The Healthcare Resort Of Leawood - Iron Horse Hlth
Inspection history, citations, penalties and survey trends for this long-term care facility in Leawood, Kansas.
- Location
- 5401 W 143rd Street, Leawood, Kansas 66224
- CMS Provider Number
- 175558
- Inspections on file
- 21
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 23 (1 serious)
Citation history
Health deficiencies cited at The Healthcare Resort Of Leawood - Iron Horse Hlth during CMS and state inspections, most recent first.
The facility failed to prevent two CNAs from bringing firearms into the building and engaging in gunfire on a resident unit, resulting in bullets traveling down a resident hallway and striking a doorframe and wall near occupied rooms. One CNA unlocked an exit door, returned toward the nurses’ station, drew a gun from his jacket, and fired multiple shots into the dining room at another CNA, who then returned fire down the hall where multiple residents resided. Staff reported hearing gunshots, seeing shell casings and smoke near the nurses’ station, and then calling 911 and checking on residents, while two residents in wheelchairs described being awakened and startled by the shots. Interviews indicated that one CNA had earlier felt uneasy about the other and retrieved a gun from his car without reporting his concern, and that an escalating argument with demeaning and vulgar comments preceded the shooting, despite an employee handbook that prohibited workplace violence and weapons on the premises.
A CNA did not have a required annual performance evaluation completed, as confirmed by record review and staff interview. Facility policy mandates yearly evaluations to identify employee strengths and training needs, but documentation for this CNA was missing.
Surveyors found that dietary staff did not wear hairnets, and multiple food items in the kitchen and walk-in refrigerator were not labeled or dated. The convection oven was dirty and had a bucket on the floor catching water from a broken pipe, and the facility could not provide a policy for foodborne illness or food storage.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report notes that safety standards were not met and supervision was lacking, but does not provide further specifics.
Surveyors found two unlocked treatment carts containing medical ointments and wound cleansers in separate units, as well as improperly labeled and expired tuberculin serum vials in a medication storage refrigerator. Nursing staff confirmed that carts should be locked when not in use, and facility policy required all medications and biologicals to be secured.
Surveyors found that clean linens were improperly stored on a PPE cart, soiled linens were left on the floor, and respiratory equipment such as a nebulizer mask and nasal cannula were not stored in a sanitary manner. Additionally, a nurse failed to use a barrier when placing an Accu-Check machine on various surfaces. Staff interviews confirmed these actions were not in line with the facility's infection control policies.
The facility did not obtain or document consent or declination for the PCV20 pneumococcal vaccine for two residents, and there was no evidence that the vaccine was offered or previously administered. An administrative nurse was unable to confirm which immunizations were offered, and the facility lacked a policy for immunizations.
A resident with muscle weakness, cognitive impairment, and a history of falls was found to have her call light placed out of reach while in bed, despite care plan instructions and facility policy requiring it to be accessible at all times. Staff interviews confirmed the expectation for call lights to be within reach, but observations showed this was not followed, resulting in a deficiency in accommodating the resident's needs.
A resident with multiple complex medical needs was discharged without a required summary of her stay or care provided. Despite the care plan and nursing notes indicating significant ADL assistance and ongoing skilled services, the medical record lacked a discharge summary, which staff confirmed was their responsibility to complete.
A resident with dementia, cognitive communication disorder, muscle weakness, and diabetes required varying levels of staff assistance for ADLs, as indicated by assessments. However, the care plan did not document the resident's current level of functioning or the specific assistance needed for tasks such as bathing, dressing, and mobility. Staff interviews confirmed that this information should be included in care plans, but it was missing in this case.
A resident with CHF and multiple comorbidities did not have daily and weekly weights obtained and documented as ordered by the physician. Staff interviews confirmed that the process for ensuring weights were taken and recorded was not followed, resulting in a lack of required documentation in the MAR, TAR, and EMR.
A resident with impaired mobility and incontinence, identified as at risk for pressure ulcers, did not have a physician-ordered pressure-reducing cushion in their wheelchair. Despite care plan documentation and staff acknowledgment of the need for such devices, repeated observations showed the cushion was not in place, and staff were unclear about their responsibilities regarding pressure-reducing devices.
A resident with multiple medical conditions and a physician order for nebulizer treatments was observed to have their nebulizer mask left on the bedside table instead of being stored in a clean, dated plastic bag as described by staff. The care plan lacked instructions for nebulizer use or mask storage, and the facility did not provide a policy for proper storage, resulting in unsanitary respiratory care practices.
A deficiency was identified when laboratory records in a resident's medical file were found to be incomplete and lacking required dates.
A resident receiving hospice care, with multiple chronic conditions and significant ADL needs, did not have a coordinated plan of care between the facility and hospice services. Staff relied on a separate hospice binder and verbal communication for updates, and key hospice information was not integrated into the facility's care plan, contrary to facility policy and staff expectations.
