Rossville Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rossville, Kansas.
- Location
- 600 E. Perry St, Rossville, Kansas 66533
- CMS Provider Number
- 175397
- Inspections on file
- 25
- Latest survey
- June 25, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Rossville Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls experienced multiple incidents due to the facility's failure to consistently implement and monitor fall prevention interventions, including missing safety signs and visual cues. Additionally, surveyors found unsecured hazardous chemicals and accessible appliances in common areas and the memory care unit, with staff lacking training on safety procedures. These deficiencies resulted in unsafe conditions for cognitively impaired and independently mobile residents.
The facility did not complete required annual performance evaluations for five CNAs who had been employed for over a year. Review of records and staff interviews confirmed that no documentation of yearly evaluations was available for these staff members, despite facility policy mandating annual reviews.
Surveyors found that food items such as ice cream and pie were stored in the kitchen freezer and refrigerator without labels or dates, and clean plates and bowls were stored facing upwards, contrary to facility policy. The kitchenette area was also found to be unsanitary, with old food debris and open, unlabeled food items. Dietary staff confirmed that these practices did not meet the facility's standards for safe food handling and storage.
The facility did not complete a thorough assessment to determine necessary resources for competent resident care during daily operations and emergencies. The assessment lacked details on shift-specific staffing for weekends and the Memory Care Unit, and PBJ data showed consistently low weekend staffing. This deficiency impacted all residents.
The facility did not submit complete and accurate direct care staffing information to CMS through PBJ, as required. Despite PBJ reports indicating low weekend staffing, administrative staff stated that weekend staffing was not low and that data was based on payroll hours. The submitted information did not accurately reflect actual staffing levels, especially on weekends.
Surveyors identified that the facility did not maintain an effective QAA program, resulting in multiple deficiencies such as undignified meal care, inaccessible call lights, unsafe wheelchair transport, unsecured hazardous materials, unsanitary storage of respiratory equipment, lack of required staff training and evaluations, incomplete staffing records, and improper medication management. These failures affected resident safety, dignity, and quality of care across several areas.
Five CNAs employed for over a year did not complete the required 12 hours of annual in-service education, including training in dementia care and abuse prevention. Facility records lacked documentation of completed training, and administrative staff confirmed the deficiency. No policy regarding yearly in-service education was provided.
Staff did not consistently ensure that call lights were within reach for several residents, leaving them unable to communicate their needs. Additionally, some residents, including those with severe cognitive impairment, were transported in wheelchairs without foot pedals, resulting in their feet dragging on the ground. Staff interviews confirmed that these practices did not align with facility policy requiring the use of assistive devices and safe transport procedures.
Surveyors found that trash, gloves, and linens were left on handrails, floors, and radiators, and that respiratory equipment for several residents, including nasal cannulas and a CPAP mask, was not stored in a sanitary manner. Additionally, a Hoyer lift was not sanitized between resident uses. Staff interviews confirmed that these practices did not align with facility policy for infection prevention and control.
A resident with severe cognitive impairment and total dependence on staff for daily care was repeatedly assisted with meals by staff standing over her, contrary to her care plan and facility policy. Staff interviews confirmed that proper procedure required sitting next to residents during meal assistance to maintain dignity, but this was not followed.
Staff left a resident's electronic medical record open and visible on a wall kiosk monitor, failing to secure the resident's private health information. Interviews with CNA, LN, and administrative nursing staff confirmed that this action was not in line with facility policy, which requires staff to maintain resident privacy and confidentiality.
A resident with complex medical needs was assisted with eating while reclined in a Broda chair, despite physician orders requiring upright positioning during meals. The care plan was not updated to reflect new dietary and positioning interventions after the resident's status changed from NPO with tube feeding to a mechanical soft diet with max assistance. Staff were unclear about the current care plan directives, and observations confirmed the resident was not positioned as ordered during meal assistance.
Staff did not provide necessary assistance with eating and positioning for two residents with severe cognitive and physical impairments. One resident was left to eat independently despite being dependent on staff for meals, while another was transported without proper footwear or footrest support, contrary to care plan requirements. Staff interviews confirmed awareness of care plans, but the needed support was not provided.
