Aspire Of Muscatine
Inspection history, citations, penalties and survey trends for this long-term care facility in Muscatine, Iowa.
- Location
- 2002 Cedar Street, Muscatine, Iowa 52761
- CMS Provider Number
- 165585
- Inspections on file
- 30
- Latest survey
- November 5, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Aspire Of Muscatine during CMS and state inspections, most recent first.
A resident with a history of violent behavior and moderate cognitive impairment physically assaulted another resident in the dining room after a wheelchair collision, resulting in facial bruising and broken glasses. Staff were unable to prevent the incident, and interviews revealed a lack of adequate behavioral health training and fear among staff in managing aggressive behaviors, despite existing policies requiring abuse prevention and dementia management training.
Staff interviews and record reviews revealed that employees, including LPNs, CNAs, and an RN, had not received adequate training in dementia care or behavioral management, despite caring for a significant population of residents with Alzheimer's and dementia. Staff reported witnessing aggressive behaviors and resident-to-resident incidents, and expressed fear and uncertainty in managing these situations. The DON confirmed the lack of training in behavioral health for staff.
Surveyors found a package of raw hamburger thawing in a refrigerator next to lettuce without a drip pan, contrary to facility policy, and observed insect traps placed on kitchen counters near food preparation areas. Staff interviews confirmed a lack of awareness regarding these practices, and the facility's pest control policy did not address insect trap placement in the kitchen.
A resident with multiple diagnoses, including COPD and a history of blood vessel blockage, was prescribed and administered apixaban, an anticoagulant, as confirmed by physician orders and the MAR. However, the care plan did not address the use of this medication, contrary to facility policy and expectations confirmed by the DON.
Two residents' care plans were not updated to reflect their current conditions and service needs. One resident's care plan still referenced ankle casts that had been removed nearly a year earlier, and another resident's care plan did not address hospice services or accurately reflect the level of assistance needed with eating. Staff interviews and record reviews confirmed these discrepancies, indicating a failure to revise care plans as required.
A resident with cognitive intactness and multiple diagnoses, including malnutrition, was not provided with necessary eating assistance despite requiring substantial help. Staff delivered meal trays without ensuring the resident was awake, positioned properly, or able to access the food, and did not remain to assist or supervise. Staff interviews confirmed the need for assistance, and the resident experienced significant weight loss. Facility policy requiring staff to help position residents and address factors affecting food intake was not followed.
A resident with multiple health conditions experienced a significant weight loss that was not promptly identified or addressed by staff. The facility failed to notify the physician or ensure timely RD follow-up, and staff did not provide necessary assistance during meals, despite the resident's physical limitations and documented need for help. The facility's policy for monitoring and intervening in cases of significant weight change was not followed.
A resident with diagnoses including Guillain-Barre Syndrome, anemia, and obesity was observed receiving oxygen therapy via nasal cannula at 4 L/min without a physician's order specifying the amount, delivery method, or administration schedule. The resident's Care Plan also lacked any focus area or interventions for oxygen therapy, and staff confirmed these omissions did not meet facility expectations.
A resident with a history of substance use disorder experienced multiple incidents of intoxication and possession of substances in the facility. Staff interviews revealed that CNAs had not received training on managing residents under the influence, and the DON confirmed there was no policy or education provided on handling substance abuse behaviors.
Kitchen staff lacked adequate training and competency, as evidenced by improper preparation of a pureed meal for a resident, inconsistent use of puree guidelines, lack of alternative menu options, and failure to document food substitutions and temperatures. The Dietary Manager and Registered Dietician were not fully aware of staff competencies or oversight responsibilities, and the facility could not provide a policy on kitchen staff training.
The facility did not consistently follow dietician-approved menus or ensure adequate, approved substitutions were available, as kitchen staff made unapproved changes and residents reported dissatisfaction with food options and portion sizes. The Registered Dietician was not always consulted about substitutions, and facility policy requiring similar nutritive value for substitutes was not consistently followed.
A resident who was cognitively intact and had documented dislikes for rice and corn was repeatedly served these foods despite informing the Dietary Manager and having this information on his tray card. The dietitian was unaware of the resident's preferences, and staff interviews confirmed the resident's complaints. Facility policy required regular review of food preferences, but this was not followed, leading to the deficiency.
The facility was cited for repeated deficiencies in food procurement and service, infection prevention and control, and the quality improvement program, as shown by multiple survey findings over time. Despite having a QAPI policy and providing staff training, the QAPI process was not effective in preventing or addressing these recurring issues.
Staff failed to follow infection control protocols during wound care for a resident with pressure ulcers by not changing gloves between wound cleansing and dressing application, and did not maintain proper catheter care for another resident by allowing the catheter bag and tubing to rest on the floor, neglecting to use required PPE, and failing to clean the catheter spigot after draining, despite facility policies and care plans outlining these requirements.
Two residents who required significant assistance with daily activities were repeatedly observed with their call lights placed out of reach, either on the floor or at the foot of the bed, despite facility policy and staff expectations to keep call lights accessible. Staff left rooms without ensuring the call lights were within easy reach, and this was documented during multiple observations and confirmed in staff interviews.
A resident who was cognitively intact and required assistance with showers was reportedly addressed with derogatory language and questioned about unpaid bills by a staff member. The incident, witnessed by another staff member, involved inappropriate comments regarding the resident's hygiene and finances, resulting in a failure to honor the resident's right to dignity and respect.
A resident with a history of substance abuse returned to the facility under the influence on multiple occasions, but staff failed to complete and document required nursing assessments despite clear signs of intoxication and abnormal lab results. This was not in accordance with facility policy or the expectations outlined by the DON.
A resident with a portable oxygen tank attached to her wheelchair was present in the designated smoking area while other residents smoked, and staff did not initially remove the tank, which was later found to be empty and carried unsecured through the facility. Staff and policy acknowledged the risk of flammable items near oxygen, but the facility failed to ensure the tank was removed before the resident entered the smoking area.
Two residents experienced significant changes in condition, including one with a notable unplanned weight loss, but the physician was not notified as required by facility policy. The DON confirmed that physician notification is expected for such events, and documentation showed the weight loss was recognized but not communicated to the MD.
The facility failed to maintain adequate staffing, resulting in insulin-dependent residents missing doses and nurses working over 17 hours without relief. On several occasions, the nurse on duty left the facility without proper coverage, and the DON was either unaware or absent. This led to significant lapses in care, with residents not receiving necessary medications and treatments.
