Accura Healthcare Of Pleasantville, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Pleasantville, Iowa.
- Location
- 909 North State Street, Pleasantville, Iowa 50225
- CMS Provider Number
- 165324
- Inspections on file
- 28
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Accura Healthcare Of Pleasantville, Llc during CMS and state inspections, most recent first.
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.
Residents and family members reported significant delays in call light response times, late medication administration, and unmet care needs due to insufficient staffing. Multiple residents with intact cognition described waiting from 30 minutes to several hours for assistance, and concerns were raised about staff shortages and delays in basic services such as laundry and room cleaning. Staffing schedules showed limited coverage, and the DON acknowledged working the floor during weekends.
Several residents with limited ROM and mobility impairments did not consistently receive restorative care or therapy-recommended interventions as directed in their care plans. Documentation was often incomplete or missing, and residents reported being unable to participate in exercises or use equipment due to staff unavailability. Staff interviews confirmed the lack of a designated restorative aide, with CNAs expected to perform restorative activities but unable to do so regularly because of staffing shortages and other duties.
The facility did not maintain an effective QAPI process, leading to repeated deficiencies in areas such as abuse prevention, resident assessment, care planning, quality of care, and infection control. High staff turnover, especially in nursing leadership, contributed to ongoing issues, and the QAPI committee's efforts were insufficient to prevent recurring citations.
The facility did not report allegations of abuse and misappropriation of resident property to state authorities within the required timeframe. In one case, a resident reported missing money, but the Administrator delayed reporting while attempting to verify details with family. In another case, staff raised concerns about a former Assistant Administrator's use of two residents' trust funds, but the incident was only investigated internally and not reported. These actions were not in compliance with facility policy and regulatory requirements for timely reporting.
Surveyors found improper food storage and handling, including thawing meat at unsafe temperatures, unlabeled and unsealed food items in freezers, and persistent kitchen sanitation issues such as a leaking sink and unclean dishwashing equipment. An LPN was also observed handling a resident's food with bare hands without hand hygiene, all in violation of facility policies.
A resident with severe cognitive impairment and vision issues was left without his corrective lenses for over two months after his glasses went missing. Despite the family's repeated requests and filing a grievance, facility staff did not schedule an optometrist appointment, and the family ultimately arranged the appointment themselves.
A resident and their representative were not given the correct CMS Advanced Beneficiary Notice (ABN) form to inform them of service options and potential financial liability for non-covered services. Instead, a different form was provided, and the facility lacked a policy for ABNs. The Administrator, who managed ABNs in the absence of a social worker, relied on forms from the corporate office and believed the correct form was used.
A resident receiving hospice care with a diagnosis of dementia did not have hospice services or dementia accurately coded on multiple MDS assessments. Staff interviews revealed turnover in the MDS Coordinator position, lack of training, and outdated care plans, leading to incomplete and inaccurate resident assessments.
Two residents did not have comprehensive care plans reflecting their current needs, including one with a chronic skin condition and another on hospice care. Staff were aware of these issues, but the care plans lacked necessary updates and details, and documentation practices were inconsistent with facility policy.
A resident with depression and intact cognition, who valued family involvement in care discussions, did not have quarterly care conferences documented over a six-month period. Staff interviews confirmed that no care conferences were held or documented during this time, and there was no policy in place to ensure compliance. The resident expressed that concerns raised in previous conferences were not addressed.
Staff did not consistently change gloves between tasks during care for a resident with an indwelling catheter, and failed to disinfect a mechanical lift between uses for different residents. These actions were not in accordance with facility policies or infection control expectations as confirmed by nursing leadership.
The facility did not ensure that three CNAs completed the required 12 hours of annual in-service education, with one CNA completing less than 9 hours, another only 1 hour, and a third none at all. The DON reported that education is provided monthly and through Relias, but the Administrator noted that night shift staff often miss these sessions.
A resident with severe cognitive impairment had personal items purchased with their trust funds, but facility staff failed to follow procedures for verifying, documenting, and distributing these items. Purchased goods were left unaccounted for at the nurse's station, receipts were incomplete and unsigned, and there were discrepancies in item sizes and missing items, resulting in improper handling of the resident's funds and belongings.
The facility did not suspend or separate an employee accused of theft from resident contact during an internal investigation, allowing the employee to remain in the facility and participate in the investigation process involving two residents' trust accounts.
Two residents with severe cognitive impairment were involved in allegations of misappropriation of funds when a staff member used their trust accounts to make purchases. The facility's investigation was limited to an independent review of receipts by the Administrator, without staff interviews or proper documentation, and items purchased were not promptly verified or distributed. Discrepancies in item sizes and missing signatures on receipts were noted, and the incident was not reported to the state agency as required by policy.
Three residents experienced delays or omissions in nursing assessment and intervention following incidents such as a puncture wound from a broken wheelchair, a hot coffee spill, and a recurring sore on the scalp. In each case, staff failed to document timely assessments or provide appropriate follow-up, and care plans or facility policies did not address the residents' needs or changes in condition.
During a COVID-19 outbreak, a LTC facility failed to provide adequate PPE and did not isolate COVID-19 positive residents, leading to 26 residents testing positive. A resident with COPD and CHF was hospitalized due to COVID-19 complications. Staff reported PPE shortages and improper usage, with some working while COVID-19 positive. The facility's infection control policies were not followed, contributing to the outbreak.
A resident with moderate cognitive impairment was found on the floor with injuries after an unwitnessed fall, having been unattended for several hours. Staff interviews revealed issues with staffing levels, lack of regular checks, and delayed responses to call lights. The facility lacked a policy on bed checks, contributing to the deficiencies in care.
Facility staff failed to secure a treatment cart, leaving it unlocked and unattended in the nurse's station area, accessible to residents. The facility had 45 residents, with 30 in the front portion of the building. Interviews with staff confirmed the frequent observation of unlocked medication carts, including the narcotic drawer, accessible to staff, visitors, or residents.
The facility failed to ensure resident safety and proper care, as evidenced by a resident with cognitive impairment who was left unattended for hours after a fall, and another resident who did not receive requested medication due to staff miscommunication. Additionally, issues with infection control practices and staff management, such as inadequate PPE and staff taking breaks together, were noted.
The facility failed to respect residents' rights, as evidenced by an LPN's refusal to administer requested medications separately, leaving a resident in pain. Another resident was left in soiled clothing for hours, and meals were served on disposable ware post-COVID-19 outbreak, undermining dignity.
The facility failed to provide scheduled bathing services for three residents and appropriate perineal care for a resident with quadriplegia, due to staffing shortages. Residents experienced missed baths and inadequate hygiene care, leading to cleanliness issues and irritation. Staff interviews confirmed that CNAs were often unable to adhere to care schedules due to being assigned additional duties.
