Southwind At Spearville
Inspection history, citations, penalties and survey trends for this long-term care facility in Spearville, Kansas.
- Location
- 102 N Pine Street, Spearville, Kansas 67876
- CMS Provider Number
- 175568
- Inspections on file
- 10
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Southwind At Spearville during CMS and state inspections, most recent first.
Surveyors observed a dietary staff member plating meals while wearing the same pair of gloves to handle multiple food items, including ready-to-eat bread, and then touching her face and glasses before continuing to plate food without changing gloves or washing hands. The staff member reported she had been trained to serve in this manner and usually changed gloves several times during the process. These practices did not follow the facility’s hand hygiene policy, which requires handwashing in designated sinks, appropriate glove use when handling ready-to-eat food, and handwashing before distributing meals.
The facility used an admission packet containing an Arbitration Provision that did not inform residents or their representatives of their right to rescind the agreement within 30 days or that signing it was not a condition of admission. All residents had signed arbitration agreements, and staff reported that the provision in the packet was the only written information provided, with explanations given verbally at admission. Administrative staff and an administrative nurse indicated that the provision had been created by a previous company and possibly altered by current leadership, and they were not aware of the specific regulatory language required to be included in the arbitration agreement.
The facility used an admission packet arbitration provision for all 22 residents that did not inform residents or their representatives of their right to participate in selecting a neutral arbitrator or a mutually convenient venue. Administrative staff reported that the arbitration provision in the admission packet was the only written information provided and that they verbally explained it at admission, but they were not aware of the specific language required to be included. The arbitration language had been created under a previous company and may have been altered by the current board and administrator, yet it still lacked the required provisions, resulting in a deficiency related to the arbitration process.
A resident with atrial fibrillation and moderately impaired cognition had a care plan and physician order indicating DNR status, but the signed DNR document was missing from the EMR. During transfer from assisted living to LTC, the signed DNR did not carry over into the current chart, and an administrative nurse acknowledged there was no process in place to monitor or verify changes to advance directives, contrary to the facility’s Advance Directives policy requiring supporting documentation with a DNR order.
Surveyors found that the beauty shop was left unlocked and unattended while containing accessible hazardous items, including disinfectant sprays, shampoo, hair spray, curling irons, and an electric razor, with an unlocked cabinet holding additional disinfectant spray. This occurred despite the presence of cognitively impaired but independently mobile residents and despite a facility policy stating a commitment to eliminate and control hazardous chemicals and meet safety standards for hazards and potential hazards.
A resident with a colostomy and history of intestinal obstruction, who was cognitively intact, had a care plan and an ostomy policy requiring staff to monitor and document bowel sounds and bowel movements, including stool output, consistency, and color each shift. Staff did not document any bowel movement information in progress notes or tasks, and continence was left unrated due to the colostomy without recording amount, frequency, or consistency. A CNA was observed emptying the colostomy bag directly into the trash without measuring or documenting the stool and reported that staff do not monitor or report bowel movement details to nurses, while an RN confirmed that this resident’s bowel movements were not included in the usual bowel report process.
A resident with HTN and CHF, prescribed multiple antihypertensives and diuretics with specific BP and pulse parameters, did not receive valsartan, metoprolol, furosemide, or hydrochlorothiazide during a morning medication pass when a CMA obtained a BP in the low 100s systolic and 40s diastolic and reported it to an LN. The LN instructed the CMA to hold all ordered medications based on nursing judgment and did not notify the physician, despite orders outlining when to contact the provider. Documentation in the EMR and MAR reflected that the medications were held per nursing judgment, and no physician notification occurred.
The facility failed to submit complete and accurate staffing information through PBJ, resulting in multiple instances where Licensed Nursing Coverage was not reported as 24 hours a day, despite adequate hours being indicated in the nursing schedule and clocking sheets. An outside agency was responsible for the inaccurate data submission prior to November 1, 2023.
The facility failed to revise care plans for four residents related to falls and nebulizer use. Observations and interviews revealed that nebulizer equipment was not properly stored or cleaned, and care plans were not updated with new interventions after falls. The facility also failed to provide a policy regarding care plans when requested.
The facility failed to conduct a criminal background check for a CNA hired on 07/08/22. The Administrative Nurse confirmed the lack of background check information, which is required by the facility's policy on abuse prevention. This failure had the potential to negatively affect resident care.
The facility failed to ensure a safe environment for a resident with severe cognitive impairment and a history of falls. Despite multiple falls and a high fall risk score, the care plan lacked effective interventions, and staff did not adequately follow the facility's accident prevention policy. This resulted in repeated falls for the resident.
The facility failed to provide necessary respiratory care for two residents, including improper storage and cleaning of nebulizers, and lacked a policy on respiratory care. Observations and staff interviews confirmed these deficiencies.
The facility failed to complete annual performance reviews for three CNAs employed for over 12 months, as confirmed by administrative staff. This lapse was identified during a review of employee files, revealing a lack of performance evaluations to ensure adequate care and services for residents.
