Accura Healthcare Of Carroll
Inspection history, citations, penalties and survey trends for this long-term care facility in Carroll, Iowa.
- Location
- 2241 North West Street, Carroll, Iowa 51401
- CMS Provider Number
- 165455
- Inspections on file
- 26
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Accura Healthcare Of Carroll during CMS and state inspections, most recent first.
The facility failed to submit accurate PBJ staffing data for the reporting period. Review showed excessively low weekend staffing was reported even though daily staffing assignment sheets reflected sufficient staffing across morning, evening, and night shifts with several RNs and CNAs working. An RN said the low staffing was tied to a prior audit issue while using an outside PBJ module that double-counted employee hours, and the DON stated the facility had no policy for correct PBJ submission and just followed the regulations.
The facility failed to show good faith efforts to correct repeat quality issues tied to insufficient nursing staff and ongoing call light concerns. CMS survey results showed repeated deficiency F725, and leadership reported that call light audits were still in progress while staff education on timely call light response continued, with call lights still remaining a concern.
Housekeeping and maintenance services were not consistently provided to keep resident rooms sanitary, orderly, and comfortable. A resident with no cognitive impairment reported bed-making and trash issues, another resident with no cognitive impairment reported dust and difficulty getting the bed made, and observations showed dust, trash on the floor, and tissue under the bed. Two residents with moderate cognitive impairment had dusty window sills, and one room had a damaged headboard. Housekeeping staff said rooms were cleaned every other day, but the cleaning schedule lacked documentation for multiple rooms and did not show deep cleaning as directed.
The facility failed to follow its abuse prevention policy when a CNA’s file did not contain a SING background check before hire. The DON stated a third-party background check was likely done, but the facility could not retrieve SING results after 30 days and later confirmed the SING check was not in the file, despite the policy requiring criminal and abuse registry checks prior to hire.
Medication Administration Not Timely: The facility failed to give medications within the required time window for multiple residents. Audits and interviews showed several meds, including insulin, levothyroxine, omeprazole, fluticasone, Tylenol, and topical Voltaren, were administered hours late, and one resident with stroke, emphysema, and insomnia reported her evening meds were often delayed until after 10 p.m. despite usually receiving them around 8 p.m.
Delayed Call Light Response: Several residents, including residents who were dependent on staff for toileting, hygiene, and transfers, reported long waits for call lights to be answered. Facility Location Event Reports documented repeated response times well over 15 minutes, including multiple waits of 17 to 39 minutes, and one resident reported waiting two hours. Resident Council minutes also showed ongoing concerns about call lights not being answered in a timely manner, and an RN stated the facility did not have a policy for call light response times.
Controlled substance records were not consistently completed for three residents receiving PRN Ativan. Staff documented doses on the MAR without signing the narcotic record, and other doses were signed out without MAR documentation. The facility also reported missing liquid Ativan after staff found wet or sticky bottles and acknowledged that refrigerated narcotics were not being routinely counted. Monthly narcotic count records for multiple halls also lacked required nurse signatures, and expired medications and treatments were observed in the med room.
Medication Timing Preference Not Honored: A resident with no cognitive impairment and diagnoses including stroke, emphysema, and insomnia reported that her evening meds were given after 10:00 p.m. instead of around 8:00 p.m., disrupting her bedtime routine. An audit showed several scheduled 8:00 p.m. meds were administered at 10:01 p.m., and resident council notes also indicated pills and treatments were not given timely. The Interim DON confirmed the meds were not administered within the expected time window.
The facility failed to complete and transmit discharge MDS assessments for two residents after their discharge from the LTC facility. The EHR showed that discharge MDSs were not set up or completed for one resident discharged to AL and another resident discharged home. The Interim DON acknowledged the missing assessments, and the MDS coordinator said she missed them while learning new job tasks.
Medication administration errors were identified for two residents during a med pass. An LPN gave Fosamax with breakfast and multiple other oral meds, including vitamins and minerals, instead of on an empty stomach with plain water as directed by the manufacturer. Another LPN gave Levothyroxine with breakfast and other meds, including calcium and a multivitamin, despite the manufacturer’s instructions to administer it before breakfast on an empty stomach. The MARs lacked specific administration directions, and the facility policy required meds to be given in accordance with manufacturer specifications.
Food Served Below Required Hot-Holding Temperature: Three residents reported that lunch and room tray food was often cold or not up to temperature. Surveyors observed room trays left on an open air cart in hallways before being passed, and a test tray showed mashed potatoes at 129.7 degrees and mixed vegetables at 121 degrees, below the CDM’s stated expectation and the facility policy requiring hot foods to be served at least 135 degrees.
Failure to use proper hand hygiene and glove changes during wound care was cited after an LPN treated two separate buttocks wounds on a resident with a stage 3 pressure ulcer, diabetes, stroke, and HTN. The LPN removed old dressings and applied wound cleanser to both areas while using the same gloves, and later stated she should have changed gloves between the separate wound sites. The ADON/IP and DON said gloves should be changed between wounds due to cross contamination concerns, and the facility policy required proper hand hygiene between resident care sites.
A resident with epilepsy, a seizure disorder, and moderate cognitive impairment missed multiple doses of Cenobamate because the medication was unavailable. Staff documented that the PCP was notified, but there was no documentation that the pharmacy was called to determine why the medication had not arrived or that the resident was monitored for effects of the missed doses. Later records noted the resident had not received an antiseizure medication for about 2 weeks, and the pharmacist documented concerns about withdrawal symptoms and increased seizure risk.
A resident with moderate cognitive impairment and seizure disorder experienced significant medication errors involving anticonvulsants. The MAR showed Cenobamate was documented as given even when it was unavailable for multiple days, and staff did not document contacting the pharmacy about the missing medication. The resident also received incorrect doses of Clobazam and Lacosamide because of admission transcription errors, which the pharmacy consultant later identified.
Multiple residents who were dependent on staff for daily care experienced significant delays in call light response, with documented wait times frequently exceeding the expected 15-minute standard, especially on weekends. Residents with complex medical needs reported waiting up to 39 minutes for assistance, and the facility lacked a formal call light policy, relying instead on state standards.
Multiple residents with complex medical conditions reported that call lights frequently took longer than 15 minutes to be answered, especially during evenings, weekends, and mornings. Facility records confirmed response times up to 39 minutes, and the DON acknowledged the issue, noting the absence of a formal call light policy and inconsistent adherence to the expected 15-minute response time.
A resident with multiple chronic conditions experienced a fall during a transfer when the care plan was not updated to reflect a change from two-person to one-person assist, as recommended by physical therapy. Staff interviews confirmed that only one staff member was assisting during transfers, and the DON acknowledged the care plan was outdated. The facility's policy required timely care plan revisions, but this was not followed.
Several residents, including those with cognitive impairment and those with intact cognition, experienced care that did not promote dignity or respect. Staff were observed or reported to have acted aggressively, used dismissive or rude language, rushed through care, and failed to respond promptly to requests for assistance, resulting in residents feeling neglected, demeaned, or discouraged from seeking help.
A CNA did not receive required dependent adult abuse recertification training within the mandated three-year period, as facility tracking incorrectly scheduled the training after the certificate's expiration. The DON confirmed staff are expected to complete DAA training before expiration.
A resident with dementia and multiple comorbidities received PRN antipsychotic and antianxiety medications for periods exceeding regulatory limits without required physician assessments, clinical rationales, or documentation of behavioral symptoms and nonpharmacological interventions prior to administration. Facility policy and federal guidelines for psychotropic medication use were not followed, as confirmed by review of clinical records and staff interviews.