The facility failed to maintain accurate health records and medication administration for two residents. One resident was left in wet clothing without proper documentation of care, while another experienced misdocumentation in medication administration, with confusion over who administered the medication. These issues highlight deficiencies in record-keeping and adherence to care protocols.
The facility inaccurately assessed a resident's behavior in the MDS following an incident where a resident shoved another, causing a fall. The MDS indicated no behavioral symptoms, contrary to the event. Additionally, the facility misreported restraint use for six residents, despite confirmation that no restraints were used.
The facility failed to implement care plans for three residents, resulting in unmet needs. A resident with severe cognitive impairment refused scheduled baths without alternative interventions being documented. Another resident with hemiplegia received baths as planned, while a third resident with moderate cognitive impairment had a care plan for sponge baths if needed, but there was no documentation of refusals or alternative methods being used.
The facility staff failed to properly administer medications for three residents, leading to unlabeled medications being stored improperly, medications being left unattended, and a resident experiencing unmanaged pain due to inaccessible medication. An LPN admitted to storing medications in a cart drawer, a CNA reported unattended medications, and a resident's grievance highlighted issues with medication placement by the ADON.
A facility failed to follow physician orders for a resident's medication administration. The MAR indicated that Memantine HCL and Mirtazapine were documented as administered, but Olanzapine was missing. An LPN attempted to administer medications to another resident who refused, yet the LPN signed out the administration on the MAR. The LPN later corrected the MAR, acknowledging the resident's refusal of morning medications.
A facility failed to provide restorative services to maintain or improve ROM and mobility for a resident. The resident, who needed moderate assistance with daily activities, reported that staff did not perform ROM exercises, which she preferred to achieve her goal of returning home. Interviews with CNAs confirmed the lack of restorative services, and the facility was found to lack a restorative policy or procedure.
The facility failed to employ a qualified Activities Director, resulting in limited and repetitive activities for residents. Activity calendars for April and May 2024 showed a lack of diverse options, with many days having no activities. Residents and staff expressed dissatisfaction, noting infrequent and unscheduled activities. The facility's assessment highlighted the need for a full-time AD, but this was not met, leading to inadequate psycho/social/spiritual support for residents.
The facility failed to maintain resident dignity during meals, with CNAs standing and feeding residents in a rushed manner due to staffing shortages. Additionally, a resident's disruptive behavior, including yelling profanities, affected the dining experience for others. Despite complaints, the administration did not address the issue, contrary to the facility's person-centered dining policy.
The facility failed to provide a comprehensive activities program, impacting residents' well-being. Activity calendars showed gaps and repetitive options like Bingo, with residents and staff expressing dissatisfaction. The absence of an Activity Director and inconsistent efforts by staff contributed to the deficiency.
The facility failed to maintain a homelike dining environment as a resident with cognitive impairments repeatedly yelled profanities during meals, disrupting others. Despite complaints from other residents, the administrator and corporate nurse did not express concern, although the team is discussing options. The facility's policy emphasizes a cheerful dining atmosphere, which was not achieved.
The facility failed to provide appropriate meal portions for residents on pureed and mechanical soft diets, with staff misinterpreting dietary conversion charts and not preparing enough food. Additionally, residents were not informed of meal options or provided with alternative choices, as menus were not posted in advance. Facility policies on portion control and menu display were not adhered to.
The facility failed to maintain safe and appetizing food temperatures during meal service. A cook recorded the Ham Loaf temperature below the required 135°F, and lettuce was served at room temperature, contrary to the facility's policy. The Administrator confirmed that staff should follow the policy for food service temperatures.
The facility failed to maintain sanitary practices in the food preparation area. Staff F was observed with an uncovered mustache and goatee, and his head cap did not contain all of his hair. He handled food with bare hands, including slicing tomatoes, filling a dressing dispenser, and handling lettuce and bread. The facility's policy required the use of gloves and utensils to avoid bare hand contact with food, which was not followed.
A facility failed to timely notify a resident's emergency contact following an emergency evacuation and transfer to another facility. The resident was evacuated early in the morning and transferred by mid-morning, but the emergency contact was not informed until the afternoon. Hospice staff assisting with the relocation expressed frustration over the communication delay. The facility's administrator acknowledged the expectation for timely notification, but no policy was provided.
The facility failed to complete discharge summaries for two residents, leading to a deficiency in communication at discharge. One resident, managed by PACE, lacked a discharge summary despite having moderately impaired cognition. Another resident, transferred for an emergency evacuation, also did not have a completed discharge summary. The facility acknowledged these oversights.
A facility failed to include a resident and their family in quarterly care plan meetings, as required. The resident, with moderate cognitive impairment and multiple diagnoses, had a care plan that emphasized family involvement. However, the responsible party was unaware of the meetings and had not been invited. The new MDS Coordinator could not find documentation of past meetings and noted the absence of a systematic process for involving residents and families.
A resident with multiple health conditions received improper medication administration, including an incorrect Thiamine dose and delayed meal after insulin injection. The CMA failed to instruct the resident to rinse their mouth after using an inhaler, violating professional standards and facility policies.
A resident with a suprapubic catheter was observed with the catheter bag improperly managed, dragging on the floor and under the wheelchair, increasing the risk of infection. The facility lacked a specific policy for catheter bag management, although a general catheter care policy existed. The resident, with a history of multiple health issues, was being treated for a urinary tract infection.
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.
Delayed Call Light Response and Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed responses to call lights and unmet care needs. Resident Council Meeting notes and grievance forms documented multiple complaints from residents and family members regarding long wait times for call light responses, delays in receiving coffee, late medication administration, and untimely blood sugar checks. Four out of seven interviewed residents with intact cognition reported waiting between 30 minutes to two hours for staff to respond to their call lights, with one resident stating he waited several hours for requested medication and treatments. Residents also reported concerns about staffing shortages and delays in laundry and room cleaning. Staffing schedules provided by the DON indicated that each shift was staffed with two CNAs and one nurse or CMA per hall, but residents and family members continued to report unmet needs and delays in care. The DON confirmed that she sometimes worked the floor when on call during weekends. The documented concerns and interviews demonstrate that the facility did not ensure adequate staffing levels to provide timely care and meet residents' needs as required.
