Atlantic Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Atlantic, Iowa.
- Location
- 1300 East 19th Street, Atlantic, Iowa 50022
- CMS Provider Number
- 165288
- Inspections on file
- 30
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Atlantic Specialty Care during CMS and state inspections, most recent first.
Failure to provide written transfer, ombudsman, and bed-hold notifications: The facility did not give the resident representative written notice of a hospital transfer or notify the state ombudsman for one resident, and it did not document bed-hold and reserve bed payment information for two residents. One resident had severe cognitive impairment and was transferred after a fall, while another resident with cancer, HF, and respiratory failure was transferred for breathing difficulty and later diagnosed with PNA. Staff stated the transfers were emergent and could not locate the required written documentation.
Late Admission MDS Submission: A resident with a BIMS score of 15/15 had an admission MDS that remained in progress past the required timeframe. The MDS Coordinator said she had been working on the floor and needed help from other facilities and an RN travel MDS staff member to complete submissions, while the DON and Regional Nurse Consultant acknowledged the facility was using a hybrid MDS process and that MDSs needed to be submitted timely per the RAI Manual.
Care plan failed to address a resident’s high-risk medication needs and wandering risk. The resident had moderately impaired cognition, vascular dementia with agitation and restlessness, required assistance with mobility, received Lorazepam for restlessness and agitation, and had repeated high wandering risk scores. Review of the care plan showed no documentation of the antianxiety medication, related side effects or monitoring needs, and no interventions for wandering; the DON acknowledged these omissions.
Incontinence care was not provided according to facility policy for a resident who was dependent for all ADLs, had severely impaired cognition, and was always incontinent of bowel and bladder. During observation, two CNAs cleaned the resident with only one wipe per area and did not complete the full pericare process described by staff, including separate wipes for different areas and cleaning the penis tip. The CNA acknowledged missing steps, and the DON stated staff should have followed the policy.
Wheelchair Not Locked During Mechanical Lift Transfer: A resident with severely impaired cognition, dementia, stroke, MS, hemiplegia, and total dependence for ADLs was transferred from bed to a wheelchair using a mechanical lift by two CNAs. The wheelchair was left unlocked while the resident was lowered onto it, and the brakes were not applied until after the resident was seated. Both CNAs stated the wheelchair should have been locked, and one said she forgot to lock it; the DON later confirmed the brakes should have been locked.
Failure to administer ordered vaccinations: one resident with intact cognition and diagnoses including Parkinsonism, HTN, and respiratory failure did not receive the annual flu vaccine despite a physician order and signed consent, with no order entered in the EHR and no documentation of administration. Another resident with severe cognitive impairment and diagnoses including a hip fracture and dementia did not receive the pneumococcal vaccine despite a physician order and signed consent, and the EHR also lacked an order and administration record. The DON stated the residents had consented but the facility had not given the vaccines yet.
Staff did not consistently monitor or document food temperatures at the steam table before and after meal service, resulting in food being served below required temperatures. Two residents reported that food was often cold, both in the dining room and on room trays. Review of temperature logs showed incomplete documentation, and staff acknowledged that temperature checks and logging were expected but not performed as required.
Surveyors identified multiple deficiencies in food storage, preparation, and sanitation, including undated and improperly stored food items, incomplete temperature and sanitizing logs, inconsistent hand hygiene, and failure to follow facility policies for food safety. Staff were observed using improper glove techniques, not dating food products, and failing to maintain cleanliness and temperature records as required.
A resident with CHF and related diagnoses did not receive consistent monitoring of weights and vital signs as required by the care plan and physician orders. Staff failed to administer PRN diuretic medication despite documented symptoms of edema and shortness of breath, and there were gaps in documentation of daily weights and skilled assessments. Nurses were unaware of the PRN order and lacked clear parameters for its use, and the facility did not have policies for CHF-related monitoring.
A resident with severe cognitive impairment and a history of pressure ulcers was repeatedly found without required protective boots and wound dressings, despite care plans and physician orders directing their use. Staff did not consistently follow protocols for reapplying dressings or ensuring protective devices were in place, and the resident was observed with exposed feet and missing treatments on multiple occasions. The DON confirmed expectations for prompt replacement of dressings, but these were not reliably met.
An unlocked and unattended medication cart was found in a hallway near resident rooms after a CMA left it unsecured while administering medications and then walked away to speak with a nurse. The DON confirmed that staff are expected to keep medication carts locked when not in view, in accordance with facility policy.
A resident did not receive a full serving of pureed baked beans as required for their modified diet, after the food dried up during preparation and was still served in an incomplete portion. The facility's policy did not specifically address portion sizes for mechanically altered diets, and staff did not prepare additional food to meet the serving requirement.
A resident with a history of CHF, acute respiratory failure, and recent heart surgery did not have vital signs documented on multiple occasions, even though nursing notes indicated the task was completed. The DON confirmed that daily skilled assessments, including vital signs, were expected, and facility policy required complete and accurate documentation.
A CNA failed to change gloves after adjusting a soiled brief for a resident with an indwelling catheter and colostomy, then touched other surfaces with the same gloved hand. Facility policy required glove changes and hand hygiene, but these practices were not followed during care.