Two residents with significant cognitive and physical impairments, both at risk for pressure ulcers, were observed without required pressure-reducing boots or floating of heels as ordered in their care plans and physician orders. Despite clear documentation and staff awareness tools, these interventions were not consistently implemented, contrary to facility policy and best practices for pressure injury prevention.
Two residents with contractures and severe cognitive impairment did not receive prescribed splints and positioning devices as ordered in their care plans and by occupational therapy. Observations showed both residents without the required devices over multiple days, and staff interviews revealed confusion about responsibility for applying splints and the timing of restorative interventions. Documentation of restorative care was inconsistent, and the facility's restorative program was in the process of being revamped, resulting in a lack of consistent implementation of required interventions.
A resident with severe cognitive and physical impairments, who recently transitioned to a mechanical soft diet while continuing tube feedings, was observed being assisted with eating while reclined in a Broda chair rather than upright as required by physician orders and care plan. Staff interviews and facility policy confirmed the need for upright positioning during meals to prevent swallowing complications, but this was not consistently followed, placing the resident at risk.
A resident with multiple diagnoses requiring CPAP therapy was found to have their CPAP mask and tubing stored on the floor instead of in a sanitary, dated bag as required by facility policy and physician orders. Staff interviews confirmed knowledge of proper storage procedures, but the equipment was not stored appropriately, resulting in a deficiency related to respiratory care equipment sanitation.
A resident with dementia and multiple comorbidities did not receive individualized, person-centered activities or interventions as required by facility policy. The care plan lacked specific dementia care strategies, and staff interviews confirmed the absence of tailored interventions, despite expectations for such care on the memory unit.
A consultant pharmacist did not identify or report the use of antipsychotic medications prescribed without CMS-approved indications for three residents with dementia and related conditions. Despite monthly medication regimen reviews, inappropriate orders for Olanzapine and Quetiapine were not flagged or reported, and there was no physician-documented rationale for their use. Nursing and administrative staff confirmed that these indications were not appropriate, and facility policy requiring timely reporting of such irregularities was not followed.
Two residents with severe cognitive impairment were prescribed antipsychotic medications without CMS-approved indications, with orders citing mood disorder, dementia, or depression as the rationale. Despite care plan reviews and pharmacy recommendations, there was no physician-documented justification or risk versus benefit analysis for the continued use of these medications, contrary to facility policy and regulatory requirements.
The facility did not retain daily nurse staffing documentation for 31 days as required, despite having a policy to keep such records accessible for at least 18 months. An administrative nurse confirmed that the staff scheduler was responsible for posting and retaining these records.
A facility failed to ensure a CNA received effective communication training, leading to an incident where the CNA and a resident engaged in inappropriate verbal exchanges. The CNA was accused of throwing a cup of ice, and both parties used inappropriate language. The facility could not provide documentation of the required training, and administrative staff were unable to confirm its completion.
A resident with schizoaffective disorder and borderline personality disorder was verbally abused by a CNA, leading to a confrontation where derogatory language was exchanged. Despite the facility's policy and care plan directives, the staff member failed to disengage or seek assistance, resulting in a deficiency in protecting the resident from verbal abuse.
A resident with dementia was discharged from a facility following aggressive behavior and arrest, but the discharge notice sent to the resident's representative was incomplete, lacking appeal rights and contact information for advocacy agencies. The notice was not verified before sending, leading to a deficiency in resident rights.
