Accura Healthcare Of Carlisle
Inspection history, citations, penalties and survey trends for this long-term care facility in Carlisle, Iowa.
- Location
- 680 Cole Street, Carlisle, Iowa 50047
- CMS Provider Number
- 165255
- Inspections on file
- 32
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Accura Healthcare Of Carlisle during CMS and state inspections, most recent first.
The facility failed to maintain an effective pest control program, resulting in an ongoing mice infestation affecting resident rooms, staff areas, and common spaces. An LPN reported mice eating food stored in a staff locker, and work orders documented a mouse in a resident room. Surveyors observed mice droppings in multiple drawers of a resident’s clothing dresser and in a vacant room near a heat register. A housekeeping aide reported that mice had chewed and torn stored activity items and that a recliner in a resident’s room contained extensive mice droppings and contaminated soft toys. In the Activity Room, where three residents were present, surveyors observed numerous black and green mice droppings near the entrance and a nightstand, along with debris behind the furniture, despite a facility policy stating it would maintain an effective pest control program for pests and rodents.
A resident with severe cognitive impairment, dependent on staff for personal care and transfers, made repeated statements over two mornings alleging rape by a male individual. Multiple CNAs heard and variably reported these allegations to an RN, but there was confusion about who notified nursing leadership. The DON stated they did not learn of the allegation until the following morning via an LPN, and the abuse report was not submitted to the State Agency until later that morning, exceeding the facility’s policy requirement to report abuse allegations within 2 hours.
A resident reported to a CNA that a male staff member, described by race and role, had raped them and another resident during the night. The CNA informed an RN, who stated they notified the DON that morning, but the DON reported not learning of the allegation until the following day. Review of staffing schedules showed a CNA matching the general description of the alleged perpetrator had worked consecutive night shifts and continued to work and have access to residents after the allegation was first reported to staff. This conflicted with facility policy requiring immediate protective measures, such as suspension or segregation of an employee accused of abuse, upon receipt of an abuse allegation.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The report notes that the environment was not maintained safely and supervision was lacking, but does not provide further specifics.
The facility inaccurately completed MDS assessments for several residents by misclassifying antiplatelet medications as anticoagulants and incorrectly coding active diagnoses and PASRR status. These errors were identified through record review and staff interviews, revealing gaps in staff knowledge and documentation practices.
The facility did not develop or implement comprehensive care plans for two residents, one with severe cognitive impairment and dementia, and another with recurrent UTIs. Both residents' care plans lacked focus areas, goals, or interventions for their respective diagnoses, despite documented medical histories and ongoing treatment needs.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as identified by surveyors through observation and record review.
Staff did not consistently secure and position a resident's catheter bag below the bladder as required by policy and the care plan. The resident, who had a suprapubic catheter and multiple health conditions, was observed with the catheter bag on the floor and above bladder level, and reported difficulty with the catheter while using a wheelchair. The DON confirmed the catheter bag should always be below bladder level.
A resident with diabetes received insulin from an LPN who did not follow manufacturer and facility procedures for insulin pen use. The LPN failed to keep the needle in the skin for the required time after injection, which is necessary to ensure the full dose is delivered. This action did not comply with the physician's orders or the manufacturer's instructions for insulin administration.
Staff failed to properly disinfect a stethoscope and a glucometer after use on two residents, and did not follow glove-changing protocols during care. An LPN placed a used stethoscope on a resident's blanket and over her neck without cleaning it, while an RN inadequately cleaned a glucometer used on multiple residents. These actions did not meet facility infection control policies or manufacturer guidelines.
The facility did not accurately submit direct care staffing data to CMS, as the PBJ report for the specified quarter omitted agency staff who worked on weekends. This omission resulted in the report triggering for excessively low weekend staffing, despite the facility maintaining a census of 70 residents.
A resident with severe cognitive impairment and total dependence for ADLs was observed with chapped, peeling lips despite a physician order for Aquaphor Lip Repair and a care plan for frequent oral hygiene. Documentation showed the lip treatment was not applied for at least 30 days, and staff interviews revealed inconsistent notification to nursing staff about the resident's condition.
Two residents at high risk for pressure ulcers did not consistently receive physician-ordered pressure-relieving devices, such as Prevalon boots and knee wedges, as observed and confirmed by staff interviews and record review. Staff failed to apply these devices as ordered, and there was no documentation of resident refusal or clinical justification for non-compliance, despite clear care plans and facility policy requiring their use.
Two residents with severe mobility and cognitive impairments did not consistently receive their physician-ordered hand splints or palm devices as required to prevent further contractures. Staff failed to apply the DME as ordered, with documentation and observations showing lapses in use and no evidence of resident refusal or medical justification for the omissions.
Staff did not wear required PPE, such as gowns and gloves, while providing direct care to two residents on Enhanced Barrier Precautions for MDRO risk. Despite clear signage and care plans indicating the need for PPE during high-contact activities, CNAs entered rooms and performed care without donning appropriate protective equipment, and staff interviews revealed confusion about EBP requirements.
The facility failed to prevent and treat pressure ulcers for three residents, leading to the development and worsening of Stage 3 ulcers. A resident with Alzheimer's developed a sacral ulcer, but treatment was delayed and supplies were unavailable. Another resident with dementia had a healed ulcer but developed a new one due to inconsistent use of pressure-relieving cushions. A third resident with Alzheimer's developed a gluteal ulcer, with treatment delayed by a week. The facility's lack of timely intervention and documentation contributed to the deterioration of the residents' conditions.
The facility failed to treat residents with dignity and respect, affecting three residents. A resident with paraplegia was hurt during bathing and called 'whiny' by a CNA. Another resident with heart failure was told by the same CNA that she was done helping her. A third resident with diabetes was instructed to urinate in her brief instead of being assisted to the bathroom. These incidents were reported to the DON, but the facility's policy on resident dignity was not followed.
A resident with severe cognitive impairment and anxiety did not receive prescribed lorazepam due to a delay in pharmacy delivery and lack of emergency kit availability. The facility's policy did not address obtaining medications for new orders, leading to the resident experiencing labored breathing and requiring emergency services. The medication arrived as emergency services did, and the resident received her first dose.
A medication cart was found unattended and unlocked in a resident hall, contrary to the facility's policy requiring medication storage to be secured when not attended by authorized staff. An LPN acknowledged the oversight and locked the cart upon returning. The DON confirmed the expectation for staff to lock medication carts when unattended.
The facility failed to secure resident-identifiable information, as observed when a laptop with multiple residents' EHRs was left unattended by an LPN. The facility lacked a policy for securing resident records, and the DON acknowledged the need for staff to ensure information is not displayed when unattended.
The facility failed to implement effective infection control policies, leading to potential cross-contamination risks. Staff were unable to locate necessary sanitizing wipes for cleaning PPE goggles and shared equipment, and improper hand hygiene practices were observed. The absence of sanitizing supplies and adherence to hand hygiene protocols contributed to the deficiencies.
A resident with mental health conditions and incontinence issues was left without timely toileting assistance, leading her to call out for help in the hallway. Despite staff presence, her request was not promptly addressed, violating the facility's dignity policy.
The facility did not maintain the required eight-hour RN coverage on nine days within a month, affecting 71 residents. On six days, there was no RN coverage, and on three days, only four hours of coverage were provided. Staff interviews confirmed the deficiency, with the CNA noting that management could not be counted towards RN coverage, and the Administrator admitting the absence of a policy for eight-hour RN staffing.
The facility failed to provide adequate nursing staff, resulting in delayed call light responses for residents. Observations and interviews revealed significant delays, with some residents waiting up to two hours for assistance. The DON admitted that call light audits had not been conducted for two months, despite the facility's 15-minute response expectation.
The facility failed to implement proper infection control measures, including Enhanced Barrier Precautions (EBP) and PPE usage, for residents at risk of MDRO and those with COVID-19. Staff did not wear gowns during high-contact care for two residents with MDRO risk, and a CNA failed to use eye protection and changed PPE improperly while caring for two COVID-19 positive residents. Interviews confirmed these actions were against facility policy and CDC guidelines.
