Shawnee Gardens Healthcare & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Shawnee, Kansas.
- Location
- 6416 Long Street, Shawnee, Kansas 66216
- CMS Provider Number
- 175267
- Inspections on file
- 33
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Shawnee Gardens Healthcare & Rehab Center during CMS and state inspections, most recent first.
The facility failed to report an allegation of abuse to the State Agency after a CMA observed an interaction between two cognitively impaired residents, including one resident being found in another resident’s room with his pants down. The CMA notified an LN, who contacted administrative staff, and an internal investigation was conducted, including interviews with both residents and review of video showing one resident in the other’s room for over a minute before staff intervened. Despite being informed of an incident described as inappropriate touching and having a policy requiring all alleged abuse to be reported, facility leadership, in consultation with corporate, decided not to report the allegation, concluding they could not determine willful intent and that the residents could make decisions about the interaction.
A resident with severe cognitive impairment and a history of stroke was denied visits from her family after the facility issued a trespassing order against her family member due to confrontational behavior and alleged verbal threats toward staff and the resident. The resident, who relied on family visits for social support, became visibly upset and expressed distress over the loss of visitation, while staff and the resident's representative confirmed no physical harm had occurred. The facility did not consult the LTC Ombudsman before restricting visitation, contrary to its policy on resident rights.
A resident with multiple comorbidities and a history of falls experienced a significant change in condition after staff failed to obtain physician-ordered urinalysis and laboratory tests. There was no documentation of attempts to collect the samples, resident refusals, or physician notification regarding the delays. The resident was later hospitalized with septic syndrome and urosepsis, and the facility could not provide the required lab results.
A cognitively impaired resident was sexually abused by another resident with a history of inappropriate sexual behaviors. The facility failed to implement preventative measures and adequately monitor the resident, leading to the incident. The victim did not consent to the touching, resulting in immediate jeopardy and fear.
A facility failed to implement effective preventative interventions for a resident with a history of sexual behaviors, placing female residents at risk. The resident's care plan lacked specific interventions for his behaviors, and incidents of inappropriate touching were not consistently documented or monitored. Staff interviews revealed inconsistencies in monitoring and reporting procedures, despite the facility's policy emphasizing resident safety and dignity.
A facility failed to effectively monitor and intervene in the behavioral health care of a resident with a history of sexual behaviors. Despite having a care plan, it lacked specific strategies and supervision requirements, leading to repeated inappropriate incidents with female residents. Staff interviews revealed inconsistencies in care plan execution, highlighting a deficiency in providing necessary behavioral health services.
The facility did not conduct a thorough assessment to determine necessary resources for competent care during routine and emergency situations. The assessment lacked details on resident capacity, input from residents, specific staffing needs, and required nursing competencies, putting all 115 residents at risk.
A facility with 115 residents failed to ensure agency staff received necessary communication training, risking impaired care and decreased quality of life. The facility could not provide training records for agency staff, including LNs and CNAs, as required by their policy. This oversight was identified during a review, highlighting a lapse in maintaining adequate training documentation.
A facility with 115 residents failed to ensure agency staff received required resident rights training, risking impaired care and decreased quality of life. The facility could not provide proof of training records for agency staff, including LNs and CNAs, during a review. Despite the facility's policy requiring sufficient staffing with appropriate training, the necessary records were unavailable, compromising resident safety and care quality.
The facility failed to ensure that agency staff received the required infection control training, as part of its infection prevention and control program. The facility could not provide proof of training records for agency staff, including an LN and a CNA. Administrative Nurse D stated that training records were typically reviewed online or communicated over the phone, but the facility was unable to provide the required records. This failure placed residents at risk for impaired care and decreased quality of life.
The facility failed to maintain resident dignity during meal assistance and personal care. Staff stood over two residents while feeding them, delayed addressing an incontinent accident in the dining room, and left a resident exposed during personal care. In the Memory Unit, a staff member made a derogatory comment about a resident's eating habits, leading to the resident refusing to eat. Additionally, staff referred to a resident as a "feeder" in a loud manner, violating the facility's dignity policy.
The facility failed to accommodate dietary preferences in the Memory Care Unit, with residents expressing dissatisfaction over limited breakfast options. Requests for specific items like pancakes, toast, and different cereals were denied, and coffee availability was delayed. Staff interviews revealed inconsistencies in food and beverage availability, contradicting the facility's policy to assess and accommodate residents' dietary needs and preferences.
The facility failed to implement effective infection control measures, including the absence of signage for Enhanced Barrier Precautions (EBP) and inadequate sanitation of shared equipment. Residents with medical conditions such as gastrostomy tubes and open wounds lacked protective equipment and signage. Additionally, staff did not perform proper hand hygiene, and trash was improperly stored, contributing to an unsanitary environment.
A resident with multiple medical conditions and impaired cognition was found to have their call light out of reach on two occasions, leaving them vulnerable to unmet care needs. Facility staff confirmed that call lights should be within reach, but this was not ensured, resulting in a deficiency.
