The Cedars
Inspection history, citations, penalties and survey trends for this long-term care facility in Mcpherson, Kansas.
- Location
- 1021 Cedars Drive, Mcpherson, Kansas 67460
- CMS Provider Number
- 175380
- Inspections on file
- 20
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at The Cedars during CMS and state inspections, most recent first.
A resident with moderately impaired cognition had their blood glucose checked by an LN at a dining room table in the presence of other residents, staff, and a visitor. After obtaining the reading from the resident’s finger, the LN announced that the blood sugar was high and that the MD might need to be contacted to start insulin. Administrative nursing staff later acknowledged that such procedures should occur in a private area, and facility policy stated that residents have the right to be treated with dignity and respect.
The facility failed to provide required Notice of Medicare Non-Coverage (NOMNC) forms to two residents when their skilled services ended. In both cases, there was no documentation that the residents or their representatives received Form CMS-10123, which explains non-coverage and the appeal process. An administrative staff member confirmed the forms were not given as required, and the facility could not produce a policy for Beneficiary Notices when requested by surveyors.
Surveyors found that the facility did not ensure appropriate indications and documentation for psychotropic medications. A resident with dementia, depression, Parkinson’s disease, and encephalopathy received an antipsychotic for dementia with agitation without a documented physician rationale, nonpharmacological interventions, or risk–benefit analysis as required by facility policy. Two other residents with dementia, depression, and anxiety had PRN antianxiety medications ordered without 14-day stop dates or specified durations, and their records lacked the required physician rationale for extended PRN use, despite staff acknowledging that such orders should include a 14-day limit and reassessment.
A resident with dementia, acute blood loss anemia, and a lower GI bleed, who required partial staff assistance with ADLs and had moderately impaired cognition per MDS BIMS, was admitted for care and later discharged home with a spouse. The care plan identified discharge as an outcome and directed staff to support the resident and family through care plan conferences, discharge planning, and discussion of alternative care options. Despite this, the clinical record did not contain a recapitulation summarizing the resident’s stay and course of treatment at discharge, and facility leadership confirmed that this required discharge documentation was not completed, contrary to the facility’s discharge planning policy.
Surveyors found that the facility failed to implement appropriate care planning and clinical parameters for two residents. A resident with DM who was dependent for mobility and received daily insulin had a care plan that only directed staff to provide a nighttime protein snack, with no further diabetes-related guidance, and the EMR lacked physician-ordered blood glucose parameters despite orders for pre-meal and bedtime checks; nursing staff and a CMA confirmed there were no parameters in the current EMR and that they relied on nursing judgment. Another resident with dementia, anxiety, severely impaired cognition, and a history of repeated falls was identified as high fall risk, yet the care plan contained only general directions such as determining causative factors, promoting exercise, and obtaining PT and pharmacy reviews, without specific individualized fall interventions. Multiple fall investigations documented the resident repeatedly scooting onto the floor in her room, with immediate responses limited to adding a fall mat and posting reminder signs, while staff reported frequent falls, use of a Wander Guard, and the practice of keeping the resident in common areas for observation.
Two residents at high risk for falls experienced multiple falls when staff did not consistently follow fall-prevention care plans and safe transfer practices. One resident with dementia and Parkinson’s disease, who required staff assistance and had a history of falls, continued to ambulate in shoes that were too large, leading to a fall with laceration, hematoma, and skin tear during assisted walking, despite a care-plan directive for properly fitting footwear. The same resident had several prior unwitnessed falls from a recliner in his room, with at least one fall lacking a documented investigation in the EMR, contrary to facility fall-reporting policy. Another resident with severe cognitive impairment, macular degeneration, and weakness, care-planned for two-person assistance with a sit-to-stand lift, slid out of the sling and fell to the bathroom floor on two occasions during sit-to-stand transfers; investigations identified incorrect sling application and use of only one staff member during one event, inconsistent with the care plan and facility policies requiring appropriate interventions and documentation after falls.
A resident with diabetes who was dependent on staff for care and received daily insulin had blood sugars checked four times per day without any physician-ordered blood glucose parameters documented in the EMR or care plan. Nursing staff reported relying on personal judgment to determine when to notify the physician, and a CMA stated she did not know what the parameters should be, noting that they were present in a prior computer system but not in the current one. An administrative nurse acknowledged that physician-ordered parameters and clear care plan directions for diabetes management were lacking, and the facility could not provide a blood sugar management policy when requested.
