Wilson Care And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilson, Kansas.
- Location
- 611 31st Street, Wilson, Kansas 67490
- CMS Provider Number
- 175205
- Inspections on file
- 20
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Wilson Care And Rehab during CMS and state inspections, most recent first.
Nursing staff did not consistently use required Enhanced Barrier Precautions or perform proper hand hygiene during direct care of two residents, including wound care and catheter management. In both cases, staff failed to don gowns and, in one instance, placed a catheter drainage bag on the floor, contrary to facility infection control policies.
Residents repeatedly reported long call light response times, incomplete care, and negative staff attitudes, including staff turning off call lights without providing assistance and being loud during activities. Despite ongoing complaints documented in Resident Council meetings and staff being re-educated, the same issues persisted, with residents continuing to feel neglected and disrespected.
The facility did not provide fully completed Medicare Advanced Beneficiary Notice (ABN) forms to three residents when skilled services ended, omitting the required estimated cost of services. This left residents without full information about their potential financial liability for non-covered services, as confirmed by administrative staff and facility policy.
A consultant pharmacist did not identify or report the lack of required blood pressure or pulse monitoring before administration of a beta blocker for a resident with multiple health conditions. Additionally, the facility did not implement the pharmacist's recommendation for specifying the dosage of Voltaren gel, resulting in incomplete medication orders. Staff interviews revealed uncertainty about monitoring requirements and the need for clear dosage instructions.
A resident with multiple complex conditions did not have blood pressure or pulse monitored prior to receiving a beta blocker, and physician orders for topical Voltaren gel lacked clear dosage instructions for some applications. Staff interviews confirmed uncertainty about monitoring requirements and acknowledged that medication orders should specify dosages, as required by facility policy.
A resident's injectable medications were found to be expired during a medication cart inspection. Both an LPN and an administrative nurse confirmed that the Lispro pens had been in use beyond their 30-day expiration period and should have been discarded, in accordance with facility policy.
A resident with multiple chronic conditions receiving hospice care did not have a care plan that included essential information such as the hospice provider's contact details, the specific services and supplies to be provided, or the schedule of hospice staff visits. Staff interviews revealed a lack of clear communication and documentation regarding hospice coordination, contrary to facility policy requiring a coordinated care plan.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
Nursing staff failed to follow required Enhanced Barrier Precautions (EBP) and hand hygiene protocols during direct care of residents under infection control interventions. In one instance, a licensed nurse prepared wound care supplies for a resident with a pressure ulcer and entered the resident's room without donning a gown as required by EBP status. The nurse also failed to perform hand hygiene before donning gloves, between glove changes, and after completing the wound dressing change. Supplies were placed directly on the resident's bedside table, and the nurse exited the room without washing or sanitizing hands. The nurse later acknowledged not realizing the omission of the gown or hand hygiene steps during the procedure. In another instance, a certified nurse aide entered a resident's room to empty a catheter drainage bag but did not don a gown as required by EBP. The aide placed the catheter drainage bag directly on the floor while obtaining a privacy bag, contrary to facility policy that requires keeping the drainage bag off the floor. Both administrative nurses confirmed that staff are expected to use gowns and gloves during such care and that the drainage bag should not be placed on the floor. Facility policies on infection prevention and indwelling urinary catheters specify the use of standard and transmission-based precautions, including proper hand hygiene and environmental practices.
Failure to Resolve Recurring Resident Council Concerns on Call Light Response and Staff Attitude
Penalty
Summary
The facility failed to resolve recurring issues reported by the Resident Council regarding call light response times and delivery of care. Over the course of nearly a year, Resident Council meeting minutes repeatedly documented concerns that staff were turning off call lights without completing requested care, not returning to assist residents, and displaying negative attitudes such as huffing, scoffing, and cussing when residents requested assistance. Residents also reported that staff were loud during activities like church and movies, and that staff frequently complained about being short-staffed or about coworkers in the presence of residents. These concerns were consistently raised in multiple council meetings, indicating a pattern of unresolved issues. Despite the facility's stated responses, such as providing staff re-education and discussing concerns at staff meetings, the same issues persisted in subsequent Resident Council meetings. Residents continued to report long wait times for call light responses and feeling like a burden to staff. Observations and interviews confirmed that these problems were ongoing, with residents expressing dissatisfaction with staff attitudes and the timeliness of care. The facility's policy required a designated staff member to respond to council concerns and for the Quality Assurance Committee to review council data, but the recurring nature of the complaints suggests these processes were not effective in resolving the deficiencies.
