Accura Healthcare Of Cresco
Inspection history, citations, penalties and survey trends for this long-term care facility in Cresco, Iowa.
- Location
- 701 Vernon Road Sw, Cresco, Iowa 52136
- CMS Provider Number
- 165490
- Inspections on file
- 26
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Accura Healthcare Of Cresco during CMS and state inspections, most recent first.
The facility did not ensure that an RN was on duty for at least eight consecutive hours on multiple days over a multi‑month period, despite having a census of 26 residents. Review of nursing schedules and staff interviews confirmed repeated dates with no RN coverage, and the Administrator acknowledged that RN staffing was an ongoing problem. The facility assessment noted that the facility was working toward meeting minimum staffing requirements.
A resident with paraplegia and a stage 4 sacral pressure ulcer had specific wound clinic orders for acetic acid application, Calmoseptine to the buttock wound, Melgisorb Ag to the wound base, air time, and then ABD dressing with tape. An RN did not leave the acetic acid–soaked gauze in place for the ordered duration, did not provide ordered air time, placed the resident on the bed without a barrier and with the wound uncovered, and repeatedly touched the computer and wound care supplies without performing hand hygiene. The RN also used the same gloved hand to apply Calmoseptine to multiple wounds and then handle and cut Melgisorb Ag before dressing the wound and documenting the treatment as completed per orders.
Two residents were transferred to other facilities without completed discharge summaries or necessary documentation. Both residents arrived at their new locations without paperwork, causing delays in obtaining admission orders and necessary treatments. Receiving providers had to contact the original facility multiple times to obtain essential information for ongoing care.
Two residents with PICC lines did not have care plans that documented the presence of the device, associated risk factors, or required monitoring, despite receiving IV medications and having relevant medical conditions. This was confirmed through record review, staff interview, and policy review.
The facility did not follow professional standards for assessing and documenting the status of PICC lines for two residents receiving IV medications. For both residents, there was no documentation of PICC site, location, or length assessments in the medical record, and required monitoring per facility policy was not performed or recorded.
A resident's trust account was not closed within the required timeframe after discharge, and the facility continued to deposit and withdraw funds from the account without the resident's knowledge or authorization. The resident was cognitively intact and managed his own finances, yet the facility failed to follow policy and regulatory requirements for account closure and proper authorization of transactions.
After the departure of the Restorative Aide, the facility discontinued all restorative programs for several residents with no documentation or rationale, and failed to conduct required monthly reviews. Staff interviews revealed a lack of training and oversight, with the DON confirming that programs were ended for staff convenience rather than resident need.
A resident with multiple chronic conditions and at risk for pressure ulcers was found by a CNA to have an open, red, and bleeding scrotum during a shower. The issue was documented on a skin monitoring form, but there was no evidence that a nurse assessed the area or that a physician was notified as required by facility policy. The DON was not informed at the time, and the area was not properly tracked or monitored.
A resident with cognitive impairment and multiple diagnoses did not receive prescribed artificial tears for 14 days due to supply issues, with no documentation of physician notification or timely pharmacy ordering. Staff interviews confirmed awareness of the shortage, and facility policy lacked clear instructions for handling unavailable medications.
A resident with severe cognitive impairment and a history of wandering accessed a key code locked basement door, fell down the stairs, and sustained injuries including a hematoma and abrasions. The care plan identified elopement and fall risks, but the resident was able to bypass the locked door, and staff were unaware of the door's vulnerability. The incident revealed a failure to ensure a hazard-free environment and adequate supervision.
A Dietary Manager's personnel file lacked documentation of required dependent adult abuse training within the mandated timeframe. Facility policy requires this training for all employees, but the employee could not provide proof of completion, and the Administrator confirmed the absence of documentation.
A resident with severe cognitive impairment and behavioral issues kicked another resident, who also had severe cognitive impairment and was on hospice care. Despite facility policy requiring notification, neither the family nor the physician of either resident was informed of the incident, and this was confirmed by staff interviews and clinical record review.
A resident with severe cognitive impairment and a history of aggressive behaviors repeatedly physically and verbally targeted another resident with significant cognitive and physical disabilities. Despite multiple documented incidents and staff awareness of the ongoing abuse, the care plan lacked interventions to address or prevent these behaviors until after a major incident occurred. Staff interviews confirmed the pattern of aggression and the absence of timely reporting or protective measures.
A resident was kicked in the face by another resident in the dining room, an incident witnessed by dietary staff. The facility did not report this abuse allegation to the Iowa Department of Inspections, Appeals, and Licensing as required by policy, and there was no documentation of the event being reported.
A resident with severe cognitive impairment and a documented history of physical and verbal aggression repeatedly exhibited abusive behaviors toward another resident and staff, including kicking and hitting, over an extended period. Despite these incidents being recorded in progress notes, no care plan interventions or investigations were initiated until much later, contrary to facility policy requiring prompt investigation of abuse.
A facility failed to complete a background check for a CNA before employment, violating its abuse prevention policy. The CNA worked several shifts over months without the required checks, despite the facility's policy mandating screening for abuse history prior to hiring. The Business Office Manager could not locate the background check and was unsure why it was not completed.
The facility was found deficient in maintaining cleanliness and proper maintenance in its kitchen and dining areas. Observations revealed multiple stains on the dining room carpet and a large black discoloration on the kitchen stove cooktop. Additionally, the kitchen floor had missing tile sections with black discoloration. The DON confirmed that the carpet's condition had been discussed in QA meetings due to infection control concerns, but no plan was in place to address it.
A facility failed to implement comprehensive care plans for two residents. One resident with a Stage 4 pressure ulcer lacked specific interventions in her care plan. Another resident on psychotropic medications and with HSV did not have documented adverse reaction monitoring or interventions in her care plan. The DON acknowledged these deficiencies.
A facility failed to conduct daily nursing assessments for a resident who tested positive for SARS-CoV-2. The resident, who was very weak and required assistance with all cares, did not have any documented assessments or vital signs on a specific day, indicating a lapse in care. The DON expected routine assessments every 12 hours, but this was not adhered to, leading to a deficiency in the care provided.
A facility failed to complete required pre and post-dialysis assessments for a resident with renal insufficiency, as documented in their care plan. The resident, who is cognitively intact, receives dialysis three times a week. A review of the EHR showed missing assessments over a 90-day period. Staff interviews confirmed the assessments were not completed, and the facility lacked a dialysis policy.
A facility failed to ensure proper monitoring and documentation for a resident on anti-viral medication. The resident's EHR lacked the HSV diagnosis, and the valacyclovir prescription did not specify a diagnosis. The care plan did not document the HSV diagnosis or necessary interventions, and the pharmacy did not review the medication usage. The DON expected pharmacy oversight, as outlined in the Medical Director's responsibilities.
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers. Record reviews showed that two residents were hospitalized without documentation of notification. The DON confirmed the absence of such documentation, despite the facility's policy requiring nurses to complete a packet including the bed-hold notice during transfers.
The facility did not have a Registered Nurse (RN) on duty for eight consecutive hours on several days, as required by federal regulations. A review of RN timesheets showed the absence of an RN on specific dates, which was confirmed by the Administrator. The facility had 27 residents at the time.
A resident with cognitive impairment repeatedly eloped from a facility due to unsecured doors and inadequate lighting. The resident accessed an unlocked medication cart, taking cigarettes and going outside unsupervised. Staff interviews and observations confirmed that medication carts were often left unattended, and the facility failed to address maintenance issues, contributing to the resident's elopement.
A resident reported waiting 45 minutes for assistance, highlighting the facility's failure to answer call lights within the professional standard of 15 minutes due to staffing issues. Additionally, the facility did not provide restorative exercises as per the resident's care plan, as confirmed by staff interviews. The lack of an active restorative program was attributed to low staffing levels, with a restorative aide often reassigned to other duties.
