
- Inspections on file
- 15
- Latest survey
- September 3, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Providence Place during CMS and state inspections, most recent first.
Staff did not test dishwashing sanitization chemicals due to lack of test strips and failed to label and date opened food items, as evidenced by an open, undated gallon of milk found in the refrigerator. Dietary staff confirmed the absence of required testing and labeling practices.
Hazardous cleaning chemicals were left unsecured and accessible to cognitively impaired, mobile residents. A resident with severe cognitive impairment experienced a non-injury fall when staff failed to lock wheelchair brakes during a transfer. Another resident with a history of falls was observed with their call light and personal items out of reach, contrary to care plan interventions. Staff interviews confirmed that these actions did not follow facility policy or care plans.
A medication storage room containing stock medications and enteral feeding solutions was found unlocked during a walkthrough. An LN confirmed the door should always be locked, but reported issues with the doorknob sticking. Facility policy requires all medications to be secured in locked storage.
Surveyors identified multiple infection control deficiencies, including trash left on a PPE cart, a clean linen closet propped open, lack of accessible hand hygiene supplies in the laundry area, and missing gloves in the dirty laundry area. Staff interviews confirmed these practices were inconsistent with facility policy and that all staff are responsible for maintaining proper infection control.
A resident with significant physical and cognitive impairments was not provided with required adaptive utensils and a two-handled cup during meals, despite documented care plans and orders. Staff served meals with standard utensils, and the resident was observed struggling to eat while wearing wrist orthoses. Staff interviews confirmed expectations to follow care plans, but the adaptive equipment was not provided as required.
A resident with severe cognitive and physical impairments, dependent on staff for personal care, was repeatedly observed with dirty fingernails containing a dark substance. Despite facility policy and staff interviews confirming responsibility for nail care during bathing and showers, staff did not consistently ensure the resident's fingernails were clean.
A resident with end-stage renal disease and multiple comorbidities did not have consistent pre- and post-dialysis communication and assessment documentation as required by facility policy. Nursing and administrative staff confirmed that dialysis communication forms were often missing from the resident's record, and procedures to obtain or return these forms from the dialysis center were not reliably followed, resulting in incomplete documentation of dialysis care.
A resident with severe cognitive impairment, decreased mobility, and multiple diagnoses was provided with bilateral bed rails without documented evidence that alternatives had been tried and failed, as required by facility policy. The assessment also lacked information on drug classifications that could increase entrapment risk, resulting in a deficiency related to bed rail use.
A resident with severe cognitive impairment and multiple diagnoses was prescribed Dulcolax DR without 'do not crush' instructions, despite a consultant pharmacist's recommendation to add this directive. The facility did not act on the pharmacist's recommendation as required by policy, and the medication administration record lacked the necessary instruction.
The facility did not accurately document and submit weekend staffing coverage hours in its Payroll Based Journaling (PBJ) reports to CMS, despite using agency staff and having no gaps in internal schedules or time sheets. This discrepancy was identified when the facility's PBJ data triggered for excessively low weekend staffing, and an administrative nurse acknowledged that agency staff hours may not have been properly reported.
Failure to Test Dishwashing Sanitizer and Label Opened Food Items
Penalty
Summary
Staff failed to properly test dishwashing sanitization chemicals and did not ensure that opened food items were labeled and dated. During a kitchen and dining area tour, surveyors observed an open, undated gallon of milk in the refrigerator. Dietary staff confirmed that dishes were being washed by hand in a three-sink system using hot water and chemicals, but there were no test strips available to verify the effectiveness of the sanitization process, nor was there a log to review. Staff also acknowledged that all opened food items should be labeled and dated, but this was not done for the milk observed during the inspection.