A resident was subjected to repeated physical actions by a CNA during a meal, which was witnessed by an RN. The RN delayed reporting the incident to management, and the facility subsequently failed to notify the state agency within the required 2-hour window, as mandated by policy. Staff interviews indicated confusion about reporting timelines, contributing to the deficiency.
A staff member accused of abuse was not promptly separated from a resident and other residents after an incident was witnessed by an RN. The RN delayed reporting the allegation to management, resulting in the staff member continuing to work her shift and interact with residents for several hours before being suspended, contrary to facility policy requiring immediate separation upon receiving abuse allegations.
A resident with multiple serious health conditions received an antidepressant medication in error for nearly two weeks due to a nurse confusing two hospice patients with similar initials. The same resident also missed several doses of a prescribed fentanyl patch for pain management because the medication was out of stock and a nurse entered a verbal order to hold the patch without direct physician communication. Staff interviews revealed confusion in the medication ordering process, and the facility lacked a specific policy for medication errors.
A resident with significant risk factors for skin breakdown developed a Stage III pressure ulcer after staff failed to implement and document necessary repositioning interventions. Despite being dependent on staff for mobility and having a care plan that identified skin integrity risks, the resident was not placed on a turning schedule, and staff did not consistently reposition the resident as required. Observations confirmed prolonged periods without repositioning, contributing to the development of the pressure ulcer.
A resident with multiple complex medical conditions, including a stage 4 pressure ulcer, experienced severe unplanned weight loss due to the facility's failure to conduct timely weight monitoring, nutritional assessments, and interventions. Despite policy requirements for regular and post-hospitalization weights, staff did not obtain weights as required, delayed reweighs after significant loss, and failed to notify the RD or physician in a timely manner, resulting in a lack of appropriate response to the resident's declining nutritional status.
The facility did not accurately complete MDS assessments for several residents, failing to document PASRR Level II status, oxygen therapy, CPAP use, and hospice care as required. Staff interviews revealed that only partial PASRR information was reviewed, and there was no facility policy guiding MDS completion, resulting in assessments that did not reflect residents' actual clinical status or services received.
Staff failed to follow posted menus and serve correct portions for residents on pureed and mechanical soft diets, resulting in inappropriate substitutions such as pudding instead of pureed cake and serving poppyseed cake and chopped lettuce to those with dietary restrictions. The dietary manager did not measure pureed food portions, leading to inconsistent servings, and both the dietary manager and dietitian were unfamiliar with proper procedures for therapeutic diets.
Staff failed to consistently use proper sanitation practices during food storage, preparation, and service, including not wearing hairnets, improper glove use, and handling food with gloved hands instead of utensils. The refrigerator for resident food items was visibly soiled, lacked temperature monitoring, and had no cleaning logs, with unclear staff responsibility for its upkeep.
Three CNAs did not complete the required 12 hours of annual in-service training due to a lack of tracking and access to the facility's education system. The facility's own assessment called for ongoing training and needs assessments, but these were not fulfilled for the CNAs reviewed.
The facility did not provide clear or complete information about room and board charges to several residents, with admission agreements missing specific rates or containing only notations instead of amounts. In one instance, a resident was not notified in writing of a rate increase, despite facility policy requiring such notification. Facility leadership acknowledged that rates should have been properly documented and communicated.
Two residents were found to be living in rooms with spider webs, stained and soiled bathroom walls and floors, missing grout, and black substances present. Family and staff interviews confirmed that these cleanliness and maintenance issues were not reported or addressed as required by facility procedures.
A resident with severe cognitive impairment and multiple diagnoses developed blisters suspected to be shingles, leading to a new order for antiviral medication. The facility did not notify the resident's family about the new medication or the suspected infection, and staff confirmed that no documentation of family notification was present.
A resident was discharged from the facility, but the required discharge MDS assessment was not set up or completed within the federally mandated timeframe. The MDS Coordinator indicated that such assessments are usually initiated on the day of discharge and checked by the social worker, but could not explain how this omission occurred. The Nurse Consultant noted that the facility lacks a specific policy for MDS completion and relies on RAI guidelines.
A resident with multiple skin impairments did not receive consistent wound care and assessments as ordered, including incomplete documentation of weekly skin checks, lack of follow-up on dietary supplement recommendations, and application of treatments not specified in physician orders. Staff interviews confirmed that required assessments and communications were not performed according to facility policy.
A resident with multiple medical conditions and a history of falls was assisted by a CNA during a transfer, became weak, and was lowered to the floor, sustaining an abrasion. After the incident, staff did not complete a root cause analysis, update the care plan with new fall interventions, or perform required follow-up assessments and vital sign checks, as required by facility policy. Staff interviews revealed inconsistent use of gait belts and incomplete documentation and investigation of the event.
Three residents with cardiac and respiratory conditions did not receive physician-ordered respiratory care, including cases where oxygen cannulas were disconnected, portable oxygen tanks were empty, and oxygen was administered at incorrect flow rates. Staff failed to monitor, document, and follow orders, and the facility lacked a policy for ensuring compliance with respiratory care protocols.
A registered nurse did not wear a gown while administering tube feedings and water flushes to a resident with a feeding tube, despite facility policy requiring Enhanced Barrier Precautions for residents with indwelling medical devices. The resident was totally dependent on staff and had recently returned from the hospital with aspiration pneumonia.
A facility failed to implement an effective pest control program, resulting in a bed bug infestation in the rooms of two residents. Staff were uncertain about the steps to take, and the facility lacked a specific policy for dealing with such infestations. One resident, with moderate cognitive deficit, was moved to a different room, while another resident, who was independent, passed away shortly after the incident. The pest control company confirmed the presence of bed bugs, but the facility's response was inadequate due to the absence of a detailed policy and staff education.
The facility failed to store, prepare, serve, and distribute food in accordance with professional standards. Staff members inconsistently practiced hand hygiene during meal preparation, and the resident unit refrigerator was improperly maintained, lacking a temperature log and containing outdated items.
The facility failed to refer a resident with severe cognitive impairment and new diagnoses of dementia and bipolar disorder for a Level II PASRR evaluation. Staff acknowledged the oversight and stated that a new PASRR should have been completed, but the facility lacked a specific PASRR policy.
A resident with severe cognitive impairment and diagnoses of Alzheimer's, anxiety, and depression had a PRN order for lorazepam without a specified stop date. The medication was administered multiple times over several months without physician review. The DON acknowledged the oversight and stated the facility lacked a policy for reviewing PRN psychotropic medications.
The facility failed to obtain bed hold notifications for four residents who were transferred to the hospital or on therapeutic leave. The DON acknowledged the oversight, believing social services were responsible. The facility's policy requires written notice for hospital transfers, which was not followed.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate direct care staffing information in the CMS Payroll Based Journal (PBJ) Staffing Data Report for the October 1 through December 31 reporting period. Review of the PBJ Staffing Data Report showed the facility triggered for excessively low weekend staffing, and the submitted weekend staffing data was found to be excessively low. However, review of facility daily staffing assignment sheets for October through December showed sufficient staffing across the morning, evening, and night shifts, with several nurses and CNAs working those shifts. During interview, an RN stated the low weekend staffing was related to a failed audit for the prior quarter while the facility was using an outside PBJ module, and that the outside company had double-counted hours for several employees, causing over-reporting in that quarter. The DON stated the facility had no policy for correctly submitting PBJ and simply followed the regulations.