Failure to Provide Consistent Restorative Care and Follow Therapy Recommendations
Penalty
Summary
The facility failed to provide appropriate restorative care and follow therapy recommendations for four residents with limited range of motion (ROM) and mobility impairments. Documentation and care plans indicated that residents with conditions such as multiple sclerosis, hemiplegia, arthritis, and spinal stenosis were to receive specific restorative nursing programs (RNP), including passive and active ROM exercises, ambulation, and use of exercise equipment. However, records showed inconsistent or missing documentation of these interventions, with many days left blank or marked as not applicable, and progress notes often stating that residents did not participate in RNPs during the review periods. Observations and interviews with residents revealed that some residents expressed a desire to participate in restorative activities, such as walking or using exercise equipment, but were unable to do so due to lack of staff availability or supervision. Residents reported waiting for staff assistance to perform exercises or use equipment, and in some cases, only received restorative interventions a few times per month despite care plan directives for more frequent activity. Staff interviews confirmed that there was no designated restorative aide, and that CNAs were expected to perform restorative activities as part of their regular duties, but often could not due to staffing shortages and competing responsibilities. Further interviews with facility leadership and therapy staff indicated a lack of clear assignment and accountability for restorative care. Therapy staff expected nursing to follow through on therapy discharge recommendations, but nursing staff reported that restorative programs were not consistently implemented or documented. The facility's policy required individualized restorative plans and monthly summaries, but these were not consistently in place or up to date. The absence of a dedicated restorative aide and reliance on CNAs to perform restorative care contributed to the inconsistent delivery and documentation of required interventions for residents with limited ROM and mobility needs.
Failure to Implement Effective QAPI Process Resulting in Repeat Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in repeated citations across multiple surveys and complaint investigations. Review of the Department of Inspections, Appeals and Licensing (DIAL) website and CMS-2567 reports revealed that the facility had recurring deficiencies in areas such as abuse prevention, resident assessment, care planning, quality of care, and infection control. These deficiencies were cited during annual surveys and complaint investigations over several years, indicating a pattern of unresolved issues. The facility also had a 1-star staffing rating for the reported quarter, attributed to high staff turnover, particularly in nursing leadership positions including the DON, ADON, and MDS nurse. Interviews with the Administrator confirmed awareness of the repeat deficiencies and acknowledged that the entire nursing department had turned over earlier in the year, with delays in filling key positions. The QAPI committee reportedly met quarterly and identified areas for improvement, but the persistent recurrence of deficiencies suggests that the QAPI process was not effective in ensuring sustained compliance. The facility's QAPI plan described a systematic approach to quality improvement, including root cause analysis and monitoring, but the ongoing repeat citations demonstrate that these processes were not successfully implemented or maintained.
Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or misappropriation of resident property to the Iowa Department of Inspections, Appeals and Licensing (DIAL) within the required 24-hour timeframe for three residents. In one case, a resident with chronic respiratory failure and diabetes, who was cognitively intact, reported missing money from her purse shortly after admission. The inventory sheet completed at admission did not list a purse or money, and staff interviews confirmed the purse was not initially observed. The resident reported the missing money to a registered nurse, who notified the Administrator. The Administrator delayed reporting the incident to DIAL, waiting to verify the amount of money with the resident's family before initiating an investigation and contacting authorities. In another incident, allegations were made that a former Assistant Administrator used two residents' trust funds to purchase items for herself. Staff reported concerns that purchased items were not properly checked in or accounted for, and receipts were not signed to validate delivery to the residents. The facility conducted an internal investigation by reviewing receipts and checking the residents' rooms for the items, but did not report the allegations to DIAL. The Administrator confirmed that the residents involved were not cognitively able to express their wants and needs, and law enforcement was not notified as there was no missing money according to the facility's findings. The facility's own policy, as well as state and federal regulations, require that all allegations of abuse, neglect, exploitation, or misappropriation be reported to DIAL within 24 hours, and in some cases within 2 hours, depending on the severity of the incident. Despite these requirements, the facility did not report the incidents within the mandated timeframe, as confirmed by staff and Administrator interviews and review of facility documentation. The failure to report was attributed to the Administrator's decision to first verify details with family members or to conduct an internal investigation before notifying authorities.
Deficient Food Storage, Handling, and Kitchen Sanitation
Penalty
Summary
Surveyors observed multiple failures in food storage, handling, and kitchen sanitation. A refrigerator/freezer labeled as non-functional was found to contain three beef roasts thawing overnight, with the internal temperature reading 56°F, well above the safe threshold. The roasts were visibly bloated, and staff could not confirm how long the temperature had been elevated. Numerous items in chest freezers were found unlabeled, undated, and unsealed, including bags of cooked eggs, French fries, poultry meat, carrots, and tater tots. Spilled food was present inside the freezer, and staff interviews confirmed that proper labeling, dating, and sealing procedures were not consistently followed. Additionally, the dishwashing unit trap had significant debris buildup that was not cleared over multiple days. Further inspection revealed a leaking sink pipe under the kitchen sink, with a large bucket of foul-smelling water and black organic buildup, which had reportedly been an issue for months. Staff interviews indicated that the problem had been reported to management but was not resolved. In the dining area, an LPN was observed handling a resident's food with bare hands without hand hygiene before or after, contrary to facility policy and staff training. Policies reviewed required all foods to be covered, labeled, and dated, and mandated the use of barriers such as gloves when handling resident food, but these were not followed in practice.
Failure to Timely Replace Resident's Corrective Lenses
Penalty
Summary
A resident with diagnoses of non-Alzheimer's dementia and amaurosis fugax, and a severely impaired cognitive status, required corrective lenses for vision. The resident was found wearing glasses that did not belong to him, and it was documented that his own glasses were missing. The facility's records show that the administrator searched for the missing glasses but was unable to locate them. Despite a grievance being filed by the resident's family in December regarding the missing glasses, the facility did not schedule an optometrist appointment to replace them in a timely manner. The family reported that they had informed facility staff about the missing glasses prior to the documented grievance date and had requested an appointment for replacement eyewear, but the facility failed to act on this request. After waiting for over two months without resolution, the family scheduled the necessary doctor's appointment themselves. The administrator later acknowledged that there was no documentation explaining why the facility did not arrange the appointment, but believed it was due to family preference.
Failure to Provide Correct Medicare Non-Coverage and ABN Forms
Penalty
Summary
The facility failed to provide the appropriate Centers for Medicare & Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) and Advanced Beneficiary Notice (ABN) forms to a resident regarding service options and potential financial liability for non-covered services. Record review showed that the resident and/or their representative received the NOMNC (CMS form 10123) with information on the right to appeal, but instead of the required ABN (CMS form 10055), the facility provided a different form (CMS form 10124-DENC), which did not indicate the option to receive or decline continued skilled services. Interviews with the Administrator revealed that there was no social worker at the facility, and the Administrator was responsible for handling ABNs, relying on forms provided by the corporate office. The Administrator believed the correct form was used but confirmed there was no facility policy for ABNs.
Inaccurate MDS Assessment and Documentation for Hospice Resident
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for a resident who was admitted to hospice care with a diagnosis of dementia. Clinical record review showed that the resident was admitted to hospice services with dementia, and the Significant Change MDS correctly indicated hospice level of care and listed dementia among active diagnoses. However, subsequent Quarterly MDS assessments did not reflect hospice services or the dementia diagnosis, and the section for special treatments, procedures, and programs was left blank. The resident's cognitive status was documented as severely impaired, but the required updates to the MDS were not made to accurately reflect the resident's current condition and services received. Interviews with facility staff revealed that there was a lack of continuity and oversight in the MDS assessment process. The MDS Coordinator position experienced turnover, and the new coordinator reported insufficient training and support, as well as outdated care plans and inaccurate MDS documentation. The facility's policy required accurate assessments by qualified staff, but this was not followed, resulting in incomplete and inaccurate resident assessments.