The facility failed to provide 8 consecutive hours of RN coverage on multiple days in December 2024. LPNs covered shifts instead, and the DON was often absent or working from home, leading to non-compliance with staffing regulations.
The facility failed to administer evening insulin and assess blood sugars for five insulin-dependent diabetic residents as ordered by the physician. An LPN on the night shift did not perform these tasks, claiming unawareness of the orders due to system differences. The Director of Nursing was unaware of the issue until informed by the surveyor, and no medication error reports were completed.
The facility failed to ensure staff had the necessary skills to manage residents with mental health needs, as evidenced by inadequate training and multiple incidents involving a resident with dementia and behavioral disturbances. Staff interviews revealed a lack of training in behavior management, leading to uncertainty and fear in handling aggressive behaviors.
A resident with intact cognition reported that a staff member used inappropriate language when asking her to remove belongings from a table, leaving her feeling disrespected and intimidated. The incident was confirmed by staff interviews, and the staff member acknowledged the mistake, stating the remark was made sarcastically. The facility's Resident Rights Policy emphasizes treating residents with respect, which was not upheld in this instance.
A resident with a history of aggression and cognitive impairment was involved in multiple altercations with other residents, including physical assaults and verbal threats. The facility failed to adequately supervise and manage the resident's behavior, leading to repeated incidents despite being aware of the resident's history. The facility's abuse prevention policy was not effectively implemented, contributing to the deficiency.
The facility failed to report abuse allegations involving two residents. A resident with intact cognition reported inappropriate language by the Activities Director, which was handled internally but not reported as abuse. Another resident with cognitive impairment was involved in an incident with inappropriate comments by maintenance staff, which was also not reported. The facility's policy requires immediate reporting of such incidents, but the Administrator did not comply, leading to a deficiency.
The facility failed to use appropriately sized slings for two residents during transfers, posing safety risks. Additionally, the facility did not complete regular smoking safety assessments for three residents, leading to an incident where they smoked unsupervised. Staff interviews revealed inconsistencies in policy implementation for both sling usage and smoking safety.
A facility failed to obtain necessary physician orders for a resident admitted for respite care, resulting in a deficiency. The resident, with Parkinson's and early memory loss, lacked orders for admission, diet, medications, and routine care. Staff noted incidents of wandering and improper medication management, highlighting inadequate care coordination. Interviews revealed a lack of communication and responsibility between the Administrator and DON, and the hospice provider was unaware of the admission.
A resident with surgical wounds was admitted to an LTC facility with specific wound care instructions, including the use of a wound VAC. The Interim DON failed to properly apply the wound VAC, resulting in a lack of suction and the resident experiencing pain. The RN on duty identified incorrect dressing application but was unable to administer pain medication due to missing physician orders. The resident's family, dissatisfied with the care, returned the resident to the hospital.
A resident admitted for short-term skilled nursing care experienced issues with a wound VAC system due to incorrect application by nursing staff. The Interim DON and an RN were unable to properly apply the device, leading to its malfunction. Family members, concerned about the resident's pain and the non-functioning wound VAC, called for an ambulance to return the resident to the hospital for appropriate care.
A facility failed to coordinate hospice services for a resident admitted for respite care, who was already receiving in-home hospice services. The resident was admitted without proper documentation, including physician orders and hospice provider information. Staff were unaware of the resident's hospice status, leading to a lack of communication and coordination with the hospice provider. The facility's policies did not address the need to identify and coordinate hospice services for respite care admissions.
A facility failed to provide necessary emergency tracheostomy equipment at the bedside for a resident with a tracheostomy, posing a risk to the resident's health. Staff were unaware of the equipment's location, and physician orders for tracheostomy care were not followed, with missed changes of the outer and inner cannulas. Staff interviews revealed a lack of training and awareness regarding tracheostomy management, and the facility's policy did not specify the equipment's location.
The facility was found to have unsanitary kitchen conditions during inspections, including greasy fingerprints, spills, and dust accumulation. The Dietary Manager acknowledged the need for cleaning, and the Administrator expected surfaces to be sanitized. The facility's policy lacked a specific cleaning schedule.
The facility did not ensure the Quality Assessment and Assurance (QAA) committee met quarterly with required members, including the Nursing Home Administrator, Director of Nursing, Medical Director representative, Infection Preventionist, and two other staff members. The Administrator acknowledged the absence of sign-in sheets for QAPI meetings, and a review of QAPI folders showed missing documentation of meeting frequency and attendees. The Regional President of Operations confirmed the necessity of quarterly meetings with required attendees.
The facility failed to implement proper infection control practices, including improper handling of a resident's catheter drainage bag and inadequate infection control surveillance. A resident's catheter bag was observed dragging on the floor, and staff did not follow proper hand hygiene and glove-changing procedures. Additionally, the facility lacked documentation for Legionella prevention and infection control data due to staff turnover.
The facility failed to maintain a clean and homelike environment, as brown stains were observed on the floor in Hall 1 on multiple occasions. Inadequate housekeeping scheduling left some halls without cleaning staff, contrary to the facility's policy requiring daily cleaning.
A facility failed to respond to resident call lights within the required 15-minute timeframe. A resident reported delays, and an observation confirmed a 26-minute response time to a call light. The facility's policy required prompt responses, with emergency lights to be answered within one minute. The administrator confirmed the 15-minute response expectation.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with a history of violent behavior, dementia with behavioral disturbance, and moderate cognitive impairment physically assaulted another resident in the dining room. The incident began when the first resident, while self-propelling his wheelchair, unintentionally ran into the second resident, who was non-verbal and attempting to move away. In response, the first resident became upset and struck the second resident in the face three times with a closed fist, resulting in bruising and broken glasses. The altercation was witnessed by nursing staff, who intervened to separate the residents. The first resident's care plan had previously identified risks for verbal and physical aggression related to his dementia and behavioral history. Staff interviews revealed that the resident had a pattern of aggressive outbursts, including screaming and combative behavior when angered. Despite these known behaviors, staff present at the time of the incident were not able to prevent the assault, and some staff expressed fear of the resident and a lack of training to manage such behaviors. The incident caused distress among other residents in the dining room, who needed reassurance of their safety. The facility's policy on abuse prevention included provisions for staff training in abuse prevention, identification, and dementia management, as well as protocols for investigating abuse. However, interviews with staff and the Director of Nursing indicated that there was a lack of adequate behavioral health training for staff, and the mental health provider only participated via telehealth, with limited resident engagement. This contributed to the facility's failure to protect residents from abuse as required.
