Regent Park Rehabilitation And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Wichita, Kansas.
- Location
- 10604 East 13th Street N, Wichita, Kansas 67206
- CMS Provider Number
- 175527
- Inspections on file
- 17
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Regent Park Rehabilitation And Healthcare during CMS and state inspections, most recent first.
The facility failed to obtain complete and properly executed informed consents for psychotropic medications for multiple residents. Several residents were receiving antidepressants, antianxiety agents, and antipsychotics, yet their psychotropic consent forms were either missing signatures or did not list the specific medications, dosages, routes, or administration frequencies. Staff reported that informed consent was required before starting or changing psychotropic drugs and that consents were to be provided to residents or their representatives, and facility policy required signed consents at initiation and with dosage increases, but the documentation for these residents did not include the necessary medication details.
A resident’s Medicare Part A coverage ended, and the resident remained for LTC on a private pay basis, but the facility could not produce evidence that the required SNF Advance Beneficiary Notice of Non-coverage (ABN) Form CMS-10055 was provided. Social service notes stated that the ABN was given and that a private pay quote was discussed, and an email to the resident’s representative referenced appeal rights and possible continued therapy, but the documentation did not specifically reference the SNF ABN or include estimated costs for continued therapy. The social worker later acknowledged she could not show that the ABN form had been provided, and no copy of the completed form was in the record, despite facility policy requiring appropriate Medicare discharge notification and appeal information when coverage ends.
A resident with hemiplegia and a documented left-hand contracture risk had physician orders and a care plan directing staff to place a rolled washcloth or splint in the hand on every day and night shift, with the MAR consistently indicating the device was in place and no refusals. However, surveyors repeatedly observed the resident with the left hand hanging in a loose fist, swollen, and without any device, while the prescribed hand splint was found across the room. Therapy staff confirmed the resident’s flaccid left arm and provision of a resting hand splint or rolled towel, and nursing and administrative staff acknowledged the device was supposed to be in the hand at all times and documented on the MAR, demonstrating a failure to follow ordered interventions to prevent contracture.
A resident with pneumonia and post-stroke hemiparesis, care planned and ordered for continuous 2L oxygen due to ineffective gas exchange, was observed in the dining area with a portable oxygen tank attached to the wheelchair but not receiving oxygen; the nasal cannula was hanging unused and the tank was empty. Staff, including an LPN and a CMA, acknowledged the resident was supposed to be on oxygen at all times, and facility policy required use of portable oxygen when off the main concentrator, but this was not followed.
A deficiency was cited when an area of the facility was not kept free from accident hazards and did not provide adequate supervision to prevent accidents, as required by safety standards.
The facility failed to follow sanitary dietary standards related to food labeling, storage, and preparation, placing all residents at risk for food-borne illness. Observations included unlabeled and undated food items, improper handling of food containers, and unsanitary use of a food thermometer.
The facility failed to secure pressurized oxygen cylinders in a locked location, leaving them accessible to six cognitively impaired residents. Additionally, a resident with severe cognitive impairment was found with her bed in a high position while unsupervised, contrary to the facility's Fall policy. These deficiencies placed residents at risk for preventable accidents and injuries.
The facility failed to properly label and store medications, including leaving a medication cart unlocked and unattended, having opened and undated insulin pens and tuberculin vaccine serum vials, and lacking daily temperature documentation for the medication refrigerator. This placed residents at risk for adverse outcomes or ineffective medication regimens.
The facility failed to provide wheelchair foot pedals for a resident with multiple medical conditions, including hemiplegia and dementia. Staff were observed propelling the resident's wheelchair without foot pedals, requiring the resident to hold her feet up. This practice was confirmed by staff interviews and violated the facility's Accommodation of Needs policy, placing the resident at risk of impaired care and decreased quality of life.
A resident with severe cognitive impairment and multiple medical diagnoses had a low air-loss mattress pump set to incorrect weight settings, despite weighing only 111.4 lbs. The care plan and physician's orders lacked specific instructions for the mattress settings, and staff were unsure about the correct settings, leading to a risk of skin breakdown and pressure ulcers.
A facility failed to store a resident's CPAP mask and oxygen tubing in a sanitary manner, placing the resident at increased risk of respiratory infections. The CPAP mask was found on the bedside table, and the oxygen tubing was on the floor, contrary to facility policy requiring these items to be stored in plastic bags when not in use.