Two residents with normal cognitive function and adequate hearing reported hearing staff swearing in the hallways, which was upsetting to them. The facility's policies emphasize treating residents with dignity, but the Regional Nurse Consultant acknowledged that such language would be distressing, indicating a failure to adhere to these standards.
Two residents experienced falls resulting in injuries, but the facility failed to complete required neurological assessments. One resident had a hematoma after an unwitnessed fall, and another had a hematoma and skin tears after a scooter accident. Incomplete assessments and delayed physician notifications were noted, contrary to facility policy.
A facility failed to provide adequate nursing staff, resulting in delayed call light responses for several residents. One resident experienced incontinence and falls due to long waits, while others reported delays of up to an hour. Staff acknowledged response times could exceed 15 minutes, especially during peak hours. Facility grievances and Resident Council Minutes highlighted concerns about untimely responses and staff inattentiveness.
The facility failed to implement proper hand hygiene and infection control during medication administration. A CMA did not consistently perform hand hygiene between residents, and another CMA failed to use appropriate PPE and hand hygiene when administering medications to residents with enhanced barrier precautions. These actions violated the facility's policies on hand hygiene, medication administration, and catheter care.
The facility failed to ensure wheelchair safety for two residents by not using foot pedals while pushing them, contrary to the facility's guidelines. One resident with normal cognitive function was pushed without foot pedals, and another with moderate cognitive impairment was pushed without a leg rest. Staff confirmed the requirement for foot pedals to prevent injury.
The facility inaccurately submitted staffing data for the CMS PBJ report, indicating excessively low weekend staffing. Review of daily assignment sheets showed similar staffing levels for weekdays and weekends, with three CNAs frequently on overnight shifts. The Administrator confirmed the incorrect submission, citing a lack of weekend management as the cause, an issue also affecting other corporate facilities.
The facility failed to serve food at appetizing temperatures to several residents, with reports of cold and overcooked meals. Observations showed food temperatures below safe levels, and staff interviews suggested issues with the delivery system. Residents expressed dissatisfaction, and the facility's policy emphasized maintaining proper food temperatures to prevent pathogen growth.
The facility failed to follow infection control protocols during resident care and medication administration. A CNA improperly wore a gown during catheter care, and two staff members did not don gowns for a resident with a catheter. A CMA neglected hand hygiene during medication rounds. Additionally, a resident with MASD reported discomfort due to prolonged bedpan use, and a CNA did not change gloves or perform hand hygiene while searching for cream. These actions reflect deficiencies in the facility's infection prevention practices.
The facility failed to provide timely assessments and interventions for residents, leading to significant deficiencies in care. A resident with severe cognitive deficits and multiple health conditions was not monitored for vital signs after a hospital stay, resulting in her passing away. Another resident experienced significant weight loss due to refusal of a nutritional supplement, with no notification to the physician or dietician. Additionally, a resident at risk for dehydration was not monitored for urinary output, and another resident did not receive required neurological assessments after a fall.
The facility failed to respond to call lights in a timely manner for 11 residents, leading to significant delays in care. A resident was left on a bedpan for over 50 minutes, while another had to transfer himself to the bathroom due to delays. Residents reported call light response times of 30-60 minutes, particularly at night, and the grievance log revealed multiple complaints about delayed responses. The DON acknowledged call light audits but denied reports of incontinence due to delays.
The facility failed to accurately document MDS information for two residents. One resident's MDS incorrectly noted anticoagulant use, conflicting with physician orders for antiplatelet medication. Another resident's MDS inaccurately recorded bed rails as restraints, while orders specified assist bars for repositioning. The DON and MDS Coordinator acknowledged the errors.
A resident with severe cognitive impairment did not have a comprehensive care plan addressing activities, as required by facility policy. Observations showed the resident was not engaged in activities, and staff confirmed the absence of a care plan. The DON acknowledged the resident's interests but noted the lack of personalized activity planning.
The facility failed to update care plans for two residents after changes in their medication orders. One resident's insulin was discontinued, but the care plan was not updated. Another resident's care plan inaccurately classified an antiplatelet medication as an anticoagulant. These actions were contrary to the facility's policy requiring care plan revisions following changes in condition or medication.
A resident with chronic skin damage did not receive prescribed treatments, leading to discomfort and pain. The resident, dependent on staff for care, reported that barrier cream was not applied as ordered, particularly after dialysis sessions. A CNA found the resident with a raw area lacking treatment, prompting an RN to apply the necessary cream and padding.
A facility failed to provide resident-centered activities for a cognitively impaired resident, lacking a care plan that incorporated the resident's known interests such as coffee and movies. Observations showed the resident was often unengaged during activities, and staff interviews confirmed the absence of a structured activity plan, despite the facility's policy to support residents' well-being.
A facility failed to provide restorative therapy for a resident with hemiplegia following a cerebral infarction. The resident's care plan included therapy sessions three times weekly, but no documentation was found for May, and the facility lacked a restorative staff member. Interviews revealed the resident was discharged from therapy after reaching maximum potential, and the Director of Nursing confirmed the absence of a restorative aide, contrary to facility policy.