Failure to Secure Hazardous Chemicals and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to secure hazardous cleaning chemicals in a locked area, leaving disinfectant bleach wipes and a Clorox spray bottle accessible in an unsecured cabinet on the 300 Hall. These chemicals were labeled with warnings indicating they were hazardous to humans and should be kept out of reach of children. Eight cognitively impaired, independently mobile residents had access to this area. Staff interviews confirmed that facility policy required chemicals to be locked up, but this was not followed at the time of observation. A resident with severe cognitive impairment, chronic kidney disease, emphysema, muscle weakness, and a history of falls experienced a non-injury fall during a transfer. Staff failed to lock the brakes on the resident's wheelchair before attempting the transfer, causing the wheelchair to move and resulting in the resident being assisted to the ground. The care plan for this resident required staff to lock wheelchair brakes before transfers, and staff had been educated on this procedure, but it was not followed during the incident. Another resident with diabetes, renal failure, cognitive impairment, and a history of falls was observed sitting in a recliner with their call light and personal items out of reach, contrary to the care plan interventions. The care plan specified that the call light and needed items should be within reach and that staff should encourage the resident to call for assistance. Staff interviews confirmed that it was everyone's responsibility to ensure fall interventions were in place as care planned, but these interventions were not implemented at the time of observation.
Medication Storage Room Found Unsecured
Penalty
Summary
A deficiency was identified when one of two medication storage rooms, specifically the 100 Hall Team Office medication storage room, was found unsecured during an initial facility walkthrough. The room contained shelves of stock medication, enteral feeding solutions, and medical supplies. A licensed nurse confirmed that the door should be locked at all times due to the presence of medications, but noted that the doorknob sometimes stuck and did not close properly. Facility staff were expected to ensure the room remained locked when exiting, as per the facility's Medication Storage policy, which requires all medication to be secured in a locked manner.
Infection Control Lapses in Trash Disposal, Linen Storage, and Hand Hygiene
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices as evidenced by several observed deficiencies. During an initial walkthrough, a clear bag of trash was found left on top of a PPE cart in the 300 halls, and a clean linen closet was observed propped open in the same area. In the laundry room, there was no visible handwashing sink or PPE available. Staff reported that handwashing required retrieving soap from the dirty laundry area, using a laundry soaking sink, and then returning to the dirty area to dry hands, indicating a lack of accessible hand hygiene supplies. Additionally, gloves were not available in the dirty laundry area, and staff were not consistently aware of the location of the handwashing sink in the laundry room. Interviews with staff confirmed that trash should not be left on PPE carts, linen closets should not be propped open, and it is the responsibility of all staff to ensure proper disposal of trash and maintenance of infection control standards. The facility's infection control policy requires the provision of necessary supplies and oversight to ensure hand hygiene, but observations and staff statements indicated lapses in these practices. These deficiencies were identified among a census of 35 residents, including seven on Enhanced Barrier Precautions.
Failure to Provide Required Adaptive Utensils During Meals
Penalty
Summary
The facility failed to provide a resident with the required adaptive utensils during mealtimes, despite clear documentation in the care plan and physician orders indicating the need for built-up silverware and a two-handled cup to support self-feeding. The resident, who had diagnoses including left-sided hemiplegia, cerebral infarction, dysphagia, muscle weakness, cognitive communication disorder, reduced mobility, and muscle contractures, was observed eating multiple meals with standard utensils and a regular cup, while wearing wrist orthoses. Staff did not offer the adaptive equipment during these meals, and the resident was noted to have difficulty handling the utensils. Interviews with staff confirmed that they were expected to review care plans and dietary requirements before serving meals, and that information about special utensils was accessible to all staff. The facility's policy required screening and provision of adaptive equipment to improve resident independence and quality of care. Despite these expectations and policies, the resident did not receive the necessary adaptive utensils during observed meals, constituting a failure to implement the care plan and physician orders.
Failure to Maintain Resident Nail Hygiene During ADL Assistance
Penalty
Summary
Staff failed to provide adequate assistance with activities of daily living (ADL) for a resident who was dependent on staff for personal care due to multiple diagnoses, including dementia, hemiparesis following a stroke, Parkinson's disease, and muscle weakness. The resident's medical record and care plan documented severe cognitive impairment and a need for staff assistance with bathing, toileting, oral hygiene, and dressing. Despite these needs, observations on multiple occasions revealed that the resident's fingernails had a dark brown substance underneath, indicating they were not being kept clean. Interviews with facility staff confirmed that CNAs are responsible for cleaning residents' fingernails during showers or bed baths, and that all staff are expected to monitor nail cleanliness. The facility's policy emphasized promoting cleanliness during bathing and showering. However, the repeated observations of dirty fingernails demonstrated that staff did not consistently ensure the resident's fingernails were clean, resulting in a failure to meet the resident's ADL needs as outlined in their care plan.