The facility failed to administer an as-needed diuretic for a resident with severe cognitive impairment and multiple health conditions and did not consistently monitor blood pressure before administering a beta-blocker to another resident with a history of stroke and hypertension.
The facility failed to maintain ongoing communication with hospice services for a resident with severe cognitive impairment and multiple medical conditions. The care plan lacked essential information, and staff were unaware of the specifics of hospice services, placing the resident at risk for delayed services and uncommunicated care needs.
The facility failed to ensure a functional call light system for each resident, affecting their ability to summon assistance. Two residents reported non-functional call lights, which was confirmed upon inspection. Maintenance staff were unaware of the immediate protocol for fixing call lights, and staff were instructed to increase checks on residents every 15 minutes if a call light was not working. The facility's policy required an operational call system, but two of the four hallways had non-functional call lights.
The facility failed to ensure the posted nursing hours included the required information and were posted in a prominent, readily accessible location. The daily census was missing from the posted staff sheet, and the information was placed under a folder outside the assistant director of nursing's office, making it difficult for residents and visitors to access. Additionally, the facility lacked a policy related to the posted nursing information.
Failure to Obtain Complete Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents and/or their representatives were fully informed about specific psychotropic medications, including their names, dosages, routes, and frequencies, as required for informed consent. For one resident with orders for mirtazapine for depression, fluoxetine for depression, and alprazolam for anxiety, the psychotropic medication consent form was dated several months after the medication orders and did not list any of the prescribed psychotropic medications or their details. Another resident with orders for mirtazapine for insomnia and fluoxetine for a mood disorder had a signed psychotropic consent form that also lacked the names of the medications, their dosages, routes, or administration frequencies. A third resident had multiple psychotropic orders, including sertraline for depression, quetiapine in two different strengths for major depressive disorder and behavioral disturbances, mirtazapine for depression, and lorazepam for anxiety. The scanned psychotropic consent for this resident was unsigned and similarly did not specify any of the psychotropic medications, their dosages, routes, or frequencies. Staff interviews confirmed that informed consent was expected before starting or changing psychotropic medications and that consents were to be provided to residents and/or their legal representatives. The facility’s own policy required a signed informed consent on initiation and with any dosage increase of psychoactive medications to ensure potential adverse effects were reviewed, but the documentation reviewed for these residents did not meet those requirements.
Failure to Provide Required SNF ABN and Cost Information When Medicare Coverage Ended
Penalty
Summary
The deficiency involves the facility’s failure to provide the required Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage (ABN) Form CMS-10055 to a Medicare Part A beneficiary when his covered stay ended and he remained in the facility. The resident census was 61, with 15 residents sampled and three reviewed for beneficiary notifications. For one resident, documentation showed that his Medicare Part A last covered day was 01/28/26, after which he remained in the facility for long-term care on a private pay basis. Facility records, including the medical record and business office documentation, did not contain evidence that the SNF ABN Form CMS-10055 was provided. A social service note dated 01/30/26 stated that the social worker provided the SNF ABN and that the resident would remain private pay for approximately 30–60 days until an apartment was available, and that a private pay quote was given to the resident’s representative. Another social service note, created on 02/09/26 with an effective date of 01/30/26, documented that the resident requested staff review the SNF ABN with his representative, who was not present and whose arrival time was unknown. Email communication from the facility to the resident’s representative on 01/27/26 indicated there was a form the resident would need to sign that reviewed his appeal rights and his right to appeal if he believed Medicare should cover the long-term care stay, and that the appeal could take up to four months while therapy continued, with room, board, and therapy to be billed if the appeal was unfavorable. However, this email chain did not mention the SNF ABN or provide an estimated cost to continue therapy services. During an interview on 02/10/26, the social worker stated the ABN should be provided prior to discharge and reported that she had provided the form, but that the resident did not sign or return it because he wanted to review it with his representative. She confirmed she was unable to show that the resident was provided with the ABN Form CMS-10055 because she did not have a copy. The facility’s policy dated 12/01/17 required appropriate notification of discharge from Medicare services, including appeal rights, when Medicare coverage ends, but the appropriate notification of discharge from Medicare services was not provided in this case.