QAPI Deficiency Related to Repeat Staffing and Call Light Concerns
Penalty
Summary
The facility failed to demonstrate good faith attempts to correct quality deficiencies related to repeat survey findings and incomplete corrections within a reasonable time frame. Review of CMS Form 2567 showed the facility received deficiency F725 for insufficient nursing staff with correction dates of 10/16/25 and 1/31/26. During an interview on 4/02/26, the Administrator and a staff RN stated the facility was still working on call light audits, had been providing education to staff on answering call lights in a timely manner while management completed the audits, and that call lights had improved somewhat but remained a concern. Review of the facility’s QAPI policy dated 5/23/23 stated that the QAPI committee analyzes performance to identify and follow up on areas of opportunity.
Housekeeping and Maintenance Services Not Maintained
Penalty
Summary
The facility failed to ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly, and comfortable interior for four residents reviewed. Resident #21, who scored 14 on the BIMS with no cognitive impairment, stated that staff sometimes did not make her bed and that the trash became so full it would not hold any more, with some trash ending up on the floor. Resident #11, who scored 13 on the BIMS with no cognitive impairment, reported difficulty getting staff to make the bed and said she had to wipe things down because it was dusty. Observations in Resident #11’s room showed dust on the window sill, tissue under the bed, a black floor under the recliner, and an overfull garbage can with trash on the floor around it, with these conditions continuing on later observations. Resident #25, who scored 9 on the BIMS with moderate cognitive impairment, was observed with a damaged headboard that was torn halfway up from the bottom and hanging free, along with a window sill covered in a thick layer of dust. Resident #24, who scored 11 on the BIMS with moderate cognitive impairment, also had a window sill with a thick layer of dust, and stated he tried to keep the room clean but could not reach the window sill because the bed was against it. Staff in housekeeping stated the beds were up against the wall with the window sills and that rooms were cleaned every other day, while the March housekeeping cleaning schedule showed no checks for cleaning rooms 201 to 213, spot cleaning on selected dates, no documentation of deep cleaning, and no documentation of cleaning the listed rooms for several days at the end of the month.
Failure to Complete Required Pre-Employment Background Check
Penalty
Summary
The facility failed to implement its abuse and neglect policy by not completing required background checks prior to staff employment. Review of Staff C, a CNA, personnel file showed no SING background check, and the facility’s employee roster listed Staff C with a hire date of 2/3/25. During interview, the DON stated that a third-party background check was likely completed before hire, but the facility could not log into the SING system to retrieve results because they were no longer available after 30 days. On follow-up interview, the DON confirmed that Staff C did not have a SING background check in the file, although another background check had been completed before the start date. The facility policy stated that an Iowa criminal record check and dependent adult/child abuse registry check would be completed on all prospective employees and other individuals engaged to provide services to residents prior to hire.
Medication Administration Not Timely
Penalty
Summary
The facility failed to administer medications in a timely manner for 11 of 20 residents reviewed. Record review, staff interview, resident interview, and medication administration audits showed multiple medications were given outside the facility’s stated 60-minute window before or after the scheduled time. The resident council notes dated 3/19/26 indicated that pills and treatments were not given timely. Resident #21, who had diagnoses including stroke, emphysema, and insomnia and scored 14 on the BIMS, stated on 3/30/26 that a nurse did not give her medications until after 10 p.m. when she usually received them around 8 p.m., which disrupted her schedule. The medication audit showed several residents had late administrations, including insulin, levothyroxine, omeprazole, pantoprazole, fluticasone, Tylenol, Zyprexa, and topical Voltaren Gel, with some medications scheduled for 5 a.m., 7 p.m., or 8 p.m. but administered hours later. The Interim DON stated on 4/1/26 that medications could be given 1 hour before to 1 hour after the scheduled time, and the facility medication administration policy also stated medications should be given within 60 minutes before or after the ordered time unless otherwise ordered by a physician.
Delayed Call Light Response
Penalty
Summary
The facility failed to provide nursing staff to assure resident safety by not responding to call lights in a timely manner for 4 of 6 residents reviewed. Resident #2, who had a BIMS score of 15 and was dependent on staff for toileting hygiene, personal hygiene, and chair/bed-to-chair transfers, reported that call lights could take 15 minutes or longer. The facility’s Location Event Report for this resident’s room documented response times of 25, 17, 26, and 18 minutes. Resident #45, who also had a BIMS score of 15 and was dependent on staff for toileting hygiene, personal hygiene, and transfers, reported that call lights sometimes took a long time to answer and that there did not seem to be enough staff. The Location Event Report for this resident’s room documented multiple response times ranging from 17 to 39 minutes, and Resident Council minutes from three monthly meetings reflected resident concerns that call lights were not being answered in 15 minutes or less. Resident #6 had a BIMS score of 14 and reported waiting two hours for a call light to be answered, stating that response time depended on staffing and call-ins and that he watched the clock to time responses. The Location Event Report for this resident’s room documented response times of 17 to 39 minutes. Resident #36 had a BIMS score of 12 and reported that call lights were usually 15 minutes or more and that he had once had a call light on for over an hour. The Location Event Report for this resident’s room documented response times of 21, 27, and 39 minutes. Staff interviews indicated that the DON expected call lights to be answered in 15 minutes or less, and an RN stated the facility did not have a policy regarding call light response times.
Controlled Substance Documentation and Reconciliation Failures
Penalty
Summary
The facility failed to document administration of lorazepam (Ativan) on both the Controlled Drug Use Record and the electronic MAR for three residents who had PRN orders for anxiety, restlessness, comfort, or shortness of breath. Resident #22 had diagnoses including non-Alzheimer's dementia, anxiety disorder, bipolar disorder, and schizophrenia, and Resident #47 had diagnoses including non-Alzheimer's dementia, anxiety disorder, depression, and schizophrenia. Resident #23 had severe cognitive impairment and chronic respiratory failure with hypoxia and shortness of breath. For each of these residents, the record showed multiple instances where Ativan was signed out on one record but not documented on the other, and other instances where it was documented as given on the MAR but not signed out on the controlled drug record. The facility self-reported that 33 ml of liquid Ativan was missing among the three residents. Staff identified a discrepancy during a narcotic count when the bottles were noted to be sticky or wet, and one resident’s Ativan box was described as wet and leaked through. Staff later stated that refrigerated narcotics were not being routinely counted, and several staff members reported they had not been consistently checking the liquid Ativan in the refrigerator. One LPN stated the last time she counted the liquid Ativan was the prior week, while another CMA said she was unaware the liquid Ativan was supposed to be refrigerated. The DON stated she compared the narcotic administration records to the MARs and could not account for all of the missing Ativan, and also stated that some nurses were giving the liquid Ativan but missing documentation on either the narcotic record or the MAR. The facility also failed to consistently reconcile controlled medications on the monthly narcotic count records for multiple halls, with numerous missing nurse on/off signatures across December 2025 through February 2026. During observation of the medication room, expired medications and treatments were found, including expired Tylenol suppositories, adhesive remover wipes, and aspirin. Facility policy required two nurses to count and validate narcotics at each shift change and required staff to sign the MAR after medication administration and sign the narcotic book for controlled substances, but the records reviewed showed repeated failures to complete those required entries and reconciliations.