The facility failed to properly manage and secure narcotic medications, with issues in documentation and accountability. A resident received Baclofen without a nurse's signature, and staff often failed to sign Controlled Drug Count Records. Interviews revealed that the ADON accessed medication carts and administered drugs without proper documentation. The facility's policy for handling narcotics was not consistently followed, leading to significant deficiencies in medication management.
The facility failed to provide necessary treatment supplies for two residents, resulting in incomplete wound care due to the unavailability of Silversorb gel and other items. Additionally, staff lacked access to a policy and procedure book, as the Administrator provided an employee handbook instead. The Administrator acknowledged the issue of restricted access to the P drive where policies were stored, and efforts were underway to organize a policy book.
A resident with cognitive impairments and a history of elopement was able to leave a secure courtyard area due to a malfunctioning garage door latch and nonfunctional floodlights. The facility allowed residents to enter the courtyard unattended, contributing to the incident. The administrator failed to report these issues to the corporate office, and the maintenance director only temporarily secured the door, leading to multiple elopement incidents.
A facility failed to report alleged financial exploitation and drug diversion to management and state authorities. Staff reported missing narcotics and muscle relaxers, but the Administrator allegedly ignored these reports. Staff feared retaliation for contacting corporate. The Administrator received a report of drug diversion late, and the Regional Clinical Quality Specialist was only informed of Flexeril discrepancies. The facility's policy required immediate reporting of such issues.
A facility failed to maintain an accurate care plan for a resident with COPD and incontinence. The resident's care plan, requiring assistance with a walker and gait belt, was not updated to reflect a change in mobility status to modified independence with a front-wheeled walker indoors. This discrepancy was confirmed by a CNA, highlighting a failure to adhere to the facility's policy for timely care plan updates.
The facility failed to assess pressure areas for two residents and did not follow medication orders for a resident, leading to delayed treatment and dissatisfaction. A resident's pressure area was not assessed for several days, and another resident's medications were administered late, contrary to the facility's policy.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to provide required Registered Nurse (RN) coverage for eight consecutive hours per day on 26 days between November 1, 2025, and January 25, 2026, while reporting a census of 26 residents. Review of nursing schedules showed that in November 2025 there was no RN coverage on the 8th, 9th, 15th, 16th, 22nd, 23rd, 27th, 29th, and 30th; in December 2025 there was no RN coverage on the 6th, 7th, 13th, 14th, 20th, 21st, 25th, 27th, and 28th; and in January 2026 there was no RN coverage on the 1st, 3rd, 4th, 11th, 17th, 18th, 24th, and 25th. Staff interviews and schedule review confirmed that the facility did not have an RN in the building for the required eight hours on these dates. The Administrator acknowledged that RN coverage was an ongoing issue and verified the lack of RN coverage on the identified dates. The facility assessment documented that the facility would continue working toward a staffing level that meets the minimum staffing final rule. No specific resident medical histories or conditions at the time of the deficiency were described in the report.
Failure to Follow Ordered Pressure Ulcer Treatment and Aseptic Technique
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer treatment as ordered for a resident with a stage 4 sacral pressure ulcer and paraplegia. The resident’s MDS showed intact cognition with a BIMS score of 15 and documented diagnoses including paraplegia and a stage 4 sacral pressure ulcer. Wound clinic orders dated 12/18/25 directed staff to apply acetic acid–dampened gauze to the wound base and surrounding skin and leave it in place for 10–15 minutes, then remove it, apply Calmoseptine around the left buttock wound, apply Melgisorb Ag (calcium alginate) to the wound base, pat dry, allow 30 minutes of air time, and then return to place an ABD pad secured with Medipore tape. During an observed wound treatment, the RN reviewed the order on the computer, performed hand hygiene, donned gloves, and opened gauze, placing half of it on supplies without a barrier. The RN touched the computer with gloved hands, dampened gauze with acetic acid, and cleansed the wound but did not leave the acetic acid–dampened gauze in place for the ordered 10–15 minutes. The resident was rolled onto her back without a barrier and the area was left uncovered while the RN applied pain cream to the resident’s shoulder. Later, the RN again touched the computer and then donned gloves without hand hygiene, used a gloved finger to obtain and apply Calmoseptine to two sacral wounds, and with the same gloved hand handled and cut Melgisorb Ag and placed it on the wound base. The RN then changed gloves without performing hand hygiene, applied an ABD pad, secured it with tape, and documented completion of the treatment. The DON acknowledged that the treatment was not completed per the physician’s orders.
Failure to Provide Discharge Summaries and Documentation During Resident Transfers
Penalty
Summary
The facility failed to complete and provide discharge summaries and necessary documentation to the receiving facilities for two residents who were transferred. For one resident with intact cognition and diagnoses including cellulitis, lymphedema, and hypertension, the electronic health record did not contain a completed discharge summary or evidence of communication with the receiving provider. The receiving facility reported delays in obtaining admission orders, which resulted in delayed medication and treatments, as the resident arrived without any paperwork or discharge summary. The facility's own discharge planning policy requires all relevant information to be provided in a discharge summary to facilitate a smooth transition and avoid unnecessary delays. Another resident, also with intact cognition and diagnoses of depression, anemia, and hypertension, was discharged to another facility without a completed discharge summary or documented communication with the receiving provider. The resident reported that the discharge process was rushed, and no discharge paperwork or orders were sent with her. The receiving facility confirmed that no discharge records accompanied the resident and that they had to repeatedly contact the prior facility to obtain the necessary information for care.
Failure to Address PICC Line Care in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement care plans that addressed the presence of Peripherally Inserted Central Catheters (PICC) and associated risk factors for two residents. For one resident with severely impaired cognition and diagnoses including heart failure, anemia, and hypertension, the care plan did not document the existence of a PICC line or include interventions and monitoring related to the device, despite the resident receiving IV medications through the PICC. The Director of Nursing acknowledged that the care plan lacked this essential information. Similarly, another resident with intact cognition and diagnoses of osteomyelitis, pneumonia, and hypertension was discharged from the hospital with a PICC line and received IV medications in the facility. However, the care plan for this resident also failed to document the presence of the PICC line, associated risk factors, or necessary monitoring. These omissions were identified through clinical record review, staff interview, and policy review, and were inconsistent with the facility's policy requiring comprehensive, person-centered care plans that address all identified needs and services.
Failure to Assess and Document PICC Line Status for Residents Receiving IV Therapy
Penalty
Summary
The facility failed to follow professional standards for the assessment and documentation of Peripherally Inserted Central Catheter (PICC) lines for two residents who required IV medications. For one resident with severe cognitive impairment and diagnoses including heart failure, anemia, and hypertension, there was no documentation in the electronic health record of any assessment of the PICC site, its location, or length during the resident's stay. The admission assessment also did not note the presence of a PICC line, and the discharge summary indicated the central line was removed due to occlusion. The Director of Nursing confirmed that nurses were expected to assess the site when administering medication but acknowledged that there was no documentation to support that these assessments occurred, nor were measurements of the catheter performed to ensure it had not moved out of place. Similarly, another resident with intact cognition and diagnoses of osteomyelitis, pneumonia, and hypertension had a PICC line on admission, but the electronic health record lacked documentation of any assessment of the PICC site, location, or length. The admission assessment also failed to document the presence of a PICC line. Facility policy required nurses to monitor the dressing, line, and resident every shift for signs of infection, malposition, or occlusion, and to document these assessments, but this was not done for either resident.