A facility failed to follow physician orders and policies for a resident with a PEG tube. The resident's feeding was set at 70 mL/hr instead of the ordered 60 mL/hr, and medications were administered via a piston syringe rather than by gravity flow. The DON confirmed that the orders were not followed, resulting in insufficient formula and water administration.
A facility failed to conduct post-dialysis assessments for a resident with chronic kidney disease and other health issues. The resident, who had intact cognitive ability, was admitted after a hospital stay and received hemodialysis treatments. The care plan required monitoring for renal insufficiency, but post-dialysis assessments were not completed on multiple occasions. The ADON acknowledged the missing assessments, which were required on dialysis days.
A resident with severe cognitive deficits experienced an unwitnessed fall, resulting in a laceration. Although the facility's policy required vital signs to be documented during neurological assessments, the resident's records lacked this information on several occasions. The DON confirmed that staff were expected to record new vital signs with each assessment.
Two residents reported being treated without dignity and respect in the facility. One resident was left on a bedpan for over 50 minutes, causing distress due to a sore, while another was scolded for drinking water and found without bedding. Staff were reported to have withheld water and responded sarcastically to requests for assistance. Additionally, a grievance highlighted rude behavior from a staff member during a resident's hospital transfer.
Failure to Provide Written Transfer, Ombudsman, and Bed-Hold Notifications
Penalty
Summary
The facility failed to provide written notification to the resident's representative and the state ombudsman when Resident #8 was transferred to the hospital. Resident #8 had a BIMS score of 03 out of 15 indicating severely impaired cognition, with diagnoses including a right hip fracture and non-Alzheimer's dementia. After a fall with a fracture and later a hospital transfer, the incident documentation noted the family was made aware, but the record did not include the required ombudsman notification for the hospitalization and did not contain written notification to the resident's representative explaining the reason for the transfer. The facility also failed to provide bed-hold and reserve bed payment information for Resident #6 and Resident #8. Resident #6 had diagnoses including cancer, heart failure, and respiratory failure, and was transferred to the hospital for breathing difficulty and later diagnosed with pneumonia. Resident #8 was transferred to the hospital after a fall. For both residents, the EHR Standard Evaluations section did not include documented bed-hold authorization with reserve payment information, and staff could not locate written notification to the resident's representative about the bed hold or the reason for the hospital transfer. Staff interviews confirmed the facility had not been notifying resident representatives in writing because the transfers were emergent, and the DON stated the nurse should have called the family about the bed hold and transfer and that the transfer should have been reported to the Ombudsman.
Late Admission MDS Submission
Penalty
Summary
The facility failed to complete and submit the admission MDS within the required time frame for one resident. Resident #83’s MDS assessment showed a BIMS score of 15/15, indicating normal cognition. The electronic clinical record showed the admission MDS, dated 3/30/26, was still in progress on 4/8/26, with an ARD of 4/6/26, making the admission MDS 2 days overdue. On 4/9/26, the MDS page showed the admission MDS as export ready. The resident’s clinical census record showed admission to the facility on [DATE], and the resident stated on 4/6/36 at 1:34 PM that she had been in the facility for 2 weeks. On 4/8/26, the MDS Coordinator acknowledged the admission MDS had not been submitted and was late, stating she had been working on the floor and needed assistance from other facilities and Staff A, RN/Travel MDS. Staff A stated she was assisting with MDS submission because staff from other facilities may not be an RN, which is required for MDS submission. The DON stated the MDS Coordinator had been working as a Charge Nurse due to increased census and staffing needs, and the Regional Nurse Consultant stated the facility had been using a Hybrid MDS to help complete and submit MDSs. Staff concurred the MDSs needed to be submitted timely according to the RAI Manual, which states the admission assessment can be no more than 14 days from the date of admission.
Care Plan Did Not Address High-Risk Medication or Wandering Risk
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident #54 that addressed identified risk factors and interventions. The resident’s MDS dated 1/30/26 showed a BIMS score of 03, indicating moderately impaired cognition, and documented diagnoses of vascular dementia with agitation and restlessness. The MDS also showed the resident required supervision/touching assistance with transfers and ambulation and received antianxiety medication during the last 7 days. A physician order dated 2/5/26 directed Lorazepam 0.5 mg by mouth twice a day for restlessness and agitation. Resident #54’s wandering evaluations documented high wandering risk scores of 16 on 11/21/25, 17 on 12/4/25, and 13 on 1/20/26. Review of the care plan with target date 5/10/26 showed the antianxiety medication, its potential side effects, and what to monitor for while taking the high-risk medication were not addressed on the comprehensive care plan. The care plan also did not address the resident’s wandering risk or interventions for wandering. The DON acknowledged on 4/8/26 that the antianxiety medication and wandering had not been addressed on the care plan and stated the care plan was updated on 4/7/26 and 4/8/26, respectively.