Medication Timing Preference Not Honored
Penalty
Summary
The facility failed to ensure a resident’s preference for medication time was honored for Resident #21, who had a BIMS score of 14 indicating no cognitive impairment and diagnoses including stroke, emphysema, and insomnia. The resident stated that a nurse did not give her medications until after 10:00 p.m. on a Saturday night, even though she usually receives them around 8:00 p.m., and that this disrupted her schedule because she wanted to get ready for bed earlier. She also stated this was not the first time it had happened and that she had been told her medications were supposed to be given earlier. A medication administration audit showed that Resident #21 had medications scheduled for 8:00 p.m., including Flonase Allergy Relief nasal suspension, magnesium glycinate, omeprazole delayed release, and melatonin, but they were administered at 10:01 p.m. Resident council notes dated 3/19/26 stated that pills and treatments were not given timely. The Interim DON stated medications could be given 1 hour before to 1 hour after the scheduled time and confirmed that Resident #21’s medications were not administered timely. The facility medication administration policy stated medications are to be administered in accordance with professional standards of practice and within 60 minutes before or after the scheduled time unless otherwise ordered by the physician.
Missed Discharge MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete and transmit discharge MDS assessments within the required timeframe for 2 of 2 residents reviewed for MDS assessments, Resident #4 and Resident #17. Resident #4 was discharged to Assisted Living on 1/7/26, and the EHR showed that a discharge MDS had not been set up or completed. Resident #17 was discharged home on 2/10/26, and the EHR also showed that a discharge MDS had not been set up or completed. During interview, the Interim DON acknowledged that both residents’ discharge MDS assessments were not completed and stated that a discharge MDS is expected when a resident discharges from the facility according to the RAI manual. The MDS Coordinator stated she had missed completing the discharge MDS for both residents while learning new job tasks. The report also states that, according to the 2025 RAI, a discharge assessment must be dated for the resident’s discharge date and completed no later than 14 days after discharge.
Medication Administration Not Per Manufacturer Instructions
Penalty
Summary
Medication administration errors were identified for 2 of 5 residents observed during the medication pass, involving failure to give medications according to manufacturer instructions. Resident #24 had a BIMS score of 11 and diagnoses including non-alzheimer's dementia, seizure disorder, and anxiety disorder. The April 2026 MAR directed Fosamax 70 mg weekly in the early morning on Wednesday for osteoporosis, but the order did not include specific administration directions. During the morning medication pass, Staff D administered Fosamax at the same time as multiple other medications, while the resident was sitting at the table eating breakfast and drinking apple juice. The medication was given with other oral medications, including vitamins and minerals, despite the manufacturer's instructions that Fosamax be taken with plain water at least 30 minutes before the first food, drink, or medication of the day and not with calcium, antacids, vitamins, or other oral medications. Resident #14 had a BIMS score of 06 and diagnoses including hypothyroidism. The April 2026 MAR directed Levothyroxine Sodium 125 mcg to be given every Monday through Saturday at breakfast, but the order lacked specific administration directions. During the morning medication pass, Staff E administered Levothyroxine with other medications while the resident was eating breakfast and sitting at the table. The medications given at the same time included Tylenol, Loratadine, Multivitamin with mineral, Oyster Calcium, and Cholecalciferol. Staff E acknowledged giving Levothyroxine with other medications and breakfast, and the Interim DON stated it was expected that Fosamax and Levothyroxine be administered on an empty stomach prior to breakfast. The facility policy required medications to be administered as ordered in accordance with manufacturer specifications.
Food Served Below Required Hot-Holding Temperature
Penalty
Summary
The facility failed to provide food at an appetizing temperature for 3 of 15 residents reviewed, including Residents #2, #5, and #45. Resident #2 had an MDS dated [DATE] showing a BIMS score of 15, indicating intact cognitive functioning, and stated during interview on 3/30/26 at 11:35 AM that lunch tray food is often cold and not warm when delivered. Resident #5 had an MDS dated [DATE] showing a BIMS score of 13, also indicating intact cognitive functioning, and stated during interview on 3/30/26 at 11:14 AM that room tray food is often cold when delivered and should be hot. Resident #45 had an MDS dated [DATE] showing a BIMS score of 15 and stated during interview on 3/30/26 at 10:32 AM that the food does not taste good and sometimes is not up to temperature. During continuous observation on 4/1/26 from 11:30 AM until 11:44 AM, room trays were observed being delivered to the East hallway on an open air cart with plates covered with lids, then delivered to the North hallway and left in the same manner before staff passed the trays in both hallways. At 11:44 AM, a test tray was obtained and temperatures were measured, showing mashed potatoes at 129.7 degrees and mixed vegetables at 121 degrees. The Certified Dietary Manager stated on 4/1/26 at 11:51 AM that food should be served at 135 degrees or warmer, and a facility policy titled Food Temperatures dated 2021 stated that hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees.
Failure to Change Gloves Between Separate Wound Care Sites
Penalty
Summary
Provide and implement an infection prevention and control program was cited after staff failed to use universal infection control measures during wound care for one resident. Resident #2 had a BIMS score of 15 and diagnoses including hypertension, diabetes mellitus, stroke, and a stage 3 pressure ulcer to the right buttocks. The resident stated that there were open areas to the buttocks and that dressing changes were being performed for those areas. Review of the physician orders showed wound care instructions for cleansing all wounds, applying wound paste daily, and using vaseline impregnated gauze after the paste. During observation of wound care, an LPN removed old dressings from the left and right buttocks while wearing the same gloves, then changed gloves and performed wound cleansing to both areas with the same gloves. The LPN later changed gloves appropriately during the paste and vaseline treatments. The LPN stated she should have changed gloves between the areas when removing old dressings and when completing new treatments to the separate areas. The ADON/IP and DON both stated they would have expected gloves to be changed between wounds and different open areas because of cross contamination concerns. The facility policy on hand hygiene stated staff should always complete proper hand hygiene between resident care sites.
Failure to Obtain and Monitor Unavailable Antiseizure Medication
Penalty
Summary
The facility failed to intervene and call the pharmacy and follow up with a physician when Cenobamate was unavailable for Resident #51, who had a seizure disorder, epilepsy, fractures and other multiple trauma, a mood disorder, and mild cognitive impairment. The resident's MDS assessment showed a BIMS score of 10, indicating moderate cognitive impairment. The care plan identified the resident as at risk for adverse effects from routine/as needed anticonvulsant use and included interventions to observe medication effectiveness, report significant side effects to the physician, and review medications as necessary. The MAR documented that Cenobamate 100 mg daily at breakfast was not given on multiple days in December, and progress notes repeatedly stated the medication was not available and pending delivery, with the PCP notified on several occasions. The record lacked documentation that staff called the pharmacy to determine why the medication had not arrived, identified the risks of not receiving the medication, or monitored the resident for possible negative effects. A hospital progress note later documented staff reported the resident had not received an antiseizure medication since admission, and hospital staff learned from the pharmacy that no prescription had been received from the hospital at discharge. A psych consult noted the resident had missed one of her antiseizure medications for the previous 2 weeks, and the pharmacist documented concerns about withdrawal symptoms and increased seizure risk.
Medication transcription and omission errors for seizure medications
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors. Resident #51 had a BIMS score of 10, indicating moderate cognitive impairment, and diagnoses that included fractures and other multiple trauma, a seizure disorder, a mood disorder, and mild cognitive impairment. The care plan identified the resident as being at risk for adverse effects from routine and PRN anticonvulsant use and included interventions to observe medication effectiveness, report significant side effects, and review medications as necessary. The resident’s MAR showed Cenobamate 100 mg daily for seizures, but the medication was not available for multiple days, and the MAR was marked as given even though the medication was not on hand. Progress notes repeatedly documented that Cenobamate was not available and that the PCP was notified, but the record lacked documentation that staff contacted the pharmacy to determine why the medication had not arrived. A hospital progress note later documented staff reported the resident had not received an antiseizure medication since admission, and a psych consult noted the resident had not received one of her antiseizure medications for the previous 2 weeks and that this may have contributed to behavioral concerns. The record also showed transcription errors on admission for other seizure medications. The hospital medication list indicated Clobazam 15 mg in the morning and Lacosamide 250 mg in the evening, but the facility MAR initially reflected different doses and later required corrections. The ADON confirmed the medication errors occurred because of transcription errors on the day of admission, and the pharmacy consultant identified the errors on 12/10/25. The resident received the wrong dose of 2 medications.
