Via Christi Village Ridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Wichita, Kansas.
- Location
- 3636 North Ridge Rd Bldg 400, Wichita, Kansas 67205
- CMS Provider Number
- 175539
- Inspections on file
- 22
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Via Christi Village Ridge during CMS and state inspections, most recent first.
A CNA took and shared a video of a resident with severe dementia, depicting the resident in a state of incontinence, without consent. The video was shown to another CNA during shift change, who reported the incident. The facility's policy prohibits such actions, but staff had not received recent documented education on privacy expectations.
A resident with a history of falls and multiple medical conditions experienced two staff-assisted falls in one day, resulting in a severe ankle fracture. The facility failed to implement immediate interventions after the first fall, where the resident's leg buckled and she was lowered to the floor by therapy staff. Despite the incident, the resident's transfer status was not reassessed, leading to another fall later that day. The facility's fall policy was not effectively followed, contributing to the resident's injury.
The facility failed to secure medications by leaving two medication carts unlocked and unattended during administration. On two separate occasions, medication carts containing narcotics, insulins, and other medications were found unlocked and unattended, potentially affecting 40 residents across two neighborhoods. Staff confirmed that the carts should have been locked when unattended, in accordance with facility policy.
A facility failed to maintain a medication administration error rate below 5%, resulting in an 81.48% error rate. An LN administered medications to residents without confirming them against the physician's order or eMAR, leading to 22 out of 27 observed errors. The LN acknowledged the failure to follow the nursing standard of care, and the facility could not provide a relevant policy when requested.
The facility failed to maintain effective infection control practices, as staff mishandled meal trays, improperly cleaned respiratory equipment, and neglected hand hygiene during wound care. Observations showed staff placing fingers on eating surfaces of plates, storing nebulizer and CPAP masks improperly, and not performing hand hygiene between glove changes during wound care. These deficiencies could lead to foodborne illnesses, respiratory infections, and wound infections.
The facility failed to document COVID-19 vaccination education and consent for five residents. Two residents' refusals lacked declination information, while three others received the vaccine without documented education on risks and benefits or written consent. The facility relied on verbal consents, contrary to its policy requiring documented education and signed consent or refusal forms.
A resident with COPD and Parkinson's disease faced potential trip hazards due to multiple electrical cords and oxygen tubing strewn across the floor in their room. Despite the facility's policy to provide a safe environment and the resident's care plan to keep pathways clear, observations showed these hazards were not addressed, posing a risk to the resident's safety.
The facility failed to maintain proper respiratory care for three residents, leading to deficiencies in equipment maintenance. One resident's oxygen tubing and nebulizer were not dated or cleaned, while another's nebulizer and CPAP equipment were improperly stored and not cleaned. A third resident's nebulizer was stored in a coffee cup, and no safety assessment was conducted for self-administration of medication. These practices violated the facility's infection prevention policy, potentially leading to respiratory illnesses.
Resident Privacy Breach Due to Unauthorized Video Recording
Penalty
Summary
A Certified Nurse Aide (CNA) took a video of a resident without the resident's consent, violating the resident's right to privacy and confidentiality. The resident involved had a diagnosis of severe dementia, with a Brief Interview Mental Status (BIMS) score indicating severely impaired cognition, and required extensive assistance with activities of daily living, including toileting and incontinent care. The video, which depicted the resident fully clothed and lying in bed with evidence of a bowel movement on both the resident and the wall, was shown by the CNA to another staff member during shift change. The second CNA immediately instructed the first to delete the video and reported the incident to administrative staff. The facility's investigation confirmed that the video was taken and shared without consent, and that staff had not received recent education regarding privacy expectations following the incident. Although the facility's policy prohibits staff from photographing or videotaping residents without consent, and requires training on privacy and abuse prevention, there was no documented evidence that staff had received updated education or signed off on privacy training after the event. The incident was observed through facility camera footage and corroborated by staff interviews and record review.