A resident's care plan was not updated to reflect the discontinuation of a Foley catheter, leaving outdated instructions regarding toileting needs. Despite the resident's ability to manage toileting independently, the care plan continued to reference the catheter. Staff interviews confirmed the oversight, highlighting the need for regular updates to care plans to ensure accurate care instructions.
A resident with severe cognitive impairment and language barriers did not receive adequate communication support, leading to multiple incidents of confusion and distress. Despite care plan instructions to use translation services, staff failed to implement these strategies, resulting in the resident's inability to communicate effectively and causing disturbances in the Memory Care Unit.
The facility failed to provide adequate ADL assistance for several residents, including toileting and eating. A resident with quadriplegia was left with urine leaking onto the floor, another with severe cognitive impairment was not checked for incontinence for over four hours, and a third resident was unable to eat due to lack of staff assistance. These deficiencies highlight a failure to adhere to care plans and provide necessary support.
A resident with multiple sclerosis and a history of pressure ulcers had their low air-loss mattress set incorrectly at 220 lbs instead of their actual weight of 137 lbs. The facility's staff failed to ensure the mattress was set according to the resident's weight, as required by the care plan and facility policy, placing the resident at risk for skin breakdown.
A facility failed to implement fall prevention measures for two residents. One resident's wheelchair lacked an anti-rollback device, despite being at risk for falls due to severe cognitive impairment and limited mobility. Another resident's bed was left in a high position, posing a fall risk, despite her dependence on staff for mobility. Staff were unsure about the implementation of these safety measures, indicating a lapse in following care plans.
A facility failed to consistently communicate a resident's medical condition with the dialysis center, leading to a deficiency in dialysis care. The resident, with multiple medical conditions, required hemodialysis three times a week. The facility's records lacked evidence of necessary pre- and post-dialysis assessments on several dates, despite expectations for nursing staff to complete and return communication sheets. This failure placed the resident at risk of potential adverse outcomes related to dialysis.
A facility failed to provide appropriate dementia-related care for a resident with severe cognitive impairment, leading to inadequate communication and supervision. The resident, who required an interpreter, was not effectively redirected during incidents of confusion and wandering. Staff did not use translation services, resulting in unmanaged interactions with other residents. This deficiency risked the resident's quality of life and dignity.
The facility failed to ensure controlled substances were reconciled between shifts, with missing signatures on Narcotic Hand Off Count Sheets for multiple dates. Staff interviews confirmed that narcotics should be counted and documented at each shift change, as per facility policy. This failure placed residents at risk for medication misappropriation and diversion.
The facility failed to ensure a CP identified and reported missing dosage and application location for a resident's medication, placing them at risk for side effects. Additionally, the facility did not ensure CP recommendations for another resident were reviewed by the physician, risking unnecessary medication use. Staff interviews revealed a lack of clarity and action regarding pharmacy recommendations.
A resident with quadriplegia and dementia was at risk due to a deficiency in medication administration. The facility failed to ensure the resident's diclofenac order included a specific dosage and application area, leading to potential unnecessary medication use. The resident required significant assistance and had severely impaired cognition, and the facility could not provide a policy on physician's orders.
The facility failed to ensure proper collaboration and communication with hospice services for two residents receiving end-of-life care. For one resident, the care plan lacked documentation of medications, personal care items, and hospice visit frequency. Another resident's care plan did not specify hospice services such as medication and equipment. Both residents had complex medical histories, and the lack of coordination created a risk of missed or delayed services.
The facility failed to obtain informed declinations for the PCV20 vaccine for two residents, whose records showed refusals without documented informed declinations. This oversight was identified during a review of the facility's immunization practices, which require a signed consent form to be placed in the resident's permanent medical record.
The facility did not comply with the requirement to post daily staffing information, including the census, and maintain these records for 18 months. Inspections revealed missing census information on posted staffing sheets and multiple missing records over several months. An administrative nurse confirmed the requirement, but the facility lacked a related policy.
A cognitively impaired resident experienced multiple falls despite various interventions. The facility failed to provide adequate post-fall care, including neurological evaluations, after an unwitnessed fall that resulted in head trauma and fractures. Staff inconsistencies in following post-fall protocols were noted.
Failure to Report Resident-to-Resident Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse between two cognitively impaired residents to the State Agency (SA) as required by policy. On 03/29/26, a CMA observed an interaction between two residents in which one resident was later alleged to have been in the other resident’s room with his pants down. The CMA reported this to an LN, who then contacted administrative staff. Administrative staff and a nurse initiated an internal inquiry, including entering the alleged victim’s room, where the resident was in bed and did not appear in distress. When questioned, the alleged victim denied concerns about visitors entering the room and stated she would tell an unwelcomed visitor to leave, and that she would not be offended by advances from a welcomed visitor. As part of the internal investigation, Social Services interviewed the alleged perpetrator, who had no recollection of any interaction with the other resident. The CMA later described that she had seen the alleged perpetrator rolling down the hallway, instructed him to return to his room, and then, upon passing near the alleged victim’s door, entered the room and immediately separated the two residents. The alleged victim yelled and questioned what the CMA was doing. Video surveillance showed that the alleged perpetrator entered the alleged victim’s room and remained there for one minute and 40 seconds before the CMA entered. The facility’s investigation narrative documented that Social Services assessed both residents for psychosocial well-being and determined neither was at risk from the allegation. During surveyor interviews, the LN stated she had been told by the CMA that she walked in on the resident in the other resident’s room with his pants down and that the alleged victim was just lying there. The LN reported she notified an administrative nurse, who directed her to call the administrator, and she did so. The administrator and administrative nurse both acknowledged they were informed of an incident of inappropriate touching between the two residents. They further stated that, after working with corporate and completing their investigation, they decided not to report the allegation to the SA because they believed the residents could make decisions about the interaction and could not define willful intent of abuse. This decision was made despite facility policy directing that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported to the SA within required time frames and that investigation results be reported within five working days.