Incontinence Care Not Completed Per Facility Policy
Penalty
Summary
Appropriate incontinence care was not provided for a resident who was dependent for all ADLs and mobility and always incontinent of bowel and bladder. The resident’s MDS identified severely impaired cognition, diagnoses of non-Alzheimer’s dementia, stroke, multiple sclerosis, and hemiplegia, and the care plan directed staff to clean the peri-area with each incontinence episode. The care plan also indicated the resident was dependent with toileting and required 2-person staff assistance. During observation of incontinence care, two CNAs provided peri-care after an incontinent episode, but the care was not completed according to the facility’s described process. One CNA wiped the resident’s entire perineal area once and discarded the wipe, then removed gloves and sanitized hands before putting on a new pair of gloves. The other CNA removed the remainder of the brief, wiped the anal area once, and discarded the wipe. Staff later stated that pericare should include removing the brief and using separate periwipes for different areas, including cleaning the penis tip and retracting the foreskin if applicable. The CNA involved acknowledged forgetting to use separate wipes and to clean the penis tip. The facility’s perineal care policy directed staff to retract the foreskin of an uncircumcised male and wash and rinse the urethral area using a circular motion, and the DON stated staff should have followed the policy.
Wheelchair Not Locked During Mechanical Lift Transfer
Penalty
Summary
The facility failed to lock the wheelchair for a resident who was dependent on mechanical lift transfers. Resident #49 had a BIMS score of 07 out of 15, indicating severely impaired cognition, and diagnoses included non-Alzheimer's dementia, a stroke, multiple sclerosis, and hemiplegia. The resident was dependent with all ADLs and mobility, required supervision with eating, and was always incontinent of bowel and bladder. The care plan also identified bladder incontinence and directed staff to clean the peri-area with each incontinence episode, and noted the resident was dependent with toileting and required 2-person staff assistance. During a continuous observation, two CNAs transferred the resident from bed to a wheelchair using a mechanical lift. Both staff positioned the sling under the resident, connected it to the lift, and raised the resident off the bed. One CNA positioned the resident in front of the wheelchair while standing behind the unlocked wheelchair, grabbed the sling, and used it to position the resident over the wheelchair cushion. The other CNA lowered the resident onto the wheelchair cushion, and the wheelchair brakes were not locked until after the resident was seated. Both CNAs stated a wheelchair should be locked when lowering a resident onto it, and one stated she forgot to lock the wheelchair during the transfer. The DON later stated staff should have locked the wheelchair brakes.
Failure to Administer Ordered Vaccinations
Penalty
Summary
The facility failed to provide the recommended influenza vaccine for one eligible resident and the recommended pneumococcal vaccine for one eligible resident. Resident #2 had intact cognition with a BIMS score of 13, diagnoses including Parkinsonism, high blood pressure, and respiratory failure, and was admitted without having received the seasonal influenza vaccine. Although a physician order allowed the annual flu vaccine and the admission documents included a signed vaccination consent form, the EHR medication list showed the influenza vaccine was never ordered, the vaccination tab did not document administration, and the care plan did not include a vaccination focus category. An encounter progress note later documented the resident’s most recent influenza vaccine as having been given on 10/06/23. Resident #8 had severely impaired cognition with a BIMS score of 03, diagnoses including right hip fracture and non-Alzheimer’s dementia, and was admitted after receiving the influenza vaccine but without having received the pneumococcal vaccine. A physician order allowed the pneumococcal vaccine if applicable, and the consent form indicated the resident consented to receive it; however, the EHR medication list showed the pneumococcal vaccine was never ordered, the vaccination tab did not document administration, and the care plan did not include a vaccination focus category. A progress note later entered pneumococcal vaccine as declined/historical with complete consent form, and the DON stated the residents had consented to the vaccinations but the facility had not administered them yet.
Failure to Monitor and Document Food Temperatures During Meal Service
Penalty
Summary
The facility failed to prepare, serve, and distribute food in accordance with professional standards, specifically by not consistently taking and documenting food temperatures at the steam table before and after meal service. Observations showed that food items were placed on the steam table an hour before service began, and meal service lasted over an hour, yet staff did not take temperatures at the steam table prior to or at the completion of meal service. Additionally, a sample tray returned to the kitchen after meal service revealed food temperatures below required serving standards. Review of food temperature logs for three months showed incomplete documentation, with 33% of required entries missing. Resident interviews indicated dissatisfaction with food temperatures, with one resident stating that food was not served at appropriate temperatures in both the dining room and in-room trays, and another resident reporting that food was often cold in the dining room. Staff interviews confirmed expectations that temperatures should be taken and logged before and after meal service, and the facility's policy required monitoring of food temperatures throughout the meal. The FDA Food Code was also referenced, indicating the need for daily oversight of cooking temperatures.
Deficiencies in Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and service within the facility's kitchen. The walk-in cooler lacked an interior thermometer and contained opened, undated food items, including cake, canned fruit, and a jug of Half and Half with an expired date and improper covering. The walk-in freezer had an unsealed, undated bag of ravioli, and the milk cooler exhibited thick, darkened frost. Additional issues included undated opened milk and a yellow substance in the reach-in refrigerator, as well as undated, opened packages of cookies and pasta in the pantry. The food preparation area was found to be dirty, with food remnants and crumbs present. Temperature logs for refrigeration units and sanitizing equipment were incomplete or missing for several days across multiple months. During meal preparation and service, staff were observed failing to consistently follow hand hygiene protocols, including donning gloves without handwashing and touching both food and packaging with the same gloves. Staff also failed to date and properly store food items, with several opened and undated products used in meal preparation. There were inconsistencies in checking and recording food temperatures before and after processing, and some food items were left uncovered in the steamer. The Registered Dietitian and Certified Dietary Manager both acknowledged these lapses, confirming that food should be dated, covered, and stored in airtight containers, and that hand hygiene should be performed between tasks and before and after glove use. Policy reviews revealed that the facility's own procedures required all food to be dated upon receipt and opening, stored in sealed containers, and for temperature logs to be maintained for all refrigeration and sanitizing equipment. Staff interviews confirmed a lack of awareness or adherence to these policies, with the new Certified Dietary Manager unsure if logs were kept for certain appliances. The Administrator and Registered Dietitian both expected compliance with these standards, but observations and record reviews demonstrated ongoing deficiencies in food safety and sanitation practices.