Delayed Call Light Response for Dependent Residents
Penalty
Summary
The facility failed to provide timely responses to call lights for four residents who were dependent on staff for various activities of daily living, including toileting hygiene, showering, dressing, transfers, and mobility. Clinical record reviews, facility document reviews, and interviews with both staff and residents revealed that call light response times frequently exceeded the facility's expected standard of 15 minutes, particularly on weekends. Documented call light logs showed multiple instances where residents waited between 17 and 39 minutes for assistance, with several occurrences of wait times over 30 minutes. Residents reported that delays were especially pronounced on weekends, and some expressed frustration with the length of time it took to receive help. The residents involved had significant medical conditions such as diabetes, heart failure, chronic obstructive lung disease, stroke, and dementia, and were largely dependent on staff for their care needs. Despite the presence of monitors displaying active call lights and their durations, the facility did not have a formal call light policy in place, instead relying on a state standard for response times. The deficiency was identified through a combination of resident interviews, review of call light logs, and staff interviews, all of which confirmed the pattern of delayed responses to resident needs.
Delayed Call Light Response Due to Insufficient Nursing Staff
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure timely response to resident call lights, as evidenced by multiple resident interviews and review of call light response logs. Several residents, all with varying degrees of cognitive function and complex medical histories including heart failure, diabetes mellitus, hyperlipidemia, morbid obesity, arthritis, hip fracture, and mental health disorders, reported that call lights often took longer than 15 minutes to be answered, particularly during evenings, weekends, and morning shifts. These delays were corroborated by facility documentation showing response times ranging from 16 to 39 minutes on multiple occasions. The Director of Nursing acknowledged that call light response times were an ongoing issue and provided logs confirming extended delays. Additionally, the DON stated that the facility did not have a formal call light policy and instead relied on general standards of care. The expectation communicated by the DON was for call lights to be answered within 15 minutes, but this standard was not consistently met, as shown by both resident reports and facility records.
Failure to Revise and Implement Accurate Care Plan for Resident Transfer Needs
Penalty
Summary
The facility failed to revise and implement an accurate care plan for one resident following changes in the resident's transfer needs. The resident, who had diagnoses including heart failure, renal insufficiency, diabetes mellitus, hyperlipidemia, and morbid obesity, was initially care planned for transfers with assistance from two staff members using a walker and gait belt. However, after being discharged from physical therapy, the resident's transfer status had improved to require only one staff member with a gait belt and walker. Despite this change, the care plan was not updated to reflect the new level of assistance needed. On the day of the incident, the resident experienced muscle jerks and dizziness while preparing to transfer from the bed to a wheelchair. The CNA assisting the resident followed the resident's preference for the gait belt placement and attempted to readjust the belt when the resident reported nausea. During this process, the resident became anxious, stood up, and fell forward onto the floor. Multiple staff responded, assessed the resident, and used a mechanical lift to transfer the resident to a wheelchair. The resident initially complained of toe pain, and later reported ankle pain, prompting a transfer to the hospital for further evaluation. Interviews with staff confirmed that the resident was being assisted by only one staff member during transfers, consistent with the updated physical therapy recommendations but inconsistent with the care plan documentation, which still indicated assistance from two staff members. The Director of Nursing acknowledged that the care plan was not correct and should have been updated to reflect the resident's current needs. Facility policy required care plans to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly assessment, but this was not done in this case.
Failure to Promote Resident Dignity and Respect
Penalty
Summary
The facility failed to provide care that promoted dignity and respect for six out of fifteen residents reviewed. Multiple staff, including CNAs, were observed or reported to have interacted with residents in a manner that was dismissive, rough, or disrespectful. For example, one resident with severe cognitive impairment and total dependence for eating was observed by an RN to have his hands swatted away multiple times by a CNA when reaching for his food, with the CNA becoming increasingly aggressive and eventually shoving the resident's wheelchair away from the table. Another resident with intact cognition reported that a CNA's attitude made her feel like a bother when asking for help, discouraging her from seeking assistance. Other residents described similar negative experiences. One resident reported that a CNA rushed through care, left the room while the resident was speaking, and delayed responding to call lights, resulting in the resident having an accident and feeling terrible. Another resident stated that a CNA was rude, rough, and left her on the toilet for 20 minutes, which she felt ruined her dignity. Additional reports included complaints of negative attitudes, rushing through care, and not providing requested assistance such as water or help off the toilet. A resident with moderately impaired cognition reported being called a derogatory name by staff after spilling food and described staff as having a short and rude tone. Hospice staff corroborated concerns about staff demeanor and responsiveness, noting that suggestions to improve the resident's mood and care were dismissed due to staffing issues. Facility policy requires staff to treat residents with respect and dignity, but the documented actions and attitudes of certain staff members did not align with these expectations, resulting in a failure to maintain or enhance residents' quality of life.
Failure to Provide Timely Dependent Adult Abuse Recertification Training
Penalty
Summary
The facility failed to provide dependent adult abuse (DAA) recertification training within the required three-year period for one of two employees reviewed. Personnel file review showed that a CNA was hired on 5/15/24 and had last completed the mandatory 2-hour DAA training on 5/8/22. According to facility policy, staff are required to complete a 1-hour recertification within three years of the initial training and every three years thereafter. Staff interviews revealed that the CNA did not have an updated DAA certificate as of the time of review, and the facility's tracking system had incorrectly marked the training as due in May 2025, rather than before the three-year expiration. The DON confirmed the expectation that staff complete DAA training prior to certificate expiration.
Failure to Limit and Document PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to comply with federal regulations regarding the use of PRN (as needed) psychotropic medications, specifically antipsychotics and antianxiety drugs, for a resident with multiple complex medical conditions, including Alzheimer's disease, anxiety disorder, and depression. The clinical record review revealed that PRN antipsychotic medications such as Haloperidol and Zyprexa were ordered and administered for periods exceeding the 14-day federal limit without documented physician assessments or clinical rationales for the extended use. Orders for these medications were repeatedly renewed for 30 days or longer, and pharmacy consulting reports consistently recommended reassessment and adherence to the 14-day limitation, but these recommendations were not followed with appropriate documentation or evaluation by the prescribing physician or practitioner. Additionally, the facility failed to document behavioral symptoms or the use of nonpharmacological interventions prior to administering PRN antianxiety medications, such as Ativan, as required by both facility policy and federal regulation. The medication administration records showed frequent use of these medications over several months, yet there was a lack of corresponding documentation of behaviors or attempts at alternative interventions before medication was given. The Director of Nursing confirmed that staff were expected to document behaviors and nonpharmacological interventions prior to administering PRN psychotropic medications, but this was not consistently done. The facility's own policy required that PRN orders for psychotropic medications be limited to 14 days unless a clinical rationale for extension was documented, and that nonpharmacological approaches be attempted first. Despite this, the clinical records lacked evidence of physician assessments, clinical rationales for extended PRN use, and documentation of behavioral monitoring or nonpharmacological interventions. These failures were observed for one resident reviewed for unnecessary medications, in a facility with a census of 47 residents.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident within the required 2-hour timeframe to the Iowa Department of Inspections, Appeals and Licensing (DIAL). According to facility documentation, a Certified Nursing Assistant (CNA) was observed by a Registered Nurse (RN) pushing a resident's hands away from his plate multiple times during breakfast and eventually wheeling the resident away from the table before he finished his meal. The RN reported the incident to the Administrator at approximately 3:30 PM, several hours after the event occurred. The facility then contacted the State Agency by phone at 4:57 PM and completed the online self-report the following morning. Staff interviews revealed that the RN believed abuse allegations without observable injury needed to be reported within 24 hours, rather than the required 2 hours. The Director of Nursing (DON) stated that staff are expected to report abuse immediately and separate the resident from the alleged abuser. Facility policy, updated in October 2022, clearly states that all allegations of resident abuse must be reported to the state agency within 2 hours. The delay in reporting the incident constituted a failure to follow both regulatory requirements and facility policy.