Improper Glove Use and Hand Hygiene During Meal Service
Penalty
Summary
Surveyors identified a deficiency in food preparation and service sanitation when observing the noon meal service for a census of 22 residents from the facility’s main kitchen. During the meal, a dietary staff member wearing gloves plated food by removing the lid from a roasting pan and using utensils to serve meat, potatoes, and spinach, then used the same gloved hand to pick up a roll and continued plating. While still wearing the same gloves, she touched her face and glasses and then resumed the plating process without removing the gloves or washing her hands. In a subsequent interview, the dietary staff member stated she had been trained to serve in that manner and typically changed her gloves about three times during the process. The facility’s written hand hygiene policy for food handlers requires that hands always be washed in designated handwashing sinks, that gloves be worn when serving residents on transmission-based precautions or when touching ready-to-eat food, and that staff perform handwashing prior to distributing meals.
Arbitration Agreement Lacked Required Rescission and Non-Condition of Admission Language
Penalty
Summary
The facility failed to ensure its arbitration agreement informed residents or their representatives of their right to rescind the agreement within 30 days of signing and that signing the agreement was not a condition of admission. With a census of 22 residents, all 22 had signed arbitration agreements, and there were no residents in active arbitration. Review of the admission packet showed that Exhibit E, titled Arbitration Provision, did not contain language notifying residents or representatives of the 30-day rescission right or that the arbitration agreement was optional and not required for admission. During interviews, an administrative staff member stated that the Arbitration Provision in the admission packet was the only information provided about the agreement and that she verbally explained it to new admissions when they signed, but there was no indication that the required language was included in writing. Another administrative nurse reported that the previous company had written the Arbitration Provision and that the current board and administrator might have modified it, and she was not aware of the specific language required to be included. A separate administrative staff member also stated they followed whatever the admission agreement said about the Arbitration Provision and acknowledged not being aware of the required elements of the provision. These findings demonstrate that the facility’s written arbitration documents, as provided to all residents at admission, lacked the federally required notifications regarding the right to rescind within 30 days and the non-mandatory nature of signing the arbitration agreement for admission, and that key administrative personnel were unaware of these specific regulatory requirements.
Deficient Arbitration Agreement Lacking Neutral Arbitrator and Venue Provisions
Penalty
Summary
The facility failed to ensure its arbitration agreement provided for the selection of a neutral arbitrator agreed upon by both parties and for the selection of a venue convenient to both parties. At the time of survey, the facility had a census of 22 residents, all of whom had signed the arbitration agreement, and there were no residents in active arbitration. Record review of the admission packet, specifically Exhibit E Arbitration Provision, showed it did not notify residents or their representatives of their right to participate in selecting a neutral arbitrator or a mutually convenient venue. During interviews, an administrative staff member stated that the Arbitration Provision in the admission packet was the only information provided about the agreement and that she verbally explained it to new admissions when they signed it. Another administrative nurse reported that the previous company that operated the facility had written the Arbitration Provision and that the current board and administrator might have modified it, and she was not aware of the specific language required in the provision. A further administrative staff member stated the facility followed whatever was written in the admission agreement regarding arbitration and acknowledged not being aware of the required elements for the Arbitration Provision. These combined actions and inactions—using an admission arbitration form that lacked required language about neutral arbitrator and venue selection, having all residents sign this form, and administrative staff’s lack of awareness of the required arbitration language—led to the identified deficiency.
Failure to Maintain Signed DNR Documentation in Clinical Record
Penalty
Summary
The facility failed to ensure that a resident’s documented Do Not Resuscitate (DNR) status was supported by a signed DNR document in the clinical record. The resident had a diagnosis of atrial fibrillation and an admission MDS showing a BIMS score of 12, indicating moderately impaired cognition. Her care plan documented that she chose to be a DNR and stated that the DNR order would be part of the medical record and reviewed with the care plan. The EMR also contained a physician’s order for a DNR. However, the EMR lacked evidence of the actual signed DNR document that was required to accompany the physician’s order. During the survey, the resident was observed in the dining room visiting with another resident. Administrative Nurse D reported that during the resident’s transfer from assisted living to long-term care, the signed DNR did not transfer into the current chart. Administrative Nurse D also stated that the facility did not have a process or system in place to monitor or verify changes for advance directives. The facility’s undated Advance Directives policy stated that a physician’s DNR order would be accompanied by supporting documentation in the resident’s clinical record, but this supporting documentation was not present for this resident.