Failure to Implement Ordered Hand Splint/Positioning Device to Prevent Contracture
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered care and services to prevent reduction in range of motion and contracture development for a resident with left-sided weakness and a left-hand contracture risk. The resident had a history of hemiplegia and hemiparesis following a stroke affecting the left nondominant side, and the admission MDS documented a contracture of the left hand with intact cognition. The care plan and physician’s orders directed staff to place a clean, dry, rolled washcloth between the resident’s fingers and palm and ensure good hygiene on every day and night shift. The MAR from late September through early February documented that the rolled washcloth was in place every day and night with no refusals, and progress notes did not document any refusals or missed treatments. Despite this documentation, surveyor observations on multiple occasions showed the resident without any device in the left hand to address contracture risk. The resident was observed in a wheelchair with the left hand hanging down in a loose fist and swollen, and later in bed with the left hand dangling, swollen, and without a rolled cloth or device. The resident reported that therapy had given her a hand device described as a pool noodle with a strap to prevent her hand from contracting and stated she should have been wearing it at the time, but it was observed across the room on her dresser. A therapy consultant reported that an evaluation had been completed for a left-hand contracture, that the resident’s left arm was completely flaccid, and that a simple resting hand splint or rolled towel had been provided for use. Nursing staff and an administrative nurse confirmed that a towel or splint was supposed to be in the resident’s hand at all times and that nurses were responsible for placement and documentation on the MAR. The facility’s restorative nursing policy stated that goals for elders receiving restorative services include preventing contractures.
Failure to Provide Ordered Continuous Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered continuous oxygen therapy to a resident with significant medical needs. The resident had diagnoses including pneumonia, anxiety, and hemiplegia/hemiparesis following a stroke, and her admission MDS documented intact cognition with receipt of oxygen. Her Care Area Assessment noted impaired physical functioning related to a past stroke with left-sided weakness and a need for staff assistance with all care. The resident’s care plan documented she was to be on oxygen related to ineffective gas exchange, with an order for two liters of oxygen continuously. Physician’s orders directed staff to monitor oxygen saturation and provide oxygen at two liters every day and night shift. During observation, the resident was seated in the dining room in a wheelchair with a portable oxygen tank attached to the back of the wheelchair and a bag containing nasal cannula tubing. The nasal cannula prongs were hanging freely and were not in use, and the resident was not receiving oxygen despite the continuous oxygen order. When a licensed nurse placed the nasal cannula on the resident and attempted to turn on the oxygen, the portable tank was found to be empty, and the nurse then returned the resident to her room to place her on oxygen via a concentrator. Subsequent interviews with a CMA and another licensed nurse confirmed their understanding that the resident required oxygen all the time, and an administrative nurse stated she expected nurses to follow the oxygen orders. The facility’s oxygen therapy policy stated that residents would use oxygen from a portable source when off the main concentrator, but this was not implemented for the resident at the time of observation.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents occurring. There is no mention of specific residents, staff, or detailed events, but the deficiency centers on the lack of appropriate hazard prevention and supervision in the area in question.
Failure to Follow Sanitary Dietary Standards
Penalty
Summary
The facility failed to follow sanitary dietary standards related to food labeling, storage, and preparation, placing all residents at risk for food-borne illness. During an initial tour, surveyors observed mixed fruit and a steam table pan containing fruit in the refrigerator without labels or dates, and a large canister of flour also without a label or date. The freezer contained opened and unsealed bags of fish, sausage, potatoes, and chicken, all without labels or dates. Additionally, a storage container of mashed potatoes in the small freezer had no lid, label, or date. During lunch service, dietary staff were seen carrying multiple residents' fruit cups while touching the tops of the opened containers. Furthermore, a dietary staff member touched the probe of a food thermometer with bare hands without cleaning it before checking food temperatures. The facility did not provide a policy related to food storage and preparation when requested.
Failure to Secure Oxygen Cylinders and Maintain Safe Bed Height
Penalty
Summary
The facility failed to secure pressurized oxygen cylinders in a safe, locked location, leaving them accessible to six cognitively impaired, independently mobile residents. During a walkthrough, it was observed that the door to the Clean Room containing 37 pressurized oxygen cylinders was propped open. Staff acknowledged that the door should have been closed and locked, as per the facility's Oxygen Storage policy, which mandates that oxygen cylinders be stored in a secured room with proper ventilation. This oversight placed the residents at risk for preventable accidents and injuries. Additionally, the facility failed to maintain Resident 11's bed at a safe height while she was unsupervised in her room. Resident 11, who had severe cognitive impairment and was dependent on staff for bed mobility, was found with her bed in a high position. Staff confirmed that beds for residents with severe cognitive impairment should never be left in a high position when unsupervised. The facility's Fall policy requires that residents be assessed for fall risks and that interventions be identified to prevent accidents. The failure to lower Resident 11's bed height placed her at risk for preventable falls and injuries.
