The Gardens At Aldersgate
Inspection history, citations, penalties and survey trends for this long-term care facility in Topeka, Kansas.
- Location
- 3220 Sw Albright Drive, Topeka, Kansas 66614
- CMS Provider Number
- 175340
- Inspections on file
- 33
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 33
Citation history
Health deficiencies cited at The Gardens At Aldersgate during CMS and state inspections, most recent first.
A resident with a history of stroke and hemiplegia, cognitively intact and fully dependent on staff for ADLs including showering, did not receive scheduled showers as care-planned and listed on the shower schedule. Over a review period, only a portion of the scheduled showers were actually provided, with discrepancies between paper shower sheets and EMR task sign-offs. The resident reported not receiving her scheduled weekday showers for several weeks, stating she did not refuse care and was not offered a bed bath. CNAs and nursing staff described expectations to document all offered showers, baths, and refusals on shower sheets and in the EMR, but only a limited number of shower sheets could be located. Administrative nursing staff confirmed that the resident did not receive showers according to the established schedule, in conflict with the facility’s ADL policy requiring necessary services to maintain personal hygiene.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. The report identifies a lapse in ensuring resident safety but does not provide further details about the specific events or individuals involved.
A resident with dementia and multiple diagnoses, including Parkinsonism and anxiety, exhibited wandering and disruptive behaviors. The facility failed to create an individualized care plan to address these behaviors, as required by their dementia care policy. Staff acknowledged the behaviors but did not consistently report incidents or update the care plan, placing the resident at risk for impaired psychosocial well-being.
A resident with multiple health conditions, including dementia and Parkinson's disease, suffered a dislocated shoulder and fractured humerus due to inadequate supervision and assistance during a transfer. The resident's care plan required two staff members for assistance, but a CNA attempted to assist the resident alone, leading to a fall from a recliner. The facility's policy on accident prevention was not followed, resulting in the resident's injuries.
A resident sustained avoidable injuries during a transfer using a Hoyer lift when two CNAs did not follow proper procedures, resulting in skin tears on both lower legs. The resident, who required extensive assistance with ADLs and had a history of lower leg pain, was not positioned correctly in a recliner, leading to significant pain and emotional distress.
A resident with a history of cerebral infarction, vascular dementia, and other medical conditions sustained serious injuries during a transfer using a Hoyer lift. Certified Nurse Aides (CNA) used a toileting sling instead of the appropriate sling, causing the resident to slip and fall, resulting in a head laceration, thoracic fracture, and intracranial hemorrhage. Interviews with involved staff and review of the resident's medical records revealed that the facility's policies on safe resident handling and transfers were not followed, leading to the incident.
Failure to Provide Scheduled Showers and Proper ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled ADL assistance with personal hygiene, specifically showers, to a dependent resident. The resident had diagnoses of cerebral infarction and hemiplegia and was documented on both annual and quarterly MDS assessments as cognitively intact with a BIMS score of 15, having no rejection of care during the observation period, and being dependent on staff for most ADLs, including showering. Care plans documented that the resident was dependent on staff for showers/baths and that she would often refuse bathing/showers, with directions to continue to offer bathing/showers and remind her of the importance of hygiene. The shower schedule listed the resident for showers on Tuesday and Friday day shifts. Review of shower sheets from early February through early April showed only five completed shower sheets, while EMR shower tasks showed staff sign-offs for several dates. In total, 16 showers were scheduled during the review period, but documentation showed the resident received only nine. During observation and interview, the resident reported she had not received her scheduled Tuesday showers for the past three weeks, stating she only received Friday baths, did not know why she was not offered showers, did not refuse showers, and was not offered a bed bath. A CNA reported that shower sheets were to be completed on paper each time a shower or bed bath was offered, including documentation of refusals, and that refusals were also to be documented in the EMR and reported to the charge nurse. A nurse stated the shower schedule was last updated in early February and that CNAs were expected to document all offered baths/showers and refusals both on shower sheets and in the EMR. Administrative nursing staff confirmed their expectation that staff complete or offer showers as scheduled, document all showers, baths, or refusals, and that only a limited number of shower sheets for the resident could be located. It was confirmed that the resident did not receive showers according to her scheduled shower days, contrary to the facility’s ADL policy requiring provision of necessary services, including bathing, to maintain good grooming and personal hygiene.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions leading to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Develop Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop an individualized dementia treatment plan for a resident, referred to as R1, who displayed dementia-related behaviors. R1's medical record indicated diagnoses of metabolic encephalopathy, Parkinsonism, anxiety, restlessness, and agitation, with a severely impaired cognition score. Despite these conditions, the care plan lacked specific interventions to address R1's behaviors, such as wandering and disruptive actions, which were documented in various skilled and behavior notes. These notes frequently lacked detailed descriptions of R1's behaviors and the staff's responses to manage or prevent further episodes. R1's care plan included general directives for engagement activities and monitoring due to wandering and elopement risk, but it did not provide comprehensive strategies tailored to R1's specific needs. Observations and interviews revealed that R1 frequently wandered into other residents' rooms, causing discomfort and potential safety issues. Staff members, including a licensed nurse and a certified nurse aide, acknowledged R1's behaviors but did not consistently report incidents to management or update the care plan accordingly. The facility's dementia care policy emphasized the importance of individualized care plans developed through an interdisciplinary team approach, involving the resident and their family. However, the facility did not adhere to this policy, as evidenced by the lack of a detailed and effective care plan for R1. This oversight placed R1 at risk for impaired psychosocial well-being and quality of life, as the facility did not adequately address or document interventions for R1's dementia-related behaviors.