Failure to Provide Staff Training in Dementia and Behavioral Health Management
Penalty
Summary
The facility failed to ensure that staff members were adequately trained to manage residents with dementia and challenging behaviors. Multiple staff interviews revealed that both new and long-term employees had not received training from the facility on dementia care or behavioral management. Staff reported witnessing resident-to-resident incidents and aggressive behaviors from residents with dementia, expressing fear and uncertainty about how to handle such situations. Employee record reviews confirmed a lack of documented training in dementia management and behavioral health for the staff reviewed. Staff members, including LPNs, CNAs, and an RN, described situations where they felt unprepared to manage aggressive or challenging behaviors, sometimes requiring additional staff to provide care safely. The Director of Nursing acknowledged the deficiency, stating that there was a recognized lack of training for staff in behavioral health. The facility had a census of 34 residents, many with Alzheimer's and dementia, yet staff consistently reported insufficient training in managing these residents' behavioral health needs.
Improper Food Thawing and Insect Trap Placement in Kitchen
Penalty
Summary
Surveyors observed improper food storage and thawing practices in the facility's kitchen. A package of raw hamburger was found thawing in the refrigerator directly next to a box of lettuce, without being placed in a drip pan and resting directly on the refrigerator rack. Staff interviews revealed that the hamburger was believed to be safe due to being sealed and the lettuce box being closed, but the Dietary Manager later acknowledged that this was not appropriate and could lead to cross contamination. The facility's policy required thawing in a drip-proof container, which was not followed in this instance. Additionally, insect traps were found placed on kitchen counter workspaces, including behind coffee pots during meal service. The Dietary Manager was unaware of the presence of these traps, and the Registered Dietician expressed concern about insect traps being located in food preparation areas. The facility's pest control policy did not address the use of insect traps in the kitchen. These observations indicate a failure to adhere to professional standards for food storage, preparation, and pest control.
Failure to Include Anticoagulant Use in Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to include the use of an anticoagulant medication, apixaban, on the care plan for a resident. The resident was cognitively intact, with a BIMS score of 15 out of 15, and had diagnoses including chronic obstructive pulmonary disease, benign prostatic hyperplasia, and urinary tract infection. Physician orders and the Medication Administration Record confirmed that the resident was prescribed and received apixaban 5 mg twice daily for a blockage of a blood vessel to the lung. However, review of the care plan revealed no focus area addressing the use of this anticoagulant medication. The Director of Nursing confirmed during an interview that the use of an anticoagulant should have been included in the care plan and stated that the MDS Coordinator is responsible for updating care plans. The current MDS Coordinator had only recently started and was not present when the care plan was developed. Facility policy requires that comprehensive care plans be based on thorough assessments, including the MDS and physician orders, but this was not followed in this instance.
Failure to Update Care Plans to Reflect Current Resident Needs
Penalty
Summary
The facility failed to update and revise care plans to reflect the current care needs and conditions of two residents. For one resident with a history of neurogenic bladder, multiple sclerosis, and anxiety disorder, the care plan continued to reference bilateral ankle casts, despite observations and staff interviews confirming that the casts had been removed almost a year prior. The care plan had not been updated to remove this outdated intervention, and both the LPN and DON acknowledged that the care plan should not reference casts if they were no longer present. For another resident with arthritis, multiple sclerosis, malnutrition, and who was receiving hospice services, the care plan did not include a focus area or interventions related to hospice care. Additionally, the care plan inaccurately stated that the resident was able to feed himself, despite the MDS indicating the resident required substantial to maximal assistance with eating. The facility's policy requires care plans to be revised as resident conditions change, but this was not followed in these cases.
Failure to Provide Eating Assistance to Dependent Resident
Penalty
Summary
Facility staff failed to provide necessary eating assistance to a resident who required substantial to maximal help with activities of daily living, specifically eating. The resident, who was cognitively intact and receiving hospice care, had diagnoses including arthritis, multiple sclerosis, and malnutrition. The Minimum Data Set (MDS) indicated the resident needed significant assistance with eating and transfers. Despite this, observations showed that staff delivered meal trays to the resident's room without ensuring he was awake, positioned properly, or aware that his meal had arrived. On two separate occasions, staff left the meal tray on the overbed table and exited the room without offering assistance or ensuring the resident could access his food. The call light was also out of reach during one observation. Interviews with staff confirmed that the resident required help to sit up and sometimes needed assistance with eating. Staff acknowledged the need to position the resident with the head of the bed elevated and to supervise or assist during meals. The resident had experienced significant weight loss, dropping from 138 to 106 pounds, and had poor intake, which was noted by the hospice nurse. Facility policy required nursing staff to help seat and position residents and identify factors that might affect food intake, but these guidelines were not followed for this resident.
Failure to Identify and Address Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to identify a significant weight loss in a resident, notify the physician, and ensure timely follow-up by the Registered Dietitian (RD). The resident, who had a history of stroke, diabetes, contractures, and GERD, was moderately cognitively impaired and required set-up assistance for eating. The resident's weight dropped from 222.4 lbs to 207.0 lbs within a short period, representing a significant weight loss, but there was no documentation of physician notification or intervention in the clinical record. Observations revealed that the resident often ate in a reclined position without staff assistance or repositioning, despite requiring help due to physical limitations. Staff interviews indicated that the resident sometimes refused meals due to fatigue or preference, and experienced oral secretions and occasional coughing during meals. However, there was no evidence that these issues were addressed or that additional nutritional support was provided during the period of weight loss. The facility's policy required re-weighing residents and notifying the RD and physician when significant weight changes occurred. Despite this, the RD did not implement interventions or request a reweight until much later, and the facility did not act promptly to address the resident's weight loss. The lack of timely identification, notification, and intervention contributed to the deficiency.
Failure to Provide Physician-Directed Oxygen Therapy and Care Plan Inclusion
Penalty
Summary
The facility failed to provide oxygen therapy in accordance with professional standards for one resident. Observation showed the resident using a nasal cannula connected to an oxygen concentrator set at 4 liters per minute. However, review of the clinical record revealed there was no physician's order specifying the amount of oxygen to deliver, the method of delivery, or whether the oxygen therapy was to be administered as needed or continuously. The only order present was to check oxygen saturation every shift and apply oxygen to keep saturation above 90% for low readings, but it did not include the necessary details for safe administration. Additionally, the resident's Care Plan did not include a focus area or interventions related to the required oxygen therapy, despite documentation that the resident needed oxygen and had relevant diagnoses such as Guillain-Barre Syndrome, anemia, and obesity. Staff interviews confirmed the expectation that oxygen usage should be reflected in both a physician's order and the Care Plan, but these were not present for the resident in question.