Failure to Develop and Update Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, as required by policy and regulatory standards. For one resident with diabetes and a history of skin cancer, the care plan did not include information about a chronic skin condition or a sore on the top of the head, despite multiple progress notes and interviews indicating the presence of a recurring, inflamed mole. Staff and the resident reported the area had been treated previously and continued to cause discomfort, but this was not reflected in the care plan. Documentation showed that staff were aware of the issue, applied treatments as needed, and eventually scheduled a dermatology appointment, but the care plan remained incomplete regarding this ongoing skin concern. For another resident with severe cognitive impairment and multiple comorbidities, including heart failure, chronic kidney disease, and dementia, the care plan was not updated in a timely manner to reflect the initiation of hospice care. There were discrepancies in physician order dates, hospice admission documentation, and the timing of care plan updates. Interviews with staff revealed that care plans and MDS assessments were not consistently accurate or current, and that the process for updating care plans was not well managed, with various staff members making entries without a clear system. The facility's own policy requires that comprehensive, person-centered care plans be developed and updated to address all identified needs and services, with measurable objectives and timeframes. However, the care plans for these two residents did not meet these requirements, as they lacked critical information about current conditions and services, and were not revised in accordance with changes in the residents' status or care needs.
Failure to Hold and Document Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were held at least quarterly and that follow-up on concerns raised during these conferences was documented for a resident with a diagnosis of depression and intact cognition. The resident's Minimum Data Set (MDS) indicated that having family or a close friend involved in care discussions was very important. While the electronic health record showed a care conference note with family and the resident in attendance on one occasion, there was no documentation of any care conferences held over a six-month period. Both the electronic and paper records lacked evidence of care conferences or follow-up on concerns discussed during this time. Interviews with the resident revealed dissatisfaction with the care conference process, stating that concerns raised were not addressed. Staff interviews confirmed that the MDS nurse was responsible for arranging care conferences but none were held during her tenure, and there was no policy in place for care conferences. The administrator and regional clinical director acknowledged the absence of care conference records and documentation, and confirmed that the facility was not in compliance with the requirement to hold and document quarterly care conferences.
Failure to Follow Infection Control Protocols During Resident Care and Equipment Use
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols during resident care and equipment handling. For one resident with a history of cerebrovascular accident, hemiplegia, and neurogenic bladder with an indwelling catheter, staff did not consistently change gloves between tasks. During observed care, a CNA changed gloves after cleaning the resident's peri-area but continued to wear the same gloves while touching the resident's clothing and assisting with other tasks, such as placing a blanket and handing the resident a grabber device. The staff also did not perform hand hygiene immediately after glove removal, as one staff member only applied hand sanitizer after removing gloves and reaching into her uniform pocket. Facility policy required gloves to be replaced when contaminated and for staff to change gloves before and after care or when moving from dirty to clean tasks. Additionally, staff failed to disinfect a mechanical lift between uses. After transferring a resident, a CNA pushed the lift into the hallway without disinfecting it, and another staff member subsequently used the same lift for a different resident without cleaning it. Facility policy stated that equipment should be cleaned and sanitized prior to use in other areas. Interviews with nursing staff and the DON confirmed the expectation that equipment such as mechanical lifts be disinfected before and after use, but this was not observed in practice.
Failure to Ensure Required CNA In-Service Education
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) completed the required minimum of 12 hours of annual in-service education for 3 out of 4 sampled CNAs who had been employed for more than one year. Review of the employee roster and education transcripts showed that one CNA completed 8.95 hours, another completed 1.0 hour, and a third completed 0 hours of in-service education during the review period. The Director of Nursing stated that mandatory in-services are held monthly and education courses are available through Relias, with the expectation that staff complete at least 12 hours of education each year. The Administrator noted that night shift staff often do not attend meetings or in-service training, making it difficult to ensure their participation.
Failure to Properly Handle Resident Funds and Property
Penalty
Summary
Facility staff failed to properly handle a resident's funds, resulting in a deficiency related to the protection of resident property. A resident with severe cognitive impairment and multiple diagnoses, including dementia and schizophrenia, had items purchased using their trust account. The purchases were made by a former Assistant Administrator, who did not follow established procedures for verifying and distributing the items. Specifically, the purchased items were left in bags at the nurse's station for weeks, and no receipts were provided to CNAs for verification. There were no signatures on the receipts to confirm that the items were delivered to the resident, and staff repeatedly requested the receipts to complete the check-in process. The facility conducted an internal investigation after allegations arose that the former Assistant Administrator may have purchased items for herself using resident funds. The investigation involved reviewing receipts and resident belongings, but the process lacked thorough staff interviews and did not include reporting the allegations to the state regulatory agency. The receipts provided were incomplete, missing identifying information, and lacked signatures from staff or the resident to validate the purchases. Additionally, there were discrepancies between the sizes of clothing purchased and the sizes typically worn by the resident, and some items listed on receipts could not be accounted for in the resident's belongings. Staff interviews confirmed that the resident typically wore XL or 2XL clothing, but several items purchased were in smaller sizes, and some items such as slippers were not observed in the resident's room. The process for purchasing and distributing items for residents who could not communicate their needs was not consistently followed, and inventory procedures were not properly documented. The lack of proper documentation, verification, and accountability in handling the resident's funds and belongings led to the deficiency.
Failure to Separate Accused Employee During Abuse Investigation
Penalty
Summary
The facility failed to implement immediate protective measures after receiving allegations of potential theft by an employee involving two residents' trust accounts. Upon being notified of the allegations, the facility initiated an internal investigation by reviewing receipts and checking account statements, and by physically verifying the purchased items in the residents' rooms. However, the employee accused of the misconduct was not suspended or separated from resident contact during the investigation. Instead, the employee remained in the facility and participated in the investigation process, including assisting the facility Administrator in identifying items in the residents' rooms. The facility's policy required immediate action to prevent further potential abuse by separating the accused employee from all residents during an investigation, either by suspension or reassignment. Despite this, the accused employee continued to have access to the facility and was not restricted from resident contact while the investigation was ongoing. The facility's census at the time was 45 residents, and the failure to follow policy was confirmed through interviews, review of the abuse investigation, and policy documentation.