Failure to Timely Separate Staff Accused of Abuse from Residents
Penalty
Summary
The facility failed to promptly separate a staff member accused of abuse from dependent residents following an incident involving a resident during breakfast. According to documentation, a Certified Nursing Assistant (CNA) was observed by a Registered Nurse (RN) repeatedly pushing a resident's hands away from his plate and eventually shoving his wheelchair away from the table before he finished his meal. The RN did not immediately report the incident to management, waiting until approximately 3:30 PM to notify the Administrator, despite the incident occurring at 7:30 AM. As a result, the accused CNA continued to work her shift and had contact with residents, including the resident involved in the alleged abuse, until she was suspended later that afternoon. Facility records, including time card data and staff interviews, confirmed that the CNA remained on duty from early morning until late afternoon, only being separated from residents after the allegation was reported to management. The facility's policy requires immediate action to prevent further potential abuse by separating the accused employee from residents upon receiving an allegation. However, this protocol was not followed, as the delay in reporting and subsequent action allowed the staff member to continue working with residents for several hours after the alleged incident.
Significant Medication Errors in Medication Administration and Ordering
Penalty
Summary
A significant medication error occurred when a nurse entered a prescription for fluoxetine for a resident who was not intended to receive it. The error happened because the nurse confused two hospice residents with similar initials while processing physician orders. As a result, the resident received 24 doses of fluoxetine over nearly two weeks before the mistake was discovered. The resident's family was notified after the error was identified, and the nurse acknowledged the mistake during an interview. Additionally, the same resident did not receive a prescribed fentanyl patch for pain management as ordered. The medication was out of stock, and the patch was not applied for several days. Documentation shows that the pharmacy was awaiting provider approval for the refill, and a verbal order to hold the patch was entered by a nurse without direct communication with the physician. The resident's family and ARNP were updated about the situation, and progress notes indicated that the resident went without the patch during this period. Interviews with staff revealed inconsistencies in the medication ordering and reordering process, including uncertainty about whether the patches had been reordered and a lack of clarity regarding the use of the emergency kit. The facility did not have a specific policy related to medication errors, instead relying on standards of practice. The resident involved had multiple complex medical conditions, including cancer, hypertension, peripheral vascular disease, COPD, malnutrition, depression, and chronic pain, and was receiving hospice services at the time of the deficiencies.
Failure to Prevent Pressure Ulcer Development Due to Lack of Repositioning Interventions
Penalty
Summary
A deficiency occurred when a resident, who was at risk for pressure ulcers due to multiple medical conditions including Type 2 diabetes with foot ulcer, peripheral vascular disease, cerebrovascular accident with hemiplegia, and requiring substantial assistance for bed mobility, developed a Stage III pressure ulcer. The resident's care plan identified risks related to skin integrity and ADL deficits but failed to document the need for turning or repositioning to prevent pressure ulcers, nor did it specify the assistance required for bed mobility. The Minimum Data Set (MDS) also indicated the resident was not on a turning/repositioning program and lacked nutrition or hydration interventions for skin management. Observations and staff interviews revealed that the resident spent significant time in a recliner, which became saturated with urine due to a clogged catheter, and was not using her bed. The facility's skin management protocol and care documentation did not include specific interventions such as regular repositioning. Staff reported that the resident was dependent on them for repositioning, but continuous observation showed that repositioning was not performed at the recommended frequency. The resident was observed to remain in the same position for extended periods, and staff did not consistently provide repositioning care, even when prompted by the nurse consultant. Wound assessments documented the development and progression of a Stage III pressure ulcer on the resident's right buttock, with moderate exudate and macerated wound edges. The facility's policy did not specify repositioning interventions, and staff interviews confirmed that repositioning was not routinely provided. The lack of timely and appropriate interventions to prevent pressure ulcer development directly resulted in harm to the resident.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to conduct appropriate weight monitoring, nutritional assessments, interventions, and timely physician/family notifications for a resident who experienced severe unplanned weight loss. The resident had multiple complex medical conditions, including anemia, diabetes mellitus, paraplegia, depression, cirrhosis, chronic kidney disease, and a stage 4 pressure ulcer. Despite being on a therapeutic diet and receiving several nutritional supplements, the resident experienced a significant weight loss of over 12% in a short period, with weights dropping from 274 lbs to 230.6 lbs over approximately two months. Documentation revealed that after a hospitalization for dehydration and norovirus, the resident was not weighed upon return to the facility, and weekly weights were not initiated as would be expected for a resident with wounds and recent acute illness. The registered dietician (RD) and nursing staff failed to obtain timely reweighs when significant weight loss was identified, and there was a lack of communication and follow-up between dietary and nursing regarding the resident's nutritional status. The RD requested a reweigh after noting a 35 lb weight loss in six weeks, but the reweigh was not completed until 12 days later, and the RD was not notified of the result. No further dietary assessments, interventions, or physician/family notifications were documented after the additional weight loss was identified. The facility's policy required residents to be weighed on admission, daily for three days, then weekly for three weeks, and then monthly unless otherwise ordered. The policy also required reweighs and physician notification for weight changes of three or more pounds. However, these protocols were not followed for this resident, as evidenced by the lack of timely weights, reweighs, and notifications. Staff interviews confirmed that there was confusion regarding the frequency of weights and that the facility did not have a specific policy addressing significant weight loss. The failure to follow established protocols and ensure timely assessment and intervention contributed to the resident's severe unplanned weight loss.
Inaccurate MDS Assessments Due to Incomplete PASRR and Service Documentation
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for 7 out of 13 reviewed residents, as identified through clinical record review, staff interviews, and reference to the 2024 Resident Assessment Instrument (RAI) Manual. Specific deficiencies included not properly documenting PASRR Level II status and related conditions for several residents who had been identified by the state process as having serious mental illness, intellectual disability, or related conditions. In multiple cases, the MDS did not reflect the PASRR findings, with required questions either marked incorrectly or left blank, despite clear instructions in the PASRR documentation and the RAI Manual. Additionally, the MDS failed to document the use of oxygen therapy, CPAP, and hospice care for residents who had active orders or were receiving these services according to their electronic health records. Interviews with facility staff revealed that the MDS Coordinator only reviewed the first page of the PASRR forms and did not follow the instructions on subsequent pages, leading to incomplete or inaccurate MDS entries. The Nurse Consultant confirmed that the facility did not have a specific policy for MDS completion and relied solely on the RAI guidelines. These actions and omissions resulted in the MDS assessments not accurately reflecting the residents' clinical status and required services, as mandated by federal assessment protocols.