Lack of Staff Training for Behavioral Health and Substance Use Disorders
Penalty
Summary
The facility failed to provide staff training to address the behavioral health care needs of a resident with a substance use disorder. Clinical record review showed that the resident was cognitively intact and had a history of alcohol and substance abuse, including recent incidents of intoxication and possession of substances and paraphernalia within the facility. The resident's care plan included interventions for impaired coping and substance use, such as monitoring for intoxication, encouraging self-calming behaviors, and addressing incidents of substance use. Interviews with certified nursing assistants revealed that they had not received training on how to manage residents under the influence of drugs or alcohol and were unsure of the appropriate actions to take in such situations. The Director of Nursing confirmed that staff had not been provided with education on handling substance abuse behaviors and that the facility lacked a policy to address resident substance abuse. These findings indicate a deficiency in ensuring staff competency and preparedness to meet the behavioral health needs of residents with substance use disorders.
Failure to Ensure Kitchen Staff Training and Competency in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that kitchen staff were adequately trained and competent to perform their job duties, as evidenced by observations and staff interviews. During meal preparation for a resident on a pureed diet, a staff member was unable to specify the amount of milk added to a pureed peanut butter and jelly sandwich and adjusted the consistency by adding more sandwich rather than using a thickener or following the posted puree chart. The staff member also did not offer a variety of alternatives, stating the resident typically only ate peanut butter and jelly sandwiches, ice cream, or pudding, and did not follow the menu for other items. The Dietary Manager was unable to confirm the training or competencies of the staff, noted that most staff were not ServeSafe certified, and admitted that the puree chart and portion sizes were not consistently used. Additionally, the Dietary Manager was unaware of who was responsible for tracking resident intake and acknowledged that staff did not consistently record food temperatures. The Registered Dietician reported that she had not recently observed the puree process and was not routinely contacted regarding menu substitutions, which were not consistently documented or signed off. The facility did not have an alternative menu, and food substitutions were infrequently logged and not reviewed by the dietician as required. The staff member involved in the puree preparation later admitted to not following proper procedures and not offering sufficient alternatives. The facility was unable to provide a policy regarding kitchen staff training and competency when requested.
Failure to Follow Dietician-Approved Menus and Provide Adequate Substitutions
Penalty
Summary
The facility failed to ensure that the dietician-approved menu was consistently followed and that adequate quantities of approved substitutions were available to all residents. Kitchen staff reported that when preparing meals, they sometimes lacked necessary ingredients and made substitutions, particularly with vegetables or fruits, without always obtaining prior approval from the Dietary Manager or Registered Dietician. Substitutions were sometimes made based on resident preferences, such as serving goulash instead of beef macaroni casserole, and additional portions of the main course were only provided if there was enough left after initial servings. The Registered Dietician confirmed that she was not always contacted regarding substitutions and only signed off on them during her visits, contrary to her expectation that planned menus be followed to meet residents' nutritional needs. Interviews with residents revealed dissatisfaction with the food, citing limited options, lack of choices, and insufficient portion sizes. The facility's policy required that food substitutes be of similar nutritive value and that the Food Services Department offer alternatives for residents who did not want the primary meal. However, the observed practices did not consistently align with these guidelines, as substitutions were not always approved or equivalent, and residents' preferences and needs were not fully met.
Failure to Honor Resident Food Preferences
Penalty
Summary
A cognitively intact resident, as identified by a perfect score on the Brief Interview for Mental Status, reported being repeatedly served rice and corn despite having previously communicated his dislike for these foods to the Dietary Manager. The resident expressed frustration, stating he was tired of receiving food he did not like and threatened to stop eating facility meals if the issue persisted. The resident also noted that the last interaction with the dietitian occurred the previous year, indicating a lack of ongoing assessment of his food preferences. Review of the resident's meal tray card confirmed that his dislike for rice and corn was documented. However, the Registered Dietitian was unaware of these preferences and stated that her previous discussions with the resident focused on carbohydrate intake rather than specific food dislikes. A CNA corroborated that the resident had complained about being served rice and corn and explained that staff are expected to return unwanted food to the kitchen for alternatives when such preferences are noted. Facility policy requires periodic review and updating of resident food preferences, but this was not followed, resulting in the resident being served unwanted food items.
Repeated QAPI Failures in Food Safety, Infection Control, and Program Oversight
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) process, as evidenced by repeated deficiencies in three key areas: food procurement, storage, preparation, and service (F812); the quality improvement program itself (F868); and infection prevention and control (F880). These deficiencies were cited in surveys conducted in April 2023, June 2024, and the current survey, indicating ongoing issues that were not adequately addressed or prevented by the facility's QAPI program. The facility had a reported census of 32 at the time of the survey. A review of facility policy and staff interviews revealed that, despite having a QAPI policy in place that emphasizes data-driven improvement and adherence to evidence-based practices, the facility did not ensure consistent implementation or effectiveness of these processes. The Director of Nursing and Interim Administrator acknowledged high staff turnover and stated that additional staff training had been provided, but the repeated citations suggest that the QAPI program was not functioning as intended to prevent recurrence of deficiencies in the identified areas.
Failure to Follow Infection Control Practices During Wound and Catheter Care
Penalty
Summary
The facility failed to implement proper infection control practices during wound care and catheter care for two residents. In the first instance, a resident with a history of arthritis, multiple sclerosis, malnutrition, and two Stage 2 pressure ulcers was observed receiving wound care from a registered nurse. The nurse cleansed the wound and, without changing gloves or performing hand hygiene, proceeded to apply zinc oxide and a new dressing, contrary to facility policy and standard infection control procedures. The facility's own wound care guidelines require staff to remove gloves and wash hands after cleansing a wound before applying new gloves for dressing application. In the second instance, a resident with heart failure, neurogenic bladder, diabetes, and an indwelling urinary catheter was observed with the catheter bag and tubing repeatedly resting on the floor, despite care plan interventions and posted Enhanced Barrier Precautions. Staff were seen handling the catheter bag and tubing without consistently using required personal protective equipment (PPE), such as gowns, and failed to clean the catheter spigot with an alcohol wipe after draining. The facility's policies and the resident's care plan specifically directed staff to keep catheter bags and tubing off the floor, use enhanced barrier precautions including gown and gloves, and clean the spigot after draining. Interviews with staff and the DON confirmed that the observed practices did not meet facility expectations or policy requirements. Staff acknowledged that gloves should be changed during wound care, catheter bags and tubing should never be on the floor, and appropriate PPE should be used during catheter care. The facility census at the time was 32 residents.