Failure to Implement Immediate Fall Interventions
Penalty
Summary
The facility failed to implement immediate interventions to prevent further falls for a resident after an initial incident where the resident's left leg buckled, and she was lowered to the floor by therapy staff. This failure resulted in another staff-assisted fall later the same day, leading to a severe fracture of the resident's left ankle. The resident, who had a history of falls and required extensive assistance for transfers and toileting, was admitted to the facility with diagnoses including congestive heart failure, dementia, diabetes mellitus, and hypertension. On the day of the incident, the resident was being assisted by therapy staff when her left leg gave out, and she was lowered to the floor. Despite this event, the resident's transfer status was not immediately reassessed or changed by therapy or nursing staff, and she continued to be assisted with minimal support. Later that evening, the resident experienced another fall when a CNA assisted her to the floor after she was unable to stand. The facility's failure to reassess and adjust the resident's care plan and transfer status after the initial fall contributed to the subsequent fall and injury. The facility's fall policy required evaluation and documentation of falls, as well as the implementation of interventions to prevent further incidents. However, the policy was not effectively followed in this case, as evidenced by the lack of immediate intervention and reassessment of the resident's needs after the first fall. The resident's severe ankle fracture was identified the following day, after which she was sent to the hospital for further evaluation and treatment.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to secure medications by leaving two medication carts unlocked and unattended during the administration of medications. On 04/03/24 at 11:35 AM, a medication cart on the D2 neighborhood was found unlocked with no nurse in the vicinity. Licensed Nurse (LN) D confirmed that the cart, which contained narcotics, insulins, and other medications, was unlocked and unattended. LN D acknowledged that all medication carts should be locked when unattended. Similarly, on 04/04/24 at 09:12 AM, a medication cart on the B2 neighborhood was observed unlocked and unattended while LN C administered medications to a resident down the hallway. LN C confirmed the cart was left unlocked and unattended and stated that it should have been locked when unattended. Administrative Nurse B reiterated that all medication carts should be locked when unattended. The facility's policy on the storage of medications, dated 01/24, mandates that compartments containing drugs and biologicals must be locked when not in use and that carts used to transport such items should not be left unattended if open or otherwise accessible. The facility's failure to adhere to this policy resulted in the medication carts on two separate neighborhoods being left unlocked and unattended, potentially affecting 20 residents on neighborhood D2 and 20 residents on neighborhood B2.
Medication Administration Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, resulting in an error rate of 81.48%. This deficiency was observed when a Licensed Nurse (LN) administered medications to residents without confirming them against the physician's order or the electronic medication administration record (eMAR). Specifically, 22 out of 27 observed medications were administered incorrectly. The LN removed medications from their packaging and administered them based on the outer wrapper's label without verifying each medication against the physician's order or eMAR. This practice was confirmed by the LN, who acknowledged the failure to follow the nursing standard of care. The report highlights specific instances where the LN administered medications to multiple residents without proper verification. For example, the LN administered two medications to one resident and a total of 13 medications to another, all without confirming the medications against the physician's order or eMAR. The facility's administrative nurse confirmed that the expectation is for staff to verify each medication's identification label with the physician's order or eMAR to ensure accuracy. The facility was unable to provide a policy related to medication administration when requested, further indicating a lack of adherence to proper procedures.