Unlocked Beauty Shop With Accessible Chemicals and Heating Devices
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment by leaving the beauty shop, which contained heating devices and chemicals, unlocked and unattended. The facility had a census of 22 residents, including three residents who were cognitively impaired but independently mobile. On 01/27/26 at 10:06 AM, surveyor observation showed the beauty shop door unlocked and open with two cans of Clippercide spray (liquid disinfectant chemical), shampoo, hair spray, two curling irons, and an electric razor on the counter, and an unlocked cabinet containing a can of Lysol spray disinfectant, with no staff present in the room. On 01/28/26 at 02:09 PM, Administrative Staff D stated she expected the beauty shop to be closed and locked when no one was in it. The facility’s undated “Control of Hazardous Chemicals” policy stated the facility is committed to eliminating and controlling hazards that could cause injury or illness to elders and to meeting safety standards where there are specific rules about hazards or potential hazards in the facility. These observations and statements show that hazardous chemicals and heating devices were accessible in an unsecured area despite the presence of cognitively impaired but mobile residents and despite the facility’s stated policy on controlling hazardous chemicals.
Failure to Monitor and Document Colostomy Output
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document bowel movements for a resident with a colostomy as required by the care plan and facility policy. The resident’s EMR documented diagnoses of colostomy and intestinal obstruction, and the admission MDS showed intact cognition with a BIMS score of 15. The resident’s care plan, initiated for dehydration or potential fluid deficit related to diuretic use, directed staff to monitor and document bowel sounds and the frequency of bowel movements. However, progress notes lacked any documentation of bowel movement monitoring, and the task documentation indicated continence was not rated due to the colostomy, with no recorded amount, frequency, or consistency of stool. During observation, a CNA was seen emptying the resident’s colostomy bag into a plastic trash bag and discarding it without any measurement or documentation of the stool. The CNA stated that staff did not monitor or document the frequency, amount, or consistency of the resident’s bowel movements and did not report this information to the nurse, although the CNA noted the stool was loose. A nurse confirmed that while night shift runs a bowel movement report for residents to check for constipation, staff did not document or monitor this resident’s bowel movements. An administrative nurse stated she expected staff to document and monitor the resident’s bowel movements, and the facility’s ostomy care policy required stool output, consistency, and color to be documented in the chart every shift, which was not done for this resident.
Failure to Administer Ordered Antihypertensives/Diuretics and Notify Physician of Medication Hold
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors and to notify the physician when ordered medications were withheld. The resident had diagnoses of HTN and CHF and was prescribed multiple antihypertensive and diuretic medications, including valsartan 320 mg daily, metoprolol tartrate 50 mg twice daily, furosemide 40 mg daily, and hydrochlorothiazide 12.5 mg daily, all with specific parameters to notify the physician if SBP was less than 90 mm/Hg or greater than 180 mm/Hg, DBP less than 40 mm/Hg or greater than 100 mm/Hg, or pulse less than 50 or greater than 110 on two consecutive checks two hours apart. The resident’s care plan directed staff to administer medications as ordered and monitor blood pressure, holding medications per physician-set parameters. On the date in question, the Medication Administration Record documented that none of the four ordered medications were given, and the EMR notes show that the CMA recorded each medication as held per nursing judgment. According to staff interviews, the CMA obtained a blood pressure reading of approximately 111/49 mm/Hg, rechecked it with the diastolic still in the 40s, and reported this to the nurse. The nurse instructed the CMA to hold the medications based on nursing judgment and confirmed that the physician was not notified. Administrative nursing staff later stated that the nurse did not notify the physician because the blood pressure was not within the parameters requiring provider notification, despite the physician’s orders specifying when to notify. The facility’s Medication Administration Policy stated that medications shall be administered safely as ordered by the physician, but the ordered antihypertensive and diuretic medications were not administered and the physician was not contacted regarding the decision to hold them.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to electronically submit complete and accurate staffing information to the federal regulatory agency through Payroll-Based Journaling (PBJ). Specifically, the facility did not accurately submit hourly staffing data for all nursing personnel for multiple dates across three fiscal quarters in 2023. The review of the PBJ Staffing Data reports for Quarter 2, Quarter 3, and Quarter 4 of 2023 revealed that the facility did not have Licensed Nursing Coverage 24 hours a day on numerous specified dates. Despite the nursing schedule and clocking sheets indicating adequate hours for 24-hour nursing coverage, the data submitted was inaccurate. An interview with Administrative Nurse B on March 27, 2024, revealed that an outside agency contracted by the previous ownership company was responsible for the submission of payroll data prior to November 1, 2023. The administrative nurse was unable to provide an explanation for the inaccurate data. The facility's policy on the mandatory submission of uniform format staffing information (PBJ) stated that the facility would electronically submit complete and accurate direct care staffing information based on payroll and other verifiable and auditable data. The facility administrator was responsible for ensuring the accuracy and timeliness of the submitted data.
