Arbor Court
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Pleasant, Iowa.
- Location
- 701 East Mapleleaf Drive, Mount Pleasant, Iowa 52641
- CMS Provider Number
- 165478
- Inspections on file
- 33
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Arbor Court during CMS and state inspections, most recent first.
Failure to Notify Ombudsman of Resident Transfers: The facility did not notify the LTC Ombudsman of hospital transfers/discharges for two residents. One resident was discharged to an acute care hospital and was not expected to return, but was not listed on the monthly transfer/discharge notice. Another resident had severe RUQ pain, purplish lips, and pursed-lip breathing, was sent by ambulance to the ED, and later returned the same day, but was also omitted from the Ombudsman notice. The Administrator stated one notification was missed and said she did not know emergency transfers required notification if the resident was not admitted.
Failure to Follow Inhaler Administration Instructions: Staff did not follow physician-ordered directions for two residents receiving steroid inhalers. One resident with dementia and severe cognitive impairment received Asmanex without being instructed to rinse and spit, and another resident with intact cognition received Trelegy without being prompted to swish and spit after use. The CMA stated she was unfamiliar with the medication instructions, while the RN and DON confirmed that rinse-and-spit directions should be followed for corticosteroid inhalers.
A facility failed to accurately obtain and implement advanced directives for a resident upon admission. The resident's verbal order for CPR was documented, but no signed document confirmed their wishes for life-sustaining measures. The DON could not locate the resident's IPOST, and although the family communicated a DNR wish, the SSD did not document the contact attempt. The facility's policy on Advanced Directives was not adequately followed.
A resident with severe cognitive impairment and mobility issues was transported in a wheelchair with only one foot pedal, despite staff acknowledging the need for two. The second pedal was broken, and there was no policy for wheelchair transport, leading to a deficiency in ensuring a safe environment.
The facility was cited for a deficiency in the accuracy of MDS assessments, specifically regarding the smoking status of two residents. Despite recent audits, the MDS was inaccurately coded, and the facility lacked a specific MDS policy, relying instead on the CMS Resident Assessment Instrument. The issue was acknowledged by the DON and MDS Coordinator, who planned to submit corrections.
A resident with multiple health conditions, including schizophrenia and diabetes, refused necessary blood draws and experienced a significant change in blood glucose levels. The facility failed to notify the resident's legal guardian of these refusals and changes, despite policy requirements. Interviews with staff revealed a lack of communication and clarity regarding the notification process.
A facility failed to resubmit a PASRR after a resident's mental health diagnoses changed, including major depressive disorder and psychotic disorder. The oversight was identified through observations and staff interviews, revealing a lack of policy and communication during staff transitions. The SSD confirmed the need for a new PASRR, but it was not submitted due to missed communication and absence of auditing procedures.
A facility failed to document post-dialysis assessments for a resident with end-stage renal disease, missing vital signs documentation on multiple occasions. Staff interviews revealed that the assessments were supposed to be recorded on a communication sheet or in the electronic health record, but were absent. The facility lacked a specific dialysis assessment policy, contributing to the oversight.
The facility inaccurately completed MDS assessments for two residents regarding their tobacco use. Despite documentation and interviews confirming their smoking habits, the MDS indicated they did not use tobacco. The DON and MDS Coordinator acknowledged the errors, and the facility lacked a specific MDS policy.
A resident with severe cognitive impairment and a history of wandering eloped from the facility due to unsecured and unalarmed doors. The resident exited through a series of doors, including one with a disengaged lock, and was found outside without shoes. The facility's interventions, such as a Wander Guard, were insufficient, and staff interviews indicated inconsistent alarm monitoring. Additionally, another resident was injured due to improper lifting methods, highlighting the facility's failure to adhere to care plans and maintain a secure environment.
A facility failed to provide a bed hold notice to a resident or their representative upon hospital transfer, as required by guidelines. The resident, who was cognitively intact and had multiple diagnoses, was transferred for treatment without the necessary documentation. Interviews with staff revealed a lack of clarity and adherence to the Bed Hold Policy, with the responsible nurse admitting to not completing the required form.
The facility failed to accurately code medications on the MDS for two residents. One resident, with diagnoses of Atrial Fibrillation and Heart Failure, was not coded for diuretic and hypnotic medications despite having physician orders. Another resident on anticoagulant therapy with Xarelto was not documented on the MDS. Interviews confirmed the omissions, and the facility lacked a specific MDS policy.
A facility failed to update a care plan for a resident identified as a smoker, despite a Smoking Safety Evaluation indicating balance issues. The resident, cognitively intact with a BIMS score of 15, was observed smoking under supervision. The MDS Coordinator was responsible for care plan updates, but the plan lacked necessary interventions per facility policy, such as supervised smoke breaks and secure storage of smoking items.