A resident with moderate cognitive impairment and paraplegia was observed without a dignity cover on their catheter bag on multiple occasions. The resident stated that the cover went missing a long time ago and was not replaced. Staff interviews confirmed that dignity covers should be used, and the DON expected them to be in place, but the facility lacked a specific policy for their use.
The facility inaccurately assessed two residents' statuses in their MDS. One resident was incorrectly documented as having an indwelling catheter, which they never had at the facility, while another resident's use of bed rails was misclassified as a restraint. The DON confirmed these were coding errors, and the facility lacked a specific policy for MDS accuracy.
A facility failed to implement a comprehensive care plan for a resident with moderate cognitive impairment, who required supervision during meals. Despite the care plan's requirement, CNAs left the resident unsupervised during meals while she was in isolation. Staff interviews revealed a lack of awareness about the resident's supervision needs, and the facility lacked a policy on following care plans, leading to the deficiency.
A facility failed to follow procedures for a resident with a PEG tube, who had diagnoses including traumatic brain dysfunction and malnutrition. A physician's order required checking the tube's placement and residual before administering medications. An LPN administered medications without verifying placement or obtaining residual, contrary to the order. The DON confirmed the expectation for these checks, and the facility lacked a policy on enteral feedings.
The facility failed to maintain hot food served at a temperature greater than 140 degrees Fahrenheit during a meal service. Observations and interviews revealed that several food items were below the required threshold, and multiple instances were found where food temperatures were not checked. Residents and staff confirmed that food trays were often served cold, both in resident rooms and dining areas. The facility's Food Temperatures policy was not adhered to, leading to the deficiency.
A resident was not allowed to vape an electronic nicotine device, despite staff being permitted to smoke and two other residents being grandfathered into the facility's no-smoking policy. The resident, who was cognitively intact, felt her rights were violated, and the Volunteer Ombudsman noted inconsistent enforcement of the smoking policy.
The facility failed to follow physician orders for a resident with Diabetes Mellitus, leading to improper administration of Lispro insulin. The resident's blood sugar was checked at 8 a.m., but the insulin was administered at 9:14 a.m., which was not in accordance with the physician's orders. Additionally, Resident Council Meeting Minutes revealed ongoing concerns about the timely administration of medications.
Failure to Maintain Effective Pest Control Resulting in Mice Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the building free from vermin infestation. Staff interviews revealed an ongoing mice problem in multiple areas, including the staff break room and resident care areas. An LPN reported that mice had eaten a snack stored in her personal locker in the break room about a week prior, and facility work orders documented a mouse in a resident room that was marked as closed. During observations, surveyors found mice droppings in four of six drawers of a resident’s clothing dresser, where socks, jeans, and personal items were stored, and in the corner of a vacant resident room near the heat register. Additional staff interviews and observations showed that the mice problem extended to common and storage areas. The Maintenance Director acknowledged an ongoing mice issue and reported that staff had recently caught live mice in their work area. A housekeeping aide stated that the mice problem was so severe that multiple items in the Activity Room storage closets, including Christmas decorations, were torn and chewed, and staff saw a live mouse jump out of one of the boxes. She also reported that when a recliner cushion in a resident’s room was pulled out, a large amount of mice droppings and some soft toys had to be discarded. During an observation of the Activity Room with three residents present, multiple mice droppings, both black and green, were noted around the room near the entrance door and a nightstand, with debris behind the nightstand. The Administrator confirmed that mice droppings were first noted at the beginning of the month and that the facility had a pest control policy stating it would maintain an effective pest control program for common household pests and rodents.
Failure to Timely Report Resident Sexual Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report a resident’s allegation of sexual abuse to the State Agency within the required 2-hour timeframe. Resident #4, who had severe cognitive impairment with a Brief Interview for Mental Status score of 4 and was dependent on staff for personal care and transfers, made multiple statements over two consecutive mornings alleging rape by a male individual. On the morning of 1/21/26, several CNAs (Staff F, G, and H) reported that Resident #4 stated a black man had raped them, with one CNA documenting that the resident also mentioned a black girl and identified the man as the one who comes in and turns the light on. Staff H’s written statement indicated they informed Staff I, an RN, at approximately 8:00 AM on 1/21/26 of the allegation. Staff I later acknowledged that Staff H reported the allegation to them that morning and stated they then called the DON around 7:30–8:00 AM to report it. Despite these reports, the DON stated they were not contacted on 1/21/26 and first became aware of the allegation the morning of 1/22/26 via a phone call from an LPN. The facility’s Incident Investigative Report showed that the online report of sexual abuse involving Resident #4 was submitted to the Iowa Department of Inspections, Appeals, and Licensing on 1/22/26 at 8:13 AM. Staff interviews revealed confusion and uncertainty among CNAs about who had notified nursing leadership on 1/21/26, with some staff believing others had reported the allegation to a nurse or the DON but unable to confirm this. The facility’s abuse policy, updated 10/19/22, required that allegations of resident abuse be reported to the State Agency no later than 2 hours after the allegation is made, which did not occur in this case.
Failure to Immediately Remove Alleged Perpetrator After Sexual Abuse Allegation
Penalty
Summary
The facility failed to protect residents from further potential abuse after an allegation of sexual abuse was reported. On the morning of 1/21/26, a CNA (Staff H) reported that Resident #4 stated a black man raped me and the black girl when asked how they had slept, and further identified the alleged perpetrator as the man who comes in and turns the light on. After completing personal cares, Staff H informed an RN (Staff I) of the allegation. Staff I acknowledged being approached by Staff H that morning and stated they called the DON at approximately 7:30 AM to report the allegation. However, the DON reported they were not contacted on 1/21/26 and first became aware of the allegation on the morning of 1/22/26. Upon becoming aware of the allegation on 1/22/26, the DON reviewed staffing schedules from the previous day and identified a CNA (Staff J) whose general description matched that provided by Resident #4 and who had worked the night shift on 1/21/26. Staffing schedules showed Staff J worked the night shifts of 1/20/26 and 1/21/26. Staff J was not suspended until 1/22/26, meaning they continued to work and had access to residents after the allegation was initially reported to staff. This sequence of events conflicted with the facility’s written Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, which requires the facility to immediately implement measures to prevent further potential abuse upon receiving an allegation, including suspending or segregating the accused employee or otherwise ensuring no resident contact while an investigation is in process. The facility submitted an online report of the sexual abuse allegation involving Resident #4 to the state agency on 1/22/26 at 8:13 AM.
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 nature of the hazards, the supervision provided, or the individuals affected are not included in the report.
Inaccurate MDS Assessments Due to Medication and Diagnosis Coding Errors
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for four out of twenty-three residents reviewed. Specifically, the MDS assessments incorrectly documented that certain residents were taking anticoagulant medications when, according to the electronic health records and physician orders, they were actually prescribed antiplatelet medications such as Clopidogrel (Plavix), which should not be classified as anticoagulants. Additionally, there were inaccuracies in coding active diagnoses, such as viral hepatitis, and in documenting PASRR (Pre-admission Screening and Resident Review) status for residents with mental health diagnoses. These errors were identified through clinical record review, staff interviews, and comparison with the Resident Assessment Instrument (RAI) Manual guidelines. The MDS Coordinator, who had been in the role since December, reported using the RAI Manual, staff input, and a medication classification list to complete assessments but demonstrated a lack of understanding regarding the correct classification of medications and the criteria for coding active diagnoses. For example, the coordinator incorrectly coded antiplatelet medications as anticoagulants and was uncertain about the look-back period for active diagnoses such as viral hepatitis. The facility's documentation practices did not align with the requirements outlined in the RAI Manual, leading to inaccurate MDS assessments for multiple residents with complex medical histories, including those with coronary artery disease, cerebrovascular accident, quadriplegia, and mental health conditions.