Failure to Timely Close Resident Trust Account and Unauthorized Transactions Post-Discharge
Penalty
Summary
The facility failed to close a resident's trust account within 30 days of discharge, as required by both facility policy and federal regulations. After discharge, the resident, who was cognitively intact and managed his own financial affairs, continued to have income deposited into and funds withdrawn from his trust account by the facility without his knowledge or authorization. The facility was not the representative payee for the resident, and there was no documentation authorizing these post-discharge transactions. Bank statements and trust transaction histories confirmed that deposits and withdrawals occurred for several months after the resident's discharge. Additionally, the facility did not provide documentation that the trust account had been closed or that a refund of the remaining balance had been processed in a timely manner. The administrator acknowledged the ongoing balance in the account and the lack of proper authorization for the transactions. Facility policy required that trust accounts be closed within 24 hours of discharge and refunded within 30 days, with all disbursements properly authorized, but these procedures were not followed in this case.
Failure to Document and Maintain Restorative Programs After Staff Departure
Penalty
Summary
The facility failed to provide documentation and rationale for discontinuing restorative programs for three residents after the designated Restorative Aide left the restorative nursing department. Record reviews showed that for each resident, restorative programs such as active range of motion exercises and other therapeutic activities were discontinued on the same date, with no evidence of monthly restorative program reviews or documented reasons for stopping the interventions. The residents involved had varying degrees of cognitive impairment and physical limitations, including needs for assistance with ambulation, dressing, and other activities of daily living, as well as diagnoses such as diabetes, obesity, muscle weakness, heart failure, anxiety, and depression. Interviews with facility staff revealed that the MDS Coordinator, who was responsible for overseeing the Restorative Program, had minimal training and had not completed any charting or reviews of restorative plans since assuming the role. The discontinuation of all restorative programs was attributed to the absence of a trained Restorative Aide, and no alternative arrangements or documentation were made to continue or review the programs. The Director of Nursing confirmed that all restorative programs were resolved or discontinued for staff convenience, and there had been no RN monthly restorative reviews for any residents in the past six months.
Failure to Document Nursing Assessment After Skin Issue Identified
Penalty
Summary
A deficiency occurred when the facility failed to document a nursing assessment after a bath aide identified an open, red, and bleeding scrotum on a resident. The resident, who had diagnoses including diabetes, heart failure, and chronic obstructive pulmonary disease, was dependent on staff for toileting hygiene and required substantial assistance with transfers. The resident was also at risk for pressure ulcers. The Certified Nursing Assistant (CNA) documented the skin issue on a shower review form, but there was no evidence in the progress notes from the date of discovery through several days later that a nurse assessed the area or that a physician was notified. Interviews revealed that the CNA reported new skin issues using a designated form, which was then placed in the MDS Coordinator's mailbox. The MDS Coordinator charted a note several days after the initial finding but did not verify that the area was tracked or monitored. The Director of Nursing (DON) was not made aware of the issue at the time and did not assess the area until days later, by which time only chronic redness was observed. Facility policy required notification of the DON and wound nurse for new skin alterations, completion of incident reports, and physician notification if deterioration or infection was observed, but these steps were not documented as completed in this case.
Failure to Administer Ordered Medication and Notify Physician
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition, diabetes, dementia, and hemiplegia did not receive their ordered artificial tears for 14 days, missing 55 doses. The September Medication Administration Record showed the medication was not administered from 9/10/25 through 9/24/25. There was no documentation in the resident's progress notes indicating that the physician was notified about the unavailability of the artificial tears or that the resident was not receiving the medication as ordered. Staff interviews revealed that the facility was aware the artificial tears were on back order with the stock supply distributor, but the medication was not ordered through the pharmacy until 9/24/25, when a nurse called the pharmacy and the medication was delivered later that day. The facility's policy instructed nurses to report supply deficiencies to the DON but did not provide guidance on notifying the prescriber or pharmacist when medications were unavailable. The DON confirmed that the physician should have been notified when medications were not received.
Resident with Cognitive Impairment Accesses Locked Door, Falls Down Stairs
Penalty
Summary
A resident with severe cognitive impairment, dementia, and a history of wandering and elopement risk was not adequately protected from accident hazards within the facility. The resident's care plan identified risks for elopement and falls, directing staff to provide supervision, diversions, and structured activities to prevent wandering. Despite these interventions, the resident was last seen in the dining room with staff before going missing. Staff initiated a search, including looking outside, and eventually found the resident at the bottom of a basement staircase, having accessed a key code locked door with his wheelchair and fallen down the stairs. The incident report documented that the resident sustained a hematoma to the face and right forearm, as well as an abrasion and bruise to the left hand, requiring evaluation at the emergency room. Staff interviews revealed that the resident may have figured out the code to the basement door, which was supposed to be locked. Observations showed that the door had a key code lock with a deadbolt latch that, if turned, would allow the door to open without entering the code, although the keys would still light up as if the code was being entered. Staff were generally unaware that the door could be accessed in this manner, and some were not even aware of the basement's existence. The maintenance staff confirmed that the door and lock were functioning as intended upon inspection, and that the door was supposed to lock automatically. However, the incident demonstrated that the resident was able to access the basement, leading to a fall and injury. The facility census at the time was 29 residents, and the event highlighted a failure to ensure the environment was free from accident hazards and that adequate supervision was provided to prevent accidents for this resident.
Lack of Documentation for Dependent Adult Abuse Training
Penalty
Summary
The facility failed to provide required dependent adult abuse training within six months of hire for one of five employees reviewed. Personnel file review for the Dietary Manager showed a hire date of 1/20/23, but there was no documentation of the mandatory Dependent Adult Abuse training in the employee's file. Facility policy requires each employee to complete a two-hour initial training, followed by a one-hour recertification every three years. During an interview, the Administrator confirmed that the training documentation was missing from the employee's file, and the employee was unable to provide proof of completion, despite claiming to have taken the training in 2023.
Failure to Notify Family and Physician of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to notify both the family and physician of an incident involving resident-to-resident abuse. Specifically, a resident with severe cognitive impairment and a history of physical and verbal behaviors was documented as having kicked another resident in the face. Progress notes indicated that the nurse observed the incident and addressed the behavior with the resident, but there was no documentation that the physician or the family of either resident involved were informed of the event. The facility's risk management policy requires that such incidents be reported to the appropriate parties, including the physician and family, and that a progress note be entered in the resident's chart. Both residents involved had severe cognitive impairment, with one resident also diagnosed with Alzheimer's disease, Down Syndrome, and moderate intellectual disabilities, and was on hospice care. Despite these vulnerabilities, the clinical records for both residents lacked evidence that their families or physicians were notified about the incident. Staff interviews confirmed that the family should have been informed, but this did not occur, constituting a failure to follow facility policy and ensure appropriate communication after a significant event.
Failure to Prevent and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from repeated physical abuse by another resident, despite multiple documented incidents of aggressive behavior. One resident with severe cognitive impairment and a history of both physical and verbal aggression, including wandering, was involved in several altercations targeting another resident. These incidents included attempts to kick, ramming with a wheelchair, verbal insults, and physical attacks such as kicking in the face and legs. Staff progress notes documented a pattern of escalating behaviors over several months, with specific references to the aggressor seeking out and targeting the same resident multiple times. Despite these ongoing incidents, the resident's care plan did not include interventions to address or prevent abusive behaviors toward others until after a significant incident occurred. Staff interviews confirmed awareness of the aggressor's pattern of seeking out and attempting to harm the other resident, yet no specific measures were implemented to prevent further abuse prior to the addition of interventions on the care plan. The facility's own abuse prevention policy defines resident-to-resident physical contact resulting in harm, pain, or mental anguish as abuse, and presumes such outcomes in residents with cognitive or physical impairments, even if no immediate injury is observed. The resident who was targeted had severe cognitive impairment, Alzheimer's disease, Down Syndrome, moderate intellectual disabilities, and was on hospice care. There were no behaviors noted for this resident during the assessment period. Staff and administrative interviews revealed a lack of timely reporting and investigation of the incidents, as well as a failure to notify family and the physician. The deficiency centers on the facility's inaction in updating the care plan and implementing protective interventions despite clear evidence of ongoing abuse.