Failure to Monitor and Intervene for CHF Resident per Care Plan and Physician Orders
Penalty
Summary
The facility failed to implement care and treatment consistent with the care plan and physician orders for a resident with congestive heart failure (CHF), coronary artery disease, renal insufficiency, and pneumonia. The resident required special monitoring of weights and vital signs due to her CHF diagnosis and was admitted with orders for diuretic therapy to manage edema and fluid retention. Despite these orders, staff did not consistently monitor the resident's weight or conduct daily vital signs as required. The Medication Administration Record showed that the PRN furosemide was not administered, even though the resident exhibited symptoms such as shortness of breath and edema, which were documented multiple times in the progress notes. The care plan directed staff to administer diuretic medications as ordered and to monitor for side effects and effectiveness every shift. However, there was a lack of documentation of daily weights and skilled assessments on several dates, and staff interviews revealed that nurses were unaware of the PRN furosemide order and lacked clear parameters for its use. The resident experienced significant weight gain and worsening edema over the course of her stay, with documentation showing a weight increase from 149.1 lbs to 168.4 lbs and progression of edema from +1 to +3 pitting in the lower extremities before scheduled diuretic therapy was initiated. Additionally, the facility did not have policies in place for documentation of skilled assessments, edema monitoring related to CHF, or weight monitoring, relying instead on nursing judgment and physician orders. The facility assessment indicated that early identification and management of heart failure and related conditions were expected, but the lack of consistent monitoring and intervention placed the resident at risk.
Failure to Implement Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
Staff failed to implement prescribed interventions for the prevention and care of pressure ulcers for a resident identified as high risk. The resident, who had severe cognitive impairment and was totally dependent on staff for all activities of daily living, had a history of pressure ulcers, including a Stage III ulcer and an unstageable sore with eschar. The care plan directed staff to float the resident's heels, ensure sheepskin boots were worn at all times, and complete weekly treatments. Orders were in place for specific wound dressings to be applied and changed on designated days and as needed if dressings fell off. Multiple observations revealed that the resident was frequently found without the required protective boots and wound dressings. On several occasions, she was seen in bed or in a wheelchair with only socks on her feet, and the protective boots were either missing or on the floor. During a treatment session, an LPN discovered that neither foot had the prescribed adhesive dressings, and the resident's feet appeared dry and scaly. The LPN acknowledged that the dressings were not in place and was unsure about the protocol for reapplying them if they fell off. The resident was also observed to have peeling skin and a red spot on her foot, though no open or reddened areas were noted at that time. The Director of Nursing confirmed that she expected staff to notify nursing when dressings fell off so they could be replaced promptly. However, the observations and staff interviews indicated that this process was not consistently followed, resulting in the resident being left without necessary protective measures and wound care. Facility policy required regular skin assessments and adherence to physician-ordered treatments, but these were not reliably implemented for this resident.
Unattended, Unlocked Medication Cart Found in Hallway
Penalty
Summary
A deficiency was identified when an unlocked and unattended medication cart was observed in a hallway near resident rooms. The incident occurred when a Certified Medication Aide (CMA) left the cart unsecured while administering medications in a resident's room and then proceeded down the hallway to speak with a nurse, leaving the cart out of her line of sight. The CMA acknowledged that she failed to lock the drawers before leaving the cart unattended. The Director of Nursing (DON) confirmed that facility policy requires medication carts to be locked at all times when not within the staff member's view. The facility had a reported census of 61 residents at the time of the observation. The facility's policy, titled 'Security of Medication Cart,' dated April 2007, specifies that medication carts must be securely locked whenever they are out of the nurse's view, which was not followed in this instance.
Failure to Provide Full Serving of Pureed Diet to Resident
Penalty
Summary
The facility failed to provide a well-balanced diet that met the nutritional and special dietary needs of a resident by serving an incorrect portion size of pureed baked beans during a meal. Observation showed that the cook prepared modified barbeque pork and pureed baked beans for residents requiring mechanically altered diets. During preparation, the cook processed and measured the food, but when serving the final pureed meal, it was noted that there was an incomplete serving of pureed baked beans due to the food drying up in the steamer. Despite this, the incomplete serving was placed on the room service tray and delivered to the resident, resulting in the resident not receiving a full serving as required. Interviews with the Registered Dietitian and the Administrator confirmed that the expectation was for residents to receive full servings according to the facility's guidelines. The Registered Dietitian stated that if there was a shortage, additional food should be prepared to ensure a complete serving. The facility's Therapeutic Diets Policy did not specifically address the preparation and portion sizes for mechanically altered diets, contributing to the deficiency.