Failure to Revise Care Plans for Falls and Nebulizer Use
Penalty
Summary
The facility failed to revise the care plans for four residents, specifically related to falls and the use of nebulizer equipment. For Resident 1, the care plan did not include interventions or staff guidance related to nebulizer treatment for respiratory care, despite physician orders indicating the need for such treatments. Observations revealed that the nebulizer equipment was not properly stored or cleaned between treatments, and interviews with staff indicated a lack of knowledge on how to update care plans using the facility's software program. The facility also failed to provide a policy regarding care plans when requested. For Resident 3, the care plan similarly lacked interventions or staff guidance regarding nebulizer treatments, despite physician orders and observations confirming the need for such treatments. Staff interviews revealed that nebulizers were not being washed between treatments, and there was a general lack of understanding on how to update care plans. The facility again failed to provide a policy regarding care plans when requested. Residents 5 and 13 had multiple falls, but their care plans were not updated with new interventions to prevent further falls. Resident 5 had several falls documented, but the care plan lacked new interventions after each fall. Similarly, Resident 13 had multiple falls, but the care plan was not revised to include new interventions to prevent further incidents. Interviews with staff confirmed that care plans were not being updated, and the facility failed to provide a policy regarding care plan revisions when requested. This deficiency led to additional falls and had the potential for physical and psychosocial injuries for the residents involved.
Failure to Conduct Criminal Background Check for Staff Member
Penalty
Summary
The facility failed to conduct a criminal background check for one of three staff members reviewed, specifically a Certified Nurse Aide (CNA) hired on 07/08/22. During a review of employee files, it was found that the CNA's file lacked any criminal background check information. This was confirmed by the Administrative Nurse, who admitted that she did not know if a background check had been conducted prior to or since the CNA's employment began. The facility's policy on Abuse, Neglect, Exploitation, and Misappropriation Prevention Program mandates that background checks be performed before extending employment offers. The failure to conduct this check had the potential to negatively affect the care delivered to residents.
Failure to Prevent Falls for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident, identified as R13, who had a history of falls and severe cognitive impairment. Despite multiple documented falls and a high fall risk score, the care plan lacked effective interventions to prevent further falls. The resident had several falls within the facility, including incidents where the resident was found on the floor in various locations such as the bathroom, beside the bed, and in front of a recliner. The facility's investigations into these falls often lacked a root cause analysis, and the care plan was not updated with new interventions to prevent additional falls. The care plan for R13 included several interventions, such as ensuring the call light was within reach, placing body pillows on both sides of the bed, and using a video camera at night. However, these interventions were either not effectively implemented or not updated following each fall. Staff interviews revealed that care should be driven by the care plan available in the Electronic Health Record (EHR), but there was a disconnect between the documented care plan and the actions taken by the staff. The facility's policy on accident prevention was not adequately followed, leading to repeated falls for R13. Administrative staff confirmed that the care plan lacked necessary interventions related to each fall and that the facility did not conduct interdisciplinary team meetings or fall huddles to address the issue. The facility's failure to provide a safe environment and adequate supervision resulted in multiple falls for R13, highlighting a significant deficiency in the facility's fall prevention and care planning processes.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care consistent with professional standards of practice for two residents, R1 and R3, regarding the use and cleaning of nebulizers. For R1, the physician's orders included the use of a nebulizer for chronic obstructive pulmonary disease (COPD), but the care plan did not include interventions related to the use and care of the nebulizer. Observations revealed that R1's nebulizer tubing and medication chamber/mouthpiece were improperly stored, and interviews with staff confirmed that the nebulizer was not rinsed between treatments as required. The facility also failed to provide a policy regarding respiratory care when requested. For R3, who had diagnoses of COPD and pleural effusion, the care plan similarly lacked interventions regarding nebulizer treatments. Observations and staff interviews indicated that the nebulizer was not washed between treatments. The facility again failed to provide a policy on respiratory care when requested. These deficiencies highlight the facility's failure to adhere to professional standards of care in providing respiratory treatments to residents.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete an annual performance review at least once every 12 months for three Certified Nurse Aides (CNA) to ensure adequate and appropriate care and services were provided to the residents. The facility reported a census of 13 residents. During a review of employee files, it was found that there were no performance evaluations for three CNAs who had been employed for over 12 months. This was confirmed by the Administrative Nurse and Administrative Staff, who acknowledged that it was their expectation to perform annual performance evaluations but admitted that these evaluations were not completed. The facility provided an undated and untitled document indicating that performance evaluations were to be performed at an unknown frequency to measure employee effectiveness and set goals for future performance and professional growth.
Latest citations in Kansas
Surveyors identified unsanitary food storage and preparation conditions, including food debris in a reach-in freezer, an unknown spilled liquid in a reach-in refrigerator, missing two-inch air gap on an ice machine drain, dirty carts used for clean dishes, and a steamtable shelf with built-up food debris. A dietary staff member acknowledged these areas needed cleaning, and it was determined the facility lacked a cleaning schedule or policy for kitchen cleanliness.