Failure to Report Resident-to-Resident Abuse to Authorities
Penalty
Summary
The facility failed to report an incident of resident-to-resident abuse to the Iowa Department of Inspections, Appeals, and Licensing (DIAL) as required by policy. Specifically, a resident was kicked in the face by another resident in the dining room, an event witnessed by dietary staff. Review of facility records showed no documentation that this incident was reported to DIAL. The facility's policy mandates that all allegations of abuse, neglect, or mistreatment be reported to the appropriate authorities within specified timeframes, but this protocol was not followed in this case. The administrator confirmed during an interview that such incidents should be reported to DIAL, yet the required reporting did not occur.
Failure to Investigate and Intervene in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate and implement interventions in response to multiple incidents of resident-to-resident abuse involving a resident with severe cognitive impairment and a history of physical and verbal aggression. Clinical record review showed that this resident exhibited repeated aggressive behaviors, including kicking, hitting, and verbal abuse directed at another resident and staff over several months. Despite documentation of these behaviors in progress notes, there were no care plan interventions addressing the resident's abusive behaviors toward others until a focused area and interventions were added months after the initial incidents. Interviews with facility leadership confirmed that no actions were taken to address or investigate the incidents prior to the addition of care plan interventions. The administrator stated that she would have investigated the abuse if she had been made aware of it, and the DON acknowledged that staff did not report the incidents as required. Facility policy directs that any observed or suspected abuse should be investigated by management, but this protocol was not followed in these cases.
Failure to Complete Background Check for CNA
Penalty
Summary
The facility failed to complete a background check for one of its current employees, a Certified Nurse Aide (CNA) referred to as Staff B, prior to employment. This deficiency was identified during a review of records, staff interviews, and policy review. The facility's policy mandates that all potential employees be screened for a history of abuse, neglect, exploitation, misappropriation of property, or mistreatment of residents before hiring. However, the background check for Staff B was only completed on January 8, 2025, despite her having worked several hours at the facility since August 2024. During an interview, the Business Office Manager was unable to locate the background check for Staff B when requested. She stated that she typically runs a background check before hiring an employee and was unsure why it was not completed or if it was misplaced. The facility's policy requires conducting an Iowa criminal record check and dependent adult/child abuse registry check on all prospective employees prior to hire, as per the Iowa Administrative Code. Despite this requirement, Staff B worked multiple shifts over several months without the necessary background check being completed, which is a violation of the facility's abuse prevention policy.
Facility Maintenance and Cleanliness Deficiency
Penalty
Summary
The facility failed to maintain cleanliness and proper maintenance in its kitchen and dining areas, as observed during a survey. In the dining room, there were multiple stains on the carpet, with the largest stain measuring approximately 10 feet by 3 feet, located next to lower cabinets in the common areas. In the kitchen, the stove cooktop had a large area of black discoloration on the stainless steel part, and the floor had multiple tiles missing sections with black discoloration between them. The Director of Nursing (DON) acknowledged that the carpet's condition had been discussed in Quality Assurance meetings due to infection control concerns and stains, but no plan was in place to address the issue.
Deficiencies in Care Plan Implementation for Pressure Ulcers and Medication Monitoring
Penalty
Summary
The facility failed to comprehensively assess and implement necessary interventions for pressure ulcers and other medical conditions for two residents. Resident #6, who had a Stage 4 pressure ulcer in the sacral region, did not have specific interventions documented in her care plan to address her condition. This oversight was identified during a record review of her care plan dated 1/7/2024, which lacked resident-specific interventions for her pressure ulcer, despite an After Visit Summary dated 12/5/2024 indicating the severity of her condition. Additionally, Resident #24, who was on multiple psychotropic medications, did not have a care plan that documented adverse reactions to monitor for or interventions and goals related to her medication use. Furthermore, her care plan lacked documentation of her diagnosis of Herpes Simplex Virus (HSV) and the necessary interventions and monitoring for her condition, despite her admission orders indicating she was on prophylactic Valtrex. The Director of Nursing acknowledged these deficiencies, stating that she would have expected comprehensive care plans for both residents, including interventions for pressure ulcers, psychotropic medication monitoring, and HSV management.
Failure to Conduct Daily Assessments for SARS-CoV-2 Positive Resident
Penalty
Summary
The facility failed to ensure that a resident who tested positive for SARS-CoV-2 received daily nursing assessments as required. The resident, identified as Resident #80, was placed in isolation due to the positive test result. Despite the resident's condition of being very weak and requiring assistance with all cares, the facility did not document any assessments or vital signs for the resident on January 8, 2025. This lack of documentation indicates that no assessments were completed on that day. The Director of Nursing (DON) stated that she would expect a SARS-CoV-2 positive resident to receive routine assessments at least every 12 hours, including a full head-to-toe assessment documented in the resident's Electronic Health Record (EHR). The facility's Agreement for Medical Director Services outlines the responsibilities of the Medical Director, which include the surveillance of the health status of residents and acting as a consultant to the Administrator and/or DON. However, the facility did not adhere to these expectations, resulting in a deficiency in the care provided to Resident #80.
Incomplete Dialysis Assessments for Resident
Penalty
Summary
The facility failed to provide complete dialysis assessments for a resident requiring such services. Resident #16, who is cognitively intact with a BIMS score of 15, has diagnoses including heart failure, hypertension, and renal insufficiency, and receives dialysis three times a week. The care plan for Resident #16 included specific instructions for monitoring vital signs and conducting pre and post-dialysis assessments on dialysis days, as well as monitoring for signs of infection and renal insufficiency. However, a review of Resident #16's Electronic Health Record (EHR) revealed missing pre and post-dialysis assessments on multiple occasions over a 90-day period. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed that these assessments were not completed as required. Additionally, the facility lacked a dialysis policy, which may have contributed to the oversight in completing the necessary assessments.
Failure to Ensure Proper Monitoring and Documentation for Anti-Viral Medication
Penalty
Summary
The facility failed to ensure proper routine monitoring and documentation for a resident receiving anti-viral medication. The resident, who was admitted with a diagnosis of Herpes Simplex Virus (HSV), was prescribed prophylactic valacyclovir. However, the resident's current diagnoses in the Electronic Health Record (EHR) did not include HSV, and the Order Summary Report did not specify the diagnosis for the valacyclovir prescription. Additionally, the resident's progress notes lacked a review by the facility's pharmacist and did not include a request for the rationale behind the valacyclovir usage. Furthermore, the resident's current care plan did not document the HSV diagnosis or the interventions needed for managing the condition. It also failed to mention the anti-viral medication and the potential adverse reactions to monitor. During an interview, the Director of Nursing expressed an expectation for the pharmacy to ensure proper diagnoses are in place for all medications. The facility's agreement with the Medical Director outlined responsibilities for coordinating medical care, including policy development and health status surveillance, but these were not adequately fulfilled in this case.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of the bed-hold policy to residents or their representatives during hospital transfers, as required. This deficiency was identified through a review of records, staff interviews, and policy documents. Specifically, the records for three hospitalizations involving two residents lacked documentation that the residents or their Power of Attorneys (POAs) were informed of the facility's bed-hold policy. Resident #15 was discharged to the hospital and returned without any record of notification, and Resident #16 experienced two hospitalizations with no documentation of notification. The Director of Nursing confirmed the absence of such documentation and explained that the nurse on duty is responsible for completing a packet that includes the bed-hold notice during acute transfers, which was not done in these cases. The facility's Acute Care Transfer Checklist requires the completion of an emergency notice of transfer/discharge and a notice of bed-hold policy and return, which was not adhered to in these instances.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to comply with federal regulations requiring a Registered Nurse (RN) to be on duty for eight consecutive hours each day. A review of RN timesheets from May 26, 2024, through June 6, 2024, revealed that the facility did not have an RN on duty on May 27, 2024, and from June 4 to June 6, 2024. The facility had a census of 27 residents during this period. The deficiency was confirmed during an interview with the Administrator on June 7, 2024, at 3:15 p.m., who acknowledged the failure to provide the required RN coverage.