Failure to Provide Complete Medicare ABN Forms with Cost Estimates
Penalty
Summary
The facility failed to provide fully completed Advanced Beneficiary Notice (ABN) CMS Form 10055 to residents or their representatives when skilled services ended. Specifically, for three residents reviewed for Medicare Liability Notices, the ABN forms given did not include the required estimated cost of continued services. The ABN is intended to inform beneficiaries that Medicare may not pay for future skilled therapy services and to provide an estimate of the potential financial liability if Medicare denies coverage. Record review showed that the ABN forms for these residents, issued at the end of their skilled services, were missing the estimated costs section. Administrative staff confirmed that the cost should be presented to allow for the possibility of appeal. The facility's policy indicated that the standard appeals process serves to notify beneficiaries of possible non-coverage and potential financial responsibility, but the omission of estimated costs on the ABN forms meant residents were not fully informed as required.
Failure to Ensure Pharmacist Review and Implementation of Medication Monitoring and Dosage Recommendations
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported the omission of required blood pressure or pulse monitoring prior to the administration of an antihypertensive beta blocker, Carvedilol, for a resident with multiple diagnoses including hypertension, aneurysm of the heart, traumatic brain injury, and transient ischemic attack. The resident had severely impaired cognition and required significant assistance with activities of daily living. The care plan directed staff to monitor for side effects of hypertensive medications and to obtain blood pressure readings as per protocol, but the physician's order for Carvedilol did not specify monitoring requirements, and the CP did not report this omission during monthly drug regimen reviews from April to November. Additionally, the facility did not implement the CP's recommendation regarding the dosage amount for Voltaren gel, a topical medication prescribed for pain. The physician's orders for Voltaren gel on multiple occasions lacked a specified dosage amount for application to the affected areas, particularly for the left shoulder. Although the CP made a recommendation for a dosage amount, the physician's response only addressed the lower extremity and did not specify a dosage for the upper extremity. This resulted in continued orders without clear dosage instructions for all prescribed sites. Interviews with staff revealed uncertainty regarding which antihypertensive medications required monitoring prior to administration, and acknowledgment that all topical medications, including Voltaren gel, require a specified dosage for administration. The facility was unable to provide a policy regarding pharmacy review when requested. These findings demonstrate failures in both the identification and reporting of medication regimen irregularities and the implementation of pharmacist recommendations.
Failure to Monitor Antihypertensive Administration and Specify Topical Medication Dosage
Penalty
Summary
The facility failed to ensure appropriate monitoring and documentation for a resident receiving antihypertensive and topical pain medications. Specifically, staff did not obtain blood pressure or pulse readings prior to administering the beta blocker Carvedilol, as required for safe use of this medication class. The physician's order for Carvedilol lacked explicit instructions to monitor these vital signs before administration. Interviews with staff revealed uncertainty regarding which antihypertensive medications required such monitoring, and it was acknowledged by nursing leadership that monitoring should have occurred. Additionally, the facility did not ensure that physician orders for Voltaren gel, a topical pain medication, included clear dosage amounts for application to affected areas. Several orders for Voltaren gel were found to be incomplete, either lacking a specified dosage or omitting the amount to be applied to certain areas, such as the left shoulder. The facility's policy required that all medication orders include the dose and adequate monitoring, but this was not consistently followed for the resident in question, who had multiple complex diagnoses and required significant assistance with activities of daily living.
Expired Injectable Medications Found on Medication Cart
Penalty
Summary
The facility failed to ensure that injectable medications for one resident were not expired. During an observation of the medication and treatment cart, two Lispro injectable pens with an open date were found for a resident, and it was verified by a licensed nurse that these pens had been put into use on that date and expired 30 days after opening. Both the licensed nurse and an administrative nurse confirmed that the pens should have been discarded after 30 days, as per the facility's policy. The facility's Storage of Medication policy states that discontinued, outdated, or deteriorated drugs must not be used and should be returned to the pharmacy or destroyed according to state regulations.
Failure to Coordinate and Document Hospice Services for Resident
Penalty
Summary
The facility failed to ensure proper collaboration and communication between the hospice provider and facility staff for a resident receiving hospice care. The resident, who had diagnoses including hypertension, chronic obstructive pulmonary disease, benign prostatic hyperplasia, and coronary artery disease, required assistance with activities of daily living, supplemental oxygen, and was incontinent. The care plan indicated the resident was on hospice services and included general directives for staff to work with the hospice team and provide comfort, but lacked specific information regarding the hospice provider's contact details, the services and supplies hospice would provide, and the frequency of hospice staff visits. Interviews with facility staff revealed gaps in knowledge and communication about the hospice services. A certified nurse aide stated that nurses typically informed staff about which residents were on hospice and when hospice would visit, but did not have access to the care plan or detailed information about hospice-provided supplies. A licensed nurse was aware the care plan mentioned hospice but could not confirm if it included specifics about supplies or visit schedules. The administrative nurse acknowledged that the care plan should include this information but it was not present at the time of review. The facility's own hospice program policy required collaboration and a coordinated care plan with the hospice provider, including documentation of services, supplies, and visit schedules in the medical record. Despite this policy, the care plan for the resident on hospice did not contain the necessary details to guide staff in coordinating care with the hospice provider, resulting in a deficiency related to the provision and documentation of hospice services.
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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