A housekeeping staff member failed to follow hand hygiene protocols while handling soiled laundry, using bare hands instead of gloves and neglecting to wash hands afterward. The facility's policy requires staff to wear gloves and perform hand hygiene after handling contaminated items, which was not adhered to in this instance.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Long-Term Care Ombudsman of resident transfers and discharges for 2 of 3 residents sampled, including a resident who was discharged to an acute care hospital and was not expected to return, and another resident who was transferred to the emergency department and later returned to the facility. Review of the MDS for one resident showed discharge to an acute care hospital, and the Notice of Transfer Form to the LTC Ombudsman for February 2026 did not list that resident as a hospital transfer/discharge. During interview, the Administrator stated she was responsible for sending monthly notifications of resident transfers and discharges to the LTC Ombudsman and acknowledged that notification had been missed for that resident. For the second resident, the EHR documented severe right upper quadrant pain, purplish lips, pursed-lip breathing, notification of the DON and provider, and an order to transfer to the ED for further evaluation. Nursing notes showed the resident left the facility by ambulance and later returned by ambulance the same day. The Notice of Transfer Form to the LTC Ombudsman for March 2026 did not include the resident’s name for the emergency hospital transfer. During interview, the Administrator stated she did not know she needed to notify the Ombudsman for emergency transfers if the resident was not admitted to the hospital.
Failure to Follow Inhaler Administration Instructions
Penalty
Summary
The facility failed to ensure staff administered medicated inhalers according to physician orders for 2 residents. One resident had a BIMS score of 7 out of 15, indicating severe cognitive impairment, and a diagnosis of dementia. That resident had an order for Asmanex Inhaler, 2 puffs twice daily for COPD with acute exacerbation, with instructions to rinse the mouth with water and spit after use. During observation, a CMA administered the inhaler but did not have the resident rinse and spit afterward. The CMA stated the MAR did not include the rinse-and-spit instruction, while the RN and DON stated the instruction should be included and that residents should rinse and spit after corticosteroid inhaler use. A second resident had a BIMS score of 13 out of 15 and diagnoses including pulmonary embolism and asthma/COPD/chronic lung disease. That resident had an order for Trelegy Ellipta, 1 puff in the morning for COPD with acute exacerbation, with directions to rinse mouth after use and hold breath for 5 to 10 seconds. During observation, the CMA administered the inhaler and the resident held her breath, but she did not swish and spit afterward and the CMA did not prompt her to do so. In later interviews, the CMA stated she was unsure about special instructions for inhalers, then acknowledged that steroid inhalers require swishing and spitting to remove residual particles and prevent fungal infections.
Failure to Implement Advanced Directives
Penalty
Summary
The facility failed to accurately obtain and implement advanced directives for a resident upon admission. The resident, admitted from a short-term general hospital, had a verbal order for CPR documented in their Order Summary Report. However, there was no signed document in the electronic health record to confirm the resident's wishes for life-sustaining measures. The Director of Nursing (DON) was unable to locate the resident's Iowa Physician Orders for Scope of Treatment (IPOST) in the binder, which is essential for communicating preferences for treatments such as CPR and artificial nutrition. The DON later stated that the resident's family had communicated a wish for Do Not Resuscitate (DNR) status, and an IPOST was completed and faxed to the physician for signature. However, the Social Services Director (SSD) acknowledged that an attempt to contact the resident's family was made but not documented. The facility's policy on Advanced Directives requires providing residents or their representatives with information and instructions regarding their rights to make such directives upon admission, which was not adequately followed in this case.
Failure to Ensure Proper Wheelchair Transport
Penalty
Summary
The facility failed to ensure that a resident's wheelchair was equipped with two foot pedals during transport, which is necessary to prevent accidents. Resident #17, who has severe cognitive impairment and uses a manual wheelchair, was observed being pushed by staff with only one foot pedal attached. This occurred on multiple occasions, with staff members acknowledging the need for two foot pedals but continuing to transport the resident with only one. The resident's medical history includes non-Alzheimer's dementia, hemiplegia or hemiparesis, arthritis, and a hip fracture, which further necessitates proper support during wheelchair transport. Interviews with staff revealed that the second foot pedal was broken, and there was no policy in place for wheelchair transport. Staff members were aware of the broken pedal but continued to transport the resident without addressing the issue. The Director of Nursing confirmed the need for two foot pedals when pushing the resident, especially since the resident could not keep her feet on one pedal. Despite this, the facility did not have a policy to guide staff on proper wheelchair transport, contributing to the deficiency.
Deficiency in MDS Accuracy for Smoking Status
Penalty
Summary
The facility was cited for a deficiency related to the accuracy of assessments, specifically under F641, during a recertification survey. The issue was identified through a review of the facility's CASPER report, which indicated that the facility had previously been cited for the same deficiency in February 2024. During the current survey, it was found that the Minimum Data Set (MDS) Comprehensive Assessments for two residents were inaccurately coded as not using tobacco, despite both residents currently smoking at the facility. This discrepancy was acknowledged by the Director of Nursing and the MDS Coordinator, who admitted the coding error and stated that corrections would be submitted. The Administrator expressed surprise at the coding issue, as she had recently audited the MDS for smoking and believed everything was correctly coded. However, during an interview, it was revealed that the facility did not have a specific MDS policy and relied on the CMS Resident Assessment Instrument (User's Manual) for MDS coding. The Administrator, along with the Regional Director of Operations and the DON, acknowledged that the new MDS Coordinator was aware of the plan of correction from the last survey but had focused more on the care plan versus the MDS for smoking issues. The facility's QAPI policy outlines a process for ensuring care and services meet quality standards, but the deficiency indicates a failure to effectively implement these measures in this instance.