Failure to Develop Comprehensive Care Plans for Residents with Dementia and Recurrent UTIs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for two out of five residents reviewed. For one resident with severe cognitive impairment and a diagnosis of non-Alzheimer's dementia, the care plan did not include any focus area, goals, or interventions related to the dementia diagnosis, despite this being documented in the resident's Minimum Data Set (MDS). For another resident with a documented history of recurrent urinary tract infections (UTIs), the care plan similarly lacked any focus area, goals, or interventions addressing the UTI diagnosis, even though the resident had multiple recent episodes of UTIs treated with antibiotics and this condition was noted by the physician. Clinical record reviews, staff interviews, and policy review confirmed these omissions. The Director of Nursing acknowledged that care plans are expected to accurately reflect residents' health conditions, including specific diagnoses and related interventions. The facility's own policy requires comprehensive, person-centered care plans with measurable objectives and timeframes for all identified needs, but this standard was not met for the residents in question.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the established plan or the expressed wishes and objectives of the resident. Specific details regarding the actions or omissions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Properly Position Catheter Bag Below Bladder Level
Penalty
Summary
Staff failed to properly secure and position a resident's catheter bag below the level of the bladder, as required by facility policy and the resident's care plan. The resident, who had a history of renal insufficiency, obstructive uropathy, diabetes, and a suprapubic catheter, was observed on multiple occasions with the catheter bag either lying on the floor under the wheelchair or hung above the level of the bladder. These observations were made during routine checks and included instances where the catheter bag contained yellow urine and was not properly secured, as well as when the resident reported difficulty accessing the call light due to running over the catheter tubing with the wheelchair. Further review of the clinical record and staff interviews confirmed that the facility's policy required the catheter bag to be kept below the level of the bladder at all times to ensure proper drainage and minimize infection risk. The Director of Nursing acknowledged that the catheter bag should be positioned below the bladder. The care plan for the resident specifically directed staff to maintain this positioning, but staff failed to consistently follow these instructions, as evidenced by the surveyor's observations.
Insulin Administration Not Performed per Manufacturer and Physician Instructions
Penalty
Summary
A deficiency occurred when staff failed to administer insulin according to both physician's orders and manufacturer instructions for a resident with diabetes and diabetic neuropathy. During a medication pass, an LPN used a new Novolog insulin flexpen, labeled and dated it, attached a needle, and primed the pen by dialing to 2 units and expelling insulin. The LPN then set the pen to 3 units, donned gloves, and injected the insulin into the resident's abdomen. However, the LPN removed the needle from the injection site within 1-2 seconds, rather than following the required procedure to keep the needle in the skin for at least 6 seconds to ensure the full dose was administered. Facility competency guidelines and manufacturer instructions both specify that after pressing the injection button, the needle should remain in the skin for a specified period to ensure the complete dose is delivered. The LPN did not adhere to this step, potentially resulting in an incomplete dose. The DON confirmed the correct procedure for insulin pen use, including the importance of priming and ensuring the full dose is administered, but the observed practice did not align with these standards.
Failure to Disinfect Resident Care Devices and Follow Infection Control Practices
Penalty
Summary
Facility staff failed to properly disinfect resident care devices and adhere to infection control practices as observed during routine care of two residents. In one instance, a resident with a history of pneumonia, on antibiotics, and receiving tube feeding via a gastrostomy tube was attended by an LPN who donned appropriate personal protective equipment but placed a used stethoscope on the resident's blanket and later draped it over her neck without disinfecting it. The LPN also handled trash and opened the resident's door with gloved hands, then continued care activities without changing gloves as required. The care plan for this resident indicated the need for enhanced barrier precautions due to the risk of multidrug-resistant organisms (MDRO) related to the indwelling tube. In another instance, an RN checked a resident's blood sugar and cleaned the glucometer with an alcohol swab for less than five seconds before storing it, despite the device being used on multiple residents. Facility policy and manufacturer instructions required the use of a specific disinfectant wipe with a two-minute wet contact time for proper disinfection. Interviews with the Director of Nursing confirmed expectations for staff to follow these infection control protocols, which were not met in these observed cases.
Failure to Accurately Report Weekend Staffing in PBJ Submission
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS for the Payroll Based Journal (PBJ) Staffing Data Report covering January 1st to March 31st, 2025. The PBJ report triggered for excessively low weekend staffing during this period. Upon review, it was determined that the facility's PBJ data submission did not include staffing agency staff who worked on weekends, despite the facility maintaining a census of 70 residents. The Administrator confirmed in an interview that the omission of agency staff led to the inaccurate reporting, and the Regional Director later submitted a PBJ report that did not reflect concerns, but the original deficiency remained due to the incomplete data submission.
Failure to Provide Ordered Lip Care and Oral Hygiene Assistance
Penalty
Summary
A resident with severe cognitive impairment, quadriplegia, and total dependence for all activities of daily living was observed with chapped and peeling lips while reclined in a Geri chair. The resident had a physician order for Aquaphor Lip Repair to be applied as needed for dry, chapped lips, and the care plan included oral hygiene assistance every two hours while awake. Despite these interventions, the Medication Administration Records for the previous 30 days showed no documentation that Aquaphor had been applied. Staff interviews revealed that CNAs were responsible for checking the resident's lips during oral hygiene and notifying the nurse if chapped lips were observed, but there was uncertainty among staff regarding notification requirements. The resident's brother had previously expressed concerns about the resident's dry, chapped lips, and a progress note indicated some improvement at one point, but no further documentation was available regarding ongoing treatment. On the day of observation, the resident's lips remained chapped and peeling, and the assigned nurse was not notified of the condition. The facility did not have a specific policy for activities of daily living, and the Director of Nursing confirmed that staff should have notified the nurse to apply Aquaphor.
Failure to Provide Ordered Pressure Ulcer Prevention Devices
Penalty
Summary
The facility failed to provide appropriate pressure ulcer prevention and care for two residents who were at high risk for developing pressure ulcers. For one resident with severe cognitive impairment, quadriplegia, and protein-calorie malnutrition, physician orders and the care plan required the use of Prevalon boots at all times except during transfers. However, observations showed the resident was repeatedly without the prescribed boots while seated in a Geri chair in the television area, and the boots were found stored in the resident's room instead of being worn. Staff interviews confirmed that the boots were not applied as ordered, and there was no documentation of resident refusal or any clinical justification for not following the order. Another resident, who had Alzheimer's disease, joint contracture, and a history of a Stage 3 sacral pressure ulcer, also had physician orders for Prevalon boots and a knee wedge to be used at all times except during transfers. Observations revealed this resident was in the dining room and later in bed without the required pressure-relieving devices in place. Staff expressed uncertainty about when the devices should be used, and the care plan and task lists did not provide clear or consistent guidance. There was no documentation of resident refusal or any reason for not using the devices as ordered. Both residents were identified as high risk for pressure ulcers according to their Braden Scale assessments, and their care plans and treatment records reflected the need for pressure-reducing interventions. Despite this, staff failed to consistently implement physician-ordered interventions, and documentation did not reflect any refusals or clinical reasons for non-compliance. Facility policy required interventions to be implemented according to physician orders, but this was not followed in these cases.
Failure to Consistently Apply Ordered DME for Residents with Limited ROM
Penalty
Summary
The facility failed to ensure that ordered Durable Medical Equipment (DME) was used as prescribed to prevent further decline in range-of-motion (ROM) for two residents with significant mobility impairments. In the first case, a resident with severe cognitive impairment, quadriplegia, and a history of stroke was observed multiple times without the required palm DME, despite a physician's order for it to be worn at all times except for pain, hygiene, or skin checks. Documentation in the electronic health record and treatment administration record indicated inconsistent application of the DME, and staff interviews confirmed lapses in following the order, with one CNA admitting to forgetting to apply the device after transporting the resident. In the second case, another resident with Alzheimer's disease, joint contracture, and severe communication limitations was observed without her bilateral hand splints, which were ordered to be worn every shift with removal allowed for two hours per day. Review of the electronic health record showed minimal documentation of splint or brace assistance over the previous 30 days, and the treatment administration record indicated the order was in place. Staff interviews revealed that the splints had been removed for a shower and were not reapplied within the prescribed timeframe, exceeding the allowed period without the splints. Both residents were dependent on staff for all activities of daily living and had documented bilateral ROM impairments. The facility's own restorative program process required licensed nurses to monitor compliance with restorative interventions, but observations and documentation revealed that staff did not consistently apply or monitor the use of prescribed DME, and there was no documentation of resident refusal or medical justification for the lapses.