Failure to Ensure Call Lights Within Reach for Dependent Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure call lights were within reach for two residents who required substantial or maximal assistance with activities of daily living. One resident, diagnosed with multiple sclerosis, arthritis, and malnutrition, was observed multiple times with the call light placed on the nightstand near the foot of the bed, out of reach, both while awake and asleep. Staff were seen leaving the room without repositioning the call light within the resident's reach, despite care plan interventions specifying this requirement. Another resident, with diagnoses including autonomic nervous system disorder, syncope, and urinary retention, and who utilized an indwelling urinary catheter, was also observed on several occasions with the call light on the floor, out of reach, whether in bed or in a wheelchair. Staff interviews confirmed the expectation that call lights should be within easy reach, and facility policy directed staff to ensure this for all residents. Despite these guidelines, repeated observations documented the call lights being inaccessible to the residents.
Failure to Treat Resident with Dignity During Hygiene and Financial Discussion
Penalty
Summary
Staff failed to treat a resident with dignity and respect during an interaction regarding personal hygiene and financial matters. The resident, who was cognitively intact and required partial to moderate assistance with showers, was reportedly called a derogatory name by the Senior Revenue Cycle Manager (SRCM) and questioned about unpaid bills and personal spending. This incident was witnessed by the Social Services Director, who reported that the SRCM used profanity when addressing the resident about taking a shower. The resident later recalled feeling ganged up on by staff about not paying rent and not taking a shower, although he did not recall the use of profanity. Multiple staff interviews provided conflicting accounts regarding the use of inappropriate language, with the SRCM and an LPN denying the use of profanity, while the Social Services Director confirmed it occurred. The resident was observed to be well-groomed and wearing clean clothing at the time of the investigation. The incident was documented in a facility-reported incident and corroborated by staff interviews, indicating a failure to honor the resident's right to dignity and respect.
Failure to Assess Resident After Return Under the Influence
Penalty
Summary
A deficiency occurred when staff failed to assess a resident with a known history of substance abuse after the resident returned to the facility under the influence. The resident, who was cognitively intact and had diagnoses including chronic obstructive pulmonary disease and substance abuse, had multiple documented incidents involving intoxication and substance use within the facility. Despite staff and resident concerns about the resident's behavior and appearance suggesting intoxication, and the detection of substances in the resident's system, there was no documented nursing assessment completed after the resident returned to the facility on two separate occasions when substance use was suspected. Facility policy required that changes in a resident's condition or status be recorded in the medical record, and the DON stated that an assessment should include vital signs, respiratory effort, pupil checks, and frequent monitoring. However, the clinical record review revealed a lack of such assessments following the incidents, indicating noncompliance with both facility policy and expected nursing practice for residents with known substance use issues.
Oxygen Tank Present in Smoking Area with Resident
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and used a wheelchair and walker for mobility, was observed in the designated smoking area with a portable oxygen tank secured to her wheelchair. The resident was present while five other residents were actively smoking, although her oxygen tank was not in use and was later found to be empty. The Director of Nursing (DON) distributed cigarettes to the other residents and assisted them in lighting their cigarettes, but did not initially notice the oxygen tank attached to the resident's wheelchair. The situation was brought to the attention of the Interim Administrator by the State Agency, prompting the DON to remove the oxygen tank from the resident's wheelchair and hand it to the Interim Administrator, who then carried the unsecured tank through the facility to the oxygen storage area. Interviews with staff and the resident confirmed that the resident typically kept an oxygen tank on her wheelchair and would notify staff when it was empty, but did not usually go outside during smoking times and no longer smoked herself. Staff acknowledged that even empty oxygen tanks could pose a flammability risk if near smoking residents. Facility policy required the removal of flammable items, including smoking articles, from areas where oxygen is administered, but did not address the safe transport of oxygen tanks. The failure to ensure the removal of the oxygen tank from the resident's wheelchair before entering the smoking area, and the subsequent handling of the tank, resulted in a lapse in accident prevention and supervision as required by facility policy and regulations.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of significant changes in condition for two out of three residents reviewed for physician notification. Specifically, one resident with a history of cerebrovascular accident, diabetes mellitus, contractures, and muscle wasting experienced a significant unplanned weight loss. The resident's weight dropped from 222.4 pounds to 207 pounds within a month, representing a 6.92% loss of body weight. This weight loss was documented in the clinical record and noted by the dietary staff, who identified the loss as significant according to facility policy and clinical guidelines. Despite the documentation of this significant weight loss and the facility's policy requiring physician notification for such changes, there was no evidence in the electronic health record that the physician was notified. The Director of Nursing confirmed during an interview that it is expected for the physician to be notified of significant weight loss. The facility's policy also clearly states that the medical doctor and registered dietician should be notified when a significant weight change is identified.
Inadequate Staffing Leads to Missed Insulin Doses and Extended Shifts
Penalty
Summary
The facility failed to ensure sufficient staffing, including a licensed nurse, to meet the needs of residents, particularly those who were insulin-dependent diabetics. On multiple occasions, the nurse on duty left the facility, resulting in six insulin-dependent diabetic residents not receiving their insulin or having their blood sugars assessed for their lunch and supper doses. This occurred on specific dates when the nurse left the facility without proper coverage, and the Director of Nursing (DON) was either unaware or not present to address the situation. Additionally, the facility experienced several instances where nurses were forced to work in excess of 17 hours without relief due to inadequate staffing. On at least four occasions, the scheduled nurse on duty had to work extended hours because there was no replacement available. This situation was exacerbated by poor communication and planning, as evidenced by the lack of coordination between the DON, the Administrator, and the nursing staff. The facility's failure to maintain adequate staffing levels and ensure that a licensed nurse was always present led to significant lapses in care. The report highlights specific instances where residents did not receive necessary medications and treatments, and staff were left without support, leading to potential risks for resident safety and well-being.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required 8 consecutive hours of staffing by a Registered Nurse (RN) daily on at least six days in December 2024. The review of nursing schedules and payroll records indicated that the facility operated with Licensed Practical Nurses (LPNs) covering shifts instead of RNs on these days. Specifically, on 12/1/24, 12/4/24, 12/13/24, 12/21/24, 12/24/24, and 12/31/24, the facility did not have an RN on duty for the required duration. The Director of Nursing (DON) was not present in the facility on some of these days and worked from home on others, contributing to the lack of RN coverage. Interviews with staff and observations further confirmed the deficiency. The DON admitted to not being in the facility for the required hours due to personal commitments and travel constraints. Staff interviews revealed that the DON typically arrived late and left early, and was often in her office with the door closed. This lack of RN presence and oversight in the facility led to the failure to meet the regulatory requirement of having an RN on duty for 8 consecutive hours each day.