The facility failed to complete and analyze Care Area Assessments (CAAs) for multiple residents after Admission, Annual, and Significant Change MDS assessments triggered areas such as cognition, mood/behavior, functional status, urinary incontinence/indwelling catheter, nutrition, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, and visual function. Instead of documenting individualized analysis of underlying causes and contributing factors, an LPN reported she had stopped writing CAA notes and relied mainly on check-off worksheets and the fact that triggers appeared in the MDS CAA section. No facility policy on CAAs was provided to surveyors, and the CAAs consistently lacked required analytical documentation for residents with diverse and significant clinical needs.
A resident with dementia, severe cognitive impairment, and an indwelling urinary catheter was repeatedly observed sitting in common areas with his catheter drainage bag resting on his lower leg, visibly filled with dark amber urine and lacking a privacy cover, despite a care plan directing staff to cover the drainage bag. CNAs reported that the bag often slid down from the resident’s thigh, that they did not use catheter dignity bags on their hall, and that they simply moved the bag back up when it slid down. An administrative nurse stated she had not considered the use of dignity bags on the memory care unit, even though the facility’s resident rights policy affirms each resident’s right to a dignified existence, privacy, and confidentiality.
Two residents with documented cognitive ability to participate in care planning were not invited to any care plan meetings, and their EMRs lacked evidence of care plan conferences, invitations, or Interdisciplinary Care Conference assessments. Administrative staff stated that invitations should be mailed or hand-delivered and uploaded to the EMR, and that an Interdisciplinary Care Conference note should be completed, but none of this documentation existed for these residents, contrary to facility policy and federal requirements for resident and/or representative participation in care planning.
A resident with C-diff and CHF, newly admitted and with a baseline care plan that did not address call light use, was repeatedly found without access to a call light. Surveyors observed the resident yelling for help with her room door closed and later noted the call light on the floor under the bed and again on the floor while the resident sat in a recliner and stated she wanted to return to bed but could not do so independently. Staff reported using a binder clip to attach the call light to the resident’s clothing because the cord lacked a clip, acknowledged the resident sometimes threw the call light to the floor, and stated that call lights should be kept within residents’ reach. An administrative nurse confirmed the expectation that call lights be accessible at all times and was unsure about the use of a binder clip, and no facility policy on call lights was provided.
Surveyors found that a resident’s bathroom and handwashing area were not maintained in a safe, sanitary, and comfortable condition, including a loose baseboard with black substance behind it, a cracked toilet seat, and an empty, improperly mounted hand soap dispenser. Maintenance staff confirmed these conditions, noted that the soap dispenser was nonfunctional, and reported that although a QR code system existed for reporting maintenance issues, these problems had not been reported. Maintenance staff also stated there were no facility policies for maintenance repair in resident rooms and no policy provided for ensuring a safe, homelike environment.
Multiple residents were affected by inaccurate MDS assessments, including a resident with dementia and an indwelling catheter who was miscoded as always incontinent of urine and independent in ADLs despite staff and EMR documentation showing long-term catheter use and total dependence for dressing and wheelchair positioning. Another resident with a history of stroke was incorrectly coded as having a restraint, even though bed grab bars were used as enablers to assist with repositioning and did not limit voluntary movement. A resident with diabetes and unsteadiness experienced two documented falls that were not captured on the MDS, and another resident with diabetes, depression, CAD, and CKD was actively receiving hospice services per EMR, social services, and staff interviews, yet hospice was not coded on the MDS. The consultant MDS nurse confirmed these were significant coding errors not in accordance with the RAI User’s Manual.
A resident with C. diff and CHF was admitted, and while a baseline care plan documenting contact precautions was created, the resident later reported not knowing what a baseline care plan was. The resident was also found yelling for help with her call light on the floor under the bed. Nursing staff stated that baseline care plans are started on the day of admission and reviewed with residents, but also indicated that residents and families are not given written copies. An administrative nurse claimed a 48-hour interdisciplinary care conference had been completed, yet no corresponding documentation existed in the EMR, and explanations about who was responsible and why it was missing were inconsistent. No facility policy for baseline care plans was provided.
A resident with dementia and severe cognitive impairment was inaccurately assessed and care planned as needing only setup or independent assistance with dressing, despite actually requiring total staff assistance. The EMR lacked clear ADL documentation, and the ADL CAA did not trigger, leading to inaccurate MDS entries and a care plan that did not match the resident’s functional status. Surveyors observed the resident sitting in a wheelchair wearing dirty, food-stained pants and being taken to the dining room without a clothing change, with the soiled pants not changed until later when two CNAs provided total assistance. Staff, including CNAs, an LN, and an administrative nurse, acknowledged that the resident needed total help with dressing and should always be in clean clothing, revealing a failure to provide appropriate ADL support and maintain clean attire.
A resident with dementia and severe cognitive impairment was transported multiple times in a wheelchair without staff ensuring that his feet remained safely on the foot pedals. Although assessments inaccurately documented that he was independent with walking using a walker and/or wheelchair, his care plan did not instruct staff on proper use of wheelchair foot pedals. During observed transports by CNAs, the resident’s shoed feet repeatedly fell off the pedals and skimmed the floor between them. Staff acknowledged that his feet did not stay on the pedals and that the pedals were not effectively adjusted, and nursing leadership confirmed expectations that feet should remain on the pedals during transport. No wheelchair safety policy was provided.