Failure to Use PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to don appropriate Personal Protective Equipment (PPE) when providing direct care to two residents who were on Enhanced Barrier Precautions (EBP). Observations showed that multiple Certified Nurse Aides (CNAs) entered the rooms of these residents without wearing gloves or gowns, despite clear signage on the doors indicating the need for such precautions during high-contact activities such as dressing, bathing, transferring, changing linens, providing hygiene, and device or wound care. The EBP orders and care plans for both residents specifically directed the use of these precautions due to their risk of multidrug-resistant organism (MDRO) colonization or infection. Interviews with staff revealed a lack of understanding regarding the requirements of EBP, with some CNAs unsure about when to use gowns and gloves or which resident the precautions applied to. Both residents involved had significant medical conditions, including quadriplegia, pressure ulcers, feeding tubes, and severe cognitive impairment, making them highly dependent on staff for all activities of daily living. The facility's policy on EBP, updated prior to the incidents, clearly outlined the need for targeted gown and glove use during high-contact care, but this was not followed during the observed care activities.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development and worsening of pressure ulcers for three residents. Resident #1, who had Alzheimer's and severe cognitive impairment, developed a new Stage 3 pressure ulcer on her sacrum. Despite the identification of the ulcer, there was a delay in implementing a treatment plan, and the necessary wound care supplies were not available in a timely manner. The resident's wound deteriorated, and there was a lack of documentation for the implementation of prescribed treatments and the use of a pressure-relieving cushion. Resident #3, who had dementia and depression, was identified with a Stage 3 pressure ulcer on the right buttock. The facility's records indicated that the ulcer was initially healed, but a new ulcer developed. There was inconsistency in the use of pressure-relieving cushions, and the facility failed to ensure the resident had the appropriate cushion in her chair, which may have contributed to the development of the new ulcer. Resident #4, who had Alzheimer's disease and severe cognitive impairment, developed a new Stage 3 pressure ulcer in the left gluteal cleft. The facility did not start treatment for the ulcer until a week after it was identified, and there was a lack of documentation regarding the implementation of the treatment plan. The facility's failure to promptly address and document the treatment of pressure ulcers contributed to the worsening of the residents' conditions.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that staff treated residents with dignity and respect, affecting three residents. Resident #2, who has paraplegia, anxiety, and depression, reported that a CNA accidentally hurt her arm during bathing and called her 'whiny' when she expressed pain. The resident's cognitive status was intact, as indicated by a BIMS score of 15 out of 15. Another incident involved Resident #7, who has heart failure, depression, and a psychotic disorder, and was reported to have been told by the same CNA that she was done helping her, although the CNA later returned to assist the resident. Resident #7 had a BIMS score of 9, indicating moderately impaired cognition. Resident #8, who has diabetes, Parkinson's, and anxiety, reported that a CNA instructed her to urinate in her brief instead of assisting her to the bathroom. This resident also had intact cognition with a BIMS score of 15. Staff interviews revealed that these incidents were reported to the Director of Nursing, although the DON stated she was not informed about the incident involving Resident #8. The facility's policy on promoting and maintaining resident dignity was not adhered to, as evidenced by these interactions.
Failure to Administer Prescribed Medication Due to Pharmacy Delay
Penalty
Summary
The facility failed to administer a prescribed medication intervention for a resident with severe cognitive impairment and multiple diagnoses, including hemiplegia, diabetes, and anxiety. The resident had a physician's order for lorazepam to be administered every six hours for anxiety/agitation. However, the medication was not administered as scheduled on two occasions because it had not been delivered by the pharmacy and was not available in the facility's emergency kit. This resulted in the resident experiencing labored breathing, prompting the family to request emergency medical services. The facility's policy on medication ordering and receiving did not provide guidance on obtaining medications for new orders, contributing to the delay in administration. The Director of Nursing indicated that the facility followed standards of care but acknowledged that nurses should special order medications and contact the pharmacy for delivery times if there were delays. The medication was eventually delivered at the same time emergency services arrived, and the resident received her first dose of lorazepam.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to properly secure medications from unauthorized access, as observed with an unattended and unlocked medication cart in a resident hall. This incident occurred when a Licensed Practical Nurse (LPN) exited a resident's room and returned to find the medication cart unlocked. The LPN then locked the cart and acknowledged that it should not have been left unlocked. The facility's policy, revised in November 2018, mandates that medication rooms, carts, and supplies must be locked when not attended by authorized personnel. The Director of Nursing (DON) confirmed that staff are expected to ensure medication carts are locked if they are leaving them unattended.
Failure to Secure Resident Information
Penalty
Summary
The facility failed to protect resident-identifiable information, as observed during a survey. On January 13, 2025, a laptop was found open with a resident's Electronic Health Record (EHR) visible, unattended by any staff. A Licensed Practical Nurse (LPN) later accessed the laptop, revealing EHR information for 16 residents, and then left the laptop unattended again. On January 14, 2025, another observation noted a laptop with a resident's EHR visible, which was later secured by another staff member. The facility lacked a policy for securing resident records, as confirmed by the Administrator, and the Director of Nursing (DON) acknowledged that staff should ensure resident information is not displayed when unattended.
Infection Control Deficiencies Due to Lack of Sanitizing Supplies and Poor Hand Hygiene
Penalty
Summary
The facility failed to implement effective infection control policies, leading to potential cross-contamination risks. On multiple occasions, staff were unable to locate purple-top sanitizing wipes (saniwipes) necessary for cleaning Personal Protective Equipment (PPE) goggles and shared equipment like the EZ Stand used for resident transfers. Staff D, E, and F confirmed the absence of saniwipes, which were supposed to be used for cleaning goggles after use in Covid+ resident rooms. Observations revealed that PPE bins contained goggles but lacked saniwipes, and a used earloop mask was improperly stored on a PPE bin. Staff G admitted to the shortage of saniwipes since a vendor change, and the Administrator acknowledged the supply issue. Additionally, Spectrum Advanced hand sanitizing wipes, not suitable for cleaning medical equipment, were found in place of the required saniwipes. Further deficiencies were noted in hand hygiene practices. Staff K, a Certified Med Aide, was observed handling multiple residents' utensils without performing hand hygiene between interactions. This was contrary to the facility's hand hygiene policy, which mandates hand hygiene after touching a resident or their environment. The Director of Nursing confirmed that staff should perform hand hygiene between residents and use saniwipes on shared equipment, highlighting a gap between policy and practice. The facility's failure to ensure the availability of appropriate cleaning supplies and adherence to hand hygiene protocols contributed to the infection control deficiencies.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to uphold the dignity of a resident by not providing an alternative method for obtaining toileting assistance. This deficiency was observed when a resident, who was rarely or never understood due to her mental status, was left without timely assistance for incontinence care. The resident, diagnosed with Chronic Kidney Disease, paranoid Schizophrenia, and PTSD, required moderate assistance for most Activities of Daily Living and was occasionally incontinent of urine and frequently incontinent of stool. On the morning of the incident, the resident was observed asking for help to be changed, but was instructed to follow her normal method of contacting staff, which was ineffective at that time. The resident, unable to receive timely assistance, walked to the main corridor and called out for help. Despite the presence of staff members in the vicinity, the resident's request was not immediately addressed until a CNA arrived and inquired if she wanted to go to breakfast, at which point the resident reiterated her need to be changed. The facility's policy on promoting and maintaining resident dignity requires staff to respond to requests for assistance promptly, yet the resident's care plan lacked specific directives for incontinence care, contributing to the delay in addressing her needs.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present for eight consecutive hours on nine out of thirty-two days reviewed between July 28th and August 28th, 2024. The facility, which reported a census of 71 residents, lacked RN coverage entirely on six specific days and only had four hours of RN coverage on three additional days. Interviews with staff, including a Certified Nurse Aide (CNA) and the Administrator, confirmed the absence of adequate RN coverage. The CNA noted that management could not be counted towards the required RN coverage, and the Administrator acknowledged the lack of a policy for ensuring eight-hour RN staffing, despite following regulations.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure timely response to call lights, compromising resident safety. Observations and interviews revealed that residents experienced significant delays in call light responses, with some waiting up to two hours. Resident #35, with no cognitive impairment, reported waiting over 30 minutes for assistance while in the bathroom, ultimately performing peri care and transferring herself back to her wheelchair. Resident #38, also cognitively intact, noted delays of 15 to 30 minutes, corroborated by a resident council meeting where attendees consistently complained about prolonged response times. Further investigation showed that Resident #2, with moderate cognitive impairment and dependent on staff for toileting and dressing, experienced call light delays of nearly two hours. Resident #41, with intact cognition and using a walker, reported waits often exceeding 30 minutes. Continuous observation in Hall 200 confirmed a call light remained unanswered for 20 minutes, as noted by a family member. The Director of Nursing acknowledged that call light audits had not been conducted for two months due to staffing changes, despite the facility's expectation of a 15-minute response time.