Failure to Prevent Armed Workplace Violence Between CNAs on Resident Unit
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision to prevent accidents, specifically by failing to prevent two CNAs from bringing firearms into the building and engaging in gunfire on a resident unit. On the night of the incident, one CNA (CNA M) walked down the Northeast (NE) corridor, unlocked an exit door, then returned toward the nurses’ station. He reached into his jacket, turned toward the dining room where another CNA (CNA N) was located, and fired multiple shots into the dining room. Video surveillance reviewed by administrative staff showed this sequence of events, including CNA M unlocking the NE corridor door, returning toward the nurses’ station, drawing a gun from his jacket, firing into the dining room, and then fleeing out the NE corridor door. In response to the gunfire from CNA M, CNA N returned an unknown number of rounds down the East Hall, where nine residents resided. A bullet grazed the wall near the room of one resident (R2), leaving a four- to six-inch graze mark, and a bullet, possibly the same one, struck the doorframe of another resident’s room (R1). Subsequent observation of the East Hall revealed a round indentation on the lower part of R1’s doorframe and a graze mark on the wall near R2’s room. In the dining room across from the East Hall, there were two bullet holes in the window and two to three bullet holes in the wall. Staff on duty reported hearing gunshots and screams, seeing smoke and shell casings near the nurses’ station, and then moving to call 911 and check on residents. Residents described being awakened and startled by the gunfire. R1, seated in a wheelchair in his room, reported initially thinking the sounds were pots and pans clanging, then realizing they were three to four shots, one of which hit his doorframe; he thought the shooter might be coming into his room for him. R2, also in a wheelchair in his room, stated that the gunshots startled him awake and that he was scared for a few seconds. Staff interviews revealed that earlier in the shift, CNA N felt uneasy about CNA M and went out to his car to retrieve his gun, which he then brought into the facility without reporting his concern to anyone. Another nurse (LN I) and a CNA (CNA O) described an escalating verbal argument between CNA M and CNA N in the dining area, including demeaning and vulgar comments, with CNA M pacing and attempting to leave while CNA N continued to pull him back into the conversation, before CNA M walked down the NE hall, returned, and began firing. The facility’s employee handbook, in effect at the time, prohibited acts or threats of violence and the possession of weapons of any kind on the property, but both CNAs nonetheless possessed guns inside the facility and engaged in gunfire on the East unit, placing residents in immediate jeopardy.
Removal Plan
- The facility began staff education on workplace violence, reporting protocols, security, anti-harassment and anti-retaliation protections, and technology and social media controls (education ongoing).
- The facility contracted with a security agency for a nighttime security guard.
- The facility notified the residents' representatives of the incident.
- The facility had a psychologist visit with residents possibly affected by the incident.
Annual Performance Evaluation Not Completed for CNA
Penalty
Summary
The facility failed to complete the required annual performance evaluation for one of five reviewed Certified Nurse Aides (CNA), specifically for a CNA hired on 10/11/23. During a review of performance evaluation and in-service training records, it was found that no yearly performance evaluation was available for this CNA when requested. An administrative nurse confirmed that the evaluation had not been completed, despite facility policy requiring annual performance reviews for all employees to identify strengths, goals, and training needs. This deficiency was identified through record review and staff interview.
Failure to Maintain Sanitary Food Storage and Preparation Practices
Penalty
Summary
Surveyors observed multiple failures to follow sanitary dietary standards in the facility's kitchen and kitchenettes. Dietary staff were seen working without hairnets, and several food items in the walk-in refrigerator, including hot dogs, hamburgers, cut-up watermelon, lettuce, and corn salad, were found covered but not labeled or dated. In the walk-in freezer, French-fried potatoes were stored in an unlabeled and undated canister. The top of the convection oven was dirty and cluttered with black gloves and dirty pan cover sheets, and a white plastic bucket was placed on the floor to catch dirty water from a broken pipe above the oven. The facility was unable to provide a policy for foodborne illness or food storage when requested.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents. Specific details regarding the actions or inactions of staff, or the condition of residents at the time, are not provided in the report.
Failure to Secure Treatment Carts and Properly Label Medication
Penalty
Summary
Surveyors observed that two treatment carts in separate units were left unlocked, one in the back nurses' station of the Hallbrook unit and another in the hallway of the Bridgewood unit. Both carts contained medical ointments and wound cleansers. Additionally, in the medication storage room on the Hallbrook unit, a refrigerator inspection revealed two vials of tuberculin serum, one of which was opened without any dates indicating when it was opened or when it should expire, and the other had been opened and was past its 30-day expiration date. Interviews with nursing staff confirmed that carts were expected to be locked when not in use and that staff were responsible for securing carts and patient information when stepping away. The facility's policy required all medications and biologicals to remain locked and secured to prevent tampering or exposure.
