Stratford Commons Rehab & Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Overland Park, Kansas.
- Location
- 12340 Quivira Road, Overland Park, Kansas 66213
- CMS Provider Number
- 175549
- Inspections on file
- 19
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 21 (1 serious)
Citation history
Health deficiencies cited at Stratford Commons Rehab & Health Care Center during CMS and state inspections, most recent first.
Expired medications, including a heartburn relief liquid antacid, Vitamin D3 soft gels, and vials of Ativan, were found in medication storage areas and carts, verified by a CMA and administrative nurses. These expired drugs were not removed from service as required by facility policy, leaving them accessible for potential administration.
Staff did not consistently wear required gowns and gloves during high-contact care activities for residents on Enhanced Barrier Precautions, including transfers and medication administration for individuals with wounds, catheters, and feeding tubes. This occurred despite clear care plans, physician orders, and available PPE supplies, as confirmed by staff and administrative interviews.
A resident with mild cognitive impairment and multiple care needs was spoken to in a disrespectful manner by a CNA when requesting assistance, including being told that staff did not like her because she needed frequent bathroom help. This led to the resident feeling like a burden and experiencing emotional distress. The incident was documented in the grievance log, and the resident council reported concerns about bullying and lack of follow-up discussion with the resident.
A resident with a documented DNR order was given CPR after being found unresponsive because staff did not verify her code status in the EMR, instead relying on a nursing report sheet that incorrectly listed her as full code. Staff interviews confirmed that procedures required checking the care plan or orders for code status, but this was not done in the incident.
A resident with severe cognitive impairment and a diagnosis of neurocognitive disorder with Lewy bodies was administered quetiapine, an antipsychotic, without a documented physician rationale or approved indication. Facility records and medication monitoring lacked evidence of abnormal behaviors or justification for the medication, and psychiatry had not assessed the resident, resulting in noncompliance with facility policy on psychotropic medication use.
A resident with pressure ulcers and osteomyelitis did not receive thorough wound assessments, as required documentation of wound characteristics and measurements was incomplete. The gluteal ulcer increased in size without documented physician notification, and staff did not consistently record wound depth or characteristics during care, contrary to facility guidelines.
A resident with cognitive impairment, muscle weakness, and a history of falls did not have the required fall prevention signage in her room, despite care plan instructions. Observations and staff interviews confirmed the absence of the "Call, Don't Fall" sign, which was intended to help prevent self-transferring and falls. This failure to implement documented interventions resulted in a deficiency related to accident prevention and supervision.
A resident with complex medical needs who required dialysis did not have their condition consistently documented and communicated to the dialysis center as required by facility policy and physician orders. Nursing staff failed to complete and send the dialysis communication form on multiple occasions, resulting in incomplete information exchange between the facility and the dialysis provider.
Expired Medications Not Removed from Service
Penalty
Summary
Surveyors observed that the facility failed to remove expired medications from areas where they could potentially be administered to residents. Specifically, two expired medications—a bottle of heartburn relief liquid antacid with an expiration date of 10/2024 and a bottle of Vitamin D3 soft gels expired since April 2023—were found in the Blue Medication cart. Additionally, two vials of Ativan, an antianxiety drug, with an expiration date of 07/2024, were discovered in the Blue medication room's emergency kit box. These findings were verified by a Certified Medication Aide and two administrative nurses, who confirmed the medications were expired and should have been removed from service. The facility's own policy required immediate withdrawal and proper disposal of outdated drugs, but this procedure was not followed, resulting in the continued presence of expired medications in medication storage areas.
Failure to Adhere to Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Staff failed to follow established infection prevention and control practices related to Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices and wounds. On multiple occasions, certified nurse aides (CNAs) and a licensed nurse (LN) did not wear required gowns while performing high-contact care activities, such as transferring a resident with wounds and a urinary catheter using a total lift, and administering medications through a gastrostomy tube. These actions were observed despite clear physician orders and care plans specifying the use of gowns and gloves for such activities under EBP protocols. The facility's infection control policy required the use of gowns and gloves during high-contact care for residents at increased risk for multidrug-resistant organism (MDRO) transmission, including those with wounds, catheters, nephrostomy tubes, and feeding tubes. Staff and administrative nurses verified that gowns should have been worn during these care activities, and signage and supplies were present at the point of care. The failure to adhere to these precautions was confirmed through direct observation, record review, and staff interviews.
Failure to Ensure Resident Dignity Due to Disrespectful Staff Conduct
Penalty
Summary
Staff failed to ensure a dignified care environment for a resident with diagnoses including depression, anxiety disorder, cognitive communication disorder, muscle weakness, and dysphagia. The resident, who had mild cognitive impairment and required substantial to maximal assistance with activities of daily living, reported that a Certified Nurse's Aide (CNA) spoke to her in a disrespectful manner when she requested assistance. The CNA allegedly told the resident that staff did not like her because she needed to use the bathroom frequently and indicated that staff were upset about her being wet often. This interaction made the resident feel like a burden and caused her emotional distress, as she expressed not wanting to be around people who did not like her. The facility's grievance log documented the resident's complaint about the CNA's conduct, noting that the CNA was repeatedly rude. The resident council also reported concerns about the resident being bullied by the CNA and noted that the facility did not discuss the impact of the incident with the resident. Staff interviews confirmed expectations for respectful treatment of residents and ongoing training on resident rights and dignity. The facility's policy required all residents to be treated in a dignified manner and for staff to receive ongoing education on these topics.