Failure to Administer Insulin and Check Blood Sugars
Penalty
Summary
The facility failed to administer evening insulin and assess blood sugars as ordered by the physician for five insulin-dependent diabetic residents during December 2024. This deficiency was identified through clinical record reviews, facility document reviews, and interviews with residents, staff, and physicians. The residents involved were supposed to receive insulin and have their blood sugar levels checked at specific times, but these orders were not consistently followed, leading to multiple missed doses and assessments. Resident #1, for example, had orders to check blood sugar three times daily and administer insulin at bedtime, but these were not completed on several occasions. Similarly, Resident #5 had orders for bedtime insulin and blood sugar checks, which were also frequently missed. The same pattern of missed insulin administration and blood sugar checks was observed for Residents #7, #15, and #16, with documentation showing that these tasks were not performed on numerous dates throughout the month. Interviews revealed that Staff H, an LPN, was responsible for the night shift during which these deficiencies occurred. Staff H claimed to be unaware of the orders due to differences in the computer system from a previous facility, and other staff members reported that she did not administer insulin or check blood sugars as required. The Director of Nursing was not aware of these issues until informed by the surveyor, and no medication error reports were completed for the missed insulin administrations.
Deficiency in Staff Competency for Behavioral Health Needs
Penalty
Summary
The facility failed to ensure that staff possessed the necessary competencies and skills to meet the behavioral health needs of residents with mental health diagnoses and behavioral disturbances. The facility had 12 out of 35 residents with Level II Pre-Admission Screening and Resident Review (PASRR) in place, indicating a need for specialized services. However, the facility's Certified Nursing Assistant Skills Competency Validation Checklist did not include behavior management or care for residents with cognitive impairments, mental illness, trauma, or PTSD as required skills. Additionally, the facility's training records for the past 12 months did not show any education on these critical topics. Resident #7, who had unspecified dementia with behavioral disturbances and violent behavior, was involved in multiple altercations with other residents and staff. The resident's care plan noted a risk for increased verbal and physical behaviors related to depression and other health concerns. Despite these documented issues, staff interviews revealed a lack of training and support in managing such behaviors. Staff members expressed fear and uncertainty in handling aggressive behaviors, with some indicating they would call for help or avoid the resident altogether. Interviews with staff, including CNAs and LPNs, highlighted a significant gap in training related to behavior management. Many staff members reported not receiving any training on managing resident behaviors, and some relied on previous experience from other facilities. The Interim Administrator acknowledged the lack of training and mentioned plans for a behavior management in-service, but at the time of the report, this training had not yet been implemented.
Inappropriate Language Used by Staff Member
Penalty
Summary
The facility failed to ensure that residents are treated in a dignified manner, as evidenced by an incident involving a staff member's use of inappropriate language towards a resident. The incident involved a resident with intact cognition, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS). The resident reported that a staff member, identified as the Activities Director, used an expletive when asking the resident to remove her belongings from a table in the activity room. This interaction left the resident feeling disrespected and intimidated. The resident filed a grievance regarding the incident, expressing that the language used by the staff member was unacceptable and made her cry. The grievance was signed by the resident and later by the Administrator. The staff member involved acknowledged the incident, stating that the remark was made in a sarcastic manner and not intended to be rude. However, the staff member admitted to having made a mistake and recognized that the language used was inappropriate in the workplace. Interviews with other staff members, including the Social Services staff and the Director of Nursing (DON), confirmed the occurrence of the incident and the inappropriate language used. The DON acknowledged that the situation should not have happened in healthcare and that the staff member's intentions were not malicious. The Administrator also confirmed the incident and noted that the resident was more concerned with the staff member's tone rather than feeling afraid. The facility's Resident Rights Policy emphasizes treating residents with respect, kindness, and dignity, which was not upheld in this instance.
Failure to Prevent Resident-to-Resident Altercations
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident altercations involving a resident known to have difficulty managing his verbal and physical behavior. Resident #7, who has a history of accusing others of theft and making threats, was involved in multiple incidents of aggression towards other residents. On one occasion, Resident #7 accused Resident #8 of stealing cigarettes, leading to a physical altercation where Resident #7 threw his walker and hit Resident #8. Resident #7 also verbally threatened Resident #9 during the same incident. Resident #7's care plan indicated a risk for increased verbal and physical behaviors due to various health concerns, including dementia with behavioral disturbances. Despite this, the facility did not complete a cognitive assessment for Resident #7, and his care plan interventions were not effectively preventing altercations. The facility's policy allowed residents to smoke unsupervised, which contributed to the altercation between Resident #7 and Resident #8. The facility's response to the incident included separating the residents and sending Resident #7 for a psychiatric evaluation, but he returned to the facility shortly after. Further incidents occurred involving Resident #7 and Resident #17, where Resident #7 physically assaulted Resident #17 on two separate occasions. In one instance, Resident #7 used a racial slur and hit Resident #17 in the head, and in another, he struck Resident #17 with a walker. These incidents highlight the facility's failure to adequately supervise and manage Resident #7's behavior, despite being aware of his history of aggression and cognitive impairment. The facility's policy on abuse prevention was not effectively implemented, resulting in repeated resident-to-resident altercations.
Failure to Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse for two residents, leading to a deficiency in their reporting obligations. Resident #1, who had intact cognition, reported an incident involving the Activities Director, where inappropriate language was used. The resident filed a grievance, expressing distress over the incident. The Administrator acknowledged the grievance but did not report it as an allegation of abuse, believing it was handled internally and not recognizing the need for external reporting. Resident #6, with moderately impaired cognition and medical diagnoses of anxiety and bipolar disorder, was involved in an incident where inappropriate comments were made by a maintenance staff member. The incident was reported to the Administrator via email by staff members who witnessed or were informed about the event. Despite being informed, the Administrator did not report the incident to the appropriate authorities, questioning the delay in notification and failing to recognize the need for immediate reporting. The facility's policy on reporting abuse allegations, dated October 2024, clearly states that all suspected violations must be reported immediately to the appropriate state agencies. However, the Administrator did not adhere to this policy, resulting in a failure to report both incidents. This oversight highlights a deficiency in the facility's handling of abuse allegations, as they did not follow their own policy or legal requirements for reporting such incidents.