Failure to Maintain Accurate Medical Records for Resident with Cardiac History
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident with significant cardiac and respiratory diagnoses, including congestive heart failure, acute respiratory failure, and a history of atrial fibrillation with rapid ventricular response. The resident's care plan required close monitoring, including daily skilled assessments and documentation of vital signs. However, on three separate occasions, the clinical record lacked documentation of vital signs, despite nursing notes indicating that obtaining new vital signs had been completed on those dates. During an interview, the Director of Nursing confirmed the expectation that skilled assessments, including vital signs, should be documented daily. The facility's policy on charting and documentation required that all medical record entries be objective, complete, and accurate, including care-specific details such as assessment data. The absence of vital sign documentation on the specified dates constituted a failure to maintain accurate medical records in accordance with accepted professional standards.
Failure to Change Gloves and Perform Hand Hygiene During Resident Care
Penalty
Summary
Staff failed to follow appropriate infection control practices when providing care to a resident with complex medical needs, including an indwelling catheter and colostomy. During care, a CNA, while wearing gloves, adjusted a soiled brief and then touched the arm of a mechanical lift and the resident's shoulder without changing gloves. The resident was noted to have a copious amount of blood around the catheter site and under the abdominal fold. Facility policy required staff to change gloves after they became soiled and to perform hand hygiene before donning clean gloves. The Director of Nursing confirmed that staff were expected to adhere to these practices.
Staff Swearing in Hallways Violates Resident Dignity
Penalty
Summary
The facility failed to uphold the residents' right to a dignified existence by allowing staff to use inappropriate language in the hallways, which was audible to residents. This deficiency was identified through interviews, clinical record reviews, and facility policy reviews. Two residents, both with intact cognitive function and adequate hearing, reported hearing staff swearing during conversations in the hallways. Resident #2 confirmed that the language was bothersome, while Resident #5 expressed that the swearing was very upsetting, although she could not identify specific staff members responsible. The facility's policies on abuse prevention and resident rights emphasize the importance of treating residents with kindness, respect, and dignity. The policies also highlight the need to maintain a culture of compassion and prevent stressful working conditions that could lead to such behavior. Despite these policies, the Regional Nurse Consultant acknowledged that swearing in the hallways would indeed be upsetting to residents, indicating a lapse in adherence to the established standards of resident care and dignity.
Incomplete Neurological Assessments After Falls
Penalty
Summary
The facility failed to provide necessary neurological assessments following falls for two residents, leading to a deficiency in care. Resident #1, who had a moderate cognitive impairment and used a wheelchair for mobility, experienced an unwitnessed fall from bed, resulting in a hematoma on the forehead. Despite the fall being reported, the neurological evaluations were incomplete, with only 7 out of 18 required assessments documented. The resident's Power of Attorney was notified of the fall a day later and observed a noticeable injury during a visit weeks after the incident. Resident #5, who had intact cognition and used a wheelchair, experienced a witnessed fall involving a motorized scooter, resulting in a hematoma and skin tears. The neurological assessments for this resident were also incomplete, with 14 out of 18 required assessments documented. The resident declined hospital transfer, and the physician was notified via fax, with orders to continue monitoring. Staff interviews revealed inconsistencies in the completion of neurological assessments and communication with physicians. The facility's policy required comprehensive neurological assessments following falls, including frequent vital sign checks and immediate physician notification of any changes. However, the assessments for both residents were incomplete, lacking full documentation of vital signs and other required evaluations. The Director of Nursing acknowledged the deficiencies in the assessments, which did not meet the facility's standards for post-fall care.
Inadequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure resident safety by not responding to call lights in a timely manner for four residents. Resident #2, with normal cognitive functioning and requiring assistance with transfers and toileting, reported waiting over 30 minutes for call lights to be answered, leading to incontinence episodes and self-transfers that resulted in falls. Resident #3, also with normal cognitive functioning and requiring total assistance for transfers and toileting, experienced call light delays of up to 30 minutes, attributing it to low staffing levels. Resident #5, with intact cognition and independent mobility, reported waiting over an hour for call lights to be answered and having to seek staff assistance actively. Resident #6, with intact cognition and requiring moderate assistance for ambulation, experienced call light delays exceeding 20 minutes, leading to self-initiated actions like leaving the room. Staff interviews corroborated the residents' experiences, with staff acknowledging that call light response times could exceed 15 minutes, particularly during peak hours when multiple lights were activated. The Director of Nursing confirmed that call lights were expected to be answered within 15 minutes. Facility grievances and Resident Council Minutes since June 2024 documented concerns about untimely call light responses and staff inattentiveness, including instances of staff being distracted by personal activities at the nurses' station. The facility's policy on answering call lights, revised in March 2021, aimed to ensure timely responses to residents' needs, but the reported incidents indicate a failure to adhere to this policy.