Failure to Provide Adequate Supervision and Assistance
Penalty
Summary
The facility failed to ensure that a resident remained free from avoidable accidents, resulting in a dislocated right shoulder and a fractured right humerus. The resident, who had diagnoses including polyosteoarthritis, Parkinson's disease, dementia, anxiety disorder, and fibromyalgia, was dependent on staff for assistance with activities of daily living and transfers. The resident's care plan required the maximum assistance of two staff members for all bed mobility and showering, and interventions were in place to ensure care was provided in pairs to make the resident feel safe. On the day of the incident, a Certified Nurse Aide (CNA) was assisting the resident in changing clothing while the resident was in a recliner. The CNA was aware that the resident required a Hoyer lift for transfers but did not obtain assistance from another staff member, as the CNA was not getting the resident up. During the process, the resident jerked forward and fell out of the recliner onto the floor, resulting in injuries. The CNA reported that sometimes access to the resident's care information was delayed, which may have contributed to the lack of adherence to the care plan. The facility's policy on accidents and supervision emphasized the need for a resident environment free of accident hazards and adequate supervision to prevent accidents. Despite this policy, the facility did not ensure that the resident received the required supervision and assistance, leading to the accident. The incident highlighted a failure to follow the care plan and ensure staff were adequately informed and prepared to provide the necessary care, as evidenced by the CNA's lack of awareness and the subsequent fall and injuries sustained by the resident.
Failure to Ensure Safe Transfer Procedures
Penalty
Summary
The facility failed to ensure an environment free from accidents for a resident, resulting in an avoidable injury. The resident, who had diagnoses including Bell's palsy, localized edema, chronic pain, and anemia, required extensive assistance with activities of daily living (ADLs) and transfers. During a transfer using a Hoyer lift, two CNAs did not follow proper procedures, leading to the resident sustaining skin tears on both lower legs. The resident's care plan specified the need for two staff members to assist with transfers using a Hoyer lift and a full-body sling, but the CNAs deviated from this protocol by pushing on the resident's legs to position her in a recliner, causing the injuries. The resident's medical record documented a history of lower leg pain and a preference for being guided by her heels rather than her legs during transfers, which the CNAs ignored. The incident occurred when the resident was being transferred from her wheelchair to a recliner. One CNA pulled on the sling while the other pushed on the resident's legs to position her further back in the recliner. This action resulted in skin tears on both of the resident's lower legs, which were assessed and treated by the facility's licensed nurse. The resident was subsequently sent to the emergency room, where she received sutures for a laceration on her right lower leg. The resident expressed that the transfer caused her significant pain and emotional distress because the staff did not listen to her instructions to use her heels instead of her legs. Interviews with staff members revealed that the proper procedure for using a Hoyer lift involves one staff member pulling on the sling from behind while the other lowers the sling with the Hoyer controls. Pushing on a resident's legs is not an approved method and can cause injuries. The facility's policy on mechanical lifts directs staff to use the lever to gently raise and move the resident to the destination and to position the resident comfortably once lowered. The facility acknowledged that the CNAs involved had received transfer training, but the training was not yet completed at the time of the incident.
Improper Sling Use During Hoyer Lift Transfer Results in Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment free from preventable accidents for Resident (R) 1 during a staff-assisted transfer using a Hoyer lift. On the day in question, Certified Nurse Aides (CNA) M and O attempted to transfer R1 from his bed to his chair using the Hoyer lift with a toileting sling. Unfortunately, R1 slipped out of the opening in the sling and fell to the floor, hitting his head on the metal leg of the Hoyer lift. This incident resulted in R1 sustaining a head laceration, a thoracic fracture, and an intracranial hemorrhage, leading to his admission to the Intensive Care Unit (ICU). The facility's failure to ensure the correct sling was used during the mechanical lift transfer placed R1 in immediate jeopardy. Various documents, including R1's Electronic Medical Record (EMR), Annual Minimum Data Set (MDS), Falls Care Area Assessment (CAA), and Care Plan, highlighted R1's medical history and care needs. R1 had diagnoses of cerebral infarction, vascular dementia, lumbar region spondylosis, epilepsy, and paroxysmal atrial fibrillation. His cognitive status varied from moderately impaired to intact, and he required extensive assistance with most activities of daily living, including transfers due to weakness on his left side and poor balance. Despite these documented needs and previous falls, the facility did not ensure the correct sling was used for R1's transfers, leading to the preventable accident. Interviews with staff members involved in the incident, including CNA M, CNA N, and Licensed Nurse G, provided insights into the events leading up to the deficiency. Both CNAs acknowledged using the wrong sling for R1's transfer, leading to him falling through the sling and sustaining injuries. Nurse G noted the use of the toileting sling as the root cause of the accident, emphasizing the importance of using the correct equipment for transfers. Administrative Nurse E and D acknowledged the error in sling selection and highlighted the need for staff education on safe transfer practices. The facility's policies and guidelines on safe resident handling and transfers were not followed, contributing to the deficiency identified during the survey.
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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