Failure to Thoroughly Investigate Alleged Misappropriation of Resident Funds
Penalty
Summary
The facility failed to conduct a thorough investigation into two allegations of misappropriation of resident funds involving two residents with severe cognitive impairment. Both residents had significant medical and cognitive conditions, including dementia, schizophrenia, and hemiplegia, which limited their ability to express their needs or preferences. The allegations centered on purchases made from the residents' trust accounts by a former Assistant Administrator, with concerns raised by staff that items purchased may not have been delivered to the intended residents and that receipts were not properly managed or verified. The facility's internal investigation primarily involved the Administrator independently reviewing receipts and comparing them to items found in the residents' rooms, without interviewing relevant staff or obtaining written witness statements. Staff interviews revealed that purchased items remained in bags at the nurse's station for weeks, and staff repeatedly requested receipts to verify and distribute the items, but these were not provided in a timely manner. There were also discrepancies in the sizes and types of items purchased compared to the residents' known needs, as reported by multiple CNAs familiar with the residents' care routines. Documentation provided by the facility included partial and reprinted receipts, which lacked clear identification of the place of purchase and did not include signatures from the purchaser, residents, or staff to confirm receipt and delivery of items. The facility Administrator did not report the allegations to the state regulatory agency as required by policy, and did not interview staff or preserve physical evidence as outlined in the facility's abuse investigation protocols. The investigation was completed without comprehensive documentation or staff involvement, and the facility failed to follow its own policies for reporting and investigating allegations of abuse or misappropriation.
Failure to Assess and Intervene for Resident Injuries and Skin Conditions
Penalty
Summary
The facility failed to complete timely assessments and provide appropriate interventions for three residents following incidents that required nursing attention. One resident, with a history of heart failure, renal insufficiency, diabetes, and limited mobility, sustained a puncture wound to the right lower calf from a broken wheelchair. Despite the resident and a CNA reporting the injury, no nursing assessment was performed for over 12 hours, and the wound was not addressed until the following day. The nurse and ADON were unaware of the injury, and the maintenance department was not notified until after the surveyor's inquiry. The care plan required staff to monitor skin and report issues, but this was not followed, resulting in delayed wound care and equipment repair. Another resident, who was severely cognitively impaired and at risk due to visual impairment and confusion, spilled hot coffee on her chest. Although the incident was reported and the physician was notified, there was no documented evidence of ongoing nursing assessment or monitoring of the affected skin area as required by the facility's process. The only documentation available was the initial incident report, and the facility acknowledged that if further assessments were completed, they were not documented. The facility also lacked policies for resident assessments or nursing documentation. A third resident, with a history of diabetes and previous skin cancer, reported a recurring sore on the top of the head. The care plan did not address this chronic skin issue, and there was no documentation of skin assessments or incident reports related to the sore. Although the resident and staff reported the issue to physicians and nurses, and treatments were attempted, there was no referral to dermatology or consistent documentation of the condition until after the surveyor's inquiry. The facility also lacked a policy for change in condition, contributing to the lack of timely assessment and intervention.
Inadequate PPE Usage and COVID-19 Outbreak in LTC Facility
Penalty
Summary
The facility failed to provide a safe environment to prevent the transmission of communicable diseases and infections, specifically during a COVID-19 outbreak. Staff did not appropriately wear Personal Protective Equipment (PPE), and PPE was not made available for staff caring for COVID-19 positive residents. This led to a significant outbreak where 26 out of 45 residents tested positive for COVID-19. Resident #16, who had a history of Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF), became COVID-19 positive and was transferred to the hospital due to shortness of breath and low oxygen levels. Staff interviews revealed that PPE, such as gowns and eye protection, was not consistently available or used during the outbreak. Staff reported that they were instructed to work even when COVID-19 positive, with only N95 masks provided, and that gowns and eye protection were unavailable until late in the outbreak. Staff also indicated that residents who tested positive were not isolated properly, and there was a lack of signage to indicate isolation precautions. The Director of Nursing (DON) and other staff acknowledged the lack of PPE and the failure to isolate COVID-19 positive residents. The DON admitted that PPE was not utilized effectively and that there was skepticism about its effectiveness in preventing transmission. The facility's policies on infection control and COVID-19 outbreak management were not followed, contributing to the spread of the virus among residents and staff.
Removal Plan
- All facility staff were educated on the appropriate use of personal protective equipment in the facility.
- All residents on isolation have isolation carts stocked and available.
- Competencies were completed with all staff currently at the facility. All staff not present will have competencies completed prior to their next shift.
- The facility initiated on-going audits of isolation and personal protective equipment three times weekly.
- Any concerns will be reported to the administrator immediately and addressed in facility QA.
Inadequate Staffing and Rounding Leads to Resident Neglect
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure the safety and care of residents, as evidenced by the incident involving Resident #9. Resident #9, who had moderate cognitive impairment and required maximal assistance with dressing and moderate assistance with toileting, was found on the floor with a bruise and a laceration on the head after an unwitnessed fall. The resident reported being on the floor for a significant portion of the night without assistance, as no staff checked on her between 3:30 AM and 8:30 AM. The resident was unable to reach her call light and had been yelling for help without response. The facility's investigation revealed that the resident was last seen at 3:30 AM and was found at 8:30 AM, indicating a lack of regular checks and rounds by the staff. Interviews with staff members highlighted issues with staffing levels and the completion of rounds. Staff B, an LPN, found Resident #9 on the floor and noted that the CNA's working that day did not complete walking rounds, which have since been mandated to be signed off. Staff members reported that the facility was short-staffed, particularly on weekends, and that all nursing staff sometimes took breaks together, leaving residents unattended. The Director of Nursing confirmed that no CNA had entered Resident #9's room from 3:30 AM until the resident was found at 8:30 AM, and expressed a desire for more frequent rounding, ideally every two hours. Additional concerns were raised by other residents and staff regarding the timeliness of call light responses and the provision of care. Resident #4 reported waiting up to 30 minutes for assistance after activating the call light, and staff members confirmed delays in responding to call lights due to staffing issues. The facility's policy required call lights to be within reach and answered promptly, but this was not consistently achieved. The facility lacked a policy on bed checks or rounds, contributing to the deficiencies in care and oversight.
Unsecured Treatment Cart in Facility
Penalty
Summary
The facility staff failed to maintain a locked and secured treatment cart, as observed on September 22, 2024, at 12:47 p.m. The treatment cart was positioned along the wall in the nurse's station area, beside the resident's paper chart rack, and was left unlocked and unattended, making it accessible to all residents in the front of the building. The facility had a census of 45 residents, with 30 residing in the front portion of the building. During interviews, the Administrator confirmed the layout of the building and the location of the residents. Staff C, a Certified Nursing Assistant (CNA), confirmed observing unlocked, unattended medication carts with drawers left open, including the narcotic drawer, accessible to any staff, visitors, or residents. Staff E, another CNA, also confirmed frequently observing unlocked and unattended medication carts.