Facility Fails to Secure Environment and Medication Carts
Penalty
Summary
The facility failed to maintain a safe and secure environment for a resident with multiple diagnoses, including schizophrenia, bipolar disorder, and moderate cognitive impairment. The resident, who was at high risk for elopement and moderate risk for falls, was found outside the facility on multiple occasions. On one occasion, the resident was found in a garage after leaving the courtyard through an unsecured door. The garage door had been previously reported as faulty, and temporary measures to secure it were inadequate. Additionally, the courtyard was inadequately lit, further compromising safety. Staff interviews revealed that residents were allowed to enter the courtyard unattended, even at night, which contributed to the resident's ability to leave the area unnoticed. The facility's maintenance director confirmed that the floodlight outside the garage was nonfunctional, and the administrator failed to notify the corporate office about the malfunctioning door and lights. This lack of communication and oversight contributed to the resident's repeated elopement incidents. Furthermore, the facility failed to secure medication carts, allowing the resident to access them unsupervised. On one occasion, the resident took cigarettes from an unlocked medication cart and went outside to smoke, later becoming upset when denied another smoke break. Observations confirmed that medication carts were left unlocked and unattended in areas accessible to residents, posing a risk to cognitively impaired individuals.
Staffing Issues Lead to Delayed Call Light Responses and Incomplete Restorative Care
Penalty
Summary
The facility failed to meet the professional standard of answering resident call lights within 15 minutes, as evidenced by interviews with Resident #3 and staff members. Resident #3 reported waiting 45 minutes for assistance, which made her feel neglected. Staff interviews confirmed that call lights were not consistently answered within the required timeframe due to staffing issues. The Resident Council minutes also documented concerns about delayed responses to call lights on multiple occasions. Additionally, the facility did not provide restorative exercises according to the individual plan of care for Resident #3. Interviews with staff, including the Administrator and the Regional Clinical Quality Specialist, revealed that the facility lacked an active restorative program due to low staffing levels. A restorative aide was frequently reassigned to other duties, preventing the implementation of restorative programs. The Director of Rehabilitation Services confirmed that restorative programs were not followed as intended.
Deficiencies in Narcotic Medication Management
Penalty
Summary
The facility failed to properly manage and secure narcotic medications, as evidenced by several deficiencies in the handling and documentation of controlled substances. A review of the Controlled Drug Administration Record for a resident revealed that a Baclofen pill was administered without a nurse's signature to validate who administered the medication. Additionally, there were multiple instances where staff failed to sign the Controlled Drug Count Record forms, indicating that narcotics were not properly counted or accounted for during shift changes. This lack of documentation and accountability was observed on several dates and shifts, leading to discrepancies in the narcotic counts. Interviews with staff members further highlighted issues with the facility's medication management practices. One LPN admitted to not counting narcotics when handing over keys during meal breaks, and it was revealed that the Assistant Director of Nursing (ADON) had access to medication carts and narcotic drawers, administering medications without proper documentation. Staff members reported that the ADON sometimes worked alone and signed off on narcotic sheets without documenting the administration of drugs on the Medication Administration Records (MARS), leading to inaccuracies. The ADON confirmed carrying spare keys to medication carts and narcotic boxes, and the facility's administrator acknowledged that multiple nurses had access to these keys, contributing to medication errors. The facility's Controlled Substances policy outlined procedures for handling, storing, and documenting narcotics, but these were not consistently followed. The policy required a physical inventory of narcotics at each shift change by two nurses, with discrepancies reported immediately to the Director of Nursing. However, the report indicated that these procedures were not adhered to, as evidenced by the lack of proper record-keeping and accountability for controlled drugs. The failure to follow established protocols and secure narcotic medications resulted in a significant deficiency in the facility's medication management practices.
Supply Shortages and Policy Access Issues in LTC Facility
Penalty
Summary
The facility failed to ensure sufficient supplies to meet the treatment needs of two residents. Resident #2 had a treatment order for a stage IV pressure area on the right hip and gluteal region, which required cleansing with wound cleanser, application of Silversorb gel, collagen powder, and an ABD pad daily. However, the facility staff were unable to perform the complete treatment on two occasions due to the unavailability of Silversorb gel. Similarly, Resident #3 had a treatment order for a wound on the right medial third toe, which required cleansing with normal saline and Betadine, but the treatment was not performed on two occasions due to a lack of supplies. Additionally, the facility failed to provide a policy and procedure book readily accessible to staff. Staff members reported that they were unable to access the necessary policies and procedures, as the Administrator directed them to an employee handbook instead. The Administrator acknowledged that the facility staff did not have direct access to the P drive where the policies were stored, and efforts were being made to organize a policy and procedure book. The Regional Clinical Quality Specialist also confirmed the lack of access to the P drive for nurses, and the Director of Nursing had to print and provide copies of the policies for the staff.
Facility Fails to Secure Environment, Leading to Resident Elopement
Penalty
Summary
The facility failed to maintain a safe and secure environment for its residents, as evidenced by multiple incidents involving a resident with a history of schizophrenia, bipolar disorder, and other health issues. This resident, who was at high risk for elopement and moderate risk for falls, was found outside the facility on several occasions. On one occasion, the resident was found in a garage after leaving the courtyard area, which was supposed to be secure. The garage door had been left in disrepair, and the resident was able to access it due to a malfunctioning latch. Staff interviews revealed that residents were allowed to enter the courtyard area unattended, even at night, which contributed to the resident's ability to leave the secure area. The staff's response to the door alarm was delayed, and the resident was unaccounted for several minutes. The facility's maintenance director had been aware of the garage door's disrepair but had only temporarily secured it with a board, which proved insufficient. Additionally, the facility's administrator failed to notify the corporate office about the malfunctioning garage access door and nonfunctional floodlights, which could have prevented the resident's elopement. The facility also identified six other residents who were cognitively impaired and prone to wandering, indicating a broader issue with maintaining a secure environment for vulnerable residents.
Failure to Report Drug Diversion and Financial Exploitation
Penalty
Summary
The facility failed to report alleged violations involving financial exploitation and drug diversion to management and the Iowa Department of Inspections, Appeals, and Licensing as required by policy. This deficiency was identified for one of six residents reviewed. Staff interviews revealed that narcotics and muscle relaxers were reported missing, but the Administrator allegedly ignored these reports. Staff members expressed fear of retaliation if they reported concerns to corporate, as they were instructed not to contact corporate directly. The Administrator admitted that the facility staff did not report the alleged drug diversion directly to her, but rather left a note under her office door, which she did not receive until three days later. The Regional Clinical Quality Specialist was only informed of discrepancies with Flexeril and expected the Administrator to report missing narcotics to the appropriate authorities. The facility's Controlled Substances policy required immediate reporting of discrepancies to the Director of Nursing, who would then initiate an investigation and report missing narcotics to the Clinical Quality Team.
Inaccurate Care Plan for Resident with COPD
Penalty
Summary
The facility failed to maintain a complete and accurate care plan for one of the residents reviewed. The care plan for this resident, who has a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and incontinence, indicated a deficit in activities of daily living (ADLs) due to shortness of breath. The care plan, initiated on August 16, 2022, required the resident to have assistance with a walker and gait belt. However, a Rehab Communication form dated May 28, 2024, indicated a change in the resident's mobility status to modified independence with a front-wheeled walker when indoors, but not outdoors. This change was not reflected in the care plan, as confirmed by a Certified Nursing Assistant during an interview on June 18, 2024. The facility's policy, revised on January 30, 2024, mandates the development and implementation of a comprehensive person-centered care plan for each resident, which should include measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. The policy also requires timely updates to the care plan to ensure that the services provided represent the resident's highest practicable physical, mental, and psychosocial well-being. The failure to update the care plan in accordance with the resident's current needs and the facility's policy led to the identified deficiency.