Failure to Prevent Accidents and Secure Environmental Hazards
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents. One resident with severe cognitive impairment, a history of repeated falls, and multiple risk factors had several documented falls. Despite being identified as a high fall risk and having numerous care plan interventions in place, the facility did not consistently implement or monitor these interventions. Observations revealed that required safety signs were missing from the resident's room, and visual cues such as bright tape on wheelchair brakes were not present. Additionally, the facility was unable to provide root cause analyses or investigations for several of the resident's falls, nor could they provide evidence that medication reviews, as required by the care plan, were completed following these incidents. Environmental hazards were also identified throughout the facility. During inspections, surveyors found that the power shut-off for the kitchenette oven and stovetop was not activated, leaving the appliances operational and accessible to residents. A working toaster was also left plugged in and accessible. In another area, an unlocked maintenance closet contained multiple bottles of hazardous disinfectant cleaners. On the secured memory care unit, a cognitively impaired and independently mobile resident was observed rummaging through an unlocked cabinet containing bleach and disinfectant spray, with no staff supervision provided at the time. Staff interviews confirmed that hazardous materials and equipment were not consistently secured, and direct care staff were not trained on how to deactivate the oven/stovetop power. The facility's own policies required that hazardous materials be kept out of residents' reach and that accident hazards be minimized through preventative interventions and supervision. However, these policies were not followed, as evidenced by the unsecured chemicals, accessible appliances, and lack of staff training. The failure to secure hazardous materials and equipment, combined with the lack of effective fall prevention interventions and monitoring, placed multiple cognitively impaired and independently mobile residents at risk for accidents and injuries.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete yearly performance evaluations for five Certified Nurse Aides (CNAs) who had been employed for more than 12 months. Record review showed that none of the five CNAs reviewed had a documented annual performance evaluation available upon request. Interviews with administrative staff confirmed that department directors were responsible for conducting these evaluations, and the facility's policy required annual formal written evaluations for all employees. This deficiency was identified through a review of personnel records and staff interviews, with no evidence provided that the required evaluations had been completed for the CNAs in question.
Failure to Maintain Sanitary Food Storage and Handling Practices
Penalty
Summary
Surveyors observed multiple failures to follow sanitary dietary standards in the facility's kitchen and dining areas. During a walkthrough, 13 uncovered cups of chocolate ice cream were found open to the air in the reach-in freezer, and these cups were both unlabeled and undated. Additionally, an opened chocolate pie was found in the refrigerator without a label or date. In the plate and utensil storage area, stacked bowls were stored in a plastic bin facing upward, and clean plates on food carts were also stored facing upwards. The open kitchenette in the main entry area had stains and old food debris inside the refrigerator and microwave, and the kitchenette freezer contained open, unlabeled, and undated food items. Dietary staff confirmed that facility policy required all food items to be labeled and dated before storage and that utensils and plates should be stored facing downward to prevent cross-contamination. The facility's Food Preparation and Service policy, revised in December 2024, specified that food service employees must handle food and equipment in compliance with safe handling practices, including proper labeling, dating, and sanitary storage. These observed practices were not in accordance with the facility's policy and professional standards, resulting in a deficiency related to food and equipment storage.
Failure to Conduct Comprehensive Facility-Wide Resource Assessment
Penalty
Summary
The facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. The assessment provided by administrative staff was updated to reflect recent CMS staffing requirements and identified required staffing needs per day, but did not specify staffing needs by shift for weekends or for the specialized Memory Care Unit. Review of the facility's Payroll Based Journal (PBJ) data over a one-year period revealed excessively low weekend staffing for all four quarters. The facility's own policy required assessment of resources for evenings, nights, and weekends, but the documentation did not meet these requirements. This deficiency affected all 74 residents in the facility.
Failure to Submit Accurate Staffing Data via PBJ
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare & Medicaid Services (CMS) through Payroll Based Journaling (PBJ), as required by federal regulations. Review of the PBJ report for all four quarters of Fiscal Year 2024 indicated the facility triggered for low weekend staffing. However, interviews with administrative staff revealed that they believed weekend staffing was not low, despite occasional call-ins, and that the information submitted was based on payroll hours. The facility's policy required submission of accurate staffing data, including agency and contract staff, using verifiable and auditable data, but the submitted information did not reflect actual staffing levels, particularly on weekends.