Failure to Notify Guardian of Resident's Medical Refusals and Condition Changes
Penalty
Summary
The facility failed to notify the legal guardian of Resident #7 about laboratory refusals and changes in the resident's condition. Resident #7, who has a history of schizophrenia, diabetes mellitus, stroke, aphasia, hemiplegia, and anxiety disorder, was under the guardianship of an agency as per a court order. Despite the resident's moderate cognitive impairment, the facility did not inform the guardian of the resident's refusal to undergo blood draws for essential tests like the Basic Metabolic Panel (BMP) and A1C, nor did they notify the guardian of a significant change in the resident's blood glucose levels. The clinical records showed multiple instances where Resident #7 refused necessary medical procedures, such as blood draws, without the guardian being informed. On one occasion, the resident refused a BMP draw, and although the resident was educated about the purpose, the refusal persisted, and the guardian was not notified. Similarly, when the resident's blood glucose level spiked to 501, the primary care provider was informed, but the guardian was not. Additionally, the resident sustained a minor injury during a transfer, which was also not communicated to the guardian. Interviews with facility staff, including the Assistant Director of Nursing, Licensed Practical Nurse, and Director of Nursing, revealed a lack of clarity and communication regarding the notification process for Resident #7's guardian. The guardian expressed a desire to be involved in the resident's care and was unaware of the refusals and changes in condition until visiting the facility. The facility's policy required notifying the resident's representative of significant changes, but this was not adhered to in Resident #7's case.
Failure to Resubmit PASRR After Change in Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the resubmission of a Preadmission Screening and Resident Review (PASRR) after a change in mental health diagnoses for a resident. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating intact cognition, was diagnosed with several mental health conditions, including major depressive disorder, anxiety disorder, and psychotic disorder. Despite these changes in diagnoses, the facility did not update the PASRR, which was initially exempted in 2019 when the resident did not meet the criteria for serious mental illness or developmental condition. The deficiency was identified through observations, clinical record reviews, and staff interviews. The Director of Nursing and the Social Services Director (SSD) acknowledged the oversight, with the SSD confirming that a new PASRR should have been submitted following the new diagnoses. The facility lacked a policy for PASRR submission and did not have procedures in place to audit for missing PASRRs. The Administrator noted that the oversight occurred during a staff transition period, and the new diagnoses were not communicated effectively within the team.
Failure to Document Post-Dialysis Assessments
Penalty
Summary
The facility failed to complete post-dialysis assessments for a resident with end-stage renal disease, who required dialysis services. The resident, identified with moderate cognitive loss, had a care plan that included dialysis sessions three times a week. The facility's records indicated an order for vital signs to be taken before and after dialysis sessions. However, there were multiple instances where post-dialysis vital signs were not documented, specifically on four occasions in October and November 2024. Interviews with staff revealed that the post-dialysis assessments were supposed to be documented on a dialysis communication sheet or in the electronic health record. However, these assessments were missing from both the communication records and the electronic health record for the specified dates. The Director of Nursing acknowledged that if the assessments were not documented, they were likely not performed. The facility did not have a specific dialysis assessment policy in place, which contributed to the oversight in documentation.
Inaccurate MDS Coding for Tobacco Use
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents regarding their tobacco use status. Resident #49, who had a Brief Interview for Mental Status (BIMS) score indicating intact cognition, was documented in the MDS as not utilizing tobacco. However, multiple sources, including a Smoke Safety Evaluation, progress notes, and interviews with the resident and staff, confirmed that Resident #49 was a smoker and regularly participated in smoking breaks. Similarly, Resident #18, with a BIMS score indicating moderate cognitive impairment, was also inaccurately documented in the MDS as not using tobacco. Interviews with the resident and staff confirmed that Resident #18 was a current smoker who smoked in designated areas with supervision. The Director of Nursing (DON) and the MDS Coordinator acknowledged the inaccuracies in the MDS coding for both residents. The DON expressed confusion over the incorrect coding, while the MDS Coordinator admitted the errors and indicated plans to submit corrections. The facility's Administrator noted that a recent audit of the MDS for smoking should have ensured correct coding, but discrepancies were still present. The facility's reliance on the Resident Assessment Instrument (RAI) for MDS coding was mentioned, but no specific MDS policy was in place. The errors were in violation of federal regulations requiring that assessments accurately reflect residents' statuses.
Failure to Prevent Resident Elopement and Injury
Penalty
Summary
The facility failed to prevent the elopement of a severely cognitively impaired resident identified at risk for wandering. The resident, who had a history of paranoid personality disorder, schizophrenia, and vascular dementia, exited the facility through a series of doors that were not properly secured or alarmed. The resident was last seen by staff standing in his doorway before being found outside the facility without shoes. The doors the resident used to exit were not alarmed to alert the nursing home section, and the lock on the door to the assisted living portion of the facility had not reengaged, allowing the resident to exit unnoticed. The resident had a documented history of wandering and agitation, with multiple notes in the clinical record indicating frequent pacing, entering other residents' rooms, and being easily redirected. Despite these behaviors, the resident was not in a locked unit, and the facility's interventions, such as the use of a Wander Guard, were insufficient to prevent the elopement. Staff interviews revealed that the resident was known to wander and that the alarms on the doors were not consistently functioning or monitored, contributing to the resident's ability to leave the facility. Additionally, the facility failed to adhere to the care plan for another resident who was dependent on a mechanical lift. This resident was lifted using a non-mechanical method, resulting in skin tears and bruising. The facility's lack of adherence to care plans and failure to maintain a secure environment for residents at risk of elopement and injury led to the identification of immediate jeopardy to the health and safety of the residents.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a bed hold notice to a resident or their representative upon transfer to the hospital, as required by state and federal guidelines. Resident #11, who was cognitively intact with a BIMS score of 12 out of 15 and had diagnoses including Coronary Artery Disease, Heart Failure, and Renal Insufficiency, was transferred to the hospital for intravenous antibiotic treatment for a urinary tract infection. Upon review, the clinical record lacked documentation of a bed hold notice being given to the resident or their representative. Interviews with facility staff, including a Registered Nurse (RN), the Administrator, and the Director of Nursing (DON), revealed that the nurse responsible for sending the resident to the hospital should review the Bed Hold Policy with the resident or family within 24 hours of the transfer. However, the RN admitted to never having filled out the bed hold form and was unsure if it should be documented in the electronic medical record. The Administrator and DON confirmed the policy but could not explain why it was not completed for Resident #11, with the DON noting she was on medical leave at the time.