Failure to Assess Pressure Areas and Follow Medication Orders
Penalty
Summary
The facility failed to provide adequate assessment and intervention for pressure areas in two residents. Resident #2 experienced an increase in drainage from a pressure area on the right hip and buttocks, which was not assessed by the facility on multiple occasions, including 5.21.24, 5.23.24, 5.24.24, 5.26.24, and 5.27.24. Similarly, Resident #3 had a pressure area on the left heel that went unassessed from 4.24.24 to 5.7.24. A corporate representative confirmed the lack of assessment for Resident #3 during an interview. Additionally, the facility failed to follow physician's orders for Resident #3 regarding medication administration. On 6.11.24, medications prescribed to be administered at 7 p.m. were given at 9:43 p.m. The resident expressed dissatisfaction with the delay, as it affected her ability to sleep due to neuropathy. The facility's Medication Administration Policy requires medications to be administered within 60 minutes of the scheduled time, which was not adhered to in this instance. Interviews with staff confirmed the delay and the resident's concerns.
Latest citations in Iowa
An LPN, unfamiliar with residents on a medication cart and faced with two residents sharing the same first name, failed to correctly identify a resident and administered a full set of another resident’s medications in addition to the resident’s own ordered morning medications, including PRN oxycodone. The resident, who had severe cognitive impairment and multiple diagnoses including hypertension and Alzheimer’s disease, subsequently experienced declining BP, reported not feeling well, and became increasingly fatigued. The facility’s policy required resident identification before medication administration, and the LPN acknowledged not knowing the residents and finding the EHR photos too small, despite their availability. Hospital records later documented hypotension, treatment with IV fluids, and a drug overdose after accidental ingestion of another resident’s medications plus the resident’s own, with persistent sinus bradycardia requiring admission for further hemodynamic monitoring.
A cognitively impaired, wandering resident with Alzheimer’s disease and behavioral symptoms was care planned as an elopement risk but was able to leave the memory care unit by holding an emergency exit door bar for 15 seconds and exiting into a stairwell and then to the employee parking lot. The door alarm functioned, but staff in the noisy dining room did not hear it while they were feeding multiple residents, including several needing extensive assistance, and only realized the resident was missing when another staff member encountered him outside and brought him back. In addition, several residents who required staff assistance for transfers and toileting experienced prolonged call light response times well beyond the facility’s 15‑minute expectation, including one who reported waiting up to an hour during meals and having an in‑room accident, another observed waiting about 25 minutes while calling out for help, and a third waiting about 17 minutes before a CNA responded.
A cognitively intact resident reported that a CNA ripped her incontinence brief during care and then refused to change it, despite the resident stating she could not wear it due to the tear. The resident became upset and informed housekeeping staff, who then asked an LPN to assist. On assessment, the LPN observed a large rip extending around the back of the brief, changed the brief, and provided peri care at the resident’s request. The resident stated the ripped brief was uncomfortable and that she did not feel treated with dignity or respect. In interviews, the CNA acknowledged telling the resident the torn brief would still work and did not change it, while the DON confirmed the CNA had refused the resident’s request for a brief change, in conflict with the facility’s dignity policy.
A deficiency was identified when a CNA did not follow manufacturer instructions for a mechanical stand while transferring a resident with severe cognitive impairment, a history of hip fracture, dementia, and muscle wasting who required substantial assistance for transfers. The resident’s care plan called for use of a mechanical stand, but during observed toileting and return-to-chair transfers, the CNA repeatedly locked and unlocked only one wheel of the device and did not keep the brakes unlocked during the actual transfer, contrary to the operator’s instructions that brakes be locked only when raising and lowering the resident during ambulation. In an interview, the DON confirmed staff were expected to follow these operator instructions and keep the wheels unlocked during transfers.
A resident with dementia, behavioral symptoms, and multiple psychotropic and cardiovascular medications was discharged to another nursing facility without a thorough or accurate discharge summary. The care plan contained a discharge planning focus but was never updated to reflect the actual discharge, and the EHR lacked documentation of discharge planning, the reason for discharge, or a recapitulation of stay, despite a family member stating they initiated the discharge due to dissatisfaction with care. The discharge instructions contained multiple medication discrepancies and omissions, including missing drugs, incorrect dosages, and absent administration frequencies, and several PRN constipation medications were not listed, contrary to the facility’s written discharge planning policy.
A resident was admitted from a hospital without a completed Preadmission Screening and Resident Review (PASRR) in the medical record, as required prior to admission. The PASRR was only completed several days later by the Hospital Liaison/Admissions Coordinator after a call alerted staff that it was missing. Both the admissions coordinator and the Administrator acknowledged that the facility relies on the hospital to provide the PASRR and that, in this case, it was missed and not done before the resident’s admission.
A resident with Alzheimer's disease, severely impaired cognition, and documented nutrition/hydration risk required partial to moderate assistance with eating and was care planned for assisted feeding with a general diet and thin liquids. During a breakfast observation, the resident was seated in a reclined Broda chair while staff placed food and beverages on an overbed table and attempted to offer chocolate milk and hot cereal without first positioning the resident upright, causing the resident to struggle to reach the cup. Facility policy on feeding required residents needing assistance to be positioned comfortably in an upright position, and the DON stated she expected residents to be upright whenever food or drink was offered, but there was no separate positioning policy in place.
A resident with a left leg fracture, muscle wasting, and impaired mobility was dependent on a mechanical lift for transfers. Staff positioned the lift at the side of the wheelchair instead of straight on, and the lift tipped and struck the resident’s forehead with the sling-holding part, causing a bruise and protruding bump. Staff interviews confirmed the transfer was done from the side and that the resident’s care plan required straight-on positioning for the lift.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance: Several residents did not receive bathing and hygiene assistance as scheduled. One resident with intact cognition and a stroke history was observed unshaven and said staff did not always shave him during showers, while staff noted the bath sheets no longer tracked shaving or nail care. Other residents with severe cognitive impairment or dependence for bathing went extended periods without baths, and one cognitively intact resident reported missing baths and wanting them. Facility records and staff interviews showed bathing schedules were not consistently followed or documented as required.
QAPI program failed to address repeated deficiencies. Review of the facility’s visit history showed repeated F689, Free of Accident Hazards/Supervision/Devices, and F880, Infection Prevention and Control, across multiple annual surveys and complaint investigations. The QAPI plan stated it would review sources of information for gaps or patterns in care systems, and the Administrator acknowledged the repeated deficiencies and said the facility would review and discuss plans to improve.
Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to follow the 5 rights of medication administration, resulting in one resident receiving another resident’s medications in addition to their own. The resident had diagnoses including hypertension, Alzheimer’s disease, and toxic encephalopathy, with a BIMS score of 3 indicating severe cognitive impairment. On the morning in question, review of the MAR showed the resident received their ordered medications, which included aspirin, calcium carbonate, vitamin C, vitamin D, fluoxetine 20 mg, furosemide 40 mg, galantamine, a lidocaine patch, memantine, acetaminophen, and PRN oxycodone around 8:00 a.m. According to the incident report and nursing progress notes, the LPN (Staff A) administered another resident’s full set of morning medications to this resident while the resident was in the dining room. These additional medications included metoprolol 60 mg, Lyrica 75 mg, oxycodone 7.5/325 mg, furosemide 40 mg, celecoxib 100 mg, Prozac 60 mg, hydroxyzine 10 mg, cetirizine 10 mg, Neuriva, Protonix 20 mg, potassium 99 mg, a multivitamin, and vitamin D3. These medications were given in addition to the resident’s own morning medications and PRN oxycodone. The nurse’s notes documented that the resident’s blood pressure readings declined from 100/50 to 85/48 and then to 73/48, and the resident complained of not feeling well and was increasingly fatigued. Staff A reported during interview that the resident had been screaming and yelling and that she did not realize there were two residents with the same first name in the back hallway. She stated it was her first time working in that hallway after training and that, although resident pictures were available in the EHR to assist with identification, she felt they were small and she did not know the residents. The facility’s medication management policy required staff to identify the resident before administering medications. Staff A’s employee record showed a prior medication occurrence in which she administered the wrong medications (including furosemide and potassium) to a resident, and she had documented previously that she was not familiar with residents when working on that cart. The resident was ultimately sent to the ER, where records documented hypotension on admission, treatment with IV fluids, and a chief complaint of drug overdose after accidental ingestion of another resident’s multiple medications in addition to the resident’s own medications, with continued sinus bradycardia requiring admission for further hemodynamic monitoring.