Failure to Follow Therapeutic Diet Menus and Portion Requirements
Penalty
Summary
The facility failed to follow the posted menus and serve appropriate portions and therapeutic diets to residents requiring pureed and mechanical soft diets. Specifically, two residents on pureed diets did not receive the correct dessert as outlined in the menu spreadsheet, with one receiving pudding instead of the required pureed orange cake without poppyseeds. Additionally, six residents on mechanical soft diets were served items not suitable for their dietary needs, such as poppyseed cake and chopped lettuce, instead of the specified alternatives like orange cake without poppyseeds and shredded lettuce. Observations during meal service revealed that the Certified Dietary Manager (CDM) did not measure food portions after pureeing, resulting in inconsistent serving sizes. The CDM was unaware that the addition of liquid during pureeing could alter the final volume, leading to residents receiving less than the required portions. Furthermore, the CDM admitted to not reading the menu spreadsheet and consistently serving inappropriate items to residents on special diets during multiple menu rotations. The Registered Dietitian also indicated unfamiliarity with the correct method for measuring pureed food portions and confirmed that residents on mechanical soft diets should not have received poppyseeds or chopped lettuce. The failure to adhere to the prescribed menus and dietary modifications resulted in residents not receiving meals that met their nutritional needs and physician-ordered therapeutic diets.
Failure to Maintain Food Sanitation and Safe Handling Practices
Penalty
Summary
The facility failed to maintain proper food sanitation and safety practices during food storage, preparation, and service. During a kitchen walkthrough, it was observed that the refrigerator designated for resident food items brought in by families was visibly soiled, lacked thermometers, and had no cleaning or temperature logs. Staff interviews revealed uncertainty regarding responsibility for monitoring and cleaning this refrigerator, and it was acknowledged that it had not been cleaned for an extended period. During lunch service, multiple staff members, including the dishwasher and Certified Dietary Manager (CDM), were observed not wearing required hairnets, and this was not corrected by other staff present. The CDM, while preparing pureed food, used gloved hands to handle food items and, at one point, used her gloved finger to wipe food off a spatula into a steam pan. Another staff member used gloved hands to manipulate baked potatoes during meal plating, despite having access to utensils. These actions were inconsistent with both facility policy and FDA Food Code requirements, which specify the use of utensils and proper glove use to prevent contamination. Additionally, two Certified Nurse Aides entered the kitchen without hairnets to obtain leftover food, and only after being observed were they reminded to wear hairnets. Staff interviews confirmed that expectations for glove use, utensil use, and hair restraint were not consistently followed or enforced. The lack of clear assignment for refrigerator monitoring and cleaning, combined with observed lapses in food handling and personal hygiene practices, contributed to the deficiency.
Failure to Ensure Annual CNA In-Service Training
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) completed the required 12 hours of annual in-service training, as evidenced by personnel record review and staff interviews. Three CNAs, all hired within the past two years, did not have documentation of completed continuing education. The Nurse Manager reported that the previous Business Manager had not been tracking CNA education in the Relias system, and one CNA had not been given access to Relias at all. The facility's own assessment indicated that ongoing training and an educational needs assessment were part of their staff training program, but these requirements were not met for the CNAs reviewed.
Failure to Provide Complete Room Rate Information to Residents
Penalty
Summary
The facility failed to provide complete and accurate information regarding room rates to residents at the time of admission and when rate changes occurred. For four residents reviewed, admission agreements either lacked the specific daily room and board charges or contained incomplete information, such as leaving the rate line blank or filling it in with non-numerical notations like 'SNF' or 'MCD.' In one case, a resident's agreement listed a base rate, but there was no documentation that the resident was notified in writing of a subsequent rate increase, as required by facility policy. Interviews with facility leadership confirmed that the room and board rates should have been clearly documented and communicated to residents or their representatives.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment for two of three residents reviewed. A family member reported concerns about the cleanliness of a resident's room, specifically noting spider webs in the corners and dirty floors. Observations confirmed the presence of spider webs behind a recliner chair, stained bathroom walls, black substances on the tile and floor, missing grout, and heavily soiled floor corners in the resident's room. A similar lack of cleanliness was observed in another resident's bathroom, with stains, missing grout, and black substances present. Interviews with the Housekeeping Manager revealed that these issues had not been reported through the facility's maintenance log, and the concerns behind the toilets had not been addressed. The Corporate Nurse confirmed that staff were expected to report such concerns to the appropriate department head. The facility's assessment indicated that department managers were responsible for maintaining inventory and ensuring preventive maintenance and cleaning schedules were in place, but these procedures were not followed in this instance.
Failure to Notify Family of New Antiviral Medication and Suspected Shingles
Penalty
Summary
The facility failed to notify the family of a resident with severe cognitive impairment, Down syndrome, and intellectual disabilities when a new antiviral medication was started for a possible shingles infection. Clinical documentation showed that the resident developed 12 intact blisters on the left side, prompting the nurse to suspect shingles and contact the physician, who then ordered Valcyclovir. However, there was no documentation that the resident's family was informed about the new medication order or the presence of blisters related to the suspected infection. Staff interviews confirmed that family notification did not occur and that such notifications are expected to be documented, but the facility lacked a specific policy on family notifications.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a Minimum Data Set (MDS) Assessment within the required federal guidelines for one resident. Clinical record review showed that the resident was discharged from the facility on 11/8/24, as documented in both the Census Line and Discharge Summary Note of the Electronic Health Record (EHR). However, upon review of the MDS Section of the EHR on 3/11/25, there was no evidence that a discharge MDS had been set up or completed for this resident. The MDS Coordinator stated that discharge MDS Assessments are typically set up on the day of discharge and are double-checked by the social worker, but she was unsure how this assessment was missed. The Nurse Consultant confirmed that the facility does not have a specific policy for MDS completion and follows the Resident Assessment Instrument (RAI) guidelines, which require a discharge assessment to be completed no later than 14 days after discharge.
Failure to Complete and Document Wound Care and Assessments
Penalty
Summary
The facility failed to complete and document appropriate assessments and interventions for a resident with multiple skin impairments, including a stage three pressure ulcer and bullous pemphigoid. The resident required substantial to maximal assistance with mobility and had diagnoses including hypertension, diabetes, septicemia, and cerebral infarction. The care plan and physician orders directed specific wound care treatments, weekly skin assessments, and dietary interventions, including the use of Juven for wound healing. However, there was a lack of follow-up and clarification regarding the dietary recommendation for Juven, and it was not initiated as recommended by the registered dietician. Observations and record reviews revealed that wound care was not consistently provided or documented according to orders. Staff applied treatments to areas not specified in the physician orders, such as the left buttocks and posterior left thigh, and used foam dressings not included in the treatment orders. Weekly skin assessments and measurements for all affected areas were not completed or documented, and there was no clear record of the progress or status of the wounds, including whether they were improving or deteriorating. Additionally, the clinical record did not reflect that all open areas, such as the left hip, were being treated per the hospital wound clinic's recommendations. Interviews with facility staff confirmed gaps in communication and documentation. The ADON acknowledged that weekly skin assessments were not performed on all areas and that there was no follow-up with the physician regarding the dietary supplement recommendation. The facility's own policy required weekly updates and physician notification for new or worsening wounds, but these procedures were not followed, resulting in incomplete care and documentation for the resident's skin conditions.