Failure to Accurately Code Medications on MDS
Penalty
Summary
The facility failed to accurately code medications on the Minimum Data Sets (MDS) for two residents, leading to deficiencies in their assessments. Resident #33, who was cognitively intact with a BIMS score of 15, had diagnoses of Atrial Fibrillation, Heart Failure, and Diabetes Mellitus. Despite having physician orders for torsemide, a diuretic, and temazepam, a hypnotic, these medications were not coded on the MDS. Observations and interviews confirmed the resident's use of these medications, yet the Assistant Director of Nursing (ADON) and Director of Nursing (DON) could not explain the omission. Similarly, Resident #38, also cognitively intact with a BIMS score of 15, was on anticoagulant therapy with Xarelto, as indicated in the care plan and physician orders. However, the MDS lacked documentation of this anticoagulant medication. Interviews with the ADON and DON confirmed the resident's use of Xarelto and acknowledged that it should have been coded on the MDS. The facility did not have a specific policy for MDS, relying instead on the guidelines of the RAI Manual.
Failure to Update Care Plan for Smoking Resident
Penalty
Summary
The facility failed to update the care plan for Resident #48 to include smoking as a focus area and necessary interventions to ensure safety. Resident #48, identified as cognitively intact with a BIMS score of 15, has a history of smoking and was observed smoking in the designated area under supervision. Despite a Smoking Safety Evaluation Form indicating Resident #48 as a smoker with balance issues, the care plan last revised did not reflect this information. The resident's smoking habit had been known for at least six months, yet the care plan was not updated accordingly. Interviews with staff revealed that the MDS Coordinator, who recently assumed the role, was responsible for updating care plans. However, any nurse could update them. The facility's smoking policy requires that smoking be addressed in care plans, with interventions such as supervised smoke breaks and secure storage of smoking paraphernalia. Despite these requirements, the care plan for Resident #48 did not include these interventions, indicating a lapse in adherence to the facility's policy.
Failure to Follow Hand Hygiene Protocols in Laundry Handling
Penalty
Summary
The facility failed to adhere to standard hand hygiene precautions for infection control when handling soiled laundry. During an observation, a housekeeping staff member, identified as Staff O, was seen using her bare hands to transfer soiled laundry from a garbage bag into a washing machine without wearing gloves. This incident involved dirty clothing protectors from residents. After handling the soiled laundry, Staff O did not perform hand hygiene, such as washing her hands, before leaving the laundry room. Interviews with the facility's Administrator and the Infection Control and Preventionist revealed that staff are expected to use appropriate personal protective equipment (PPE), including gloves, when handling soiled laundry. The facility's policy mandates hand hygiene before and after glove use and after handling contaminated items. Staff O acknowledged her failure to follow these procedures, admitting she forgot to wear gloves and did not wash her hands before leaving the laundry room. The facility's hand hygiene policy, dated April 28, 2022, outlines the importance of hand hygiene in preventing healthcare-associated infections and specifies when it should be performed.
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An LPN, unfamiliar with residents on a medication cart and faced with two residents sharing the same first name, failed to correctly identify a resident and administered a full set of another resident’s medications in addition to the resident’s own ordered morning medications, including PRN oxycodone. The resident, who had severe cognitive impairment and multiple diagnoses including hypertension and Alzheimer’s disease, subsequently experienced declining BP, reported not feeling well, and became increasingly fatigued. The facility’s policy required resident identification before medication administration, and the LPN acknowledged not knowing the residents and finding the EHR photos too small, despite their availability. Hospital records later documented hypotension, treatment with IV fluids, and a drug overdose after accidental ingestion of another resident’s medications plus the resident’s own, with persistent sinus bradycardia requiring admission for further hemodynamic monitoring.
A cognitively impaired, wandering resident with Alzheimer’s disease and behavioral symptoms was care planned as an elopement risk but was able to leave the memory care unit by holding an emergency exit door bar for 15 seconds and exiting into a stairwell and then to the employee parking lot. The door alarm functioned, but staff in the noisy dining room did not hear it while they were feeding multiple residents, including several needing extensive assistance, and only realized the resident was missing when another staff member encountered him outside and brought him back. In addition, several residents who required staff assistance for transfers and toileting experienced prolonged call light response times well beyond the facility’s 15‑minute expectation, including one who reported waiting up to an hour during meals and having an in‑room accident, another observed waiting about 25 minutes while calling out for help, and a third waiting about 17 minutes before a CNA responded.