Failure to Honor Resident Visitation Rights
Penalty
Summary
A resident with a history of cerebral infarction and severe cognitive impairment, as indicated by a BIMS score of three, was denied the right to receive visitors of her choosing at the time of her choosing. The resident's care plan allowed her to make daily decisions and emphasized maintaining a consistent routine to reduce confusion. Despite this, the facility issued a trespassing order against the resident's family member following an incident where the family member was reported to have been confrontational with staff and allegedly threatened to slap the resident. The family member denied threatening the resident but admitted to using profanity and confronting staff. The facility's investigation documented that staff intervened when the family member became verbally abusive and refused to leave, resulting in police involvement and the issuance of a trespassing order that barred the family member from visiting for one year. The resident expressed distress over the inability to see her family, stating that her family was her only visitor and that she never felt unsafe around them. The resident became visibly upset and cried when discussing the situation, indicating a negative impact on her psychosocial well-being. Interviews with staff and the resident's representative revealed that while the family member had issues controlling anger and was verbally abusive to staff, there was no evidence of physical violence toward the resident. The facility did not consult the Long-Term Care Ombudsman regarding the visitation restriction. The facility's policy states that residents have the right to receive visitors of their choosing, but this right was not upheld in this case, resulting in social isolation and emotional distress for the resident.
Failure to Obtain and Document Physician-Ordered Labs and Notify Physician of Delays
Penalty
Summary
The facility failed to obtain a physician-ordered urinalysis (UA) and other laboratory tests for a resident, despite orders being placed. The resident had a history of chronic kidney disease, recurrent UTIs, atrial fibrillation, repeated falls, and cognitive communication deficits. Orders for a UA, CBC, CMP, and magnesium were placed, but the medical record lacked documentation of any attempts to collect the samples or any refusals by the resident prior to a significant change in condition. There was also no evidence that the physician was notified of the inability to obtain the samples or of any refusals. The resident experienced multiple falls and a change in condition over several days, including confusion, disorientation, and eventually unresponsiveness with respiratory distress. Despite these changes, staff did not document attempts to obtain the ordered tests, nor did they notify the physician about the delays or the resident's refusals. Interviews with staff confirmed that while some claimed the resident refused the UA and labs, there was no documentation of these refusals or of physician notification in the medical record. The facility's own policies required timely notification of changes in condition and provision of physician-ordered services, but these were not followed. Ultimately, the resident was sent to the hospital in an unresponsive state with a high fever and was admitted to the ICU for septic syndrome, urosepsis, and other acute conditions. The lack of timely diagnostic testing and failure to notify the physician of the delays or refusals contributed to a delay in care. The facility was unable to provide any results for the ordered tests, and staff interviews revealed inconsistent practices and a lack of adherence to documentation and notification protocols.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to prevent an episode of resident-to-resident sexual abuse involving two cognitively impaired residents. On the specified date, staff witnessed one resident groping another resident's nipples, breast, and buttocks while both were seated at the dinner table on a locked unit for cognitively impaired residents. The victim voiced that she did not consent to the touching, placing her in immediate jeopardy and at risk for ongoing abuse and fear. The resident who committed the abuse had a history of sexual behaviors related to psychiatric illness, as noted in his medical records. Despite this, his care plan did not adequately address his sexual behaviors, and he was moved to a new unit without implementing preventative interventions. The resident's care plan included instructions for staff to explain and reinforce why his behaviors were inappropriate, but it failed to prevent the incident. Additionally, the facility's staff did not ensure close monitoring of the resident, which contributed to the occurrence of the abuse. The facility's policy on abuse, neglect, and exploitation was not effectively enforced, as evidenced by the failure to protect the victim from abuse. The facility did not identify and implement necessary preventative measures related to the resident's sexual behaviors upon his relocation to a new unit, placing other female residents at risk for similar incidents. This deficiency resulted in feelings of fear and potential psychosocial harm for the victim.
Removal Plan
- R1 was placed on one-on-one supervision until psychiatric evaluation can be completed.
- The facility identified all at-risk residents on the unit.
- Staff were provided in-service on abuse, neglect, and exploitation with comprehensive testing.
- Safe survey conducted on female residents of unit.