Failure to Maintain Effective QAA Program and Address Multiple Quality Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assessment and Assurance (QAA) program, as evidenced by multiple deficiencies identified during the survey. Surveyors observed that the QAA committee did not adequately address or correct quality deficiencies prior to the survey, resulting in ongoing issues affecting resident care and safety. The facility's QAPI policy outlined a comprehensive, data-driven approach to quality improvement, but in practice, the facility did not implement or follow through with these processes, as shown by the repeated and varied deficiencies across multiple care areas. Specific deficiencies included failures in providing dignified care during meals, ensuring reasonable accommodation for residents' needs such as accessible call lights and safe wheelchair transport, and protecting the privacy and confidentiality of medical records. Additional issues were noted in the areas of nutrition and hydration, with improper positioning of residents during meals, and in the use of pressure-reducing devices for residents at risk of pressure ulcers. The facility also failed to apply necessary splints for residents with contractures and dysphagia, and did not secure hazardous materials or equipment, exposing cognitively impaired residents to immediate jeopardy. Environmental hazards, lack of effective fall interventions, and unsanitary storage of respiratory equipment were also documented. Further deficiencies were found in staff management and training, including the absence of required yearly performance evaluations and in-service education for Certified Nurse Aides, incomplete and inaccurate staffing data submission, and failure to maintain required nurse staffing records. The facility did not conduct a thorough facility-wide assessment to determine necessary resources for competent care, and failed to ensure person-centered activities for residents with dementia. Medication management was also deficient, with the consultant pharmacist and physicians not providing appropriate indications or risk-benefit analyses for antipsychotic medications. Dietary services were found lacking in sanitary standards, and infection control practices were not consistently followed, as evidenced by improper storage of oxygen tubing, CPAP masks, and unsanitary handling of equipment and supplies.
Failure to Ensure Required In-Service Education for CNAs
Penalty
Summary
The facility failed to ensure that five Certified Nurse Aides (CNAs), each employed for more than 12 months, completed the required 12 hours of in-service education within the past year. Record review showed that none of the sampled CNAs had documentation of completing the mandated in-service training, which includes education in dementia care and abuse prevention. During an interview, an administrative nurse confirmed that it was a team responsibility to ensure direct care staff received the required education, and acknowledged the facility had recently hired a clinical nursing educator to assist with in-services. Additionally, the facility was unable to provide a policy related to the required yearly in-service education.
Failure to Ensure Call Light Accessibility and Safe Wheelchair Transport
Penalty
Summary
Staff failed to ensure that several residents had access to their call lights, leaving them unable to communicate their needs. During observations, multiple residents were found in their beds with call lights either on the floor, behind the bed, or otherwise out of reach. These residents attempted to locate their call lights but were unsuccessful. Interviews with staff confirmed that call lights are expected to be within reach of all residents at all times, but this was not consistently maintained. Additionally, staff were observed transporting residents in wheelchairs without foot pedals attached. Several residents, including those with severe cognitive impairment, were pushed in their wheelchairs while their feet dragged or slid on the ground. Staff interviews confirmed that foot pedals are required to be used during transport to prevent residents' feet from touching the ground. The facility's policy requires reasonable accommodation of residents' needs, including the use of assistive devices and ensuring safety during transport, but these practices were not followed.
Infection Control Deficiencies in Equipment and Environmental Sanitation
Penalty
Summary
Surveyors observed multiple infection control deficiencies throughout the facility, including trash, gloves, and trash bags left on handrails and floors in various halls, as well as linens, dishes, and other items placed on radiators and registers. Additionally, two residents' nasal cannula oxygen tubing was found wrapped around stationary canisters in their rooms and not stored in a sanitary manner. Another resident's CPAP mask and tubing were observed lying on the floor between the bed and the wall, rather than being stored in a clean bag as required by facility policy. These observations were corroborated by staff interviews, which confirmed that respiratory equipment should be stored in dated bags and that trash should not be left on surfaces or the floor. Further, shared equipment such as the Hoyer lift was not sanitized between resident uses, as evidenced by a Certified Medication Aide moving the lift from one resident's room to another without cleaning it. Staff interviews indicated awareness of the proper procedures for storing respiratory equipment and sanitizing shared devices, as well as the availability of cleaning supplies. The facility's infection prevention and control policy requires maintaining a safe and sanitary environment to prevent the transmission of communicable diseases, but these practices were not consistently followed, resulting in the cited deficiencies.