A cognitively intact resident reported that a CNA ripped her incontinence brief during care and then refused to change it, despite the resident stating she could not wear it due to the tear. The resident became upset and informed housekeeping staff, who then asked an LPN to assist. On assessment, the LPN observed a large rip extending around the back of the brief, changed the brief, and provided peri care at the resident’s request. The resident stated the ripped brief was uncomfortable and that she did not feel treated with dignity or respect. In interviews, the CNA acknowledged telling the resident the torn brief would still work and did not change it, while the DON confirmed the CNA had refused the resident’s request for a brief change, in conflict with the facility’s dignity policy.
A deficiency was identified when a CNA did not follow manufacturer instructions for a mechanical stand while transferring a resident with severe cognitive impairment, a history of hip fracture, dementia, and muscle wasting who required substantial assistance for transfers. The resident’s care plan called for use of a mechanical stand, but during observed toileting and return-to-chair transfers, the CNA repeatedly locked and unlocked only one wheel of the device and did not keep the brakes unlocked during the actual transfer, contrary to the operator’s instructions that brakes be locked only when raising and lowering the resident during ambulation. In an interview, the DON confirmed staff were expected to follow these operator instructions and keep the wheels unlocked during transfers.
A resident with dementia, behavioral symptoms, and multiple psychotropic and cardiovascular medications was discharged to another nursing facility without a thorough or accurate discharge summary. The care plan contained a discharge planning focus but was never updated to reflect the actual discharge, and the EHR lacked documentation of discharge planning, the reason for discharge, or a recapitulation of stay, despite a family member stating they initiated the discharge due to dissatisfaction with care. The discharge instructions contained multiple medication discrepancies and omissions, including missing drugs, incorrect dosages, and absent administration frequencies, and several PRN constipation medications were not listed, contrary to the facility’s written discharge planning policy.
A resident was admitted from a hospital without a completed Preadmission Screening and Resident Review (PASRR) in the medical record, as required prior to admission. The PASRR was only completed several days later by the Hospital Liaison/Admissions Coordinator after a call alerted staff that it was missing. Both the admissions coordinator and the Administrator acknowledged that the facility relies on the hospital to provide the PASRR and that, in this case, it was missed and not done before the resident’s admission.
A resident with Alzheimer's disease, severely impaired cognition, and documented nutrition/hydration risk required partial to moderate assistance with eating and was care planned for assisted feeding with a general diet and thin liquids. During a breakfast observation, the resident was seated in a reclined Broda chair while staff placed food and beverages on an overbed table and attempted to offer chocolate milk and hot cereal without first positioning the resident upright, causing the resident to struggle to reach the cup. Facility policy on feeding required residents needing assistance to be positioned comfortably in an upright position, and the DON stated she expected residents to be upright whenever food or drink was offered, but there was no separate positioning policy in place.
A resident with a left leg fracture, muscle wasting, and impaired mobility was dependent on a mechanical lift for transfers. Staff positioned the lift at the side of the wheelchair instead of straight on, and the lift tipped and struck the resident’s forehead with the sling-holding part, causing a bruise and protruding bump. Staff interviews confirmed the transfer was done from the side and that the resident’s care plan required straight-on positioning for the lift.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance: Several residents did not receive bathing and hygiene assistance as scheduled. One resident with intact cognition and a stroke history was observed unshaven and said staff did not always shave him during showers, while staff noted the bath sheets no longer tracked shaving or nail care. Other residents with severe cognitive impairment or dependence for bathing went extended periods without baths, and one cognitively intact resident reported missing baths and wanting them. Facility records and staff interviews showed bathing schedules were not consistently followed or documented as required.
QAPI program failed to address repeated deficiencies. Review of the facility’s visit history showed repeated F689, Free of Accident Hazards/Supervision/Devices, and F880, Infection Prevention and Control, across multiple annual surveys and complaint investigations. The QAPI plan stated it would review sources of information for gaps or patterns in care systems, and the Administrator acknowledged the repeated deficiencies and said the facility would review and discuss plans to improve.
Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to follow the 5 rights of medication administration, resulting in one resident receiving another resident’s medications in addition to their own. The resident had diagnoses including hypertension, Alzheimer’s disease, and toxic encephalopathy, with a BIMS score of 3 indicating severe cognitive impairment. On the morning in question, review of the MAR showed the resident received their ordered medications, which included aspirin, calcium carbonate, vitamin C, vitamin D, fluoxetine 20 mg, furosemide 40 mg, galantamine, a lidocaine patch, memantine, acetaminophen, and PRN oxycodone around 8:00 a.m. According to the incident report and nursing progress notes, the LPN (Staff A) administered another resident’s full set of morning medications to this resident while the resident was in the dining room. These additional medications included metoprolol 60 mg, Lyrica 75 mg, oxycodone 7.5/325 mg, furosemide 40 mg, celecoxib 100 mg, Prozac 60 mg, hydroxyzine 10 mg, cetirizine 10 mg, Neuriva, Protonix 20 mg, potassium 99 mg, a multivitamin, and vitamin D3. These medications were given in addition to the resident’s own morning medications and PRN oxycodone. The nurse’s notes documented that the resident’s blood pressure readings declined from 100/50 to 85/48 and then to 73/48, and the resident complained of not feeling well and was increasingly fatigued. Staff A reported during interview that the resident had been screaming and yelling and that she did not realize there were two residents with the same first name in the back hallway. She stated it was her first time working in that hallway after training and that, although resident pictures were available in the EHR to assist with identification, she felt they were small and she did not know the residents. The facility’s medication management policy required staff to identify the resident before administering medications. Staff A’s employee record showed a prior medication occurrence in which she administered the wrong medications (including furosemide and potassium) to a resident, and she had documented previously that she was not familiar with residents when working on that cart. The resident was ultimately sent to the ER, where records documented hypotension on admission, treatment with IV fluids, and a chief complaint of drug overdose after accidental ingestion of another resident’s multiple medications in addition to the resident’s own medications, with continued sinus bradycardia requiring admission for further hemodynamic monitoring.