- Psychiatric evaluation will be completed.
Failure to Implement Preventative Interventions for Resident's Sexual Behaviors
Penalty
Summary
The facility failed to implement effective preventative interventions to manage a resident's sexual behaviors, which placed female residents at risk. The resident in question, identified as R1, had a history of sexual behaviors related to psychiatric illness, as noted in his medical records. Despite this, his care plan lacked specific interventions to address his sexual behaviors towards female residents, and there was insufficient supervision and monitoring when he was outside his room. The care plan did not include necessary precautions such as supervision around female residents or monitoring while he was out of his room. Multiple incidents were documented where R1 engaged in inappropriate sexual behaviors towards female residents. These incidents included inappropriate touching and physical aggression, which were not adequately addressed in his care plan or through staff supervision. For instance, R1 was observed touching a female resident inappropriately during meal service, and another incident involved him touching a female resident's arm despite her attempts to push him away. These behaviors were not consistently documented or monitored in his electronic medical records, indicating a lack of effective intervention and oversight. Interviews with staff revealed inconsistencies in the understanding and implementation of monitoring and reporting procedures for R1's behaviors. Staff members were aware of R1's history but did not consistently document or monitor his behaviors as required. The facility's policy on abuse, neglect, and exploitation emphasized the need for resident safety and dignity, yet the facility failed to protect female residents from R1's inappropriate behaviors. This deficiency placed R2 and 19 other female residents at risk, highlighting a significant lapse in the facility's duty to provide a safe environment.
Inadequate Behavioral Monitoring and Interventions for Resident
Penalty
Summary
The facility failed to implement effective behavioral monitoring and interventions for a resident with a history of sexual behaviors related to psychiatric illness. The resident, who had diagnoses including chronic obstructive pulmonary disease and depression, exhibited sexually inappropriate behaviors towards female residents. Despite having a care plan that noted these behaviors, the plan lacked specific triggers, coping strategies, and supervision requirements necessary to prevent such behaviors. The resident's electronic medical records and care plan did not adequately document or address these behaviors, leading to repeated incidents. Multiple incidents were documented where the resident engaged in inappropriate touching and aggressive behaviors towards female residents. These incidents were recorded in the resident's progress notes, but there was a lack of consistent monitoring and documentation in the electronic medical records, particularly in the Tasks and Treatment Administration Report sections. The facility's policy required ongoing behavioral monitoring and supervision for cognitively impaired residents, but this was not effectively implemented for the resident in question. Interviews with facility staff revealed inconsistencies in the understanding and execution of the care plan. Staff were aware of the resident's history and the need for monitoring, but the care plan did not clearly outline the necessary interventions and supervision. The facility's failure to provide adequate behavioral health care and services placed the resident at risk for continued behavioral episodes and unmet care needs.
Inadequate Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment, dated [DATE], did not specify the facility's resident capacity, nor did it include input from residents and their representatives. Additionally, it lacked details on the specific staffing needs for each unit based on the resident population and did not identify the competencies and skill sets required by nursing staff to adequately care for the residents. An administrative nurse mentioned that the assessment was recently revised, but the facility could not provide a policy related to the assessment when requested. This oversight placed all 115 residents at risk for inadequate care.
Failure to Provide Required Communication Training for Agency Staff
Penalty
Summary
The facility, with a census of 115 residents, failed to ensure that agency staff received the required communication training, which is essential for providing quality care. During a review on September 11, 2024, the facility could not provide proof of training records for agency staff, including Licensed Nurses K and L, and Certified Nurse's Aide OO. Administrative Nurse D mentioned that the facility typically reviews training records online or receives information over the phone about the training or classes completed by agency staff. However, the facility was unable to provide the requested training records by September 18, 2024. According to the facility's Nursing Services and Sufficient Staffing policy, revised in October 2022, the facility is responsible for ensuring sufficient staffing with appropriate training, competencies, and skill sets to assure resident safety and the highest level of resident care. The failure to complete the required communication training for staff providing care in the facility placed residents at risk for impaired care and decreased quality of life.
Failure to Provide Required Resident Rights Training for Agency Staff
Penalty
Summary
The facility, with a census of 115 residents, failed to ensure that agency staff received the required resident rights training, which is essential for providing proper care and maintaining the quality of life for residents. During a review on 09/11/24, the facility could not provide proof of training records for agency staff, including Licensed Nurses K and L, and Certified Nurse's Aide OO. Administrative Nurse D mentioned that the facility typically reviews training records online or receives information over the phone regarding the training or classes completed by agency staff. However, the facility was unable to provide the necessary training records when requested on 09/18/24. According to the facility's Nursing Services and Sufficient Staffing policy, revised in October 2022, the facility is required to provide sufficient staffing with appropriate training, competencies, and skill sets to ensure resident safety and achieve the highest level of resident care. The failure to complete the required resident rights training for staff who provided care in the facility placed residents at risk for impaired care and decreased quality of life.