Inadequate Sling Usage and Smoking Safety Assessments
Penalty
Summary
The facility failed to use appropriately sized slings for two residents during transfers, which posed a risk to their safety. Resident #2, who had moderately impaired cognition and was on hospice care, was transferred using a mechanical lift with a sling that was too small. Staff A and Staff B were aware of the inappropriate sling size but proceeded with the transfer. The care plan for Resident #2 did not address changes in mobility or specify the correct sling size. Similarly, Resident #4, who also had moderately impaired cognition and required assistance with transfers, was transferred using a sling that did not adequately cover the resident, as the appropriate size was unavailable. Staff members were inconsistent in their knowledge of sling sizes, and the facility lacked a clear system for ensuring the correct sling sizes were used for each resident. The facility also failed to complete regular assessments for resident safety related to smoking for three residents. Resident #7, who had severely impaired cognition and a history of making threats, did not have an updated Smoking Safety Assessment. Resident #8, who had intact cognition but required assistance for position changes, also lacked an updated assessment and a signed acknowledgment of the facility's smoking policy. Resident #9, with intact cognition, similarly lacked an updated assessment and acknowledgment. An incident occurred where these residents were outside smoking without staff supervision, highlighting the facility's failure to adhere to its smoking policy, which required regular assessments and supervision. Interviews with staff revealed a lack of clarity and consistency in the implementation of policies related to both sling usage and smoking safety assessments. The Director of Nursing acknowledged the deficiencies in the care plans and the need for a system to track sling sizes. The facility's policy on safe lifting and movement of residents was not adequately followed, as there were not enough slings in the required sizes, and staff were not consistently trained in their use. Additionally, the facility's smoking policy was not properly enforced, as assessments were not completed quarterly or with significant changes in condition, and residents were not consistently supervised while smoking.
Failure to Obtain Physician Orders for Respite Care Resident
Penalty
Summary
The facility failed to obtain necessary physician orders for a resident admitted for respite care, resulting in a deficiency. The resident, who was admitted on two separate occasions, lacked physician orders for admission, diet, medications, code status, and routine care. Additionally, there was no contact information for a provider, nor were there assessments related to the resident's current health status, fall risk, or elopement risk. The resident's clinical record only included a handwritten note from the family outlining the resident's daily schedule and a typed informational sheet signed by the Administrator. During the resident's stay, staff noted several incidents indicating a lack of proper care coordination. The resident, who had Parkinson's disease and early memory loss, was observed wandering at night, attempting to leave the facility, and trying to eat from other residents' plates. Staff were unaware of the resident's hospice status and additional medications for anxiety, which were not documented in the facility's records. The resident's behavior and lack of proper medication management highlighted the facility's failure to follow its own policies for admission and care. Interviews with staff and administrators revealed a lack of communication and responsibility for obtaining the necessary physician orders. The Administrator and DON each believed the other was responsible for coordinating the resident's care, leading to confusion and inadequate documentation. The hospice provider was also unaware of the resident's admission, indicating a breakdown in communication between the facility and external care providers. The facility's policies required physician orders and a baseline care plan, which were not followed in this case.
Improper Wound VAC Application and Pain Management
Penalty
Summary
The facility failed to properly implement the application and maintenance of a wound VAC system for a resident with surgical wounds. The resident, who had a history of colostomy and recent cholecystectomy, was admitted to the facility from a local hospital with specific wound care instructions, including the use of a wound VAC. However, upon arrival, there was a lack of documentation regarding the resident's admission and the care provided. The Interim Director of Nursing (DON) attempted to apply the wound VAC but was unsuccessful in achieving a proper seal, which is necessary for the device to function correctly. The situation was further complicated when the resident's family arrived and found the resident in pain, with the wound VAC not functioning. The Registered Nurse (RN) on duty, who was called in to relieve the DON, identified that the adhesive dressing was incorrectly applied over the colostomy bag, preventing the wound VAC from working. Despite attempts to rectify the situation, the RN was unable to administer pain medication due to the absence of written physician orders, and the resident's family decided to return the resident to the hospital for appropriate care. Interviews with staff and family members revealed that the resident was not listed in the facility's computer system as a current resident, which hindered documentation and access to necessary medical orders. The resident's family expressed dissatisfaction with the care provided, leading to the resident's readmission to the hospital. The facility's failure to ensure proper wound VAC application and pain management contributed to the deficiency identified in the report.
Incompetent Wound VAC Management
Penalty
Summary
The facility failed to ensure that nursing staff were competent in applying and managing a wound VAC system for a resident with surgical wounds. The resident was admitted from a local hospital for short-term skilled nursing care with the goal of returning home. The hospital discharge documents included specific instructions for wound care, which involved the use of a wound VAC system. However, the Interim Director of Nursing (DON) and other nursing staff were unable to correctly apply the wound VAC, leading to its malfunction. On the day of the resident's admission, the DON attempted to apply the wound VAC but encountered difficulties due to the resident's long abdominal incision and colostomy appliance. The DON's application of the adhesive dressing over the colostomy bag was incorrect, preventing the wound VAC from functioning properly. Despite multiple attempts by the DON and Staff B, RN, to reapply the wound VAC, they were unsuccessful in achieving a proper seal, and the device continued to malfunction. Family members of the resident expressed concern about the resident's pain and the non-functioning wound VAC. They observed that the dressing was incorrectly applied over the colostomy bag, which was not how hospital staff had applied it. Due to the ongoing issues and the resident's discomfort, the family called for an ambulance to return the resident to the hospital for appropriate care. The facility's documentation noted the resident's condition upon arrival and the subsequent attempts to apply the wound VAC, but these efforts were ultimately unsuccessful.