Failure to Provide Dignified Meal Assistance
Penalty
Summary
Staff failed to provide a dignified care environment for a resident with severe cognitive impairment and multiple medical diagnoses, including aphasia, dementia, and hypertension. The resident was totally dependent on staff for all activities of daily living and required set-up assistance during meals, as documented in her care plan and assessments. Despite care plan instructions to provide supervision, cueing, and a quiet environment during mealtimes, staff were observed standing over the resident while attempting to feed her during both breakfast and lunch on separate occasions. The resident consumed only a small portion of her meal during one of these observed instances. Interviews with facility staff, including a CNA and an administrative nurse, confirmed that the expectation was for staff to sit next to residents when providing meal assistance and not to stand over them. The facility's own dementia care policy emphasized the importance of ensuring a dignified care environment. The observed actions were inconsistent with both facility policy and staff expectations, resulting in a failure to honor the resident's right to dignity during mealtimes.
Failure to Secure Resident Medical Record Information
Penalty
Summary
Facility staff failed to secure and protect the privacy and confidentiality of a resident's medical record. On one occasion, staff left the resident's point of care (POC) information open and visible on the electronic medical record (EMR) wall kiosk monitor. Interviews with a certified nurse aide, a licensed nurse, and an administrative nurse confirmed that staff are expected to lock screens and not leave resident information visible after charting. Facility policy requires staff to maintain resident privacy and dignity by protecting personal and medical information.
Failure to Update Care Plan and Ensure Proper Positioning During Meals
Penalty
Summary
The facility failed to ensure that a resident with multiple complex medical conditions, including dementia, Parkinson's disease, hemiplegia, and respiratory failure, was positioned appropriately in his Broda chair while being assisted with eating. The resident had recently transitioned from being NPO and dependent on tube feeding to receiving a mechanical soft diet with max assistance, in addition to continued enteral feedings. Despite physician orders specifying that the resident should be upright in the wheelchair during meals and remain upright for 30 minutes post intake, observations showed the resident was reclined back in his Broda chair during meal assistance on multiple occasions. The resident's care plan was not updated in a timely manner to reflect the new dietary orders and positioning requirements. The care plan continued to direct staff to provide tube feedings and water flushes, but lacked revised interventions for the current nutrition/eating order, including the need for upright positioning during oral intake. Staff interviews revealed uncertainty about whether the care plan had been updated to include the new diet and positioning interventions, and the MDS coordinator or nurses were identified as responsible for ensuring care plan updates following status changes. Facility policy required that the comprehensive care plan be reviewed and revised upon a change in resident status, with the interdisciplinary team collaborating on new interventions. However, the lack of timely care plan revision and failure to direct staff on the resident's current dietary and positioning needs resulted in the resident being assisted with eating while not properly positioned, contrary to physician orders and best practices for safe swallowing.
Failure to Provide Required ADL Assistance and Positioning
Penalty
Summary
Staff failed to provide necessary assistance with activities of daily living (ADLs) for two residents with severe cognitive and physical impairments. One resident, diagnosed with epilepsy, dysphagia, and dementia, was documented as being dependent on staff for eating and other ADLs. Despite this, multiple observations showed the resident left unattended during meals, struggling to eat a pureed diet without staff assistance or encouragement, even though the care plan and assessments clearly indicated a need for substantial to maximum assistance. Another resident, with diagnoses including Alzheimer's disease, congestive heart failure, and dysphagia, was also dependent on staff for ADLs and required specific positioning and footwear for safety and comfort. Observations revealed this resident was transported in a wheelchair without socks or appropriate footwear, and the footrest was not positioned correctly, leaving her feet dangling and uncovered. The care plan specified the need for bilateral lower extremity support and appropriate footwear, but these interventions were not provided as required. Interviews with staff confirmed that care plans and the Kardex were available to guide the level of assistance needed, and that it was the staff's responsibility to ensure residents received the necessary support. Facility policy required that residents unable to perform ADLs independently must receive services to maintain nutrition, hygiene, and comfort, but these requirements were not met for the two residents observed.