Elopement of Wandering Resident and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for a cognitively impaired, wandering resident and failure to respond to resident call lights within the facility’s stated 15‑minute expectation. One resident with Alzheimer’s disease, bipolar disorder, and anxiety disorder had a care plan identifying risk for elopement due to wandering and documented behaviors of agitation, aggression, restlessness, and continuous pacing/wandering within the unit. This resident ambulated independently with a walker and had a BIMS score indicating impaired cognition. On the evening of the incident, the resident finished supper in the memory care dining room and then repeatedly walked the hallway with his walker, eventually approaching an emergency exit door at the far end of the hall, away from the dining room. Video and documentation show that the resident stood at the emergency exit door, held the door bar down for the required 15 seconds to release the egress, and then exited through the door into a stairwell and out to the employee parking lot. The door alarm and 15‑second egress functioned, but staff in the dining room did not hear the alarm due to noise from residents, staff conversation, and the television. At the time, two CNAs and one LPN were in the dining room feeding multiple residents, including several who required assistance, and staff reported that the resident was very quick, wandered constantly, and was difficult to keep seated. Staff interviews revealed that one CNA noticed the resident was no longer in the dining room around the same time another staff member reported they were looking for him, and only then did staff recognize the back exit door alarm sounding. A nurse arriving for her shift in the parking lot encountered the resident outside with his walker and escorted him back inside, after which he was assessed and found in stable condition. The deficiency also includes failure to respond to resident call lights within the professional standard of 15 minutes for multiple residents. One resident with intact cognition but dependent or substantial/maximal assistance needs for toileting reported that during meal hours it could take up to an hour for staff to answer the call light, resulting in an in‑room accident. Another resident, alert and oriented but occasionally forgetful and requiring two‑person assistance for transfers, was observed with the call light on for approximately 25 minutes in the morning while repeatedly yelling for help; staff walked past in the hallway without answering the light until a staff member finally entered the room. A third resident, requiring one‑person assistance for transfers, was observed with the call light on for about 17 minutes before a CNA entered to assist. The DON stated that the facility’s expectation is that call lights be answered within 15 minutes, and the facility’s policy directs all staff from all departments to respond to call lights and either assist or obtain appropriate help, but the observed response times exceeded this standard for the residents involved. Staff interviews further described the conditions contributing to these call light delays and supervision gaps. Staff on the memory care unit reported that typical evening staffing consisted of one nurse, one CMA, and two CNAs, and that while this was manageable when routines went smoothly, it became inadequate when residents had behaviors, were sundowning, or when events such as falls or changes in condition occurred. A CMA stated that at least three CNAs were needed on the memory care unit due to multiple residents requiring two‑person assistance, noting that when two CNAs were in a room providing care, they could not monitor the rest of the unit. Staff also reported that the back exit door alarm was faint and difficult to hear from the dining room, and some staff were not fully aware of the configuration of the back stairwell and exit leading to the parking lot. These conditions, combined with high resident care needs and noise levels during meals, contributed to the resident’s elopement and to prolonged call light response times for several residents. Maintenance and administrative staff confirmed that the south/back exit door from the unit led to another unalarmed door and then to the outside employee parking lot, and that the facility did not receive system reports when door alarms were activated. The Administrator was unable to verify when a door alarm went off or when an exit door was breached. The facility’s Wandering Resident policy stated that residents at risk for elopement should receive adequate supervision to prevent accidents and that staff must be vigilant in responding to alarms in a timely manner, and the call light policy required prompt response by all staff. Despite these policies, the documented events show that the resident at risk for elopement was able to leave the secured unit and reach the parking lot without timely staff detection, and that multiple residents experienced call light response times significantly longer than the facility’s stated 15‑minute standard.
Failure to Honor Resident Request for Brief Change and Maintain Dignity
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and respect when a cognitively intact resident’s request for a brief change was not honored. The resident, with a BIMS score of 15 indicating no cognitive impairment, reported being upset because a CNA (Staff N) ripped her brief during care and then refused to change it. The resident self-propelled down the hallway stating she was upset about the ripped brief and that staff would not change it. A housekeeping staff member (Staff M) observed the resident’s distress, was told that the CNA had refused to change the brief despite a large rip, and then asked an LPN (Staff O) to assist with changing it. During the subsequent brief change, Staff O performed hand hygiene, used gloves, removed the resident’s pants and brief, and provided peri care at the resident’s request before applying a new brief and redressing the resident. Observation of the removed brief revealed a large rip on the left side extending past the middle of the resident’s back. The resident stated the brief with the hole was uncomfortable and that she felt staff did not provide her with dignity and respect when her request for a new brief was not honored. Staff O confirmed that the brief had a very large hole and that the resident was very upset, reporting she did not feel treated with dignity or respect and that the ripped brief was uncomfortable. In an interview, Staff N acknowledged caring for the resident that day, stated the resident had been upset and had “behaviors,” and reported that when the resident said she wanted her brief changed because it was ripped, Staff N told her the brief would still work and that urine would not get everywhere, characterizing the tear as “just a little tear.” Staff N stated the resident did not explicitly ask her to change the brief. The DON later stated that Staff N had ripped the brief, the resident had requested a brief change, Staff N said she would not change it, and acknowledged that a lack of dignity occurred when Staff N refused to change the resident’s brief, contrary to the facility’s dignity policy.
Improper Use of Mechanical Stand Brakes During Resident Transfers
Penalty
Summary
Surveyors identified a deficiency related to accident prevention when staff failed to properly use a mechanical stand’s brakes during transfers for one resident. The resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment, required substantial assistance for transfers, and had diagnoses including hip fracture, dementia, and muscle wasting. The care plan documented initiation of a mechanical stand for transfers. During observation, a CNA applied a sling, locked the right wheel of the mechanical stand, lifted the resident from a chair, then unlocked the right wheel and positioned the resident over the toilet. The CNA then lowered the resident onto the toilet and locked the right wheel. After the resident finished, the CNA lifted the resident from the toilet, unlocked the right wheel, positioned the resident over the chair, locked the right wheel, and lowered the resident, thereby failing to keep the mechanical stand brakes unlocked during the transfer as required by the operator’s instructions, which specified that brakes should only be locked when raising and lowering the resident during ambulation. In an interview, the DON stated that staff were expected to follow the operator’s instructions and keep the wheels unlocked during transfers, confirming that the observed practice did not align with the manufacturer’s guidance for safe operation of the mechanical stand.