Unsanitary Kitchen Conditions and Lack of Cleaning Policy
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions when surveyors observed multiple cleanliness and equipment issues in the kitchen. During an initial kitchen tour on 04/27/26 at 08:57 AM, the three-door reach-in freezer was found with food debris on the bottom shelf, and the three-door reach-in refrigerator had an unknown spilled liquid on the bottom shelf. The drain to the ice machine did not have the required two-inch air gap. Two black two-tiered plastic carts used to store clean dishes had food debris on the bottom tier, and the bottom shelf of the steamtable, which was used to store plate covers, had a buildup of food debris. On 04/28/26 at 01:57 PM, a dietary staff member confirmed these areas required cleaning, and it was identified that the facility did not have a cleaning schedule or a policy regarding kitchen cleanliness. No specific residents, medical histories, or clinical conditions were mentioned in the report in relation to this deficiency.
Failure to Complete and Analyze Care Area Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive Care Area Assessments (CAAs) with analysis of underlying causes, contributing factors, and risk factors for multiple residents following MDS assessments. Record review showed that numerous residents had Admission, Annual, or Significant Change MDS assessments that triggered CAAs in areas such as mood/behavior, cognitive loss/dementia, functional abilities, communication, urinary incontinence/indwelling catheter, nutritional status, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, visual function, and psychosocial well-being. For each of these triggered areas, the corresponding CAAs lacked analysis of the findings. This pattern was identified for residents with a wide range of clinical issues, including dementia, incontinence, falls, pressure ulcers, nutritional concerns, psychotropic medication use, pain, and functional decline. During an interview, a licensed nurse reported that she had stopped writing CAA notes the previous year after being told to do so by someone she could not identify. She stated that she did not write anything on the triggered CAAs and that, at times, she would document risk concerns only on a main check-off worksheet, relying on the fact that the triggers were already reflected in the MDS CAA section. The facility did not provide a policy regarding CAAs when requested. These findings demonstrate that the facility did not ensure that comprehensive assessments were fully completed as required when residents were first admitted and periodically thereafter.
Failure to Maintain Dignity and Privacy for Resident with Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to a dignified existence by not maintaining privacy for his urinary catheter drainage bag as directed in his care plan. The resident had diagnoses including bladder calculus and dementia, with a BIMS score of one indicating severe cognitive impairment, and was dependent on staff for toileting hygiene with an indwelling urinary catheter and constant urinary incontinence. His care plan, revised 03/23/26, instructed staff to cover his drainage bag with a privacy cover. However, during observations on 04/27/26, the resident was seen sitting in his wheelchair at his room doorway and later in the dining room with his catheter drainage bag resting on his lower left leg, supported by his shoe, containing dark amber urine and visible to visitors and other residents, without a privacy cover. Staff interviews confirmed that the catheter drainage bag frequently slid from the resident’s left thigh down to his lower leg and that staff did not consistently reposition it or use dignity/privacy bags. One CNA stated he had never placed a dignity bag on the resident’s drainage bag, and another CNA reported that staff on their hall did not utilize catheter dignity bags, instead just moving the bag back up when it slid down. An administrative nurse acknowledged she had not considered staff use of dignity bags for urinary catheters on the memory care unit. The facility’s Resident Rights policy, approved 12/2024, stated that each resident has the right to a dignified existence including privacy and confidentiality, which was not followed in this case.
Failure to Involve Cognitively Able Residents in Care Plan Meetings
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were given the opportunity to participate in the development and implementation of their person-centered plans of care. For one resident with a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognition, the electronic medical record showed an admission MDS and a Significant Change MDS, but there was no documentation of any care plan meeting in the prior four months. This resident reported not being invited to any care plan meeting. For a second resident with a BIMS score of 14, indicating intact cognition, the electronic medical record contained an admission MDS and a Quarterly MDS, but there was no documentation of a care plan meeting in the prior two months. This resident also reported not being invited to any care plan meeting. Administrative staff reported that residents and/or family members were supposed to be mailed or hand-delivered invitations to attend care planning meetings and that a copy of the invitation should be uploaded into the EMR. They further stated that an Interdisciplinary Care Conference assessment should be completed in the EMR during the care plan meeting. However, the administrative nurse confirmed that there was no documentation of invitations, Interdisciplinary Care Conference assessments, or completed care plan meetings for the two residents. The facility’s care planning policy stated that social services should attend care plan meetings and that the team presents information to the resident and/or representative about progress toward care plan goals, and referenced federal law requiring resident and/or representative participation in care plan meetings to the extent possible, but this process was not carried out or documented for the two residents identified.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach and to reasonably accommodate the resident’s needs and preferences. The resident had documented diagnoses of C-diff and CHF, and her baseline care plan dated 04/23/26 directed staff to evaluate for changes in level of consciousness but did not include any direction regarding call light use or accessibility. On 04/28/26 at 08:06 AM, surveyors observed the resident’s room door closed while she yelled loudly for help several times. When a licensed nurse entered the room, the resident was lying on her left side in bed, stated she wanted to get up, and reported she could not find her call light. The call light was observed on the floor under her bed. Later that morning, a CNA attached the call light to the resident’s shirt using a black and silver binder clip because the call light cord did not have its own clip. On 04/29/26 at 12:15 PM, the resident was seated in a recliner with the call light again lying on the floor out of her reach; she reported she wanted to go to bed and could not get herself back into bed. Staff interviews revealed that the CNA used the binder clip to keep the call light attached to the resident, and the licensed nurse stated staff should make sure the call light is clipped to the resident’s clothes and reported that the resident would throw her call light on the floor. An administrative nurse stated she expected staff to ensure all residents always have their call lights in reach and was unsure about using a binder clip to hold a call light in place. The facility did not provide a policy regarding call lights.