Inadequate Hand Hygiene and Infection Control During Medication Administration
Penalty
Summary
The facility failed to implement appropriate hand hygiene and infection control practices during medication administration, as observed on multiple occasions. Staff A, a Certified Medication Aide (CMA), did not consistently perform hand hygiene between administering medications to four residents. Similarly, Staff B, another CMA, failed to complete consistent hand hygiene between administering medications to sixteen residents. These lapses in hand hygiene were observed during medication administration rounds, indicating a systemic issue in adhering to infection control protocols. Specific incidents further highlighted the deficiency in infection control practices. Staff B placed eye drops in her pocket along with gloves and a tissue, then proceeded to administer oral medication to a resident without proper hand hygiene. Additionally, Staff B handled a basin used by a resident for toileting without following appropriate hand hygiene and PPE protocols. Another incident involved Staff B providing eye drops to a resident with enhanced barrier precautions (EBP) without using the required PPE, such as gowns, and failing to maintain catheter care standards by allowing a catheter bag to touch the floor. These actions were contrary to the facility's policies on hand hygiene, medication administration, and catheter care, as well as the guidelines for EBP.
Failure to Ensure Wheelchair Safety for Residents
Penalty
Summary
The facility failed to protect residents from potential accidents and injuries by not adhering to proper wheelchair safety protocols. Resident #3, who has normal cognitive function and uses a manual wheelchair for mobility, was observed being pushed by a Certified Medication Aide without the use of foot pedals. This action contradicts the resident's care plan, which indicates that the resident normally self-propels the wheelchair. The absence of foot pedals while being pushed poses a risk of injury to the resident. Similarly, Resident #9, who has moderate cognitive impairment and also uses a wheelchair for mobility, was observed being pushed by the Assistant Director of Nursing without a leg rest on the right side. Despite the resident's ability to self-propel, the lack of proper foot support while being pushed is against the facility's guidelines. Multiple staff members, including CNAs, CMAs, and the Director of Nursing, confirmed that foot pedals must be used when pushing residents in wheelchairs to prevent injury. The facility's guidelines clearly state that footrests should be used when pushing residents, yet this protocol was not followed in these instances.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate staffing reports for the CMS Payroll Based Journal (PBJ) Staffing Data Report for the period of October 1 to December 31. The PBJ Staffing Data Report, run on May 31, 2024, indicated excessively low weekend staffing. Upon reviewing the Facility Daily Assignment Sheets for October, November, and December 2023, it was found that staffing for nurses and CNAs was scheduled similarly for weekdays and weekends, with three CNAs frequently on the overnight shift during both periods in December. On June 5, 2024, the Administrator confirmed that the data submission for the PBJ was incorrect and mentioned that the issue was due to the absence of management on weekends, a problem also present in other facilities managed by the corporate entity.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing temperature to four residents, as observed during a survey. Resident #7, with moderate cognitive impairment, reported that the food was cold and overcooked. Similarly, Resident #60, also with moderate cognitive impairment, expressed dissatisfaction with the cold food, stating it was unfit even for a pet. Observations on June 5 revealed that the food temperatures were below the required safe levels, with breaded shrimp and carrots measuring 113.5 and 113 degrees, respectively. Staff interviews indicated awareness of the issue, with one staff member suggesting that the delivery system might be contributing to the problem. Residents #9 and #38, both without cognitive impairment, also reported receiving cold food. Resident #9 mentioned that this had occurred several times over the past two weeks, while Resident #38 noted frequent occurrences of cold food. The Resident Council Minutes from June 5 documented complaints about cold food, and the facility's policy on food preparation and service emphasized the importance of maintaining food temperatures to prevent the growth of harmful pathogens. The policy stated that potentially hazardous food must be kept below 41 F or above 135 F, highlighting the facility's failure to adhere to these guidelines.
Infection Control Deficiencies in Resident Care and Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection prevention practices during personal care and medication administration for several residents. In one instance, a Certified Nursing Assistant (CNA) provided catheter care to a resident without properly wearing a gown, as the sleeves were pushed up over the elbows. The Director of Nursing (DON) confirmed that the expectation was for the gown to be worn correctly during such procedures. Another incident involved two staff members who did not don gowns while providing catheter care to a resident with a neurogenic bladder, despite the facility's policy requiring enhanced barrier precautions for residents with indwelling medical devices. Additionally, a Certified Medication Assistant (CMA) failed to perform hand hygiene during multiple medication administrations. The CMA was observed removing medication from the cart, administering it to residents, and returning to the cart without washing hands before or after these tasks. The DON stated that the facility's policy required hand hygiene before and after direct contact with residents and when handling medications, which was not followed in this case. Furthermore, a resident with Moisture Associated Skin Damage (MASD) reported that staff often left him on a bedpan for extended periods, causing discomfort and irritation to the affected area. During an observation, a CNA changed the resident's brief and searched for a cream without changing gloves or performing hand hygiene, despite the resident's complaint of pain and request for salve. These actions indicate a lack of adherence to infection control protocols, contributing to the deficiencies noted in the facility's infection prevention and control program.