Deficiencies in Resident Care and Staff Management
Penalty
Summary
The facility failed to administer care in a manner that ensured the safety and well-being of its residents, as evidenced by the incident involving a resident with moderate cognitive impairment who experienced an unwitnessed fall. The resident was found on the floor with a head injury and had been there for several hours without assistance, as staff failed to conduct regular checks between 3:30 AM and 8:30 AM. The resident was unable to reach the call light and had attempted to clean up the blood from her injury. The facility's investigation confirmed that the resident was last seen at 3:30 AM and was not checked on until she was found on the floor at 8:30 AM, highlighting a significant lapse in monitoring and care. Another deficiency was noted in the administration of medication to a resident who had no cognitive impairment. The resident reported that a nurse attempted to administer both Tramadol and Tylenol together, despite the resident's request to take them separately. The nurse left the room without providing the requested medication, and it was only after another nurse intervened that the resident received the Tramadol. The Director of Nursing (DON) and the Administrator were aware of the incident but did not conduct a timely investigation or address the grievance appropriately, indicating a lack of proper communication and follow-up on resident concerns. The report also highlighted issues with infection control practices and staff management. Staff reported a lack of proper personal protective equipment (PPE) and inadequate training on Enhanced Barrier Precautions (EBP). Additionally, there were concerns about staff taking breaks together, leaving the facility understaffed at times. The Infection Preventionist (IP) was unable to perform her duties effectively due to being overworked and lacking access to necessary computer programs for tracking infections. The Administrator acknowledged these issues but had not taken sufficient steps to address them, contributing to the facility's failure to maintain a safe and effective care environment.
Deficiencies in Resident Care and Dignity
Penalty
Summary
The facility failed to honor the resident's right to a dignified existence and self-determination, as evidenced by multiple incidents involving staff interactions with residents. One incident involved a resident who requested specific pain medications separately, but the LPN insisted on administering them together, leading to a verbal altercation. The resident, who was paralyzed and experiencing back pain, was left without the requested medication for an extended period, causing distress and offense. The LPN did not follow the resident's request and failed to document the administration of medication properly. Another deficiency was observed with a resident at risk for skin breakdown due to incontinence. The resident was left with a large wet area on their clothing for an extended period after lunch, indicating a failure to provide timely personal care. The CNA involved did not change or reposition the resident as expected, leaving the resident in a state of undignified care. This neglect was contrary to the facility's policy of checking and changing residents at least every two hours. Additionally, the facility continued to serve meals on Styrofoam plates with plastic silverware even after the COVID-19 outbreak had ended, which was not in line with the residents' rights to be treated with dignity. The dietary staff and management did not update their practices following the outbreak, leading to a continued use of disposable dining ware, which was not necessary at the time of the survey. These actions collectively demonstrate a pattern of neglecting residents' rights and failing to provide a dignified living environment.
Deficiencies in Bathing and Perineal Care Due to Staffing Issues
Penalty
Summary
The facility failed to provide bathing services according to the individual schedules and preferences of three residents. Resident #2, who is severely cognitively impaired, was scheduled for baths twice a week but refused on multiple occasions without alternative interventions being offered. Resident #4, who is cognitively intact, expressed a preference for two baths a week but was observed with oily hair, indicating a lack of cleanliness. Resident #5, with moderately impaired cognitive skills, was scheduled for baths twice a week, but staff interviews revealed that staffing issues often prevented adherence to these schedules. Additionally, the facility failed to provide appropriate perineal care for Resident #10, who is cognitively intact and has a diagnosis of traumatic spinal cord dysfunction and quadriplegia. The resident reported that night shift CNAs did not properly cleanse her perineal and gluteal regions, leading to irritation and itching. This concern was documented in Resident Council minutes and a grievance form, highlighting ongoing issues with the quality of care provided during the night shift. Interviews with staff members confirmed that the facility's failure to adhere to residents' bathing schedules and requests was due to staffing shortages. CNAs reported being pulled to perform other duties, which limited their ability to provide scheduled baths. The facility's policy required two baths per week for each resident, but this standard was not consistently met, as evidenced by the observations and interviews conducted during the survey.
Deficiencies in Documentation and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate electronic health records for two residents, leading to deficiencies in care documentation. For Resident #20, the facility's records indicated that the resident was incontinent of urine, as documented by Staff H, a CNA, without actually checking the resident. Observations revealed that Resident #20 had a large wet area on his clothing, which was not addressed by Staff H, who left the resident in this condition. This discrepancy between the observed condition and the documented record highlights a failure in accurately documenting the resident's care needs and actions taken. In the case of Resident #10, there was a failure in the medication administration process. The resident, who had no cognitive impairment, reported that Staff G, an LPN, attempted to administer both Tramadol and Tylenol together, despite the resident's request to receive them separately. Staff G documented the administration of Tramadol in the MAR, although it was actually administered by Staff I, an RN, after the resident's initial refusal. This misdocumentation and confusion over who administered the medication indicate a lack of proper communication and adherence to medication administration protocols. The Director of Nursing (DON) and other staff interviews confirmed these discrepancies, acknowledging that the documentation did not reflect the actual care provided. The facility's policies require accurate documentation of care and medication administration, which were not followed in these instances. These deficiencies in record-keeping and medication administration could potentially impact the quality of care provided to the residents.
Inaccurate Resident Assessment and Restraint Coding
Penalty
Summary
The facility failed to provide an accurate assessment of a resident's behavior during the observation period of the Minimum Data Set (MDS). Specifically, an incident occurred where a resident shoved another resident against the wall, resulting in a fall. However, the MDS assessment completed shortly after the incident inaccurately indicated that the resident showed no signs of delirium, mood, or behavioral symptoms directed towards others. Additionally, the facility inaccurately coded their 802 Matrix related to restraints, identifying six residents as using restraints when an email from the Clinical Nurse Specialist confirmed that no residents utilized restraints in the facility.
Failure to Implement Care Plans for Residents
Penalty
Summary
The facility failed to implement care plans for three residents, leading to deficiencies in meeting their needs. Resident #2, who was severely cognitively impaired, had a care plan that required assistance with bathing twice a week. However, the resident refused baths on multiple occasions without any documented alternative interventions, such as bed baths or changes in schedule, being attempted. This lack of follow-up on refusals indicates a failure to adhere to the care plan and address the resident's hygiene needs. Resident #4, who was cognitively intact but had hemiplegia, received baths as scheduled without refusals, indicating compliance with the care plan. In contrast, Resident #5, who had moderately impaired cognitive skills and required substantial assistance, had a care plan that included sponge baths if full baths were not tolerated. Despite receiving baths on scheduled days, there is no documentation of refusals or the need for alternative bathing methods, suggesting that the care plan was not fully implemented or monitored for effectiveness.