Failure to Maintain Safe and Sanitary Resident Bathroom Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, functional, sanitary, and comfortable environment in Resident 87’s bathroom and handwashing area. During an environmental tour with Maintenance Staff UU, surveyors observed an approximately four-foot section of loose baseboard to the left of and behind the toilet, with a black substance present on the wall and floor behind the loose baseboard. They also noted an approximately three-inch crack in the toilet seat and an empty hand soap dispenser hanging above the handwashing sink, mounted with exposed lag bolt fasteners. Maintenance Staff UU confirmed these conditions, acknowledged that the soap dispenser did not work, and stated that the toilet seat should be replaced, the bathroom baseboard removed, the black substance tested for mold, and the sheetrock removed and replaced. Further interview with Maintenance Staff UU revealed that the facility had implemented a QR code system for staff and visitors to report maintenance items, but the issues in this resident’s bathroom had not been reported through that system. He also reported that there had been a leak behind the handwashing sink that had flowed into the bathroom area, leading to the sink’s replacement, but he had received no report of the specific deficiencies observed in the bathroom. Additionally, Maintenance Staff UU stated that the facility did not have policies for maintenance repair in residents’ rooms, and the facility did not provide a policy for ensuring a safe, homelike environment.
Inaccurate MDS Coding for ADLs, Restraints, Falls, and Hospice Services
Penalty
Summary
The deficiency involves the facility’s failure to complete accurate Minimum Data Set (MDS) assessments in accordance with the Resident Assessment Instrument (RAI) User’s Manual, resulting in multiple residents’ clinical status not being correctly reflected. For one resident with dementia and severe cognitive impairment, the Significant Change and subsequent Quarterly MDS assessments coded him as always incontinent of bladder and independent with eating and upper body dressing, with use of a walker and wheelchair. However, the electronic medical record showed ongoing indwelling catheter care each shift and no documentation of walker use, wheelchair mobility, or dressing requirements during the review period. Staff interviews revealed that this resident had an indwelling catheter for more than a year, had not walked for several years, and was dependent on staff for all ADLs, including dressing and wheelchair positioning, contradicting the MDS coding. Observations showed the resident slumped in a wheelchair, wearing a hospital gown over clothing, with a visible catheter bag on his lower leg and feet frequently skimming the floor despite foot pedals being present, further indicating dependence and catheter use not accurately captured on the MDS. Another deficiency involved a resident with a history of stroke, hemiplegia, and hemiparesis whose Significant Change MDS coded the use of “other restraint.” During observation, the resident was seen in bed with bilateral grab bars at the head of the bed and her right arm positioned on a pillow. The resident reported using the grab bars to help move and reposition herself in bed. CNAs and administrative nursing staff confirmed that the facility did not use restraints and that the grab bars were used as enablers to assist residents with repositioning and to increase independence. Administrative staff acknowledged that the MDS coding for restraints was inaccurate because the grab bars did not limit the resident’s voluntary movement or access to her body. A further inaccuracy was identified for a resident with diabetes, atrial fibrillation, unsteadiness of feet, and a toe fracture. Both a Significant Change and a Quarterly MDS documented intact cognition, partial/moderate assistance with transfers, no ambulation, and no falls. However, progress notes in the EMR documented two unwitnessed falls during the look-back period, including one where the resident was found on the floor next to the bed with a forehead skin tear and another where the resident was found sitting on a fall mat on the floor with a scratch on the ankle. These documented falls were not reflected on the MDS. In addition, another resident with diabetes, depression, CAD, and chronic kidney disease had a Significant Change MDS that coded no hospice services, while the EMR contained a hospice certification and physician orders initiating hospice services, and social service notes and staff interviews confirmed that hospice services, including bathing by a hospice aide, were being provided during the look-back period. The consultant MDS nurse confirmed that these assessments were inaccurate and not completed in accordance with the RAI User’s Manual, constituting significant errors in coding for urinary status, ADL dependence, restraints, falls, and hospice services. The consultant MDS nurse stated that the resident with the indwelling catheter should have been coded as not rated for urinary continence due to catheter placement rather than as always incontinent, and that his ADL status should not have been coded as independent given his dependence on staff for dressing and wheelchair positioning. For the resident with grab bars, the nurse confirmed that the grab bars were used as enablers and not as restraints, making the restraint coding inaccurate. For the resident with documented falls, the MDS failed to capture falls that occurred within the look-back period, and for the resident receiving hospice services, the MDS did not reflect hospice care that was active during the look-back period. These miscodings met the RAI Manual’s definition of significant error, in which the resident’s overall clinical status is not accurately represented on the assessment and the error has not been corrected by a more recent assessment.