Failure to Ensure Infection Control Training for Agency Staff
Penalty
Summary
The facility, with a census of 115 residents, failed to ensure that agency staff received the required infection control training, which is a part of its infection prevention and control program. During a review on 09/11/24, the facility was unable to provide proof of training records for agency staff, specifically for Licensed Nurse (LN) K, LN L, and Certified Nurse's Aide (CNA) OO. Administrative Nurse D mentioned that the facility would typically review records online or receive information over the phone regarding the training or classes completed by agency staff. However, the facility was unable to provide the required training records as requested on 09/18/24. The facility's Nursing Services and Sufficient Staffing policy, revised in 10/2022, indicated that the facility would provide sufficient staffing with appropriate training, competencies, and skill sets to ensure resident safety and achieve the highest level of resident care. The failure to ensure the completion of the required infection control training for staff who provided care in the facility placed the residents at risk for impaired care and decreased quality of life.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to maintain the dignity of several residents during meal assistance and personal care. Two residents, R17 and R41, were observed being fed by staff who stood over them, which is against the facility's policy of sitting with residents during meals. Another resident, R92, experienced an incontinent accident in the dining room, and staff delayed in addressing the situation, leading to other residents noticing and commenting on the incident. Additionally, R35 was left exposed during personal care with the room door open, compromising privacy. In the Memory Unit, staff failed to treat R108 with respect during mealtime. Activity Z made a derogatory comment about R108's eating habits, which led to R108 refusing to eat and moving away from the table. Furthermore, staff referred to R35 as a "feeder" in a loud manner in the hallway, which is disrespectful and against the facility's dignity policy. Interviews with staff confirmed that these actions were not in line with the expected standards of care, which emphasize maintaining resident dignity and privacy.
Failure to Accommodate Dietary Preferences in Memory Care Unit
Penalty
Summary
The facility failed to accommodate the dietary preferences of its residents, particularly in the Memory Care Unit. Multiple residents expressed dissatisfaction with the lack of meal options, specifically during breakfast. One resident repeatedly requested pancakes and toast but was denied and given Cheerios instead. Another resident asked for a different type of cereal but was told only Cheerios were available. Additionally, residents were informed that seconds were not available, and coffee requests were delayed until the arrival of the breakfast cart. The Resident Council also reported that alternative meal options were not provided for breakfast, and pancakes were only served on Saturdays. Staff interviews revealed inconsistencies in the availability of food and beverages. A CNA mentioned that coffee was always available but required a call to the kitchen, and alternative menus were only offered for lunch and dinner. An administrative nurse stated that staff should communicate with the kitchen for additional items, and units should have drinks and snacks available. However, a dietary staff member indicated that alternatives for breakfast could not be provided, although pancakes, coffee, and cereal options were available upon request. The facility's Food Preferences policy stated that residents' dietary needs and preferences should be assessed and accommodated, but this was not effectively implemented, leading to the deficiency.
Inadequate Infection Control Measures
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by several deficiencies observed during a survey. The facility did not provide appropriate signage or indicators to alert staff and visitors of residents on Enhanced Barrier Precautions (EBP), which are necessary to reduce the transmission of resistant organisms. Specifically, rooms of residents with medical conditions such as percutaneous endoscope gastrostomy tubes, open wounds, and suprapubic catheters lacked protective equipment and signage indicating EBP. Additionally, shared equipment like the Hoyer lift was not sanitized between uses, and staff did not perform adequate hand hygiene during resident care, as observed when a CNA failed to change soiled gloves before touching clean items. The facility also failed to maintain a sanitary environment, as evidenced by improper trash storage and uncleaned spills. Large trash bags containing soiled items were left on the floor across from the nurse's station, and a brown substance was found in a dining room cabinet. Administrative Nurse D confirmed that signs should be posted for residents requiring EBP, and staff should adhere to hand hygiene protocols. The facility's Infection Prevention and Control Program, dated 11/01/19, was not effectively implemented, placing residents at risk for infectious diseases.
Resident's Call Light Inaccessible
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which left the resident vulnerable to unmet care needs. The resident, identified as R37, had multiple medical conditions including sleep apnea, diabetes mellitus, hypertension, congestive heart failure, bipolar disorder, depressive disorder, Parkinson's disease, chronic obstructive pulmonary disease, dysphagia, and end-stage renal disease. The resident was documented as having moderately impaired cognition and was dependent on staff for activities of daily living, including eating, showering, and personal hygiene. Observations on two separate occasions revealed that the resident's call light was on the floor, out of reach, while the resident was either in bed or in a wheelchair. Interviews with facility staff, including a licensed nurse, a certified nurse's aide, and an administrative nurse, confirmed that call lights should be within reach of residents at all times. The facility's policy on the accommodation of needs also stated that reasonable accommodations should be made for individual resident needs and preferences. Despite these guidelines, the facility did not ensure that the resident's call light was accessible, resulting in a deficiency in care.