Failure to Apply Pressure-Reducing Devices for At-Risk Residents
Penalty
Summary
The facility failed to ensure that pressure-reducing devices were in place for two residents who were at risk for the development of pressure ulcers. One resident, with diagnoses including epilepsy, dysphagia, and dementia, was documented as having severely impaired cognition and was dependent on staff for mobility and activities of daily living. Physician orders and care plans specified the use of pressure-relieving boots on both lower extremities, but multiple observations over several days showed the resident without these boots while seated in a Broda chair and while in bed. Staff interviews revealed a lack of documentation and inconsistent communication regarding the application of these devices, despite the care plan and physician orders. Another resident, with a history of hypertension, anemia, Alzheimer's disease, diabetes, and other conditions, was also identified as being at risk for pressure ulcers due to incontinence and immobility. The care plan required the use of a foam mattress and floating of heels in bed, as well as the use of pressure-relieving boots. Observations found the resident in bed without heels floated and the boots not in use, despite being present in the room. Staff interviews indicated that information about the need for these interventions was available in the care plan and Kardex, but the interventions were not consistently implemented. The facility's own policy committed to the prevention of avoidable pressure injuries and the promotion of healing for existing injuries. However, the lack of adherence to physician orders and care plans for pressure ulcer prevention devices resulted in a failure to provide appropriate care for residents at risk, as evidenced by direct observations and staff statements.
Failure to Apply Prescribed Splints and Positioning Devices for Residents with Contractures
Penalty
Summary
The facility failed to ensure that two residents with contractures and impaired mobility received appropriate application of prescribed splints and positioning devices as recommended by occupational therapy and documented in their care plans and physician orders. For one resident with severe cognitive impairment, multiple diagnoses including Alzheimer's disease, contractures, and muscle weakness, the care plan and physician orders specified the use of bilateral upper extremity resting hand splints for 4-6 hours daily, with hand rolls as an alternative and regular skin checks. However, over several days of observation, the resident was repeatedly seen without the required splints or hand rolls, and staff interviews revealed confusion about who was responsible for applying these devices and when restorative therapy was provided. Another resident, also with severe cognitive impairment, contractures, and dysphagia, had a care plan and orders for the use of a cockup splint for the left wrist to address contractures. Observations showed the resident without the prescribed splint, with the affected hand and wrist curled to the chest. Staff interviews again indicated uncertainty regarding responsibility for applying splints and the timing of restorative interventions. The facility's restorative nursing program policy required maintenance and restorative services to maintain or improve residents' abilities, but documentation and staff responses indicated a lack of consistent implementation. The deficient practice was further evidenced by gaps in restorative nursing documentation, with progress notes not updated for several months and restorative tasks inconsistently marked as completed. Administrative staff acknowledged the restorative program was being revamped, but at the time of the survey, there was no clear process ensuring that residents with contractures received the prescribed supportive devices and interventions as outlined in their care plans and physician orders.
Failure to Properly Position Resident During Meal Assistance
Penalty
Summary
Staff failed to ensure a resident with multiple complex medical conditions, including dementia, Parkinson's disease, hemiplegia, and a history of respiratory failure, was properly positioned in his Broda chair while being assisted with eating. The resident had recently transitioned from being NPO and dependent on tube feeding to receiving a mechanical soft diet with continued enteral nutrition. Physician orders and the care plan specified that the resident should be upright during oral intake to minimize the risk of swallowing complications. On two separate occasions, the resident was observed reclined in his Broda chair at approximately a 45-degree angle while being assisted with meals. Staff members, including a CNA and an activities staff member, provided assistance without ensuring the resident was in the required upright position. After realizing the improper positioning, one staff member adjusted the chair, but the resident had already been assisted with eating while reclined. Interviews with staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that the expectation was for the resident to be upright during meals to reduce the risk of choking or aspiration. Facility policy also directed staff to ensure residents were appropriately positioned during meals. The failure to follow these directives resulted in the resident being at risk for swallowing complications and possible aspiration during meal assistance.
CPAP Equipment Not Stored in Sanitary Manner
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including respiratory failure, COPD, Parkinson's disease, and schizophrenia, was observed to have their CPAP mask and tubing stored on the floor between the bed and the wall, rather than in a sanitary manner. The resident's care plan and physician orders required the use of CPAP nightly, regular cleaning of the mask and tubing, and proper storage of respiratory equipment. The facility's policy also specified that CPAP equipment should be cleaned according to guidelines and stored in a bag with a date when not in use. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that the expectation was for all respiratory equipment to be stored in a dated bag and that bags should be changed weekly. Despite these policies and staff knowledge, the resident's CPAP equipment was not stored as required, leading to a failure to maintain sanitary conditions for respiratory care equipment.