Elopement of Wandering Resident and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for a cognitively impaired, wandering resident and failure to respond to resident call lights within the facility’s stated 15‑minute expectation. One resident with Alzheimer’s disease, bipolar disorder, and anxiety disorder had a care plan identifying risk for elopement due to wandering and documented behaviors of agitation, aggression, restlessness, and continuous pacing/wandering within the unit. This resident ambulated independently with a walker and had a BIMS score indicating impaired cognition. On the evening of the incident, the resident finished supper in the memory care dining room and then repeatedly walked the hallway with his walker, eventually approaching an emergency exit door at the far end of the hall, away from the dining room. Video and documentation show that the resident stood at the emergency exit door, held the door bar down for the required 15 seconds to release the egress, and then exited through the door into a stairwell and out to the employee parking lot. The door alarm and 15‑second egress functioned, but staff in the dining room did not hear the alarm due to noise from residents, staff conversation, and the television. At the time, two CNAs and one LPN were in the dining room feeding multiple residents, including several who required assistance, and staff reported that the resident was very quick, wandered constantly, and was difficult to keep seated. Staff interviews revealed that one CNA noticed the resident was no longer in the dining room around the same time another staff member reported they were looking for him, and only then did staff recognize the back exit door alarm sounding. A nurse arriving for her shift in the parking lot encountered the resident outside with his walker and escorted him back inside, after which he was assessed and found in stable condition. The deficiency also includes failure to respond to resident call lights within the professional standard of 15 minutes for multiple residents. One resident with intact cognition but dependent or substantial/maximal assistance needs for toileting reported that during meal hours it could take up to an hour for staff to answer the call light, resulting in an in‑room accident. Another resident, alert and oriented but occasionally forgetful and requiring two‑person assistance for transfers, was observed with the call light on for approximately 25 minutes in the morning while repeatedly yelling for help; staff walked past in the hallway without answering the light until a staff member finally entered the room. A third resident, requiring one‑person assistance for transfers, was observed with the call light on for about 17 minutes before a CNA entered to assist. The DON stated that the facility’s expectation is that call lights be answered within 15 minutes, and the facility’s policy directs all staff from all departments to respond to call lights and either assist or obtain appropriate help, but the observed response times exceeded this standard for the residents involved. Staff interviews further described the conditions contributing to these call light delays and supervision gaps. Staff on the memory care unit reported that typical evening staffing consisted of one nurse, one CMA, and two CNAs, and that while this was manageable when routines went smoothly, it became inadequate when residents had behaviors, were sundowning, or when events such as falls or changes in condition occurred. A CMA stated that at least three CNAs were needed on the memory care unit due to multiple residents requiring two‑person assistance, noting that when two CNAs were in a room providing care, they could not monitor the rest of the unit. Staff also reported that the back exit door alarm was faint and difficult to hear from the dining room, and some staff were not fully aware of the configuration of the back stairwell and exit leading to the parking lot. These conditions, combined with high resident care needs and noise levels during meals, contributed to the resident’s elopement and to prolonged call light response times for several residents. Maintenance and administrative staff confirmed that the south/back exit door from the unit led to another unalarmed door and then to the outside employee parking lot, and that the facility did not receive system reports when door alarms were activated. The Administrator was unable to verify when a door alarm went off or when an exit door was breached. The facility’s Wandering Resident policy stated that residents at risk for elopement should receive adequate supervision to prevent accidents and that staff must be vigilant in responding to alarms in a timely manner, and the call light policy required prompt response by all staff. Despite these policies, the documented events show that the resident at risk for elopement was able to leave the secured unit and reach the parking lot without timely staff detection, and that multiple residents experienced call light response times significantly longer than the facility’s stated 15‑minute standard.