Failure to Update Resident's Care Plan Post-Catheter Removal
Penalty
Summary
The facility failed to update the care plan of a resident, identified as R106, to reflect his current toileting needs after the discontinuation of his Foley catheter. R106 was admitted with a Foley catheter, which was removed shortly after admission. Despite this change, the care plan continued to indicate the presence of the catheter and did not provide updated instructions for his toileting needs. This oversight was identified during a review of the resident's care plan, which lacked necessary updates to reflect his ability to independently manage his toileting and personal hygiene. Observations and interviews with staff revealed that the care plan should have been updated to reflect the resident's current needs. A CNA and a licensed nurse both acknowledged that the care plan was outdated and should have been revised to remove references to the Foley catheter. The administrative nurse confirmed that care plans should be reviewed and updated regularly, including when there are changes in a resident's condition. The failure to update the care plan placed the resident at risk for impaired care due to uncommunicated care needs.
Failure to Utilize Translation Services for Non-English Speaking Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R99, received appropriate supportive care and services to maintain her quality of life. R99, who has severe cognitive impairment, dementia, general anxiety disorder, and a cognitive communication disorder, was not provided with adequate tools or strategies to communicate her needs, wants, or feelings. Despite her care plan indicating the need for an interpreter and the use of translation services, staff did not utilize these resources effectively, leading to multiple incidents where R99 was unable to understand or be understood by staff. On several occasions, R99 was observed wandering the Memory Care Unit and entering other residents' rooms, causing confusion and distress. Staff attempted to redirect her using English, which she did not understand, and failed to use available translation services or cue cards to communicate with her. This lack of communication led to incidents where R99 inadvertently disturbed other residents, such as attempting to assist another resident during lunch, which resulted in a verbal altercation. The facility's failure to implement the necessary communication strategies as outlined in R99's care plan placed her at risk for decreased quality of life, isolation, and impaired dignity. Despite having policies in place for communication with residents with limited English proficiency, staff did not consistently apply these measures, contributing to the deficiency identified in the report.
Deficiencies in ADL Assistance for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, leading to deficiencies in care. Resident 92, who had diagnoses of quadriplegia, dementia, and encephalopathy, was dependent on staff for all ADLs, including toileting. Despite being on a two-hour check schedule, Resident 92 was observed with urine leaking from his brief onto the dining room floor, indicating a failure to provide timely incontinence care. Staff interviews revealed that Resident 92 was not checked and changed as required, especially before meals, which was a directive in his care plan. Resident 68, who had severe cognitive impairment and was dependent on staff for all ADLs, was left without toileting or incontinence checks for over four hours while sitting in a Broda chair. This lack of attention to his toileting needs was contrary to his care plan, which required regular checks and changes to maintain dignity and prevent skin breakdown. Staff interviews confirmed that Resident 68 should have been checked every two hours and provided with bathroom opportunities after meals. Resident 37, with multiple diagnoses including sleep apnea, diabetes, and Parkinson's disease, was dependent on staff for eating and other ADLs. On one occasion, Resident 37 was left in bed with his breakfast tray out of reach, and he was unable to eat without assistance. Despite his request to be taken to the dining room, he was not assisted due to a lack of available staff. This resulted in Resident 37 being unable to consume his meal, as observed when his tray was removed with most of the food untouched. Staff interviews indicated that there should have been enough staff to assist with his needs, but this was not provided, leading to a deficiency in care.
Improper Setting of Low Air-Loss Mattress for Resident
Penalty
Summary
The facility failed to ensure that a resident's low air-loss (LAL) mattress pump was set correctly according to the resident's weight, which is crucial for pressure ulcer prevention and care. The resident, who had multiple sclerosis, heart failure, and a history of pressure ulcers, was dependent on staff for all functional abilities and was incontinent of both bladder and bowel function. The resident's care plan included the use of a LAL mattress to prevent skin breakdown, but the mattress was found to be set at 220 lbs, which was inappropriate for the resident's actual weight of 137 lbs. The deficiency was identified through observations, record reviews, and interviews. The resident's electronic medical record (EMR) and treatment administration record (TAR) documented the requirement for the LAL mattress to be checked every shift to ensure it was set correctly based on the resident's weight. However, the TAR lacked documentation of the resident's weight or the setting of the LAL machine. Interviews with staff revealed a lack of knowledge regarding the correct setting for the LAL mattress, with both a certified nurse aide and a licensed nurse unable to specify the appropriate setting. The facility's policy on the use of support surfaces required that such devices be utilized according to the manufacturer's recommendations and checked each shift for proper functioning. Despite this policy, the resident's LAL mattress was not set according to the physician's order or the resident's weight, placing the resident at risk for complications related to skin breakdown and pressure ulcers.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement the fall intervention of anti-rollback devices for a resident, identified as R41, as per his care plan. R41 had severe cognitive impairment and was dependent on staff assistance for various activities of daily living. Despite being at risk for falls due to his medical conditions and limited mobility, his wheelchair lacked the necessary anti-rollback device, which was observed during a survey. Staff members, including a CNA and a licensed nurse, were unsure if the device had ever been placed on the wheelchair, indicating a lapse in following the care plan. Another deficiency was noted when a resident, identified as R36, was found with her bed left in a high position, posing a risk for falls. R36 had severely impaired cognition and was dependent on staff for mobility and other daily activities. Observations showed that her bed was elevated three feet off the floor, and she was unable to lower it herself. Staff members, including a CNA and a licensed nurse, acknowledged that the bed should not have been left in such a position, highlighting a failure to ensure a safe environment. The facility's policies on accidents and supervision were not adequately followed, as evidenced by the lack of implementation of individualized interventions to minimize fall risks for both residents. The care plans for R41 and R36 were not effectively executed, placing them at risk for preventable accidents and injuries. The facility's failure to adhere to its own policies and care plans resulted in these deficiencies, as noted by the surveyors.