A resident with dementia, metabolic encephalopathy, DM, atrial fibrillation, and chronic pain experienced a decline in ADLs and was admitted to hospice for senile degeneration of the brain. The MDS documented hospice services and increased need for assistance, but the facility’s care plan did not include any information that the resident was on hospice or reflect coordination with hospice services. An administrative nurse confirmed the omission, despite a facility end-of-life policy requiring interdisciplinary care planning for hospice and end-of-life care.
The facility did not employ a full-time certified dietary manager while providing meals to 33 residents. A dietary staff member preparing meals confirmed she was not certified and was still completing coursework and testing for certification, yet was responsible for managing specialized diets, including pureed diets for two residents and minced and moist diets for three residents. Administrative staff later verified that this staff member was not certified, despite facility policy requiring sufficient competent personnel in the food and nutrition services department.
A facility failed to report an allegation of rough care as potential abuse to the LNHA and SA. A resident with severe cognitive impairment and other medical conditions was reportedly handled roughly by a CMA during a transfer, leading to the resident yelling out. Despite a CNA witnessing and reporting the incident, it was not immediately reported to the LNHA or SA, placing the resident at risk for ongoing mistreatment.
A resident with severe cognitive impairment and multiple medical conditions was allegedly handled roughly by a CMA during a transfer, leading to the resident yelling out. Despite the report of potential abuse, the facility did not immediately suspend the involved staff member or conduct a thorough investigation, as required by policy. This delay in action placed the resident at risk for continued abuse.
Public Blood Glucose Testing and Discussion Compromised Resident Dignity
Penalty
Summary
The facility failed to protect and promote the dignity of Resident 23, who had a Brief Interview for Mental Status (BIMS) score of 11 indicating moderately impaired cognition, when obtaining and discussing blood glucose results in a public setting. On 01/21/26 at 7:55 AM, a licensed nurse checked the resident’s blood sugar using a glucometer while the resident was seated at a dining room table, with five other residents, staff, and a visitor present. After obtaining the reading from the resident’s right index finger, the nurse verbally stated in the dining room that the resident’s blood sugar was high and that the physician might need to be contacted to start insulin. Administrative staff later confirmed that blood sugar checks should not be performed in the dining room and that residents should be taken to their room or a private area, and facility policy on resident rights documented that residents have the right to be treated with dignity and respect. This conduct, occurring in a communal dining area in the presence of other residents, staff, and a visitor, constituted a failure to provide care in a manner that maintained Resident 23’s dignity and respected their right to privacy regarding personal health information.
Failure to Provide Required Medicare Non-Coverage Notices to Beneficiaries
Penalty
Summary
The facility failed to provide required Medicare beneficiary notices to two residents whose skilled services were ending, resulting in a deficiency related to lack of Notice of Medicare Non-Coverage (NOMNC) Form CMS-10123. For one resident, skilled services ended on 11/20/25, and for the other resident, skilled services ended on 01/13/26; in both cases, the facility lacked documentation that the resident or their representative received Form 10123, which should have included a detailed explanation of non-coverage and the appeal process. During an interview on 01/23/26 at 1:40 PM, an administrative staff member confirmed that Form 10123 was not provided to these two residents and acknowledged that it should have been given to the resident or representative. Additionally, when requested on 01/23/26, the facility was unable to provide a policy for Beneficiary Notices.
Failure to Ensure Appropriate Indications and 14-Day Limits for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate indications and documentation for psychotropic medication use, including antipsychotic and PRN antianxiety drugs. One resident with diagnoses of dementia, depression, Parkinson’s disease, and encephalopathy was admitted post-hospitalization and had severely impaired cognition, requiring staff assistance with most ADLs. This resident received Seroquel 25 mg twice daily for a diagnosis of dementia with agitation. The care plan documented monitoring for side effects and effectiveness, but the electronic medical record lacked a documented physician rationale for the continued use of Seroquel, including documentation of unsuccessful attempts at nonpharmacological symptom management and a risk-versus-benefit analysis. An administrative nurse confirmed that the resident was receiving an antipsychotic with a diagnosis of dementia, which was identified as an inappropriate indication under facility policy, and that the physician and consultant pharmacist had recognized the need for a different diagnosis. The facility’s own Antipsychotic Medication Administration policy required that antipsychotics only be used when necessary to treat a specific, documented condition and that orders include a diagnosis, condition, or indication for use from a defined list of acceptable conditions. The policy also required comprehensive assessment, routine dose reduction, and behavioral interventions unless clinically contraindicated. Despite these requirements, the documentation for the resident on Seroquel did not include the necessary physician rationale or evidence of nonpharmacological interventions attempted prior to or alongside antipsychotic use, as required by the policy. The deficiency also includes failures related to PRN antianxiety medications for two other residents with dementia, depression, and anxiety diagnoses and severely impaired cognition. One resident had a physician’s order for alprazolam 0.5 mg by mouth every eight hours PRN for anxiety, and another had an order for lorazepam 0.5 mg by mouth every four hours PRN for anxiety. Both orders lacked a 14-day stop date or any specified duration. Their electronic medical records did not contain evidence of a physician’s rationale for extended PRN use, including a risk-benefit rationale statement and duration, as required by the facility’s Psychotropic Medication Use policy. Nursing staff acknowledged that PRN psychotropic orders were supposed to have a 14-day stop date and that the physician should reassess the residents to determine ongoing need, but this had not been implemented in these cases.