Infection Control Deficiencies in PPE Usage
Penalty
Summary
The facility failed to implement universal infection control measures and Enhanced Barrier Precautions (EBP) for two residents at risk for Multi-Drug Resistant Organisms (MDRO). Resident #2, with a diagnosis of paraplegia and chronic obstructive pulmonary disease, had a physician's order for EBP due to the risk of MDRO related to a catheter and wound. However, during an observation, a Certified Nursing Assistant (CNA) did not wear a gown while performing catheter care, contrary to the care plan and facility policy. Similarly, Resident #7, diagnosed with traumatic brain dysfunction and other conditions, had a physician's order for EBP, but staff failed to don gowns during enteral feeding and incontinence care, as observed on multiple occasions. The facility also failed to properly use personal protective equipment (PPE) for two residents with a positive COVID-19 diagnosis. Resident #49 and Resident #60, both with moderate cognitive impairment, were in isolation due to their COVID-19 status. During an observation, a CNA donned a gown, gloves, and mask but failed to wear eye protection while supervising a meal for Resident #60. The CNA then proceeded to move between rooms and the shower room without changing PPE, which is against the expected protocol for transmission-based precautions. Interviews with staff, including the Director of Nursing (DON), confirmed that the expectation was for gowns to be worn during high-contact care activities and for eye protection to be used when required by transmission-based precautions. The facility's policy on Enhanced Barrier Precautions, updated in May 2024, aligns with the Centers for Disease Control and Prevention (CDC) guidelines, which emphasize the importance of PPE in preventing the spread of MDROs and other infections. However, the observations and staff interviews indicate a failure to adhere to these guidelines, leading to the deficiencies noted in the report.
Failure to Provide Dignity Cover for Catheter Bag
Penalty
Summary
The facility failed to uphold the dignity of a resident by not providing a privacy cover for a catheter bag. Resident #2, who has moderate cognitive impairment, paraplegia, and chronic obstructive pulmonary disease, was observed on two separate occasions without a dignity cover on their urinary drainage bag. The resident reported that the facility never covers the drainage bag and that the cover went missing a long time ago. Interviews with staff, including a CNA and CMA, confirmed that urinary drainage bags should have dignity covers. The Director of Nursing expressed that her expectation was for dignity bags to be used, while the Administrator noted that the facility does not have a specific policy for dignity bags, instead following general standards of care.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately assess and document the status of two residents, leading to discrepancies in their Minimum Data Set (MDS) assessments. For Resident #38, the MDS inaccurately documented the presence of an indwelling catheter, despite the resident stating they had not used a catheter in about two years and had never had one at the facility. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) also showed no physician's order for a catheter, and the resident's care plan did not include any mention of an indwelling catheter. The Director of Nursing (DON) confirmed that this was a coding mistake and that the resident had never had a catheter while at the facility. For Resident #2, the MDS indicated the use of bed rails daily, classifying them as a restraint, despite an assessment in the Electronic Health Record stating that the bed rails were used for positioning purposes. The resident had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. The DON acknowledged the expectation for MDS assessments to be completed and coded correctly. Additionally, it was noted that the facility lacked a specific policy for ensuring MDS accuracy, relying instead on general regulatory compliance.
Failure to Implement Comprehensive Care Plan for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with moderate cognitive impairment, as documented in the Minimum Data Set (MDS). The care plan specified that the resident could eat independently in the dining room with supervision after setup. However, during observations, staff members left the resident unsupervised during meals while she was in isolation due to COVID-19. On two separate occasions, Certified Nursing Assistants (CNAs) delivered the resident's meal tray, set it up, and left the room without providing the required supervision. Staff interviews revealed that the CNAs were unaware of the resident's supervision needs during meals. The Director of Nursing (DON) acknowledged that the resident's care plan required supervision during meals, especially during isolation. Additionally, the facility lacked a policy on following care plans, which was considered a standard of care. This oversight led to the resident being left unsupervised during meals, contrary to her documented care plan requirements.
Failure to Verify PEG Tube Placement and Residual
Penalty
Summary
The facility failed to implement policies and procedures regarding the technical aspect of feeding tubes, specifically for Resident #7, who has a diagnosis of traumatic brain dysfunction, pneumonia, malnutrition, and artificial openings of the gastrointestinal tract. The physician's orders for Resident #7 required checking the placement and residual of the Percutaneous Endoscopic Gastrostomy (PEG) tube before administering medications. However, during an observation, a Licensed Practical Nurse (LPN) accessed the resident's PEG tube and administered a flush and medications without verifying the tube's placement or obtaining residual. The LPN later acknowledged that a residual check should have been completed. The Director of Nursing (DON) confirmed that the expectation is for residual checks and placement verification to be completed as ordered. Additionally, the facility lacked a policy related to enteral feedings for review.
Failure to Maintain Proper Food Temperatures
Penalty
Summary
The facility failed to maintain hot food served at a temperature greater than 140 degrees Fahrenheit during a meal service. Observations and interviews revealed that the temperatures of several food items were below the required threshold, including taco casserole at 135 degrees, rice at 137 degrees, and mashed potatoes at 120 degrees. Staff A, the cook, confirmed that the mashed potatoes were not placed on the steam table properly, which contributed to the low temperature. The facility's Steamtable Temperature logs showed multiple instances where food temperatures were not checked for various meals throughout April 2024. Staff B, the Dietary Manager, confirmed that the logs were not completed thoroughly as per facility policy. Interviews with residents and staff further corroborated the issue of cold food being served. Resident #1 and several CNAs/CMA staff members confirmed that food trays were often served cold, both in resident rooms and dining areas. The Resident Council Meeting Minutes also documented complaints about food being served cold or burnt and dry meat. The facility's Food Temperatures policy from 2021 stated that all hot food items must be cooked, held, and served at a temperature of at least 135 degrees Fahrenheit, and temperatures should be periodically checked to ensure compliance. However, the facility failed to adhere to this policy, leading to the deficiency.
Failure to Treat Resident with Dignity and Respect Regarding Smoking Policy
Penalty
Summary
The facility failed to treat a resident with dignity and respect by not allowing her to vape an electronic nicotine device, despite staff members being permitted to smoke and two other residents being grandfathered into the facility's no-smoking policy. The resident, who was cognitively intact with a BIMS score of 15 out of 15, expressed discontent during an interview, stating that she felt her rights were violated. The resident had signed an Admission Agreement identifying the facility as a non-smoking campus, but she claimed she was not of sound mind at the time due to taking Methadone, which affected her ability to make clear decisions. The Volunteer Ombudsman also voiced concerns about the facility's inconsistent enforcement of its smoking policy, noting that staff members were observed smoking in both designated and non-designated areas. The facility's smoking policy, as outlined in the Admission Agreement and Employee Handbook, prohibits smoking and vaping on the property. However, the policy allowed staff to smoke in designated areas during breaks, which contributed to the resident's perception of unfair treatment. The facility's failure to uniformly enforce its smoking policy and to consider the resident's preference to vape led to the deficiency in treating the resident with dignity and respect.