Failure to Complete Fall Assessment and Interventions After Resident Fall
Penalty
Summary
The facility failed to provide adequate nursing supervision and follow established protocols to prevent accidents and injuries for a resident identified as being at risk for falls. The resident, who had intact cognition but required substantial to maximal assistance with bed mobility and transfers, experienced a fall while being assisted from a commode to a recliner. The care plan indicated the resident was at risk for falls and included interventions such as the use of a call light for assistance, appropriate footwear, and nonskid strips for safety. Despite these interventions, the resident became weak during a transfer, was lowered to the floor by a CNA, and sustained an abrasion from the nonskid strips. Following the incident, there was a lack of documentation regarding a new fall intervention, root cause analysis (RCA), and follow-up fall assessments, including vital signs. The incident report did not include a new intervention or RCA, and the care plan was not updated to reflect any changes after the fall. Staff interviews revealed uncertainty about whether a gait belt was used during the transfer, and it was noted that some staff used gait belts inconsistently. The CNA involved could not recall if a gait belt was used, and the resident reported that staff varied in their use of this safety device. Further interviews with nursing staff and administration confirmed that the required risk management and RCA processes were not completed due to incorrect coding of the incident report. The facility's policy required all accidents and incidents to be reported, investigated, and reviewed, with immediate actions and interventions documented. However, these procedures were not followed after the resident's fall, resulting in a failure to implement additional safety measures or conduct a thorough investigation as required by facility policy.
Failure to Provide Physician-Ordered Respiratory Care
Penalty
Summary
The facility failed to provide physician-ordered respiratory care for three residents with significant cardiac and respiratory diagnoses. For one resident with atrial fibrillation, heart failure, and respiratory failure, observations showed her oxygen cannula was not connected to the concentrator, leaving her without prescribed oxygen. Family members reported repeated incidents where the resident's oxygen supply was disconnected or depleted, including during out-of-facility appointments and while in the dining room, with staff unaware of the issue. Care conference notes documented ongoing family concerns about the resident not receiving oxygen as ordered. Another resident with atrial fibrillation and pneumonia was observed receiving oxygen at a higher flow rate than ordered, with staff unaware of the correct physician order, which had not been processed after hospital discharge. A third resident with coronary artery disease and respiratory failure was seen short of breath and flushed while using a portable oxygen tank that was empty, with staff failing to monitor and replace the tank as needed. The facility lacked a policy for following or documenting physician orders, and staff interviews confirmed gaps in communication and adherence to prescribed respiratory care.
Failure to Use Enhanced Barrier Precautions During Tube Feeding
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions (EBP) during care for a resident who had recently returned from the hospital with a feeding tube due to aspiration pneumonia. Nursing notes indicated that the resident was totally dependent on staff for transfers, toileting, and meals, and tube feedings were initiated upon return to the facility. During an observation, a registered nurse donned disposable gloves but did not wear a gown while administering tube feedings and water flushes through a syringe. Facility policy required staff to use EBP, including gowns, for residents with indwelling medical devices such as feeding tubes, and staff were expected to be competent in these precautions.
Pest Control Deficiency Leads to Bed Bug Infestation
Penalty
Summary
The facility failed to establish and implement an effective pest control program, leading to an infestation of bed bugs in the rooms of two residents. On December 8, 2024, staff reported the presence of bugs in the room shared by two residents. Despite the initial sighting, staff were uncertain about the steps to take to mitigate the spread of the pests, which were later confirmed to be bed bugs. The facility lacked a specific policy or procedure for dealing with such infestations, resulting in confusion and delayed action. Resident #1, who had a moderate cognitive deficit and required substantial assistance with daily activities, was moved to a different room after bugs were found. However, the resident expressed uncertainty about the situation and desired to return to his original room. Resident #2, who had intact cognitive ability and was independent in most activities, passed away shortly after the incident. The housekeeping staff removed a recliner from the room, but other items were left, and the residents were not immediately relocated or showered. Interviews with staff revealed a lack of training and awareness regarding pest control procedures. The Housekeeping Supervisor and other staff members were unsure of the appropriate actions to take, and there was no documentation of skin assessments for the residents. The pest control company confirmed the presence of bed bugs on December 10, 2024, but the facility's response was inadequate due to the absence of a detailed policy and staff education on handling such situations.
Failure to Adhere to Food Safety and Infection Control Standards
Penalty
Summary
The facility failed to store, prepare, serve, and distribute food in accordance with professional standards. Observations revealed that staff members, including the Cook/Dietary and Dietary Manager, inconsistently practiced hand hygiene while donning and doffing gloves during meal preparation and service. Staff A was observed touching various surfaces and food items without changing gloves or washing hands properly. Similarly, the Dietary Manager and Staff B also failed to perform hand hygiene between glove changes and upon entering the kitchen, which is against the facility's infection control policies. Additionally, the resident unit refrigerator was found to be improperly maintained. The refrigerator, located in the staff break room, lacked a temperature log and contained multiple items without names or opened dates. Some items were significantly past their best-by dates, and the freezer was dirty and disorganized. The Administrator acknowledged that there was no designated person responsible for monitoring the refrigerator, despite the facility's policies requiring regular checks and proper labeling of food items. These deficiencies indicate a failure to adhere to infection control and food safety standards as outlined in the facility's policies.
Failure to Complete PASRR Evaluation for Resident with New Diagnoses
Penalty
Summary
The facility failed to refer a resident with an initial negative Level I result for the Pre-Admission Screening and Resident Review (PASRR) to the appropriate state-designated authority for a Level II PASRR evaluation and determination. This deficiency was identified for one of four residents reviewed. Specifically, Resident #14 had a Minimum Data Set (MDS) indicating severe cognitive impairment and diagnoses of non-Alzheimer's dementia, depression, and bipolar disorder. Despite these new diagnoses, the facility did not complete a new PASRR evaluation as required by regulations. During interviews, staff acknowledged that a new PASRR should have been completed following the new diagnoses. The Social Services staff and the Director of Nursing (DON) both stated that their expectation was for a new PASRR evaluation to be conducted after any new diagnosis that could potentially change the PASRR status. However, the facility did not have a specific policy for PASRR and claimed to follow the regulations, which led to the oversight in Resident #14's case.
Failure to Review PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that as-needed (PRN) orders for psychotropic medications did not exceed 14 days without physician review for one resident. Resident #52, who had severe cognitive impairment with diagnoses of Alzheimer's disease, anxiety, and depression, had a PRN order for lorazepam intensol oral concentrate without a specified stop date. The medication was administered 15 times in March, 31 times in April, and 4 times in May. The Director of Nursing (DON) acknowledged that the PRN psychotropic medication had not been reviewed with the physician and stated that the facility did not have a policy for reviewing PRN psychotropic medications, although they followed regulations.
Failure to Obtain Bed Hold Notifications
Penalty
Summary
The facility failed to obtain bed hold notifications for four residents who were transferred to the hospital or on therapeutic leave. Specifically, Resident #11 had an unpaid hospital leave from 11/14/23 through 11/17/23, Resident #45 had a discharged hospital stay from 4/26/24 through 5/1/24, Resident #15 had an unpaid hospital leave from 4/1/24 to 4/5/24, and Resident #43 had an unpaid hospital leave from 2/2/24 to 3/5/24. In all these cases, the facility did not provide the required bed hold notifications as mandated by federal regulations. During an interview, the Director of Nursing (DON) acknowledged that the facility did not have the bed hold notifications for the mentioned residents and believed that social services were responsible for completing them. The facility's policy, dated 5/15/23, requires providing written notice regarding transfer to the hospital and appeal rights, but this was not adhered to in these instances. The facility reported a census of 50 residents at the time of the survey.
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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.
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