Failure to Properly Label and Store Medications
Penalty
Summary
The facility failed to properly label and store medications, which placed residents at risk for adverse outcomes or ineffective medication regimens. Specifically, a licensed nurse left a medication cart unlocked and unattended in the 100-hallway. Additionally, the treatment cart contained three opened and undated insulin pens, and the medication room contained two opened and undated vials of tuberculin vaccine serum. The medication refrigerator temperature log also lacked evidence of daily temperature measurements and documentation for multiple dates in March and April 2024. Interviews with staff confirmed that insulin pens and tuberculin vaccine serum vials should be labeled and dated when opened, and the medication refrigerator temperature should be monitored and documented daily. The facility's Storage of Medications policy requires all drugs and biologicals to be stored in a safe, secure, and orderly manner, with compartments locked when not in use. The facility's failure to adhere to these policies could potentially cause adverse consequences or ineffective treatment for the residents.
Failure to Provide Wheelchair Foot Pedals
Penalty
Summary
The facility failed to provide wheelchair foot pedals for Resident 40, who has multiple medical conditions including hemiplegia, cerebral infarction, hypertension, dementia, overactive bladder, and glaucoma. The resident's care plan indicated she required extensive assistance with activities of daily living (ADLs) and used a wheelchair for mobility. Despite this, staff were observed propelling the resident's wheelchair without foot pedals on multiple occasions, requiring the resident to hold her feet up while being moved. This practice was confirmed by staff interviews, where both a Licensed Nurse and a Certified Nurse's Aide stated that wheelchairs should have foot pedals when propelled by staff. The facility's Accommodation of Needs policy mandates that each resident has the right to receive services with reasonable accommodation of individual needs, including the use of equipment and assistive devices necessary for daily living activities. The failure to provide wheelchair foot pedals for Resident 40 was a direct violation of this policy, placing the resident at risk of impaired care and decreased quality of life. The deficiency was documented through observations, interviews, and record reviews, highlighting a significant lapse in adhering to the facility's own standards and policies.
Incorrect Low Air-Loss Mattress Settings
Penalty
Summary
The facility failed to ensure that a resident's pressure-reducing interventions were implemented correctly. The resident, who had severe cognitive impairment and multiple medical diagnoses including COPD, dementia, dysphagia, repeated falls, and a pressure ulcer, was dependent on staff for bed mobility, transfers, toileting, bathing, and dressing. The resident's care plan included the use of a low air-loss mattress to prevent further skin breakdown and pressure ulcers. However, the care plan lacked specific instructions related to the monitoring and settings for the mattress pump, and the physician's orders also did not include these details. Observations revealed that the resident's low air-loss mattress pump was consistently set to an incorrect weight setting, ranging from 180 lbs to 210 lbs, despite the resident weighing only 111.4 lbs. Interviews with staff indicated that they were unsure if the care plan covered instructions for the mattress settings and that they were expected to check the bed and equipment each shift. The facility's policy on low air-loss mattresses stated that the mattress should be adjusted no less than 50 pounds above the patient's weight or to the patient's preference or comfort level, but this was not followed in practice. The failure to set the low air-loss mattress pump to the appropriate weight setting placed the resident at risk for complications related to skin breakdown and pressure ulcers. The facility's lack of specific instructions in the care plan and physician's orders, combined with staff's uncertainty about the correct settings, contributed to this deficiency.
Improper Storage of CPAP Mask and Oxygen Tubing
Penalty
Summary
The facility failed to ensure the proper storage of a resident's CPAP mask and oxygen tubing, which were found in unsanitary conditions. The CPAP mask was observed lying directly on the bedside table, and the oxygen tubing was found undated and unbagged on the floor. This was contrary to the facility's policy, which required these items to be stored in plastic bags when not in use to prevent contamination. Interviews with staff confirmed that the CPAP mask and oxygen tubing should always be stored in a sanitary manner, and the oxygen tubing should be replaced if it touches the floor. The resident involved had a history of obstructive sleep apnea, respiratory failure with hypoxemia, and hypertension, and was documented to have severely impaired cognition. The care plan for the resident lacked specific instructions for cleaning and storing the CPAP mask. The facility's failure to adhere to its own policies placed the resident at increased risk of developing respiratory infections and complications. The deficiency was identified during an observation and was corroborated by staff interviews and a review of the resident's medical records.