Failure to Complete Accurate and Thorough Discharge Summary and Documentation
Penalty
Summary
Surveyors identified a failure to complete a thorough and accurate discharge summary and related discharge documentation for one resident who was discharged from the facility. The resident was admitted in early March with moderate cognitive impairment, a Brief Interview for Mental Status (BIMS) score of 08, and documented delusions and behavioral symptoms. Diagnoses included dementia with agitation, anxiety disorder, and depression. Although the care plan contained a discharge planning focus initiated shortly after admission, it did not contain any updates or documentation related to the resident’s actual discharge later that month. The electronic health record (EHR) contained a communication note indicating that transport to another nursing facility was arranged and a health status note stating that the resident was discharged, with physician orders and a face sheet faxed and a report called to the receiving facility. The resident’s EHR did not contain documentation of the discharge planning process, the reason for the discharge, or a recapitulation of the resident’s stay. A family member reported that the family initiated the discharge due to dissatisfaction with care, but there was no documentation in the EHR reflecting that the family initiated the discharge. The Long Term Care Ombudsman reported that no one contacted her during the resident’s stay, although her office did receive notice of the transfer. The facility’s own discharge planning policy required that discharge planning begin on admission, be routinely updated in the comprehensive care plan, and that the evaluation of discharge needs and the final discharge plan be completely documented in the clinical record and discussed with the resident or representative. Review of the resident’s discharge instructions and March medication administration record revealed multiple discrepancies and omissions in the discharge summary. One medication (Amlodipine 10 mg) was listed without any frequency or time of administration. Several medications that the resident was receiving, including Donepezil 10 mg, Lisinopril 5 mg, and Buspirone 10 mg twice daily, were not included on the discharge summary. Other medications were inaccurately documented, such as Memantine, which was ordered as 20 mg once daily but listed as 10 mg twice daily, and Seroquel, ordered as 50 mg twice daily but listed as once daily. Several PRN constipation medications were also omitted. The Regional Nurse Consultant confirmed that the facility’s EHR contained a discharge assessment tool that was not completed for this resident and acknowledged the multiple medication discrepancies on the discharge summary form.
Failure to Complete PASRR Evaluation Prior to Admission
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) evaluation for a resident with an admission date of 4/22/26. The resident’s electronic health record documented admission from a hospital on 4/22/26, but review of the record showed no PASRR completed at the time of admission. A PASRR form for this resident was later obtained and showed it was completed on 4/27/26 by the Hospital Liaison/Admissions Coordinator, several days after the resident had already been admitted. During interview, the Hospital Liaison/Admissions Coordinator stated that the hospital usually completes the PASRR, acknowledged receiving a call the previous night that the PASRR was not in the chart, and admitted she had missed completing it prior to admission even though it should have been done. The Administrator similarly reported that the facility relies on receiving the PASRR from the hospital admission records and that, in this case, the PASRR was missed and not completed prior to the resident’s admission. This resulted in a deficiency for failure to ensure a PASRR evaluation was completed prior to admission for 1 of 3 reviewed residents, in accordance with PASRR requirements.
Failure to Properly Position Resident Upright During Assisted Feeding
Penalty
Summary
Surveyors identified a deficiency in resident positioning during mealtime for a resident with Alzheimer's disease and severely impaired cognition, as evidenced by a Brief Interview for Mental Status score of 2. The resident’s MDS indicated a need for partial to moderate assistance with eating, and the care plan documented nutrition and hydration risk related to end-stage diagnosis, cognitive limitations, and weakness, with directions for a general diet, thin liquids, and assistance with eating. During a breakfast observation on the Magnolia Unit, the resident was seated in a Broda chair that was reclined back. A dietary aide placed food on the table in front of the resident, and a CNA then placed beverages and food on an overbed table before walking away, while the resident remained reclined with eyes closed and the plate of food untouched. Later in the same observation period, another CNA offered the resident chocolate milk while the Broda chair remained tilted backward, and the resident had to struggle to move her head up and forward to reach the cup. The same CNA then offered hot cereal, which the resident declined by saying “later.” A different CNA subsequently offered another drink of chocolate milk, again without adjusting the reclined position of the Broda chair. Policy review showed the facility’s “Feeding of Residents by Staff” policy required that residents unable to feed themselves be assisted per their care plan and be positioned comfortably in an upright position. In an interview, the DON stated there was no specific positioning policy, that staff received positioning education in training, and that her expectation was that residents be placed in an upright position whenever food or drink was offered.
Mechanical Lift Transfer Caused Resident Forehead Injury
Penalty
Summary
The facility failed to provide a safe and adequate mechanical lift transfer for Resident #18, who had a left leg fracture, muscle wasting, and impaired gait and mobility, but no cognitive impairment based on a BIMS score of 15. The resident’s care plan required two staff members to use a mechanical lift for transfers because the resident was nonweight-bearing on the left leg. The care plan update also directed staff to approach the wheelchair straight on and not from the side, and to have the resident bend the right leg and turn away from the lift during transfers. During a wheelchair transfer, staff positioned the mechanical lift at the side of the wheelchair and began the transfer. The lift tipped and struck the resident’s forehead with the part that held the sling. The resident sustained a bruise and a protruding bump on the left forehead, and the incident documentation noted the resident’s head was hit on the lift. The resident later reported that the lift almost fell to the floor and that additional staff were needed to return it upright. Staff interviews confirmed that the transfer was performed from the side of the wheelchair. One CNA stated the lift may have caught on bars under the wheelchair and acknowledged that staff had been educated not to use the lift from the side. Another CNA stated the lift was used from the side because the resident did not want her leg hit by the lift, and identified the sling-holding part of the lift as the piece that struck the resident’s forehead. The DON stated the proper procedure was to position the mechanical lift directly in front of the wheelchair rather than to the side.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living for 5 of 8 residents reviewed, specifically related to bathing and shaving. Resident #3 had a BIMS score of 15 and was dependent on staff for personal hygiene, with diagnoses including renal insufficiency, stroke, hemiplegia, and seizure disorder. The resident was observed unshaven, stated he was getting showers but not shaved every time, and said he needed help shaving since his stroke. Facility records showed showers were documented without indicating whether shaving was completed, and staff interviews confirmed the bath sheets no longer tracked shaving or nail care, while the DON stated male residents should be offered shaving during showers and it should be documented if completed or refused. Resident #1 had a BIMS score of 4, diagnoses including muscle weakness, diabetes, and hip fracture, and was care planned as an extensive assist for bathing. Review of the follow-up report showed the resident went 17 days without a bath and later 19 days without a bath. Resident #11 had a BIMS score of 3, diagnoses including depression, hypertension, and anemia, and was scheduled for bathing on Wednesday morning and Friday afternoon, but the follow-up report showed gaps of 6 days, 6 days, and 18 days between baths. Resident #27 also had a BIMS score of 3 with depression, hypertension, and anemia, was scheduled for bathing on Monday and Thursday afternoon, and the follow-up report showed the resident went 19 days and then 20 days without a bath, with refusals documented on two occasions. Resident #85 had a BIMS score of 15, diagnoses including hypertension, depression, and need for assistance with personal care, and stated she did not get 2 baths the prior week and wanted them. Her care plan identified her as dependent for bathing, but lacked bathing frequency, and the task list scheduled bathing for Monday morning and Wednesday afternoon. The follow-up report showed multiple extended gaps between baths, including 12 days, 7 days, 18 days, and 7 days. Facility policy stated bathing is intended to promote cleanliness, provide comfort, and observe skin condition, and the Regional Nurse Consultant stated bathing should be completed as scheduled.
QAPI Program Failed to Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive and effective QAPI program and did not have a plan that described the process for conducting QAPI and QAA activities. Review of the DIAL website visit history showed repeated deficient practices identified during the facility’s annual survey and complaint investigation on 3/27/25 and during the annual survey, complaint, and facility-reported incident investigation on 4/19/26. The repeat deficiencies included F689, Free of Accident Hazards/Supervision/Devices, which had been repeated in the previous three consecutive annual surveys, and F880, Infection Prevention and Control, which had been repeated in the previous four consecutive annual surveys. The facility’s QAPI plan stated that it would review sources of information to determine whether gaps or patterns existed in systems of care that could result in quality problems or opportunities for improvement. During an interview on 4/23/26 at 1:28 PM, the Administrator acknowledged the repeated F689 and F880 deficiencies and stated the facility would review and discuss plans to improve.
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