Failure to Complete Discharge Recapitulation for Resident Stay
Penalty
Summary
The deficiency involves the facility’s failure to complete a recapitulation of a resident’s stay and course of treatment upon discharge. The resident had diagnoses of dementia, acute blood loss anemia, and a lower gastrointestinal bleed, and an admission 5-Day Medicare MDS documented a BIMS score of nine, indicating moderately impaired cognition. The resident required partial staff assistance with toileting hygiene, showers, dressing, personal hygiene, and transfers. The care plan documented that the resident was to be discharged from the facility and directed staff to encourage verbalization of fears and concerns, clarify misconceptions, and provide the resident and family with opportunities to attend care plan conferences, participate in discharge planning, and consider alternative care options. Nurse’s notes documented that the resident was admitted with a lower gastrointestinal bleed and anemia and later discharged home with her husband. However, the clinical record lacked a completed recapitulation summarizing the resident’s stay and course of treatment in the facility. On interview, the Administrative Nurse confirmed that a recapitulation upon discharge was not completed for this resident. The facility’s Discharge Planning policy stated that discharge planning is part of the comprehensive care plan and that all discharge planning activities are to be documented in the resident’s clinical record, but the required recapitulation was not present in this case.
Failure to Implement Diabetes Management Parameters and Individualized Fall Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate care planning and clinical parameters for a resident with diabetes mellitus. One resident with a documented diagnosis of diabetes had an admission MDS showing intact cognition and dependence on staff for toileting hygiene, mobility, and transfers, and received daily insulin. The resident’s care plan directed staff only to provide a nighttime protein snack to keep blood sugars even and did not include any further direction related to diabetes management. A physician order required blood sugars to be obtained before meals and at bedtime for diabetes, but the medical record did not contain any blood sugar parameters. A licensed nurse confirmed there were no parameters and stated he would use his own nursing judgment to decide when to notify the physician, and a CMA reported not knowing what the parameters should be, noting that parameters had existed in a prior computer system but were absent in the new one. An administrative nurse stated the resident should have physician-ordered blood sugar parameters and that the care plan should direct staff on what to monitor for regarding the resident’s diabetes. The deficiency also includes failure to implement individualized fall interventions for another resident with dementia, anxiety, repeated falls, and severely impaired cognition. This resident was dependent on staff for ambulation, toileting hygiene, and lower-body dressing, and required substantial assistance for mobility and supervision with transfers. The admission MDS documented that the resident was at risk for falls, had no functional impairment, and had experienced two or more falls since admission. The care plan instructed staff to determine and address causative factors of falls, provide exercise and strength-building activities, obtain a PT consult for strength and mobility, and request a pharmacist medication review, but did not include specific, individualized fall interventions beyond these general directions. Multiple fall assessments and investigations documented that the resident was at high risk for falls and had several episodes of being found on the floor after scooting herself in her room, often near the room door, with falls described as unwitnessed and without injury. Immediate interventions documented in the fall investigations included obtaining a fall mat and placing signs in the room to remind the resident to call for help before attempting to transfer. Observations showed the resident in a low bed with a fall mat, able to stand with a gait belt and ambulate steadily with a walker, and staff reported she had numerous falls in her room, wore a Wander Guard that alarmed frequently, and was often placed in a recliner in the dayroom so staff could watch her. An administrative nurse stated that the resident had many falls in her room and that staff should have put interventions in place for those falls, and further confirmed that all the incidents where she scooted on the floor in her room were considered falls. The facility’s Resident Care Plan policy required evaluation by the interdisciplinary team, initiation of a care plan within 48 hours of admission, and review and revision of the care plan when resident needs changed, but the documented care plans did not reflect individualized interventions for the resident’s repeated falls.