Failure to Ensure Consistent Pre- and Post-Dialysis Communication and Assessment
Penalty
Summary
The facility failed to consistently communicate a resident's medical condition through pre- and post-dialysis communication prior to and after hemodialysis sessions. The resident in question had multiple complex medical diagnoses, including end-stage renal disease requiring hemodialysis, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, peripheral vascular disease, and a recent cervical spine fracture requiring a neck collar. The care plan required daily assessment of the arteriovenous (AV) fistula and completion of dialysis communication forms before and after each dialysis session. However, review of the electronic medical record revealed missing documentation of pre- and post-dialysis assessments and communication forms on several specified dates. Interviews with nursing staff and administration confirmed that the process for handling dialysis communication sheets was not consistently followed. Staff reported that completed forms were to be placed in a binder and scanned into the resident's chart, and if missing, the dialysis center was to be contacted for a report. Administrative staff acknowledged ongoing issues with obtaining completed communication sheets from the dialysis center and had attempted to address this by sending the forms in a binder. Despite these procedures, the required documentation was not consistently present, resulting in a failure to ensure proper communication and assessment related to the resident's dialysis care.
Failure to Document Alternatives Prior to Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident had a documented risk assessment that included alternatives that had been tried and failed prior to the use of bed rails. The resident in question had diagnoses of major depressive disorder, Alzheimer's disease, cerebrovascular accident, and was noted to have severely impaired cognition, decreased mobility, blindness, and dementia. The care plan indicated the use of bilateral upper quarter bedrails to assist with bed mobility, and the facility's assessment documented that the resident's representative had given verbal consent for the side rails. However, the assessment did not include documentation of alternatives to bed rails that had been attempted and found ineffective, nor did it address drug classifications that could increase the risk of entrapment. Observations confirmed that the resident was using bilateral upper bed rails, and staff interviews revealed that side rail assessments were conducted at admission, quarterly, annually, and with significant changes. Staff also stated that the interdisciplinary team reviewed factors such as medication, mobility, mental status, safety awareness, and history of falls when making decisions about side rail use. Despite these procedures, the facility's policy required that appropriate alternatives be attempted before installing bed rails, and this was not documented in the resident's assessment, resulting in a deficiency.
Failure to Implement Pharmacist's Medication Safety Recommendation
Penalty
Summary
The facility failed to act upon the Consultant Pharmacist's recommendation to add 'do not crush' instructions to a resident's Dulcolax delayed release (DR) medication order. The resident in question had diagnoses of major depressive disorder, Alzheimer's disease, and a history of cerebrovascular accident, with severely impaired cognition and significant assistance required for activities of daily living. The resident's care area assessment indicated a risk of adverse side effects from medications, and the care plan directed nursing staff to administer medications as ordered by the physician. However, the medication order for Dulcolax DR did not include 'do not crush' instructions, despite the pharmacist's recommendation documented in the monthly medication review. Review of the resident's medication administration record for the relevant month confirmed the absence of the 'do not crush' directive for Dulcolax. Interviews with administrative nursing staff revealed an expectation that pharmacy recommendations would be reviewed and acted upon within seven days, but this was not done in this case. The facility's policy required that drug regimen reviews be conducted monthly by a licensed pharmacist, with any identified irregularities reported to the attending physician, medical director, and director of nursing services for action. The failure to implement the pharmacist's recommendation resulted in a deficiency related to the management of the resident's medication regimen.
Failure to Accurately Report Weekend Staffing in PBJ Data
Penalty
Summary
The facility failed to submit accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) through Payroll Based Journaling (PBJ) by not properly documenting weekend staffing coverage hours. During the review period, the facility reported a census of 36 residents and a sample of 12 residents was included. Although the facility's working schedules, time sheets, and posted staffing hours showed no gaps or loss of hours, the submitted PBJ data triggered for excessively low weekend staffing for the first quarter of the fiscal year. An administrative nurse confirmed that agency staff were used during the period in question, but their hours may not have been appropriately documented in the PBJ reporting. The facility's policy required accurate electronic reporting of staffing and census information to CMS and mandated that this information be made available to residents, family members, and the public within 24 hours of a request.
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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