Failure to Communicate Resident's Condition with Dialysis Center
Penalty
Summary
The facility failed to consistently communicate a resident's medical condition with the dialysis center, which led to a deficiency in providing safe and appropriate dialysis care. The resident, who required hemodialysis due to end-stage renal disease, had multiple medical conditions including sleep apnea, diabetes mellitus, hypertension, congestive heart failure, bipolar disorder, depressive disorder, Parkinson's disease, chronic obstructive pulmonary disease, and dysphagia. The resident's care plan specified that dialysis was to be conducted three times a week, with specific instructions for pre- and post-dialysis assessments and communication with the dialysis center. However, the facility's records lacked evidence of pre-hemodialysis assessments on several specified dates and post-hemodialysis assessments on other dates. Interviews with nursing staff revealed that there was an expectation for nurses to fill out and send pre-dialysis communication sheets with the resident and ensure post-dialysis sheets were completed and returned. Despite these expectations, the facility's failure to consistently follow these procedures placed the resident at risk of potential adverse outcomes and physical complications related to dialysis.
Failure to Provide Dementia-Related Care Services
Penalty
Summary
The facility failed to provide appropriate dementia-related care services for a resident, identified as R99, who was diagnosed with dementia, general anxiety disorder, and cognitive communication disorder. The resident's care plan indicated the need for an interpreter due to her non-English language communication and required staff to encourage her independence while ensuring supervision, especially when outside. Despite these instructions, staff did not utilize translation services or cue cards to communicate effectively with R99 during incidents of confusion and wandering. On multiple occasions, R99 exhibited behaviors such as wandering into other residents' rooms and attempting to assist them, which led to confusion and distress among the residents. Staff interventions were inadequate as they attempted to redirect R99 in English, which she did not understand, and failed to use available translation services. This lack of effective communication and supervision resulted in R99's continued wandering and interactions with other residents, which were not appropriately managed. The facility's policy required staff to provide assistance and services as outlined in each resident's care plan and to monitor and update care plan interventions as needed. However, the staff did not adhere to these guidelines, as evidenced by their failure to use translation services and adequately supervise R99, leading to a deficiency in providing dementia-related care. This deficiency placed R99 at risk for decreased quality of life, isolation, and impaired dignity.
Failure to Reconcile Controlled Substances Between Shifts
Penalty
Summary
The facility failed to ensure that controlled substances were properly accounted for and reconciled between shifts, as evidenced by missing signatures on the Narcotic Hand Off Count Sheets for multiple dates in July, August, and September 2024. Specifically, there were missing signatures for either the on-coming or off-going nurse during both morning and evening shifts on several occasions. This lack of documentation was observed in the medication rooms and carts on the 100 halls, indicating a failure to adhere to the facility's policy requiring narcotic counts and signatures at each shift change. Interviews with facility staff, including a Certified Medication Aide and a Licensed Nurse, confirmed that narcotics were supposed to be counted and documented with signatures at each shift change. The facility's policy on Controlled Substance Administration and Accountability, dated January 1, 2020, mandates safeguards to prevent loss, diversion, or accidental exposure of controlled substances. Despite this policy, the facility did not ensure accurate reconciliation of controlled medications, placing residents at risk for medication misappropriation and diversion.
Failure to Address Medication Regimen Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported missing dosage and application location for a physician-ordered medication for a resident, referred to as R92. R92 had multiple diagnoses, including quadriplegia, dementia, and encephalopathy, and required significant assistance for daily activities. The resident's medication orders for diclofenac sodium external gel lacked specific dosage amounts and application locations, which were not identified or reported by the CP during monthly medication regimen reviews from May 2024 to August 2024. This oversight placed the resident at risk for unnecessary medication side effects. Additionally, the facility did not ensure that the CP's recommendations for another resident, referred to as R35, were submitted to the attending physician for review. R35 had severe cognitive impairment and multiple diagnoses, including diabetes mellitus, depressive disorder, atrial fibrillation, and hypertension. The resident's electronic medical record showed that recommendations were made by the CP in March and May 2024, but there was no evidence that these recommendations were reviewed or addressed by the attending physician. This failure to act on the CP's recommendations placed R35 at risk for unnecessary medication use and potential side effects. Interviews with facility staff revealed a lack of clarity and action regarding pharmacy recommendations. Licensed Nurse J stated she was not involved with pharmacy recommendations, and Administrative Nurse D confirmed that the facility could not locate documentation showing that the physician had reviewed the CP's recommendations for R35. The facility's Medication Regimen Review policy required thorough evaluation and documentation of medication regimens, but these procedures were not followed, leading to the deficiencies identified in the report.