Failure to Honor Resident's DNR Advance Directive
Penalty
Summary
The facility failed to honor a resident's advance directive regarding Do Not Resuscitate (DNR) status. The resident, who had diagnoses including muscle weakness, atrial fibrillation, cognitive communication disorder, heart failure, and peripheral vascular disease, was documented in the electronic medical record (EMR) and care plan as having a DNR order, signed by both the resident and her medical provider. Despite this, when the resident was found unresponsive, staff initiated cardiopulmonary resuscitation (CPR) without verifying her code status in the EMR. The nursing report sheet incorrectly indicated she was a full code, leading staff to begin CPR. Interviews with facility staff revealed that the expectation was for staff to check the care plan or physician's orders for updated advanced directives before initiating emergency interventions. However, in this incident, staff did not verify the resident's DNR status prior to starting CPR. The facility was unable to provide a policy related to advance directives when requested by surveyors. This failure to follow the resident's documented wishes and established procedures resulted in the deficiency.
Antipsychotic Medication Administered Without Proper Indication
Penalty
Summary
The facility failed to ensure that a resident was free from the use of an antipsychotic medication without a proper physician-documented indication. The resident in question had diagnoses of neurocognitive disorder with Lewy bodies and a cognitive communication deficit, with severely impaired cognition and a need for maximum or full staff assistance with activities of daily living. Despite these conditions, the resident was administered quetiapine, an antipsychotic, daily as ordered by the physician for a mood disorder. The care plan included a Black Box Warning for quetiapine, noting increased risk of death in elderly patients with dementia-related psychosis and that the medication was not approved for such use. The facility's policy required that psychotropic medications only be used for specific, documented conditions, and that antipsychotics generally be reserved for certain diagnoses, none of which were present in this case. Record review showed that the resident's electronic medical record and medication administration record lacked documentation of any abnormal behaviors or a written physician rationale for the use of quetiapine without an approved indication. The pharmacist had provided recommendations for the physician to indicate the reason for use, but the physician did not document a rationale. Additionally, psychiatry had not assessed the resident. These actions and omissions resulted in the use of an antipsychotic medication without proper justification, contrary to facility policy and regulatory requirements.
Failure to Thoroughly Assess and Document Pressure Ulcers
Penalty
Summary
The facility failed to thoroughly assess and document the progression of pressure ulcers for a resident diagnosed with osteomyelitis of the sacrococcygeal region, including the sacrum and coccyx. The resident was admitted with pressure ulcers on the left gluteus and right heel, and physician orders directed specific wound care interventions, including the use of heel protectors, a low air loss mattress, and evaluation by a wound care specialist. However, skin assessments lacked complete documentation, such as wound characteristics and depth measurements. Notably, the gluteal pressure ulcer increased significantly in size, but the assessment did not include all required details, and there was no documentation that the physician was informed of this change. During wound care observations, staff performed cleaning and dressing changes but did not consistently measure or document the depth of the wounds as required. The facility's own guidelines specified that wound type, location, stage, measurements, undermining or tunneling, drainage, odor, and assessment of the wound bed and surrounding tissue should be recorded in the electronic medical record. Despite these requirements, documentation was incomplete, and there was a lack of evidence that the physician was notified of the worsening condition, contributing to the deficiency.
Failure to Implement Fall Prevention Interventions for At-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement fall prevention interventions for a resident with multiple risk factors for falls. The resident had diagnoses including depression, anxiety disorder, cognitive communication disorder, muscle weakness, and dysphagia, and was assessed as having mild cognitive impairment with a BIMS score of 12. She required substantial to maximal assistance with activities of daily living and had a history of a non-injury fall since admission. Her care plan specified the need for a "Call, Don't Fall" sign in her room as part of her fall prevention interventions, along with instructions for staff to anticipate her needs and encourage use of the call light before transferring. Despite these documented interventions, observations on two consecutive days revealed that the required fall prevention sign was not present in the resident's room or bathroom. The resident was unable to locate the sign, and staff interviews confirmed that such signs were typically placed by the bed or toilet to prevent self-transferring. The facility's policy required staff to assess and implement interventions to ensure resident safety, and administrative staff confirmed that nurses were responsible for ensuring interventions were in place. The failure to implement the specified fall prevention intervention constituted a deficiency in providing a safe environment and adequate supervision to prevent accidents.
Failure to Ensure Proper Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care and services consistent with professional standards of practice, specifically regarding communication and collaboration with the dialysis center. The resident had multiple complex medical conditions, including end-stage renal disease, acute osteomyelitis, sepsis, chronic ulcers, diabetes mellitus, anemia, peripheral vascular disease, muscle weakness, and fatigue. The resident was highly dependent on staff for activities of daily living and had ongoing pain, unhealed pressure ulcers, and a surgical wound. The care plan and physician orders required staff to complete and send a dialysis communication sheet with the resident to the dialysis center and ensure it was returned and completed for each visit. Despite these directives, the facility failed to provide the required information on the resident's condition on the dialysis communication form for multiple documented dates. Staff confirmed that they did not complete the necessary sections of the form as required by facility policy and physician orders. The facility's policy specified that the nurse in charge was responsible for initiating and sending the communication form with the resident on dialysis days, but this process was not consistently followed, resulting in incomplete communication between the facility and the dialysis center.
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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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