Failure to Coordinate Hospice Services for Respite Care Resident
Penalty
Summary
The facility failed to identify and coordinate hospice services for a resident admitted for respite care, who was already receiving established in-home hospice services. The resident was admitted to the facility on two separate occasions without proper documentation, including physician orders, medical history, or hospice provider information. The facility's staff were unaware of the resident's hospice status, which was only discovered during a family call when the resident's family mentioned his hospice care and medications. Staff interviews revealed a lack of communication and coordination between the facility and the hospice provider. The resident was not listed in the facility's computer system, and there were no physician orders or proper admission documentation. Staff members, including an RN and LPN, expressed concerns about the lack of orders and the resident not being listed in the system. The Director of Nursing (DON) and the Administrator had conflicting views on who was responsible for coordinating the resident's care and communicating with the hospice provider. The hospice provider was unaware of the resident's admission to the facility until a home visit after the first respite stay. The hospice provider emphasized the importance of coordination for respite care, including physician orders and communication with facility staff. The facility's policies did not address the need to identify and coordinate hospice services for residents admitted for respite care, leading to a breakdown in communication and care coordination for the resident.
Failure to Provide Emergency Tracheostomy Equipment and Care
Penalty
Summary
The facility failed to ensure that emergency equipment, specifically an obturator for a tracheostomy tube, was available at the bedside for a resident with a tracheostomy. This deficiency was identified through observations and staff interviews, which revealed that the necessary emergency tracheostomy set was not present in the resident's room. Staff members, including a Registered Nurse (RN) and the Director of Nursing (DON), were unaware of the location of the emergency equipment, with the RN initially stating it would be placed in the locked medication room and the DON later indicating it might be in a back storage room. This lack of readily available emergency equipment posed a significant risk to the resident's health and safety. The resident in question had a history of respiratory failure, heart failure, and anxiety disorder, and was receiving tracheostomy care. Despite the resident's intact cognition, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS), the facility did not adhere to physician orders regarding the maintenance of the tracheostomy. The Medication Administration Record (MAR) showed that the outer cannula was not changed as ordered, and there were multiple instances where the inner cannula was not changed twice daily as required. This failure to follow physician orders further compromised the resident's care. Interviews with staff members revealed a lack of training and awareness regarding the management of the resident's tracheostomy. One RN admitted to not having received training on tracheostomy care, while an LPN stated she would rely on another staff member if the tracheostomy came out. The DON acknowledged that the facility had not changed the resident's tracheostomy set due to a lack of supplies and expressed reluctance to use the emergency kit. The facility's policy on respiratory system management did not specify where the tracheostomy set should be located, contributing to the confusion and inadequate response to the resident's needs.
Facility Fails to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during two separate inspections. During the initial kitchen tour, surveyors noted several unsanitary conditions, including drips on the floor near the coffee pot, greasy fingerprints on the Atosa refrigerator, and a black substance on the refrigerator's interior vent. Additionally, a pink liquid was found on the refrigerator's interior floor, and a yellow substance, cheese shreds, and crumbs were observed inside the Avatco refrigerator. A towel saturated with liquid was found on the bottom of the fridge with a bag of lettuce placed on it. Dust particles were hanging from the fire suppression system above the stove burners, and dark brown stains and black buildup were present on the floor and wall of the dry storage room. Large spills were noted on the floor of the white Frigidaire, and dark smudges covered the outside of another refrigerator. Thick black dust particles were also observed on the Air King fan. A follow-up observation revealed that the unsanitary conditions persisted, with additional issues noted. Plastic cups were found in upper cupboards with dark drips and stains on the liner, and plastic pitchers were stored on the floor of the bottom cupboards, which were covered with black spots and crumbs. The facility's policy on Sanitation/Infection Control indicated that the Dietary Manager was responsible for supervising sanitation and housekeeping procedures, but the policy lacked a specific cleaning schedule. The Dietary Manager acknowledged the need for cleaning, and the Administrator expressed an expectation for kitchen surfaces to be cleaned and sanitized.
Failure to Ensure Required QAA Committee Attendance and Meeting Frequency
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee was attended by the required members and met at least quarterly. The required members include the Nursing Home Administrator or representative, Director of Nursing, Medical Director representative, Infection Preventionist, and two other members of the facility's staff. During the survey, the Administrator admitted that sign-in sheets for the Quality Assurance Performance Improvement (QAPI) meetings were not available. A review of three QAPI folders revealed a lack of documentation regarding the required meeting frequency and attendees. The Regional President of Operations confirmed that QAPI meetings should occur quarterly with the necessary attendees. A document titled Quality Assurance Performance Improvement Management, dated January 2024, indicated that the QAPI Committee should meet at least monthly to effectively identify issues requiring QAPI activities.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by several observations and interviews. A resident was observed wheeling himself through the dining room with his indwelling catheter drainage bag dragging on the floor, which was half full of urine. Staff members, while emptying the drainage bag, did not perform hand hygiene between tasks and raised the drainage bag above the resident's bladder, contrary to proper procedure. The resident had intact cognition and was at risk for a urinary tract infection due to his medical conditions, including obstructive uropathy and chronic kidney disease. Additionally, the facility did not conduct ongoing infection control surveillance, as the infection control data was unavailable due to administrative staff turnover. Another resident, who had a tracheostomy and was at risk for ineffective airway clearance, had their tracheostomy inner cannula replaced without following proper glove-changing procedures. The facility also lacked documentation for identifying and preventing Legionella growth and other waterborne pathogens. The Regional Vice President of Operations confirmed that infection control surveillance and water management practices were not being adequately performed.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a clean, well-maintained, and homelike environment for its residents, as evidenced by observations of brown stains on the floor in Hall 1 on multiple occasions. On one occasion, a housekeeper mopped the floor, removing the stain, but stains reappeared days later. The housekeeping staff was inadequately scheduled, with only one housekeeper assigned to clean specific halls, leaving Halls 1 and 2 without scheduled cleaning on a particular day. The Housekeeping Supervisor acknowledged the absence of scheduled staff for these halls, and the Regional Vice President of Operations confirmed that someone should be scheduled daily to clean each hall. The facility's housekeeping policy, dated June 2016, indicated that common areas and resident rooms should be maintained in a clean and sanitary condition, with daily cleaning of resident rooms.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to respond to resident call lights within the required 15-minute timeframe for at least one resident. On June 24, 2024, a resident reported that staff did not respond to call lights within 15 minutes. During an observation on the same day, another resident's call light was illuminated for 26 minutes before a Certified Nursing Assistant responded. This resident also remarked that staff frequently do not respond to call lights within the expected time. The facility's policy, dated August 2023, directed staff to answer call lights as soon as practicable, with emergency call lights to be answered within one minute. The facility's administrator confirmed that staff should respond to call lights within 15 minutes.
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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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