Failure to Honor Resident Request for Brief Change and Maintain Dignity
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and respect when a cognitively intact resident’s request for a brief change was not honored. The resident, with a BIMS score of 15 indicating no cognitive impairment, reported being upset because a CNA (Staff N) ripped her brief during care and then refused to change it. The resident self-propelled down the hallway stating she was upset about the ripped brief and that staff would not change it. A housekeeping staff member (Staff M) observed the resident’s distress, was told that the CNA had refused to change the brief despite a large rip, and then asked an LPN (Staff O) to assist with changing it. During the subsequent brief change, Staff O performed hand hygiene, used gloves, removed the resident’s pants and brief, and provided peri care at the resident’s request before applying a new brief and redressing the resident. Observation of the removed brief revealed a large rip on the left side extending past the middle of the resident’s back. The resident stated the brief with the hole was uncomfortable and that she felt staff did not provide her with dignity and respect when her request for a new brief was not honored. Staff O confirmed that the brief had a very large hole and that the resident was very upset, reporting she did not feel treated with dignity or respect and that the ripped brief was uncomfortable. In an interview, Staff N acknowledged caring for the resident that day, stated the resident had been upset and had “behaviors,” and reported that when the resident said she wanted her brief changed because it was ripped, Staff N told her the brief would still work and that urine would not get everywhere, characterizing the tear as “just a little tear.” Staff N stated the resident did not explicitly ask her to change the brief. The DON later stated that Staff N had ripped the brief, the resident had requested a brief change, Staff N said she would not change it, and acknowledged that a lack of dignity occurred when Staff N refused to change the resident’s brief, contrary to the facility’s dignity policy.
Improper Use of Mechanical Stand Brakes During Resident Transfers
Penalty
Summary
Surveyors identified a deficiency related to accident prevention when staff failed to properly use a mechanical stand’s brakes during transfers for one resident. The resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment, required substantial assistance for transfers, and had diagnoses including hip fracture, dementia, and muscle wasting. The care plan documented initiation of a mechanical stand for transfers. During observation, a CNA applied a sling, locked the right wheel of the mechanical stand, lifted the resident from a chair, then unlocked the right wheel and positioned the resident over the toilet. The CNA then lowered the resident onto the toilet and locked the right wheel. After the resident finished, the CNA lifted the resident from the toilet, unlocked the right wheel, positioned the resident over the chair, locked the right wheel, and lowered the resident, thereby failing to keep the mechanical stand brakes unlocked during the transfer as required by the operator’s instructions, which specified that brakes should only be locked when raising and lowering the resident during ambulation. In an interview, the DON stated that staff were expected to follow the operator’s instructions and keep the wheels unlocked during transfers, confirming that the observed practice did not align with the manufacturer’s guidance for safe operation of the mechanical stand.
Failure to Complete Accurate and Thorough Discharge Summary and Documentation
Penalty
Summary
Surveyors identified a failure to complete a thorough and accurate discharge summary and related discharge documentation for one resident who was discharged from the facility. The resident was admitted in early March with moderate cognitive impairment, a Brief Interview for Mental Status (BIMS) score of 08, and documented delusions and behavioral symptoms. Diagnoses included dementia with agitation, anxiety disorder, and depression. Although the care plan contained a discharge planning focus initiated shortly after admission, it did not contain any updates or documentation related to the resident’s actual discharge later that month. The electronic health record (EHR) contained a communication note indicating that transport to another nursing facility was arranged and a health status note stating that the resident was discharged, with physician orders and a face sheet faxed and a report called to the receiving facility. The resident’s EHR did not contain documentation of the discharge planning process, the reason for the discharge, or a recapitulation of the resident’s stay. A family member reported that the family initiated the discharge due to dissatisfaction with care, but there was no documentation in the EHR reflecting that the family initiated the discharge. The Long Term Care Ombudsman reported that no one contacted her during the resident’s stay, although her office did receive notice of the transfer. The facility’s own discharge planning policy required that discharge planning begin on admission, be routinely updated in the comprehensive care plan, and that the evaluation of discharge needs and the final discharge plan be completely documented in the clinical record and discussed with the resident or representative. Review of the resident’s discharge instructions and March medication administration record revealed multiple discrepancies and omissions in the discharge summary. One medication (Amlodipine 10 mg) was listed without any frequency or time of administration. Several medications that the resident was receiving, including Donepezil 10 mg, Lisinopril 5 mg, and Buspirone 10 mg twice daily, were not included on the discharge summary. Other medications were inaccurately documented, such as Memantine, which was ordered as 20 mg once daily but listed as 10 mg twice daily, and Seroquel, ordered as 50 mg twice daily but listed as once daily. Several PRN constipation medications were also omitted. The Regional Nurse Consultant confirmed that the facility’s EHR contained a discharge assessment tool that was not completed for this resident and acknowledged the multiple medication discrepancies on the discharge summary form.
Failure to Complete PASRR Evaluation Prior to Admission
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) evaluation for a resident with an admission date of 4/22/26. The resident’s electronic health record documented admission from a hospital on 4/22/26, but review of the record showed no PASRR completed at the time of admission. A PASRR form for this resident was later obtained and showed it was completed on 4/27/26 by the Hospital Liaison/Admissions Coordinator, several days after the resident had already been admitted. During interview, the Hospital Liaison/Admissions Coordinator stated that the hospital usually completes the PASRR, acknowledged receiving a call the previous night that the PASRR was not in the chart, and admitted she had missed completing it prior to admission even though it should have been done. The Administrator similarly reported that the facility relies on receiving the PASRR from the hospital admission records and that, in this case, the PASRR was missed and not completed prior to the resident’s admission. This resulted in a deficiency for failure to ensure a PASRR evaluation was completed prior to admission for 1 of 3 reviewed residents, in accordance with PASRR requirements.