Infection Control Deficiencies in Meal Handling, Respiratory Equipment, and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by several observations and interviews. Staff were observed mishandling meal trays by placing their thumbs over the edge and into the eating surface of plates while delivering them to residents in the dining area. This practice was contrary to the facility's expectations, as confirmed by dietary staff and administrative nurses, who stated that plates should be carried by the bottom to avoid contamination. The facility's policy on preventing foodborne illness lacked specific instructions on handling resident plates, contributing to this deficiency. In addition, the facility did not adhere to infection control standards in the cleaning of respiratory equipment for residents with chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA). Observations revealed that nebulizer and CPAP masks were improperly stored and not cleaned after each use, as required by the facility's respiratory care policy. Administrative staff confirmed that nebulizers should be cleaned and dried after use, and CPAP masks should be cleaned according to manufacturer's guidelines, which were not provided. This oversight had the potential to lead to respiratory illnesses for the affected residents. Furthermore, the facility failed to ensure proper hand hygiene during wound care for a resident with a history of transient ischemic attack, stroke, vascular dementia, and osteoarthritis. A licensed nurse was observed changing gloves multiple times without performing hand hygiene between phases of wound care, contrary to the facility's wound care policy. This lapse in infection control practices could lead to wound infections, negatively impacting the resident's health.
Deficiency in COVID-19 Vaccination Documentation and Education
Penalty
Summary
The facility failed to ensure that five residents or their representatives acknowledged receipt of COVID-19 vaccination information and education. Specifically, the documentation for two residents indicated that they refused the COVID-19 vaccine, but the facility was unable to provide any declination information. For three other residents, the documentation showed that they received the COVID-19 vaccine, but there was no evidence of education provided regarding the risks and benefits, nor was there a written consent to administer the vaccine. The facility's policy required that residents be educated about vaccines and that this education be documented in the resident's record. Additionally, residents or their representatives were to sign a consent or refusal form for vaccines. However, the facility relied on verbal consents and did not have a no acceptance/declination consent form or an education information form, as confirmed by the Administrative Nurse. This lack of documentation and adherence to policy led to the deficiency identified in the report.
Trip Hazards from Electrical Cords and Oxygen Tubing
Penalty
Summary
The facility failed to maintain an environment free from accident hazards for a resident, identified as R28, who had chronic obstructive pulmonary disease and Parkinson's disease. The resident required extensive assistance for most activities except eating and ambulation, which were independent. Observations revealed multiple electrical cords plugged into two power strips next to the resident's recliner, with cords strewn across the floor in the walking path between the recliner and the bed. Additionally, the resident's oxygen tubing was found on the floor in the walking path from the bathroom to the bed and recliner area. These conditions were observed on multiple occasions, indicating a failure to address the potential trip hazards. The facility's Safety and Supervision of Residents policy, dated December 2017, stated the commitment to providing a safe environment but did not specifically address the placement of power cords or oxygen tubing. Interviews with the administrative nurse and maintenance staff confirmed that the cords and tubing on the floor posed a trip hazard. Despite the resident's care plan, which included instructions to keep pathways clear due to a moderate risk for falls, the facility did not take adequate measures to prevent these hazards, potentially compromising the resident's safety and wellbeing.
Deficient Respiratory Care Practices in LTC Facility
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in maintaining respiratory equipment. For one resident, the oxygen tubing and nasal cannula were not dated, and the nebulizer equipment was left uncovered and unlabeled with an unknown liquid remaining in the chamber. This was confirmed by multiple staff members, including a Certified Nurse Aide, a Licensed Nurse, and a Certified Medication Aide, who acknowledged the lack of proper labeling and cleaning of the equipment. The facility's policy required the nebulizer components to be rinsed and dried after each use, which was not adhered to, potentially leading to respiratory infections. Another resident with chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) had a nebulizer mask stored with an unknown liquid inside the chamber and a CPAP mask hung from the bedrail. Observations over several days showed that the equipment was not cleaned or stored properly, as required by the facility's infection prevention policy. Administrative nurses confirmed that the equipment should be cleaned after each use, but this was not done, posing a risk of infection. A third resident, also diagnosed with COPD, had nebulizer equipment stored improperly, with one setup left intact inside a coffee cup. The resident reported that staff pre-loaded the nebulizer with medication for self-administration, but no safety assessment was performed to ensure the resident could safely self-administer the medication. The facility's policy required cleaning and drying of nebulizer components after each use, which was not followed, increasing the risk of respiratory illnesses.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