Failure to Provide Person-Centered Dementia Care Interventions
Penalty
Summary
The facility failed to provide necessary person-centered activities and interventions for a resident diagnosed with dementia, as required by their own policy and care standards. The resident had multiple diagnoses, including dementia, major depressive disorder, Parkinson's disease, and bipolar disorder, and was dependent on staff for activities of daily living, used a wheelchair, and required a feeding tube. The resident's care plan included general communication strategies and environmental modifications but lacked individualized, person-centered activities and services specific to dementia care needs. Observations showed the resident was left alone, vocalizing in his native language, with no staff present to provide engagement or support. Interviews with staff, including a CNA, a licensed nurse, and an administrative nurse, revealed that they expected a dementia care plan with specific interventions for residents with dementia, especially those residing on the memory care unit. However, they could not explain why such person-centered dementia interventions were not in place for this resident. The facility's own dementia care policy required individualized, non-pharmacological approaches and meaningful activities, but these were not reflected in the resident's care plan or observed care.
Failure to Identify and Report Inappropriate Antipsychotic Use by Consultant Pharmacist
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported the lack of appropriate Centers for Medicare and Medicaid Services (CMS) approved indications for the use of antipsychotic medications in three residents. Multiple monthly drug regimen reviews were conducted by the CP, but the reviews did not identify or report that antipsychotic medications, such as Olanzapine (Zyprexa) and Quetiapine (Seroquel), were being prescribed for diagnoses that are not CMS-approved indications, such as dementia, mood disorder, and depression. The facility's policy required the CP to complete a monthly review for each resident and report irregular findings within 72 hours, but this was not followed in these cases. One resident with severe cognitive impairment and multiple diagnoses, including dementia and mood disorder, received Olanzapine for extended periods under various orders, all lacking a CMS-approved indication. The CP's monthly reviews from January 2024 through March 2025 did not identify or report this inappropriate use. Another resident with dementia, major depressive disorder, Parkinson's disease, and bipolar disorder received Seroquel for agitation and bipolar disorder, but the orders also lacked CMS-approved indications for use in dementia. The CP again failed to identify or report these irregularities during the monthly reviews. A third resident with dementia, depression, and hypertension was prescribed Seroquel for agitation and later for depression, without a physician-documented rationale for these indications. Although the CP eventually recommended a change in the medication indication, there was still no documentation of an appropriate rationale, and the facility could not provide one when requested. Interviews with nursing staff and administrative nurses confirmed that the use of antipsychotic medications for mood, dementia, or depression alone was not appropriate and that the CP was expected to report such irregularities, which did not occur as required by facility policy.
Failure to Document CMS-Approved Indications for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that physicians provided appropriate Centers for Medicare and Medicaid Services (CMS) approved indications for the use of antipsychotic medications for two residents. In both cases, the medical records documented the use of antipsychotic medications for diagnoses such as mood disorder, dementia, and depression, none of which are CMS-approved indications for these medications in residents with dementia. The orders for antipsychotic medications, including Olanzapine and Quetiapine, repeatedly lacked a documented, appropriate rationale for use as required by CMS guidelines. For one resident with severe cognitive impairment, multiple orders for Olanzapine were issued over several months, each time citing mood disorder or dementia as the indication. The care plan and assessments noted the resident's significant cognitive and physical impairments, as well as the use of multiple psychotropic medications. Despite ongoing monitoring and care plan reviews, there was no documentation of a CMS-approved indication for the antipsychotic, nor was there evidence of a risk versus benefit analysis for its continued use. Another resident, also with severe cognitive impairment and a history of dementia and depression, was prescribed Quetiapine for agitation and later for depression. The consulting pharmacist identified that the indication for use was not approved, and although the order was changed to depression, there was still no physician-documented rationale for the use of the antipsychotic. Staff interviews confirmed that the diagnoses used were not appropriate indications for antipsychotic use, and the facility's own policy required that psychotropics only be used when necessary to treat a specific condition and after considering risks and benefits. The lack of appropriate documentation and rationale for these medications constituted the deficiency.