Failure to Administer Medications as Ordered and Monitor Vital Signs
Penalty
Summary
The facility failed to administer an as-needed diuretic medication as ordered for a resident with severe cognitive impairment and multiple health conditions, including obstructive sleep apnea, respiratory failure, and hypertension. The resident's care plan required staff to administer medications as ordered and to monitor for weight gain, which would necessitate the administration of the diuretic. However, the facility's records showed that the diuretic was not administered on several occasions when the resident's weight indicated it was necessary. Observations also noted that the resident's CPAP mask and oxygen tubing were not properly stored, indicating a lack of adherence to care protocols. Another resident with a history of stroke, hemiplegia, hypertension, and dementia was prescribed metoprolol, a beta-blocker, with specific instructions to monitor blood pressure and pulse before administration. The facility's records lacked consistent evidence that these vital signs were monitored before giving the medication. Interviews with staff confirmed that the blood pressure should be documented before administering the medication, but this was not consistently done. The facility's policies required that all medications be administered as ordered and that residents be monitored for adverse drug reactions. Despite these policies, the facility failed to follow physician orders for both residents, leading to potential risks of unnecessary medication side effects or ineffective therapeutic regimens.
Failure to Maintain Communication with Hospice Services
Penalty
Summary
The facility failed to maintain ongoing communication with hospice services related to a resident's bi-weekly hospice visits. The resident, who had severe cognitive impairment and multiple medical conditions including COPD, dementia, dysphagia, repeated falls, and a pressure ulcer, was dependent on staff for various activities of daily living. Despite being on hospice care, the resident's care plan lacked essential information such as contact details for the hospice service, the services provided, and the frequency of hospice nursing staff visits. Additionally, the facility's electronic medical records did not contain scanned hospice communications showing the bi-weekly visits and the services provided during those visits. Interviews with facility staff revealed a lack of awareness and documentation regarding the hospice services provided to the resident. Licensed Nurse J and Administrative Nurse D were unsure about the location of hospice documentation and the specifics of the services, medications, and equipment provided by hospice. The facility had stopped using communication books, and the hospice documentation was not readily available in the care plan or the nursing office. This lack of communication and documentation placed the resident at risk for delayed services and uncommunicated care needs, as the facility did not collaborate effectively with hospice services to ensure comprehensive care.
Non-Functional Call Light System
Penalty
Summary
The facility failed to ensure a functional and fully operational call light system for each resident, placing them at risk for delayed care and decreased psychosocial well-being. Resident 212 reported that her call light had not worked since her admission, and she was instructed to yell for help if needed. An inspection confirmed the call light was non-functional. Similarly, Resident 6 reported her call light was not working, which was also confirmed upon inspection. Maintenance staff stated the system is checked weekly, but there was no clear protocol for immediate resolution if the call light could not be fixed right away. Licensed Nurse J and Certified Medication Aide M indicated that staff would notify maintenance and increase the frequency of checks on residents every 15 minutes if a call light was not functioning. Administrative Nurse D acknowledged issues with the new call light system and stated that staff were expected to notify the on-call supervisor and maintenance for any outages. The facility's Call Light policy required an operational electronic call system, and in case of malfunction, nursing staff were to initiate 15-minute resident checks. The facility failed to ensure operational call lights in two of the four hallways, affecting the residents' ability to summon assistance when needed.
Failure to Post Required Nursing Staffing Information
Penalty
Summary
The facility failed to ensure the posted nursing hours included the required information and were posted in a prominent, readily accessible location for residents or visitors. The facility identified a census of 66 residents. Upon review of 18 months of posted nurse staffing information, it was found that the daily census was not included on the posted staff sheet. Additionally, the posted nursing staff information was located on the wall outside the assistant director of nursing's office under a folder, which required visitors and residents to flip the folder up to see the information. Administrative Staff A confirmed this setup and acknowledged that the posted staffing was covered. The facility was also unable to provide a policy related to the posted nursing information.
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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