Medication Administration Deficiencies
Penalty
Summary
The facility staff failed to adhere to professional standards of practice in medication administration for three residents. For Resident #10, a Licensed Practical Nurse (LPN) was observed removing medication cups from a cart, which were not labeled with the resident's name or the actual medication present. The LPN admitted to placing the medications in the cart's top drawer after the resident refused them before lunch, a practice confirmed by the Clinical Nurse Specialist. Additionally, a Certified Nursing Assistant (CNA) reported that nursing staff often left medications unattended on dining room tables and bedside stands. Resident #1 was found to have medication under his bed, indicating non-compliance with prescribed doses. The Environmental Services Supervisor confirmed finding a pill at the foot of the bed and reported it to the charge nurse. She also observed a nurse leaving medications in an unknown resident's room and found pills scattered throughout the building. For Resident #21, who had a diagnosis of Amyotrophic Lateral Sclerosis and chronic pain, a grievance was filed after the Assistant Director of Nursing (ADON) left medications on the bedside table out of reach, resulting in a pain pill being lost in the bed. The resident reported the issue, which was resolved, but the incident left her in pain overnight until the pill was found the next morning.
Failure to Follow Physician Orders in Medication Administration
Penalty
Summary
The facility failed to follow physician orders for a resident, leading to a deficiency in medication administration. The Medication Administration Record (MAR) for the resident indicated that Memantine HCL and Mirtazapine were documented as administered, but Olanzapine was absent from the medication cart. During an observation, it was confirmed that all three medications were documented as administered, despite the absence of Olanzapine. This discrepancy was acknowledged by the Clinical Nurse Specialist. Further observations revealed that a Licensed Practical Nurse (LPN) attempted to administer crushed medications to another resident, who refused to take them. Despite the refusal, the LPN signed out the administration of the medications on the MAR. The LPN later admitted that the resident refused the morning medications, but she failed to correct the MAR initially. The LPN eventually updated the MAR to reflect the proper documentation, acknowledging that the resident did take the noon medications after some time, but not the morning ones.
Failure to Provide Restorative Services for Resident
Penalty
Summary
The facility failed to provide restorative services to maintain or improve the range of motion (ROM) and mobility for a resident, as observed during a survey. Resident #5, who required moderate assistance with toileting hygiene and upper body dressing, reported that staff did not perform ROM exercises, which she preferred as part of her goal to return home. Interviews with two Certified Nursing Assistants (CNAs) confirmed the lack of restorative services for residents. Additionally, an email from the Clinical Nurse Specialist revealed that the facility lacked a restorative policy or procedure. The Clinical Nurse Specialist and the Director of Nursing acknowledged that the facility's restorative program required restructuring and appropriate follow-through.
Lack of Activities Director Leads to Insufficient Resident Engagement
Penalty
Summary
The facility failed to employ a qualified Activities Director (AD), resulting in a lack of diverse and engaging activities for residents. The facility's activity calendars for April and May 2024 showed limited and repetitive activities, such as Bingo, shopping, and crafts, with several days having no activities at all. Interviews with residents and staff revealed dissatisfaction with the current activity offerings, noting that activities were infrequent, lacked variety, and often did not occur at scheduled times. The facility's assessment indicated the need for a full-time AD and various activities to support residents' psycho/social/spiritual needs, but these were not being met. Residents expressed their dissatisfaction with the lack of music and other preferred activities, and staff confirmed the absence of an AD. The facility administrator acknowledged the lack of a completed activity calendar for several months and cited water damage as a reason for the missing calendars. Nursing staff attempted to fill the gap by organizing activities when possible, but these efforts were inconsistent and insufficient. The Director of Nurses and other staff members confirmed the need for an AD to ensure residents have access to meaningful activities.
Lack of Dignity in Dining Experience
Penalty
Summary
The facility failed to uphold the dignity of residents during dining experiences in the main dining room, as observed during three meals. Certified Nursing Assistants (CNAs) were seen standing and walking around the table while feeding residents, rather than sitting and providing individualized attention. This practice was attributed to staffing shortages, with only one or two staff members available to assist multiple residents, leading to a rushed and impersonal feeding process. Interviews with staff confirmed that this method was used to ensure timely feeding, despite the lack of dignity it afforded the residents. Additionally, the dining experience was disrupted by a resident who repeatedly yelled profanities and made loud noises throughout meals. This behavior was noted to be ongoing and had been a concern for other residents, who expressed discomfort and a desire to sit elsewhere. Despite these complaints, the facility's administrator did not perceive the behavior as problematic, citing the need to avoid isolating the disruptive resident. The facility's policy emphasized a person-centered dining approach, aiming for a cheerful and respectful atmosphere, which was not reflected in the observed dining experiences.
Deficiency in Resident Activities Program
Penalty
Summary
The facility failed to provide a comprehensive activities program that catered to the interests and needs of its residents, impacting their physical, mental, and psychosocial well-being. The activity calendars for April and May 2024 showed significant gaps, with multiple days lacking any scheduled activities and others offering repetitive or singular options like Bingo, shopping, or crafts. Interviews with residents and staff revealed dissatisfaction with the limited variety and frequency of activities, with some residents expressing a lack of engagement and interest in the available options. The absence of an Activity Director further exacerbated the situation, as staff struggled to fill the gap by occasionally bringing in pets or children, but these efforts were inconsistent and insufficient. The facility's administration acknowledged the lack of a structured activities program, citing issues such as water damage and the absence of an Activity Director as contributing factors. Despite having a job description for a Director of Life Enrichment, which outlined the need for a diverse and daily activities program, the facility failed to implement these guidelines. The facility assessment from January 2024 highlighted the need for social, psychosocial, and spiritual support through activities, yet the facility did not meet these requirements, leaving residents without adequate opportunities for engagement and enrichment.
Disruptive Dining Environment Due to Resident Behavior
Penalty
Summary
The facility failed to provide a homelike dining environment for its residents, as observed during three meal observations in the common dining area. During these observations, a resident with a history of non-traumatic brain dysfunction and Alzheimer's disease was noted to be yelling profanities and making loud noises throughout the meals. This behavior was disruptive to other residents, as evidenced by interviews with two other residents who expressed discomfort and a desire to sit elsewhere. One resident, with moderate cognitive impairment, described the dining experience as unpleasant, while another resident with intact cognition expressed frustration at having to leave her friend due to the disruptive behavior. The facility's administrator and corporate nurse acknowledged the behavior of the disruptive resident but did not express concern, with the administrator stating that many residents cannot eat in their rooms and that others are used to the behavior. The corporate nurse mentioned that the team is discussing options to address the issue. The facility's policy on person-centered dining emphasizes the importance of a cheerful, inviting, and friendly dining atmosphere, which was not upheld in this situation.