Infection Control Deficiencies in Linen and Equipment Handling
Penalty
Summary
Surveyors identified multiple infection control deficiencies during their review of the facility. Clean linens, including towels, washcloths, and a bed sheet, were observed placed on top of a personal protective equipment (PPE) cart in the hallway, rather than being stored in a sanitary manner. In one instance, soiled linen was found on the floor of a resident's room. Additionally, respiratory equipment such as a nebulizer mask and nasal oxygen tubing were not stored properly; the nebulizer mask was left on a bedside table and the nasal cannula was thrown on top of an oxygen canister at the bottom of a resident's bed, rather than being kept in a clean, dated plastic bag as required by facility policy. Further deficiencies were observed in the handling of blood glucose monitoring equipment. A licensed nurse was seen placing the Accu-Check machine directly onto various surfaces, including a medication cart, a shower room counter, and the arm of a Broda chair, without using a barrier as required. Staff interviews confirmed that these practices were inconsistent with facility infection control policies, which mandate the use of barriers for equipment and proper storage of linens and respiratory devices to prevent contamination.
Failure to Document and Offer Pneumococcal Vaccinations and Lack of Immunization Policy
Penalty
Summary
The facility failed to obtain consent or declination for the Pneumococcal Conjugate Vaccine (PCV20) for two residents, despite reviewing their immunization status as part of a sample of five residents. For one resident, the clinical record showed declinations for PCV13 and PPSV23, but lacked documentation that PCV20 was offered, declined, or previously administered. For another resident, records indicated administration of PPSV23 and PCV13, but again lacked documentation regarding PCV20 being offered, declined, or historically administered. Additionally, an administrative nurse was unable to confirm which immunizations were offered at the facility, and the facility did not provide a policy for immunizations.
Failure to Ensure Call Light Accessibility for Resident with High Fall Risk
Penalty
Summary
A deficiency occurred when staff failed to ensure a resident had access to her call light, which was required for her to communicate her needs. The resident had multiple medical diagnoses, including muscle weakness, overactive bladder, a need for assistance with personal care, a history of falling, and a cognitive communication disorder. Her care plan specifically instructed staff to keep the call light within reach at all times due to her high risk for falls and need for substantial to maximal assistance with activities of daily living. Despite these documented needs and instructions, observations showed that the resident's soft-touch call light was placed on a bedside table across the room, out of her reach, while she was in bed on multiple occasions. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that the expectation was for call lights to be within reach of residents at all times and checked each shift. The facility's Fall Management System policy also required appropriate equipment and interventions to ensure resident safety and prevent falls. The failure to follow these protocols and care plan instructions resulted in the resident being unable to communicate her needs, constituting a deficiency in reasonably accommodating her needs and preferences.
Failure to Document Resident Discharge Summary
Penalty
Summary
The facility failed to provide a final summary of a resident's status at discharge, as required. The resident in question had multiple diagnoses, including infection and inflammatory reaction due to a knee prosthesis, MRSA, pain, cognitive decline, major depressive disorder, and dysphagia. Documentation showed the resident required significant assistance with activities of daily living (ADLs) such as eating, oral hygiene, toileting, transfers, and bed mobility. The care plan indicated ongoing skilled services to help the resident regain strength and return home, with identified risks including further ADL decline, falls, incontinence, skin breakdown, and pain. On the day of discharge, the resident's husband arrived to take her home, and nursing staff notified the physician of the discharge. However, the medical record did not contain a summary of the resident's stay or a recompilation of her care, as required by facility policy. Interviews with nursing staff confirmed that it was the responsibility of the nurse in charge, or the DON if not completed, to document this summary, but it was not done in this case.
Failure to Document Resident's Required ADL Assistance in Care Plan
Penalty
Summary
The facility failed to identify and document the specific level of care assistance required for activities of daily living (ADLs) for a resident with multiple medical diagnoses, including dementia, cognitive communication disorder, muscle weakness, and diabetes mellitus. The resident's Minimum Data Set (MDS) indicated she needed partial to moderate assistance with lower body dressing, footwear, bathing, toileting, and oral hygiene, and supervision or touch assistance with upper body dressing, personal hygiene, bed mobility, and walking. The Functional Abilities Care Area Assessment (CAA) also indicated a need for staff assistance with ADLs and self-care. However, the care plan did not specify the resident's current level of functioning or the required level of assistance for bathing, transfers, dressing, oral hygiene, meals, and bed mobility. Observations showed the resident was able to walk with a walker and prepare for meals independently, and she reported no concerns about her care. Interviews with staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that care plans should include detailed information about each resident's level of functioning and assistance needs. The facility's policy required comprehensive assessments and individualized interventions, with care plans reviewed and updated as needed, but this was not reflected in the resident's care plan documentation.