Failure to Follow Fall-Prevention Care Plans and Safe Transfer Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and follow fall-prevention care plans for two residents at high risk for falls. One resident (R9) had dementia without behavioral disturbance and Parkinson’s disease, with documented high fall risk and multiple prior falls. His care plan included multiple fall-prevention interventions, including a directive for the family to provide properly fitting shoes. Despite this, R9 continued to use shoes that were too big, and during an assisted walk with a gait belt and walker he tripped over his feet and fell, sustaining a laceration to the left eyebrow, a hematoma, and a skin tear to the left elbow, requiring emergency room evaluation and wound closure. The fall investigation specifically identified that his shoes were too big, and an administrative nurse acknowledged that the oversized shoes contributed to the fall and that staff should have followed the fall care plan intervention. R9’s records also showed repeated falls in his room and from his recliner prior to the injury fall. On multiple occasions, staff heard a crash from his room and found him on the floor next to his recliner or air conditioner/heater unit after he attempted to get up or prepare his bed. Although his care plan directed staff to place the call light and personal items within reach, educate him to use the call light for assistance, offer a urinal every two hours, and encourage use of the dayroom for supervision when restless, he continued to experience falls in his room. One nurse’s note documented a fall from his recliner with staff then moving him to the dayroom for visualization, but the electronic medical record lacked a corresponding fall investigation for that event, despite facility policy requiring completion of a Fall Report and further investigation after any fall. The second resident (R43) had dementia with severely impaired cognition, macular degeneration, repeated falls, and weakness, and was assessed as high risk for falls. Her care plan included use of a fall mat, staff education on proper sling placement, and a requirement for two staff with a sit-to-stand lift for transfers. She experienced two separate falls during sit-to-stand lift transfers to or from the toilet. In the first incident, her knees gave out and she slid out of the sling onto the bathroom floor. In the second incident, she let go of the lift, slid through the belt on the sling, and fell onto her bottom. In both cases, the fall investigations identified issues with the use of the sit-to-stand lift and sling, including that the sling was not put on correctly and that only one staff member was present during one of the falls, contrary to the care plan directive for two-person assistance. Staff interviewed later were unaware of these prior sit-to-stand falls and described her as a one-to-two-person transfer who could use the sit-to-stand lift if needed, indicating that the care plan directions and fall history were not consistently followed in practice. Facility policies on Falls-Accident Reporting and the Resident Fall Checklist required that after any fall, licensed staff complete a Fall Report, perform a head-to-toe assessment before assisting the resident off the floor, notify the physician and responsible party, determine appropriate interventions to prevent further falls, update the care plan, obtain witness statements for falls with injury or possible injury, and document progress notes every shift for three days. The documented events for R9 and R43 show that falls occurred in the context of high fall risk, existing fall-prevention care plans, and specific policy requirements, yet the facility did not consistently implement the care-planned interventions (such as ensuring properly fitting shoes and two-person sit-to-stand transfers) or fully document and investigate all falls as required by its own policies.
Lack of Physician-Ordered Blood Glucose Parameters for Insulin-Dependent Diabetic Resident
Penalty
Summary
Surveyors identified a deficiency related to unnecessary drugs and inadequate blood glucose management for one resident with diabetes mellitus. The resident had a diagnosis of diabetes, was cognitively intact with a BIMS score of 13, and was dependent on staff for toileting hygiene, mobility, and transfers. The MDS documented that the resident received insulin daily, and the care plan directed staff to provide a nighttime protein snack to keep blood sugars even, but the care plan did not include specific directions related to diabetes management. A physician order directed staff to obtain blood sugars before meals and at bedtime, yet the medical record lacked any physician-ordered blood sugar parameters. During interviews, a licensed nurse confirmed that there were no blood sugar parameters for the resident and stated he relied on his own nursing judgment to decide when to notify the physician if blood sugars seemed too high. A CMA reported that she did not know what the resident’s blood sugar parameters should be and stated that parameters had existed in a previous computer system but were absent in the new system. An administrative nurse acknowledged that the resident should have physician-ordered blood sugar parameters and that the care plan should provide direction to staff regarding the resident’s diabetes. When requested, the facility was unable to provide a policy for blood sugar management.