Deficiencies in Meal Preparation and Menu Posting
Penalty
Summary
The facility failed to prepare and serve appropriate portions for residents on pureed and mechanical soft diets. Observations revealed that Staff F did not prepare enough food, resulting in insufficient portions of ham loaf and tater tots for residents. The dietary conversion chart used by Staff F lacked a column for nine servings, leading to incorrect portion sizes. Additionally, Staff F was unaware of the meaning of 'SH' on the dietary conversion chart, further contributing to the portioning errors. The facility's policy on portion control, which mandates that individuals receive appropriate portions as outlined on the menu, was not adhered to. Furthermore, the facility did not provide residents with menu options or alternatives, nor were menus posted in advance. Residents reported not knowing what meals would be served and expressed a lack of choice in their meals. The Administrator acknowledged that menus were only posted on a whiteboard before each meal and that no full menu or alternative options were provided in writing. The facility's policies on displaying menus and person-centered dining, which emphasize individualized nutrition care and the posting of planned menus, were not followed.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain food at safe and appetizing temperatures during meal service, as observed by surveyors. On June 5, 2024, at 11:15 AM, a cook, identified as Staff F, recorded the temperature of the lunch menu items, noting the Ham Loaf at 139.5°F and the lettuce at 40.8°F. However, during food service, the lettuce was served at room temperature from a serving bowl on the counter. Later, at 1:20 PM, Staff F recorded the Ham Loaf temperature at 129.5°F, which was below the facility's policy requirement for hot foods to remain above 135°F. The facility's policy, dated 2021, mandates that hot foods should stay above 135°F and cold foods below 41°F during the holding and plating process until the food leaves the service area. On June 7, 2024, the Administrator confirmed that staff should adhere to the facility's policy regarding food service temperatures. The failure to maintain these temperatures as per the policy was identified as a deficiency during the survey.
Sanitary Practices Deficiency in Food Preparation
Penalty
Summary
The facility failed to maintain sanitary practices in the food preparation area, as observed during a survey. Staff F was seen with an uncovered mustache and goatee, and his head cap did not contain all of his hair. Additionally, Staff F handled food with bare hands, slicing tomatoes and placing them in serving dishes without gloves. He also retrieved a serving scoop from a drawer and placed it face-down on a counter used for food preparation. Furthermore, Staff F filled a dressing dispenser, allowing the nozzle tip to touch his ungloved palm, and handled lettuce with bare hands, placing it back into a bowl after touching a resident's plate. He also used bare hands to place buttered bread in a skillet, reached into a bag of cheddar cheese, and cut a cooked sandwich on a plate. The facility's policy on General Food Preparation and Handling, dated 2021, indicated that bare hands should never touch ready-to-eat raw food directly, and disposable gloves should be used and discarded after each use. Employees are required to wash hands before putting on gloves and after removing them. The policy also directed staff to use tongs or other serving utensils to serve bread or other items to avoid bare hand contact with food. The Administrator confirmed that Staff F should have been wearing beard and hair nets and that gloves should be worn for all meal preparation.
Failure to Timely Notify Emergency Contact of Resident Evacuation
Penalty
Summary
The facility failed to provide timely notification to the emergency contact of a resident who was evacuated and transferred to another facility. The incident involved Resident #94, who had a planned discharge assessment with an anticipated return. On the morning of the incident, an emergency evacuation was initiated at approximately 4:30 AM, and the resident was transferred to another facility by 9:10 AM. However, the resident's emergency contact was not notified of the evacuation and transfer until approximately 2:50 PM. Hospice staff assisting with the relocation expressed frustration over the lack of communication to the resident's emergency contact. The facility's administrator acknowledged the expectation for timely notification, but no policy was provided.
Failure to Complete Discharge Summaries for Two Residents
Penalty
Summary
The facility failed to complete discharge summaries for two residents, leading to a deficiency in the communication of necessary information at the time of discharge. Resident #43, who was admitted for skilled services, had a BIMS score indicating moderately impaired cognition and required supervision for bathing. Despite being managed by the PACE program, the facility did not provide a discharge summary, as confirmed by the Director of Nursing. The discharge documentation was stored in a separate system by PACE, and the facility acknowledged the failure to meet the discharge summary requirement. Similarly, Resident #94, who was transferred to another facility for an emergency evacuation, did not have a completed discharge summary. The record lacked a recapitulation of the resident's stay, and the Corporate Nurse confirmed the absence of the discharge summary. The responsibility for this oversight was attributed to a former staff member, and the facility recognized that the discharge summary should have been completed.
Failure to Include Resident and Family in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that quarterly interdisciplinary team meetings included the resident and/or their representative to discuss changing goals and review or revise the care plan for one resident. This deficiency was identified during a review of records, interviews with the responsible party, and staff interviews. The resident in question had a moderately impaired cognitive status, as indicated by a score of 9 out of 15 on the Brief Interview for Mental Status (BIMS) exam. The resident had diagnoses including non-traumatic brain dysfunction, dementia, renal diseases, depression, and chronic pain. The care plan, initiated earlier in the year, included interventions to keep the resident and family informed about health conditions and to encourage family involvement. During an interview, the responsible party for the resident stated they had never been informed about the option to participate in care plan meetings, nor had they received any invitations to such meetings. The responsible party expressed a desire to be involved in the care planning process. Additionally, the MDS Coordinator, who was new to the facility, reported being unable to locate any past documentation on care plan conferences and acknowledged the absence of a systematic process for including residents and families in quarterly care conferences. The facility did not have a policy regarding these conferences and claimed to follow regulatory processes.
Medication Administration Deficiency
Penalty
Summary
The facility failed to adhere to professional standards during medication administration for a resident with multiple diagnoses, including heart disease, diabetes, and respiratory failure. During an observation, a Certified Medication Aide (CMA) attempted to administer Thiamine to the resident but used a 100 mg pill from a stock bottle instead of the prescribed 50 mg dose. The CMA recognized the error after being prompted by a surveyor and returned the incorrect pill to the stock bottle, which is against the facility's medication administration policy. Additionally, the resident was given a fast-acting insulin injection by an LPN, but the meal was not served promptly, leaving the resident waiting for food. Furthermore, the CMA failed to instruct the resident to rinse their mouth after using the Trelegy inhaler, as required by the medication administration record (MAR) and manufacturer instructions. These actions demonstrate a lack of adherence to professional standards and facility policies, as confirmed by the Director of Nurses (DON) during an interview.
Inadequate Catheter Care Leading to Infection Risk
Penalty
Summary
The facility failed to provide appropriate catheter care to minimize or prevent complications from urinary tract infections for a resident with a suprapubic catheter. The resident, who had a history of seizure disorders, cerebral infarction, intellectual disability, renal disease, and neurogenic bladder, required maximum assistance for personal hygiene and dressing. Observations revealed that the resident's catheter bag was improperly managed, as it was seen on the floor and dragging under the wheelchair, which poses a risk for infection. Interviews with staff and the Director of Nursing confirmed that the catheter bag should not be on the floor, acknowledging the associated risks of urinary tract infections. The facility lacked a specific policy addressing the management of urinary catheter bags, although they had a general catheter care policy aimed at preventing infection. The resident's responsible party was notified of a recent urinary tract infection, for which the resident was being treated with antibiotics.
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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