Failure to Follow Physician's Orders for Weight Monitoring in CHF Patient
Penalty
Summary
The facility failed to follow a physician's order for daily and weekly weights for a resident diagnosed with congestive heart failure (CHF), among other conditions. The resident's electronic medical record (EMR) included orders for daily weights for three consecutive days and weekly weights thereafter, which were not documented as completed on the specified dates. The July Medication Administration Record (MAR), Treatment Administration Record (TAR), and Weights/Vital Signs tab lacked evidence of daily weights for three days and weekly weights for two separate weeks. Interviews with staff confirmed that the process for obtaining and documenting weights involved communication between CNAs and nurses, with the charge nurse responsible for ensuring orders were followed and weights were recorded in the EMR. The resident had a history of CHF, overactive bladder, pain, dementia, cellulitis, lack of coordination, communication deficit, need for assistance with personal care, a healing fracture, and Parkinson's disease. The care plan required nursing staff to administer medications as ordered and monitor for side effects, with specific mention of monitoring for adverse effects of medication every shift. Despite these directives, the required weights were not obtained or documented as ordered, resulting in a failure to provide care in accordance with the physician's orders and the facility's policy.
Failure to Provide Ordered Pressure-Reducing Device for At-Risk Resident
Penalty
Summary
A deficiency occurred when a resident, identified as being at risk for pressure ulcers due to impaired mobility and incontinence, did not have a physician-ordered pressure-reducing cushion in place on their wheelchair. The resident's medical record documented diagnoses including difficulty walking, dementia, lack of coordination, muscle weakness, and a need for assistance with personal care. The care plan and assessments indicated the resident was at risk for pressure-related injuries and required monitoring and assistance with turning and repositioning. Despite a physician order for a cushion to be used in the wheelchair, multiple observations over several days found the resident's wheelchair lacked the required cushion, and no cushion was present in the room. Interviews with staff revealed inconsistent understanding and implementation of responsibilities regarding pressure-reducing devices. Certified Nurse Aides and Licensed Nurses stated that ensuring pressure-reducing devices were in place was a shared responsibility, and that such devices should be listed on the resident's care plan or Kardex. However, there was uncertainty among staff about which residents required these devices, and the ordered cushion was not in use as required by the resident's care plan and physician order. The facility's policy required pressure-reducing devices for individuals restricted to a chair, but this was not followed for the resident in question.
Failure to Store Nebulizer Mask in a Sanitary Manner
Penalty
Summary
A deficiency was identified when a resident's nebulizer mask was repeatedly observed stored in an unsanitary manner, specifically left on the bedside table rather than in a clean, designated container. The resident had multiple medical conditions, including hypertension, peripheral vascular disease, bilateral below-knee amputations, a colostomy, muscle weakness, and required significant assistance with activities of daily living. The resident was prescribed Ipratropium-Albuterol nebulizer treatments three times daily for wheezing. Despite staff interviews indicating that nebulizer masks should be rinsed, air dried, and stored in a dated plastic bag, direct observations on multiple occasions showed the mask left out on the bedside table. The resident's care plan did not include instructions for nebulizer use or mask storage, and the facility was unable to provide a policy regarding proper storage of nebulizer masks. These actions and omissions led to the failure to ensure safe and sanitary respiratory care for the resident.
Incomplete and Undated Laboratory Records
Penalty
Summary
The facility failed to keep complete, dated laboratory records in the resident's record. This deficiency was identified through review of documentation, which revealed that laboratory records were either incomplete or missing required dates. The lack of proper documentation was directly observed in the resident's medical record.
Failure to Coordinate Hospice and Facility Care Plans
Penalty
Summary
The facility failed to ensure a coordinated plan of care between the facility and hospice services for a resident who was admitted to hospice. The resident had multiple diagnoses, including fibromyalgia, hypertension, peripheral vascular disease, major depressive disorder, diabetes mellitus, muscle weakness, and senile degeneration of the brain, and required significant assistance with activities of daily living. The resident's care plan documented admission to hospice and outlined comfort measures, maintenance of dignity, and the provision of supplies by hospice. However, review of records and staff interviews revealed that information regarding hospice services, such as supplies provided and the schedule of hospice staff, was not consistently included in the facility's care plan. Instead, this information was maintained separately in a hospice binder at the nurse's station, and staff relied on verbal communication and the binder for updates. Certified Nursing Aides and Licensed Nurses reported that they did not believe hospice information was integrated into the facility's care plan, and the Administrator confirmed that while communication with hospice was good, the care plans between the facility and hospice should match. The facility's policy required individualized, interdisciplinary plans to address residents' needs, but the lack of a unified, coordinated care plan placed the resident at risk for inappropriate end-of-life care. The deficiency was identified through observation, record review, and staff interviews, which demonstrated a failure to develop and maintain a coordinated plan of care as required.
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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