Failure to Follow Physician Orders for Insulin Administration
Penalty
Summary
The facility failed to follow physician orders for a resident with Diabetes Mellitus, leading to improper administration of Lispro insulin. The Medication Administration Record (MAR) indicated that the resident should receive 3 units of Lispro insulin subcutaneously with meals and to hold if blood sugars were less than 90. Additionally, a sliding scale of Lispro insulin was to be administered based on blood sugar levels. On the observed date, a Licensed Practical Nurse (LPN) administered 3 units of scheduled Lispro insulin along with 2 units of sliding scale Lispro insulin to the resident's left arm after the resident had already eaten breakfast. The blood sugar was checked at 8 a.m. and recorded as 172, but the insulin was administered at 9:14 a.m., which was not in accordance with the physician's orders. The Nurse Practitioner confirmed that this was not the correct procedure for administering the insulin. The Resident Council Meeting Minutes also revealed ongoing concerns about the timely administration of medications. Specifically, residents reported that night medications were not passed on time and that medications were not administered on time on multiple occasions. These concerns were documented in the meeting minutes from January and February. This indicates a pattern of issues related to medication administration within the facility, contributing to the deficiency identified by the surveyors.
Latest citations in Iowa
An LPN, unfamiliar with residents on a medication cart and faced with two residents sharing the same first name, failed to correctly identify a resident and administered a full set of another resident’s medications in addition to the resident’s own ordered morning medications, including PRN oxycodone. The resident, who had severe cognitive impairment and multiple diagnoses including hypertension and Alzheimer’s disease, subsequently experienced declining BP, reported not feeling well, and became increasingly fatigued. The facility’s policy required resident identification before medication administration, and the LPN acknowledged not knowing the residents and finding the EHR photos too small, despite their availability. Hospital records later documented hypotension, treatment with IV fluids, and a drug overdose after accidental ingestion of another resident’s medications plus the resident’s own, with persistent sinus bradycardia requiring admission for further hemodynamic monitoring.
A cognitively impaired, wandering resident with Alzheimer’s disease and behavioral symptoms was care planned as an elopement risk but was able to leave the memory care unit by holding an emergency exit door bar for 15 seconds and exiting into a stairwell and then to the employee parking lot. The door alarm functioned, but staff in the noisy dining room did not hear it while they were feeding multiple residents, including several needing extensive assistance, and only realized the resident was missing when another staff member encountered him outside and brought him back. In addition, several residents who required staff assistance for transfers and toileting experienced prolonged call light response times well beyond the facility’s 15‑minute expectation, including one who reported waiting up to an hour during meals and having an in‑room accident, another observed waiting about 25 minutes while calling out for help, and a third waiting about 17 minutes before a CNA responded.
A cognitively intact resident reported that a CNA ripped her incontinence brief during care and then refused to change it, despite the resident stating she could not wear it due to the tear. The resident became upset and informed housekeeping staff, who then asked an LPN to assist. On assessment, the LPN observed a large rip extending around the back of the brief, changed the brief, and provided peri care at the resident’s request. The resident stated the ripped brief was uncomfortable and that she did not feel treated with dignity or respect. In interviews, the CNA acknowledged telling the resident the torn brief would still work and did not change it, while the DON confirmed the CNA had refused the resident’s request for a brief change, in conflict with the facility’s dignity policy.
A deficiency was identified when a CNA did not follow manufacturer instructions for a mechanical stand while transferring a resident with severe cognitive impairment, a history of hip fracture, dementia, and muscle wasting who required substantial assistance for transfers. The resident’s care plan called for use of a mechanical stand, but during observed toileting and return-to-chair transfers, the CNA repeatedly locked and unlocked only one wheel of the device and did not keep the brakes unlocked during the actual transfer, contrary to the operator’s instructions that brakes be locked only when raising and lowering the resident during ambulation. In an interview, the DON confirmed staff were expected to follow these operator instructions and keep the wheels unlocked during transfers.
A resident with dementia, behavioral symptoms, and multiple psychotropic and cardiovascular medications was discharged to another nursing facility without a thorough or accurate discharge summary. The care plan contained a discharge planning focus but was never updated to reflect the actual discharge, and the EHR lacked documentation of discharge planning, the reason for discharge, or a recapitulation of stay, despite a family member stating they initiated the discharge due to dissatisfaction with care. The discharge instructions contained multiple medication discrepancies and omissions, including missing drugs, incorrect dosages, and absent administration frequencies, and several PRN constipation medications were not listed, contrary to the facility’s written discharge planning policy.
A resident was admitted from a hospital without a completed Preadmission Screening and Resident Review (PASRR) in the medical record, as required prior to admission. The PASRR was only completed several days later by the Hospital Liaison/Admissions Coordinator after a call alerted staff that it was missing. Both the admissions coordinator and the Administrator acknowledged that the facility relies on the hospital to provide the PASRR and that, in this case, it was missed and not done before the resident’s admission.
A resident with Alzheimer's disease, severely impaired cognition, and documented nutrition/hydration risk required partial to moderate assistance with eating and was care planned for assisted feeding with a general diet and thin liquids. During a breakfast observation, the resident was seated in a reclined Broda chair while staff placed food and beverages on an overbed table and attempted to offer chocolate milk and hot cereal without first positioning the resident upright, causing the resident to struggle to reach the cup. Facility policy on feeding required residents needing assistance to be positioned comfortably in an upright position, and the DON stated she expected residents to be upright whenever food or drink was offered, but there was no separate positioning policy in place.
A resident with a left leg fracture, muscle wasting, and impaired mobility was dependent on a mechanical lift for transfers. Staff positioned the lift at the side of the wheelchair instead of straight on, and the lift tipped and struck the resident’s forehead with the sling-holding part, causing a bruise and protruding bump. Staff interviews confirmed the transfer was done from the side and that the resident’s care plan required straight-on positioning for the lift.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance: Several residents did not receive bathing and hygiene assistance as scheduled. One resident with intact cognition and a stroke history was observed unshaven and said staff did not always shave him during showers, while staff noted the bath sheets no longer tracked shaving or nail care. Other residents with severe cognitive impairment or dependence for bathing went extended periods without baths, and one cognitively intact resident reported missing baths and wanting them. Facility records and staff interviews showed bathing schedules were not consistently followed or documented as required.
QAPI program failed to address repeated deficiencies. Review of the facility’s visit history showed repeated F689, Free of Accident Hazards/Supervision/Devices, and F880, Infection Prevention and Control, across multiple annual surveys and complaint investigations. The QAPI plan stated it would review sources of information for gaps or patterns in care systems, and the Administrator acknowledged the repeated deficiencies and said the facility would review and discuss plans to improve.
Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to follow the 5 rights of medication administration, resulting in one resident receiving another resident’s medications in addition to their own. The resident had diagnoses including hypertension, Alzheimer’s disease, and toxic encephalopathy, with a BIMS score of 3 indicating severe cognitive impairment. On the morning in question, review of the MAR showed the resident received their ordered medications, which included aspirin, calcium carbonate, vitamin C, vitamin D, fluoxetine 20 mg, furosemide 40 mg, galantamine, a lidocaine patch, memantine, acetaminophen, and PRN oxycodone around 8:00 a.m. According to the incident report and nursing progress notes, the LPN (Staff A) administered another resident’s full set of morning medications to this resident while the resident was in the dining room. These additional medications included metoprolol 60 mg, Lyrica 75 mg, oxycodone 7.5/325 mg, furosemide 40 mg, celecoxib 100 mg, Prozac 60 mg, hydroxyzine 10 mg, cetirizine 10 mg, Neuriva, Protonix 20 mg, potassium 99 mg, a multivitamin, and vitamin D3. These medications were given in addition to the resident’s own morning medications and PRN oxycodone. The nurse’s notes documented that the resident’s blood pressure readings declined from 100/50 to 85/48 and then to 73/48, and the resident complained of not feeling well and was increasingly fatigued. Staff A reported during interview that the resident had been screaming and yelling and that she did not realize there were two residents with the same first name in the back hallway. She stated it was her first time working in that hallway after training and that, although resident pictures were available in the EHR to assist with identification, she felt they were small and she did not know the residents. The facility’s medication management policy required staff to identify the resident before administering medications. Staff A’s employee record showed a prior medication occurrence in which she administered the wrong medications (including furosemide and potassium) to a resident, and she had documented previously that she was not familiar with residents when working on that cart. The resident was ultimately sent to the ER, where records documented hypotension on admission, treatment with IV fluids, and a chief complaint of drug overdose after accidental ingestion of another resident’s multiple medications in addition to the resident’s own medications, with continued sinus bradycardia requiring admission for further hemodynamic monitoring.
Elopement of Wandering Resident and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for a cognitively impaired, wandering resident and failure to respond to resident call lights within the facility’s stated 15‑minute expectation. One resident with Alzheimer’s disease, bipolar disorder, and anxiety disorder had a care plan identifying risk for elopement due to wandering and documented behaviors of agitation, aggression, restlessness, and continuous pacing/wandering within the unit. This resident ambulated independently with a walker and had a BIMS score indicating impaired cognition. On the evening of the incident, the resident finished supper in the memory care dining room and then repeatedly walked the hallway with his walker, eventually approaching an emergency exit door at the far end of the hall, away from the dining room. Video and documentation show that the resident stood at the emergency exit door, held the door bar down for the required 15 seconds to release the egress, and then exited through the door into a stairwell and out to the employee parking lot. The door alarm and 15‑second egress functioned, but staff in the dining room did not hear the alarm due to noise from residents, staff conversation, and the television. At the time, two CNAs and one LPN were in the dining room feeding multiple residents, including several who required assistance, and staff reported that the resident was very quick, wandered constantly, and was difficult to keep seated. Staff interviews revealed that one CNA noticed the resident was no longer in the dining room around the same time another staff member reported they were looking for him, and only then did staff recognize the back exit door alarm sounding. A nurse arriving for her shift in the parking lot encountered the resident outside with his walker and escorted him back inside, after which he was assessed and found in stable condition. The deficiency also includes failure to respond to resident call lights within the professional standard of 15 minutes for multiple residents. One resident with intact cognition but dependent or substantial/maximal assistance needs for toileting reported that during meal hours it could take up to an hour for staff to answer the call light, resulting in an in‑room accident. Another resident, alert and oriented but occasionally forgetful and requiring two‑person assistance for transfers, was observed with the call light on for approximately 25 minutes in the morning while repeatedly yelling for help; staff walked past in the hallway without answering the light until a staff member finally entered the room. A third resident, requiring one‑person assistance for transfers, was observed with the call light on for about 17 minutes before a CNA entered to assist. The DON stated that the facility’s expectation is that call lights be answered within 15 minutes, and the facility’s policy directs all staff from all departments to respond to call lights and either assist or obtain appropriate help, but the observed response times exceeded this standard for the residents involved. Staff interviews further described the conditions contributing to these call light delays and supervision gaps. Staff on the memory care unit reported that typical evening staffing consisted of one nurse, one CMA, and two CNAs, and that while this was manageable when routines went smoothly, it became inadequate when residents had behaviors, were sundowning, or when events such as falls or changes in condition occurred. A CMA stated that at least three CNAs were needed on the memory care unit due to multiple residents requiring two‑person assistance, noting that when two CNAs were in a room providing care, they could not monitor the rest of the unit. Staff also reported that the back exit door alarm was faint and difficult to hear from the dining room, and some staff were not fully aware of the configuration of the back stairwell and exit leading to the parking lot. These conditions, combined with high resident care needs and noise levels during meals, contributed to the resident’s elopement and to prolonged call light response times for several residents. Maintenance and administrative staff confirmed that the south/back exit door from the unit led to another unalarmed door and then to the outside employee parking lot, and that the facility did not receive system reports when door alarms were activated. The Administrator was unable to verify when a door alarm went off or when an exit door was breached. The facility’s Wandering Resident policy stated that residents at risk for elopement should receive adequate supervision to prevent accidents and that staff must be vigilant in responding to alarms in a timely manner, and the call light policy required prompt response by all staff. Despite these policies, the documented events show that the resident at risk for elopement was able to leave the secured unit and reach the parking lot without timely staff detection, and that multiple residents experienced call light response times significantly longer than the facility’s stated 15‑minute standard.
Failure to Honor Resident Request for Brief Change and Maintain Dignity
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and respect when a cognitively intact resident’s request for a brief change was not honored. The resident, with a BIMS score of 15 indicating no cognitive impairment, reported being upset because a CNA (Staff N) ripped her brief during care and then refused to change it. The resident self-propelled down the hallway stating she was upset about the ripped brief and that staff would not change it. A housekeeping staff member (Staff M) observed the resident’s distress, was told that the CNA had refused to change the brief despite a large rip, and then asked an LPN (Staff O) to assist with changing it. During the subsequent brief change, Staff O performed hand hygiene, used gloves, removed the resident’s pants and brief, and provided peri care at the resident’s request before applying a new brief and redressing the resident. Observation of the removed brief revealed a large rip on the left side extending past the middle of the resident’s back. The resident stated the brief with the hole was uncomfortable and that she felt staff did not provide her with dignity and respect when her request for a new brief was not honored. Staff O confirmed that the brief had a very large hole and that the resident was very upset, reporting she did not feel treated with dignity or respect and that the ripped brief was uncomfortable. In an interview, Staff N acknowledged caring for the resident that day, stated the resident had been upset and had “behaviors,” and reported that when the resident said she wanted her brief changed because it was ripped, Staff N told her the brief would still work and that urine would not get everywhere, characterizing the tear as “just a little tear.” Staff N stated the resident did not explicitly ask her to change the brief. The DON later stated that Staff N had ripped the brief, the resident had requested a brief change, Staff N said she would not change it, and acknowledged that a lack of dignity occurred when Staff N refused to change the resident’s brief, contrary to the facility’s dignity policy.
Improper Use of Mechanical Stand Brakes During Resident Transfers
Penalty
Summary
Surveyors identified a deficiency related to accident prevention when staff failed to properly use a mechanical stand’s brakes during transfers for one resident. The resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment, required substantial assistance for transfers, and had diagnoses including hip fracture, dementia, and muscle wasting. The care plan documented initiation of a mechanical stand for transfers. During observation, a CNA applied a sling, locked the right wheel of the mechanical stand, lifted the resident from a chair, then unlocked the right wheel and positioned the resident over the toilet. The CNA then lowered the resident onto the toilet and locked the right wheel. After the resident finished, the CNA lifted the resident from the toilet, unlocked the right wheel, positioned the resident over the chair, locked the right wheel, and lowered the resident, thereby failing to keep the mechanical stand brakes unlocked during the transfer as required by the operator’s instructions, which specified that brakes should only be locked when raising and lowering the resident during ambulation. In an interview, the DON stated that staff were expected to follow the operator’s instructions and keep the wheels unlocked during transfers, confirming that the observed practice did not align with the manufacturer’s guidance for safe operation of the mechanical stand.