Failure to Properly Position Resident Upright During Assisted Feeding
Penalty
Summary
Surveyors identified a deficiency in resident positioning during mealtime for a resident with Alzheimer's disease and severely impaired cognition, as evidenced by a Brief Interview for Mental Status score of 2. The resident’s MDS indicated a need for partial to moderate assistance with eating, and the care plan documented nutrition and hydration risk related to end-stage diagnosis, cognitive limitations, and weakness, with directions for a general diet, thin liquids, and assistance with eating. During a breakfast observation on the Magnolia Unit, the resident was seated in a Broda chair that was reclined back. A dietary aide placed food on the table in front of the resident, and a CNA then placed beverages and food on an overbed table before walking away, while the resident remained reclined with eyes closed and the plate of food untouched. Later in the same observation period, another CNA offered the resident chocolate milk while the Broda chair remained tilted backward, and the resident had to struggle to move her head up and forward to reach the cup. The same CNA then offered hot cereal, which the resident declined by saying “later.” A different CNA subsequently offered another drink of chocolate milk, again without adjusting the reclined position of the Broda chair. Policy review showed the facility’s “Feeding of Residents by Staff” policy required that residents unable to feed themselves be assisted per their care plan and be positioned comfortably in an upright position. In an interview, the DON stated there was no specific positioning policy, that staff received positioning education in training, and that her expectation was that residents be placed in an upright position whenever food or drink was offered.
Mechanical Lift Transfer Caused Resident Forehead Injury
Penalty
Summary
The facility failed to provide a safe and adequate mechanical lift transfer for Resident #18, who had a left leg fracture, muscle wasting, and impaired gait and mobility, but no cognitive impairment based on a BIMS score of 15. The resident’s care plan required two staff members to use a mechanical lift for transfers because the resident was nonweight-bearing on the left leg. The care plan update also directed staff to approach the wheelchair straight on and not from the side, and to have the resident bend the right leg and turn away from the lift during transfers. During a wheelchair transfer, staff positioned the mechanical lift at the side of the wheelchair and began the transfer. The lift tipped and struck the resident’s forehead with the part that held the sling. The resident sustained a bruise and a protruding bump on the left forehead, and the incident documentation noted the resident’s head was hit on the lift. The resident later reported that the lift almost fell to the floor and that additional staff were needed to return it upright. Staff interviews confirmed that the transfer was performed from the side of the wheelchair. One CNA stated the lift may have caught on bars under the wheelchair and acknowledged that staff had been educated not to use the lift from the side. Another CNA stated the lift was used from the side because the resident did not want her leg hit by the lift, and identified the sling-holding part of the lift as the piece that struck the resident’s forehead. The DON stated the proper procedure was to position the mechanical lift directly in front of the wheelchair rather than to the side.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living for 5 of 8 residents reviewed, specifically related to bathing and shaving. Resident #3 had a BIMS score of 15 and was dependent on staff for personal hygiene, with diagnoses including renal insufficiency, stroke, hemiplegia, and seizure disorder. The resident was observed unshaven, stated he was getting showers but not shaved every time, and said he needed help shaving since his stroke. Facility records showed showers were documented without indicating whether shaving was completed, and staff interviews confirmed the bath sheets no longer tracked shaving or nail care, while the DON stated male residents should be offered shaving during showers and it should be documented if completed or refused. Resident #1 had a BIMS score of 4, diagnoses including muscle weakness, diabetes, and hip fracture, and was care planned as an extensive assist for bathing. Review of the follow-up report showed the resident went 17 days without a bath and later 19 days without a bath. Resident #11 had a BIMS score of 3, diagnoses including depression, hypertension, and anemia, and was scheduled for bathing on Wednesday morning and Friday afternoon, but the follow-up report showed gaps of 6 days, 6 days, and 18 days between baths. Resident #27 also had a BIMS score of 3 with depression, hypertension, and anemia, was scheduled for bathing on Monday and Thursday afternoon, and the follow-up report showed the resident went 19 days and then 20 days without a bath, with refusals documented on two occasions. Resident #85 had a BIMS score of 15, diagnoses including hypertension, depression, and need for assistance with personal care, and stated she did not get 2 baths the prior week and wanted them. Her care plan identified her as dependent for bathing, but lacked bathing frequency, and the task list scheduled bathing for Monday morning and Wednesday afternoon. The follow-up report showed multiple extended gaps between baths, including 12 days, 7 days, 18 days, and 7 days. Facility policy stated bathing is intended to promote cleanliness, provide comfort, and observe skin condition, and the Regional Nurse Consultant stated bathing should be completed as scheduled.
QAPI Program Failed to Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive and effective QAPI program and did not have a plan that described the process for conducting QAPI and QAA activities. Review of the DIAL website visit history showed repeated deficient practices identified during the facility’s annual survey and complaint investigation on 3/27/25 and during the annual survey, complaint, and facility-reported incident investigation on 4/19/26. The repeat deficiencies included F689, Free of Accident Hazards/Supervision/Devices, which had been repeated in the previous three consecutive annual surveys, and F880, Infection Prevention and Control, which had been repeated in the previous four consecutive annual surveys. The facility’s QAPI plan stated that it would review sources of information to determine whether gaps or patterns existed in systems of care that could result in quality problems or opportunities for improvement. During an interview on 4/23/26 at 1:28 PM, the Administrator acknowledged the repeated F689 and F880 deficiencies and stated the facility would review and discuss plans to improve.
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