Failure to Coordinate Facility and Hospice Care in Resident Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure coordinated care and services between the facility and hospice for a resident receiving hospice services. The resident had diagnoses including dementia, metabolic encephalopathy, DM, atrial fibrillation, and chronic pain, and a Significant Change MDS showed a BIMS score of eleven, indicating moderately impaired cognition. The MDS documented that the resident required extensive staff assistance with toilet hygiene and supervision with oral hygiene, personal hygiene, and other ADLs, and that the resident was receiving hospice services. The ADL care plan noted a decline in the resident’s ability to care for herself after a fall in assisted living, with increased confusion, several falls, and increased need for staff assistance with most ADLs. Despite the resident’s admission to hospice on 11/14/25 with a diagnosis of senile degeneration of the brain, review of the clinical record showed that the facility’s care plan did not contain any information indicating that the resident was on hospice services. On observation, the resident was seen dressed in street clothes and eating breakfast at the dining room table. During an interview, an administrative nurse confirmed that the facility care plan lacked any indication that the resident was receiving hospice services and verified that the resident had been on hospice since 11/14/25. The facility’s End of Life policy stated that end-of-life care, including hospice, should be provided through an interdisciplinary approach with a care plan developed by the team to address actual and potential problems, but this coordination with hospice was not reflected in the resident’s care plan.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to provide the services of a full-time certified dietary manager for 33 residents who received their meals from the kitchen. During observation of lunch meal preparation, a dietary staff member confirmed she was not a certified dietary manager, reported she was still taking the course and had not yet taken the certification test, and was functioning in the kitchen despite this. She also identified that two residents were on a pureed diet and three residents were on a minced and moist diet. Later, administrative staff confirmed that this dietary staff member was not certified. The facility’s Personnel policy stated that the food and nutrition services department would be staffed with sufficient competent personnel to carry out departmental functions, but the facility did not have a certified dietary manager in place. No additional resident-specific medical histories or conditions beyond the need for pureed and minced and moist diets were documented in the report.
Failure to Report Alleged Rough Care as Potential Abuse
Penalty
Summary
The facility failed to ensure that staff identified and reported an allegation of rough care as potential abuse immediately to the Licensed Nursing Home Administrator (LNHA) and the State Agency (SA) as required. This deficiency was identified during a survey involving a resident with severe cognitive impairment, dementia, hypertension, and other medical conditions. The resident was dependent on staff for various aspects of personal care and had a history of verbal behaviors and care refusal. On a specific date, a Certified Nurse Aide (CNA) witnessed a Certified Medication Aide (CMA) handling the resident roughly during a transfer, which resulted in the resident yelling out. The CNA reported the incident to a Licensed Nurse (LN), who then informed Administrative Nurse D via email. However, the incident was not reported to the LNHA or the SA immediately, as required by the facility's policy on abuse, neglect, and exploitation prevention. The failure to report the incident promptly placed the resident at risk for ongoing abuse and mistreatment. Despite the CNA's report and the subsequent examination of the resident, which found no new bruising, the facility did not take the necessary steps to ensure the allegation was addressed according to regulatory requirements. This oversight highlights a significant lapse in the facility's abuse reporting protocol.
Failure to Investigate and Protect Resident from Alleged Abuse
Penalty
Summary
The facility failed to initiate protective measures and fully investigate an allegation of abuse involving a resident with severe cognitive impairment and multiple medical conditions, including dementia and major depressive disorder. The resident was dependent on staff for various aspects of care and had a history of verbal behaviors and care refusal. On a specific date, a Certified Nurse Aide (CNA) reported witnessing a Certified Medication Aide (CMA) potentially handling the resident roughly during a transfer, which was followed by the resident yelling out in distress. Despite the report of potential abuse, the facility did not immediately suspend the involved staff member or conduct a thorough investigation. The incident was initially reported to a Licensed Nurse (LN), who noted typical bruising on the resident's arms but did not find any new bruising. The LN communicated the concern to an Administrative Nurse, but the information was not promptly relayed to the appropriate administrative staff for further action. This delay in communication and action resulted in the staff member continuing to work with residents until a later date when the issue was escalated. The facility's policy required immediate reporting and suspension of staff involved in alleged abuse, but these procedures were not followed. The failure to adhere to the policy and promptly address the allegation placed the resident at risk for continued abuse. The lack of immediate protective measures and a comprehensive investigation highlights a significant deficiency in the facility's handling of abuse allegations.
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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