Failure to Complete Accurate and Thorough Discharge Summary and Documentation
Penalty
Summary
Surveyors identified a failure to complete a thorough and accurate discharge summary and related discharge documentation for one resident who was discharged from the facility. The resident was admitted in early March with moderate cognitive impairment, a Brief Interview for Mental Status (BIMS) score of 08, and documented delusions and behavioral symptoms. Diagnoses included dementia with agitation, anxiety disorder, and depression. Although the care plan contained a discharge planning focus initiated shortly after admission, it did not contain any updates or documentation related to the resident’s actual discharge later that month. The electronic health record (EHR) contained a communication note indicating that transport to another nursing facility was arranged and a health status note stating that the resident was discharged, with physician orders and a face sheet faxed and a report called to the receiving facility. The resident’s EHR did not contain documentation of the discharge planning process, the reason for the discharge, or a recapitulation of the resident’s stay. A family member reported that the family initiated the discharge due to dissatisfaction with care, but there was no documentation in the EHR reflecting that the family initiated the discharge. The Long Term Care Ombudsman reported that no one contacted her during the resident’s stay, although her office did receive notice of the transfer. The facility’s own discharge planning policy required that discharge planning begin on admission, be routinely updated in the comprehensive care plan, and that the evaluation of discharge needs and the final discharge plan be completely documented in the clinical record and discussed with the resident or representative. Review of the resident’s discharge instructions and March medication administration record revealed multiple discrepancies and omissions in the discharge summary. One medication (Amlodipine 10 mg) was listed without any frequency or time of administration. Several medications that the resident was receiving, including Donepezil 10 mg, Lisinopril 5 mg, and Buspirone 10 mg twice daily, were not included on the discharge summary. Other medications were inaccurately documented, such as Memantine, which was ordered as 20 mg once daily but listed as 10 mg twice daily, and Seroquel, ordered as 50 mg twice daily but listed as once daily. Several PRN constipation medications were also omitted. The Regional Nurse Consultant confirmed that the facility’s EHR contained a discharge assessment tool that was not completed for this resident and acknowledged the multiple medication discrepancies on the discharge summary form.
Failure to Complete PASRR Evaluation Prior to Admission
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) evaluation for a resident with an admission date of 4/22/26. The resident’s electronic health record documented admission from a hospital on 4/22/26, but review of the record showed no PASRR completed at the time of admission. A PASRR form for this resident was later obtained and showed it was completed on 4/27/26 by the Hospital Liaison/Admissions Coordinator, several days after the resident had already been admitted. During interview, the Hospital Liaison/Admissions Coordinator stated that the hospital usually completes the PASRR, acknowledged receiving a call the previous night that the PASRR was not in the chart, and admitted she had missed completing it prior to admission even though it should have been done. The Administrator similarly reported that the facility relies on receiving the PASRR from the hospital admission records and that, in this case, the PASRR was missed and not completed prior to the resident’s admission. This resulted in a deficiency for failure to ensure a PASRR evaluation was completed prior to admission for 1 of 3 reviewed residents, in accordance with PASRR requirements.
Failure to Properly Position Resident Upright During Assisted Feeding
Penalty
Summary
Surveyors identified a deficiency in resident positioning during mealtime for a resident with Alzheimer's disease and severely impaired cognition, as evidenced by a Brief Interview for Mental Status score of 2. The resident’s MDS indicated a need for partial to moderate assistance with eating, and the care plan documented nutrition and hydration risk related to end-stage diagnosis, cognitive limitations, and weakness, with directions for a general diet, thin liquids, and assistance with eating. During a breakfast observation on the Magnolia Unit, the resident was seated in a Broda chair that was reclined back. A dietary aide placed food on the table in front of the resident, and a CNA then placed beverages and food on an overbed table before walking away, while the resident remained reclined with eyes closed and the plate of food untouched. Later in the same observation period, another CNA offered the resident chocolate milk while the Broda chair remained tilted backward, and the resident had to struggle to move her head up and forward to reach the cup. The same CNA then offered hot cereal, which the resident declined by saying “later.” A different CNA subsequently offered another drink of chocolate milk, again without adjusting the reclined position of the Broda chair. Policy review showed the facility’s “Feeding of Residents by Staff” policy required that residents unable to feed themselves be assisted per their care plan and be positioned comfortably in an upright position. In an interview, the DON stated there was no specific positioning policy, that staff received positioning education in training, and that her expectation was that residents be placed in an upright position whenever food or drink was offered.
Mechanical Lift Transfer Caused Resident Forehead Injury
Penalty
Summary
The facility failed to provide a safe and adequate mechanical lift transfer for Resident #18, who had a left leg fracture, muscle wasting, and impaired gait and mobility, but no cognitive impairment based on a BIMS score of 15. The resident’s care plan required two staff members to use a mechanical lift for transfers because the resident was nonweight-bearing on the left leg. The care plan update also directed staff to approach the wheelchair straight on and not from the side, and to have the resident bend the right leg and turn away from the lift during transfers. During a wheelchair transfer, staff positioned the mechanical lift at the side of the wheelchair and began the transfer. The lift tipped and struck the resident’s forehead with the part that held the sling. The resident sustained a bruise and a protruding bump on the left forehead, and the incident documentation noted the resident’s head was hit on the lift. The resident later reported that the lift almost fell to the floor and that additional staff were needed to return it upright. Staff interviews confirmed that the transfer was performed from the side of the wheelchair. One CNA stated the lift may have caught on bars under the wheelchair and acknowledged that staff had been educated not to use the lift from the side. Another CNA stated the lift was used from the side because the resident did not want her leg hit by the lift, and identified the sling-holding part of the lift as the piece that struck the resident’s forehead. The DON stated the proper procedure was to position the mechanical lift directly in front of the wheelchair rather than to the side.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living for 5 of 8 residents reviewed, specifically related to bathing and shaving. Resident #3 had a BIMS score of 15 and was dependent on staff for personal hygiene, with diagnoses including renal insufficiency, stroke, hemiplegia, and seizure disorder. The resident was observed unshaven, stated he was getting showers but not shaved every time, and said he needed help shaving since his stroke. Facility records showed showers were documented without indicating whether shaving was completed, and staff interviews confirmed the bath sheets no longer tracked shaving or nail care, while the DON stated male residents should be offered shaving during showers and it should be documented if completed or refused. Resident #1 had a BIMS score of 4, diagnoses including muscle weakness, diabetes, and hip fracture, and was care planned as an extensive assist for bathing. Review of the follow-up report showed the resident went 17 days without a bath and later 19 days without a bath. Resident #11 had a BIMS score of 3, diagnoses including depression, hypertension, and anemia, and was scheduled for bathing on Wednesday morning and Friday afternoon, but the follow-up report showed gaps of 6 days, 6 days, and 18 days between baths. Resident #27 also had a BIMS score of 3 with depression, hypertension, and anemia, was scheduled for bathing on Monday and Thursday afternoon, and the follow-up report showed the resident went 19 days and then 20 days without a bath, with refusals documented on two occasions. Resident #85 had a BIMS score of 15, diagnoses including hypertension, depression, and need for assistance with personal care, and stated she did not get 2 baths the prior week and wanted them. Her care plan identified her as dependent for bathing, but lacked bathing frequency, and the task list scheduled bathing for Monday morning and Wednesday afternoon. The follow-up report showed multiple extended gaps between baths, including 12 days, 7 days, 18 days, and 7 days. Facility policy stated bathing is intended to promote cleanliness, provide comfort, and observe skin condition, and the Regional Nurse Consultant stated bathing should be completed as scheduled.
QAPI Program Failed to Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive and effective QAPI program and did not have a plan that described the process for conducting QAPI and QAA activities. Review of the DIAL website visit history showed repeated deficient practices identified during the facility’s annual survey and complaint investigation on 3/27/25 and during the annual survey, complaint, and facility-reported incident investigation on 4/19/26. The repeat deficiencies included F689, Free of Accident Hazards/Supervision/Devices, which had been repeated in the previous three consecutive annual surveys, and F880, Infection Prevention and Control, which had been repeated in the previous four consecutive annual surveys. The facility’s QAPI plan stated that it would review sources of information to determine whether gaps or patterns existed in systems of care that could result in quality problems or opportunities for improvement. During an interview on 4/23/26 at 1:28 PM, the Administrator acknowledged the repeated F689 and F880 deficiencies and stated the facility would review and discuss plans to improve.
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.