Failure to Provide and Communicate Baseline Care Plan to New Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide a summary of the baseline care plan to a newly admitted resident and to ensure that the baseline care plan process was completed and documented as required. The resident’s EMR documented diagnoses of C. difficile and CHF. The Entry MDS was completed on the admission date, and the admission MDS was noted as in progress with no information available. A baseline care plan dated the day after admission documented contact precautions, including staff use of gowns and masks when changing contaminated linens and proper handling and bagging of soiled linens. However, during an interview several days after admission, the resident reported she did not know what a baseline care plan was, indicating that the plan had not been explained or summarized to her. Further observations and interviews showed additional failures in implementing and communicating the baseline care plan. On one occasion, the resident was heard yelling for help with her room door closed; when a nurse entered, the resident stated she wanted to get up but could not find her call light, which was observed on the floor under the bed. A nurse reported that the baseline care plan was started on the day of admission and that nurses would review it with the resident, but also stated that the charge nurse would not provide a written copy of the baseline care plan to the resident or family. An administrative nurse reported she would review the baseline care plan with the resident and/or family and claimed to have completed a 48-hour interdisciplinary care conference, but there was no opened or completed conference note in the EMR. She gave inconsistent explanations regarding who was responsible and why the conference note was missing. The facility did not provide a policy for baseline care plans.
Failure to Provide Accurate ADL Assessment and Timely Clothing Changes
Penalty
Summary
The facility failed to provide appropriate assistance with activities of daily living (ADLs), specifically dressing and clothing changes, for a resident with severe cognitive impairment. The resident had a diagnosis of dementia and repeated Brief Interview for Mental Status (BIMS) scores of one, indicating severe cognitive impairment. Despite this, both a Significant Change MDS and a Quarterly MDS inaccurately documented that the resident required only setup assistance with lower body dressing. The ADL Care Area Assessment did not trigger, and the resident’s care plan, revised on 03/23/26, inaccurately instructed staff that the resident was independent with dressing. The electronic medical record lacked staff documentation of the resident’s ADL needs, resulting in care instructions that did not reflect the resident’s actual functional status. On the day of observation, the resident was seen sitting in a wheelchair wearing black pants with food crumbs on them in the morning, and later was transported by a CNA to the dining room still wearing the same dirty pants. The pants were not changed until early afternoon, at which time two CNAs provided total assistance to change the dirty pants, and the resident was unable to participate in dressing or undressing. During interviews, the CNAs, a licensed nurse, and an administrative nurse all stated that residents should always be dressed in clean clothing and confirmed that this resident required total staff assistance with dressing. These observations and interviews showed that the resident’s actual need for total assistance with dressing and clothing changes was not accurately reflected in the MDS, care plan, or ADL documentation, and that the facility did not ensure the resident was kept in clean clothing as expected by facility policy for ADL care.
Failure to Maintain Safe Wheelchair Foot Positioning During Resident Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision during wheelchair transport for a resident with dementia. The resident’s EMR documented a diagnosis of dementia and a BIMS score of one on both a Significant Change MDS and a Quarterly MDS, indicating severe cognitive impairment. These MDS assessments inaccurately documented that the resident was independent with walking using a walker and/or wheelchair, and the ADL CAA did not trigger. The resident’s care plan, revised 03/23/26, identified cognitive impairment due to dementia but did not include instructions for staff on the use of wheelchair foot pedals while propelling the resident. On multiple observed occasions, staff propelled the resident in a wheelchair without maintaining his feet safely on the foot pedals. During transport from his room to the dining room, the resident’s left shoed foot fell from the foot pedal and skimmed the floor between the pedals, and later, during transport from the dining room to the shower room, both shoed feet skimmed the floor between the pedals. CNAs reported that the resident’s feet never stayed on the foot pedals and described the pedals as useless because he could not keep his feet on them. A licensed nurse confirmed the resident’s feet did not always remain on the foot pedals when staff propelled him and stated the pedals should be adjusted to better fit his needs. An administrative nurse stated it was the expectation that staff ensure the resident’s feet remained on the foot pedals during transport and that pedals should be lowered if needed. The facility did not provide a policy regarding wheelchair safety.
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