Failure to Maintain Required Nurse Staffing Records
Penalty
Summary
The facility failed to maintain the required daily nurse staffing data for the mandated 18-month period. During a review of posted staffing sheets covering a specified timeframe, it was found that documentation for 31 specific days was missing and could not be provided by the facility. The facility had a census of 74 residents at the time of the review. According to an administrative nurse, the staff scheduler was responsible for ensuring that nursing hours were both posted and retained as required. The facility's policy stated that nurse staffing information should be readily available and maintained in the Human Resources Department for at least 18 months or as required by state law.
Deficiency in Effective Communication Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nurse Aide (CNA) received the required education on effective communication, which led to an incident involving inappropriate interactions between the CNA and a resident. The incident occurred when the CNA, identified as CNA M, was heard by a Licensed Nurse (LN) speaking with a resident, who responded negatively to the CNA's presence. Later, the resident requested a cup of ice, and upon the CNA's return, a verbal altercation ensued, with both the resident and the CNA using inappropriate language towards each other. The CNA was accused of throwing a cup of ice, which resulted in water and ice being observed on the floor, side table, and bed. The CNA claimed that the resident used racial slurs, and the situation escalated to the point where local law enforcement was notified. The facility was unable to provide documentation that the CNA had completed the required effective communication training, which was part of the onboarding process. Administrative staff could not confirm whether the training had been completed, and the facility did not have a policy on the required education, including effective communication training. This lack of documentation and training contributed to the incident, placing residents at risk for impaired care.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R1, from verbal abuse by a staff member, specifically a Certified Nursing Assistant (CNA) referred to as CNA M. R1, who has a history of schizoaffective disorder and borderline personality disorder, was involved in an incident where verbal abuse occurred. The resident's care plan noted that R1 frequently rejected care and had outbursts, and staff were instructed to handle her with calmness and redirection. However, during an interaction, CNA M and R1 engaged in a verbal altercation where inappropriate and derogatory language was exchanged. The incident began when CNA M brought a cup of ice to R1, which led to a confrontation. Witness statements from Licensed Nurses (LNs) G and H indicated that R1 accused CNA M of throwing the ice, and both parties used racial slurs and derogatory terms towards each other. The situation escalated, with R1 becoming noticeably upset and agitated. Despite the facility's policy to prevent abuse and the care plan's directives, the staff member did not disengage or seek assistance, resulting in a failure to protect R1 from verbal abuse. The facility's policy on Abuse, Neglect, and Exploitation requires the protection of residents from verbal abuse, defined as the use of disparaging and derogatory terms. The incident was reported to local law enforcement, and the facility took immediate action by suspending CNA M. However, the deficiency in ensuring R1's protection from verbal abuse was evident, as the staff did not follow the established procedures to de-escalate the situation and safeguard the resident's well-being.
Incomplete Discharge Notification for Resident with Dementia
Penalty
Summary
The facility failed to provide the required information on an involuntary notification of discharge to a resident and/or his representative, which placed the resident at risk for an inappropriate discharge and impaired resident rights. The resident, who had a diagnosis of dementia with severe cognitive impairment and behavioral disturbances, was admitted to the facility and later discharged following an incident where he exhibited aggressive behavior towards staff. On the day of the incident, the resident hit an employee, continued to be agitated, and was eventually arrested by the police after further aggressive actions. The facility's records indicated that an emergency discharge was ordered due to the resident's violence against staff and subsequent arrest. However, the Notice of Transfer or Discharge provided to the resident's representative was incomplete, lacking essential information such as the resident's appeal rights and contact details for relevant advocacy agencies. The notice was sent via email, but the second page was blank, and the necessary information was not verified before sending. Interviews with administrative staff revealed that the notice was the first one sent by the staff member responsible, and there was uncertainty about whether the correct form was used. The facility's policy required that in cases of emergency discharge, notice requirements and procedures for facility-initiated discharges be followed, but this was not adhered to in this instance, leading to the deficiency.
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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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