Deficiency in Medication Administration for a Resident
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary drugs, specifically regarding the administration of diclofenac, a topical medication used to treat pain and swelling. The resident, identified as R92, had a physician's order for diclofenac sodium external gel 1% to be applied to the affected area three times a day for pain. However, the order lacked a specified dosage amount and did not indicate the specific location for application. This oversight placed the resident at risk of unnecessary medication administration and potential adverse side effects. R92's medical history included diagnoses of quadriplegia, dementia, and encephalopathy, with a documented severely impaired cognition. The resident required substantial to total assistance for functional abilities and was always incontinent of both bladder and bowel. During the survey, it was observed that the licensed nurse applied the medication without a specified dosage, and the administrative nurse confirmed that all orders should indicate the amount and area for application. The facility was unable to provide a policy regarding physician's orders when requested, highlighting a deficiency in ensuring proper medication administration for R92.
Lack of Collaboration with Hospice Services
Penalty
Summary
The facility failed to ensure proper collaboration and communication between the nursing home and hospice services for two residents, R20 and R5, who were receiving hospice care. For R20, the facility did not document a comprehensive care plan that included the medications covered by hospice, personal care items provided, and the frequency of hospice visits. The hospice communication book also lacked a current hospice care plan, physician order with admitting diagnosis, and a list of medications covered by hospice. This lack of documentation and communication created a risk of missed opportunities for services and delayed addressing of physical, mental, and psychosocial needs. R20's medical history included dementia, major depressive disorder, diabetes mellitus, and chronic obstructive pulmonary disease. Observations noted that R20 had severely impaired cognition and required assistance with activities of daily living. Despite being admitted to hospice care, the facility's care plan did not reflect the necessary coordination with the hospice provider, as evidenced by the absence of detailed documentation regarding hospice services. Similarly, for R5, the facility's care plan did not specify the services provided by hospice, such as medication, equipment, and supplies, or the schedule of hospice worker visits. R5's medical conditions included convulsions, bipolar disorder, depressive disorder, anxiety, cerebral infarction, Bell's palsy, protein-calorie malnutrition, weakness, dysphagia, and congestive heart failure. Despite receiving hospice services, the facility failed to ensure a collaborative process was in place to communicate necessary information regarding R5's care, which had the potential for negative outcomes.
Failure to Obtain Informed Declination for PCV20 Vaccine
Penalty
Summary
The facility failed to offer and/or obtain an informed declination for the Pneumococcal Conjugate Vaccine (PCV20) for two residents, identified as R35 and R75. Both residents' Electronic Medical Records (EMR) documented a refusal for the PCV20 vaccination, yet their clinical records lacked evidence of an informed declination. This deficiency was identified during a review of the facility's immunization practices, which included a sample of 26 residents out of a census of 115. The facility's Vaccine Information Statement, revised on 06/01/22, mandates that a copy of the most current vaccine information statement be provided to the resident or their legal representative before vaccine administration, and that a signed consent form be placed in the individual's permanent medical record. However, the facility was unable to provide evidence of informed declinations for R35 and R75, placing them at increased risk for complications related to pneumonia.
Failure to Post Daily Staffing Information and Maintain Records
Penalty
Summary
The facility failed to comply with the requirement to post daily staffing information, including the census, and to maintain these records for 18 months. During an inspection on 09/16/24, it was observed that the staffing sheet displayed in the main lobby was dated 09/13/24 and did not include the census. The following day, the posted staffing sheet had the correct date but still lacked the census information. A review of the facility's records from 04/01/23 to 09/16/24 revealed multiple missing daily posted staffing records between 07/12/23 and 12/01/23. Administrative Nurse D confirmed the requirement to post daily staffing hours with the census and maintain these records for 18 months. The facility was unable to provide a policy related to the posting of staffing information.
Failure to Prevent Falls and Provide Post-Fall Care
Penalty
Summary
The facility failed to identify and implement appropriate, resident-centered interventions to prevent falls for a cognitively impaired resident. Despite multiple falls and documented interventions, the resident continued to fall, indicating that the interventions were ineffective. The resident's care plan included measures such as staff education, medication review, and placing signs in the resident's room, but these did not prevent further falls. On one occasion, the resident experienced an unwitnessed fall that resulted in head trauma. The facility failed to ensure that the resident received post-fall care, including neurological evaluations and nursing assessments. Although initial neurological checks were performed, there was a lack of evidence that these checks were continued as required. The resident was later found to have nasal bone fractures and multiple rib fractures. Interviews with staff revealed inconsistencies in the implementation of post-fall protocols. One nurse did not check if the resident was on anticoagulant medication, which would have necessitated immediate hospital transfer. Another nurse did not receive a callback from the on-call provider and did not attempt to call again. These lapses in care placed the resident at risk for increased pain and other complications.
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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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