Deficiencies in Resident Monitoring and Care
Penalty
Summary
The facility failed to provide accurate and timely assessments and interventions for several residents, leading to significant deficiencies in care. Resident #120, who had severe cognitive deficits and multiple health conditions, experienced a lack of vital sign monitoring after returning from a hospital stay for influenza A and aspiration pneumonia. Despite being lethargic and having difficulty swallowing, vital signs were not documented for an extended period, and the resident was eventually found unresponsive with a subdural hematoma, leading to her passing away. Resident #57, who had intact cognitive ability but multiple health issues including diabetes and chronic kidney disease, experienced significant weight loss. The resident frequently refused a prescribed nutritional supplement, and there was no documentation that the physician or dietician was notified of these refusals. The resident expressed dissatisfaction with the taste of the supplement and mentioned a preferred alternative available during dialysis, which was not pursued by the facility. Resident #59, who had profound intellectual disabilities and was dependent on tube feedings and a urinary catheter, was at risk for dehydration. The facility failed to monitor his urinary output as recommended by the dietician. Additionally, Resident #119, who had severe cognitive deficits and was at risk for falls, did not receive the required neurological assessments after an unwitnessed fall, as vital signs were not consistently documented. These failures highlight significant lapses in the facility's monitoring and response to changes in residents' conditions.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner for 11 out of 21 residents reviewed, leading to significant delays in care. Resident #57, who had intact cognitive ability and was dependent on staff for toileting and transfers, reported being left on a bedpan for over 50 minutes after returning from dialysis. Despite using the call light, it took an additional 15 minutes for staff to assist him, resulting in a sore on his bottom. Resident #49, also with intact cognitive ability, expressed that he often had to transfer himself to the bathroom due to call light delays exceeding 30 minutes, risking falls and further injury. Resident #6, with moderate cognitive deficits, required substantial assistance for transfers and reported call light response times of 30-60 minutes, particularly at night. Resident #9, with no cognitive impairment, experienced a two-hour delay in call light response, leading to incontinence of urine and bowel. Resident #31, also cognitively intact, noted that call light response times often exceeded 15 minutes, with staff citing understaffing as a reason for delays. The resident council minutes from several months documented ongoing complaints about prolonged call light response times. The facility's grievance log revealed multiple complaints over the past six months about delayed responses to call lights, including instances where residents had to resort to banging on walls or having family members call the facility for assistance. The Director of Nursing acknowledged that call light audits had been conducted, with one instance of a call light delay exceeding 15 minutes noted. However, the DON stated that no resident had reported being incontinent due to prolonged call light delays, despite evidence to the contrary from resident interviews and grievances.
Inaccurate MDS Documentation for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessment information was entered in the Minimum Data Set (MDS) for two residents. For one resident, the MDS inaccurately documented the use of anticoagulant medication, while the clinical physician orders indicated the resident was on an antiplatelet medication, clopidogrel. The resident had a moderate cognitive deficit and was independent in daily activities, with diagnoses including hypertension, Alzheimer's Disease, anxiety, and muscle weakness. The care plan was inconsistent with the MDS, as it noted anticoagulant use related to a left anterior fascicular block. For another resident, the MDS inaccurately documented the use of bed rails as a restraint, while the electronic health record and clinical physician orders indicated the use of assist bars for repositioning due to muscle weakness. The resident had intact cognition. The Director of Nursing and the MDS Coordinator acknowledged the error, with the coordinator admitting to possibly marking the MDS incorrectly. The facility's policy requires individuals completing any portion of the MDS to certify the accuracy of their entries.
Lack of Comprehensive Care Plan for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide a comprehensive care plan for a resident with severe cognitive impairment, as evidenced by a Brief Interview for Mental Status (BIMS) score of 0. The care plan lacked focus, goals, or interventions for activities, and incorrectly documented insulin for a resident who was not on insulin. Observations revealed that the resident was often not engaged in activities, such as sitting alone at bingo without participating, sleeping in the dayroom, and not being present during outdoor activities. Staff interviews confirmed that there was no care plan for activities, and the resident's interests were limited to movies and coffee, with no encouragement to participate in other activities. The facility's policy on care plans, which requires goals and objectives to be resident-oriented, behaviorally stated, measurable, and timely, was not followed. The Director of Nursing acknowledged the absence of a care plan for activities and stated that the resident enjoyed coffee and socializing outside. Despite this, the resident was primarily observed attending exercise sessions without participating, indicating a lack of personalized activity planning to promote the resident's well-being.
Failure to Update Care Plans Following Medication Changes
Penalty
Summary
The facility failed to update the care plans of two residents following changes in their medication orders, leading to deficiencies in care planning. Resident #57, who was admitted with a diagnosis of diabetes mellitus among other conditions, had an insulin order discontinued due to lack of use. However, the care plan was not updated to reflect this change, despite the facility's policy requiring care plans to be reviewed or revised when there is a change in condition or when a desired outcome has been achieved. Similarly, Resident #36, who had a moderate cognitive deficit and was on an antiplatelet medication, had their care plan inaccurately reflect the medication as an anticoagulant/blood thinner. The care plan was not updated to correctly classify the medication, which was clopidogrel (Plavix), an antiplatelet. This oversight occurred despite the facility's policy that care plans should be revised to reflect accurate medication classifications.
Failure to Follow Physician's Orders for Skin Treatment
Penalty
Summary
The facility failed to follow physician's orders for a resident with chronic skin damage on the gluteal area related to moisture and positioning. The resident, who had intact cognitive ability, was totally dependent for toileting, transfers, and lower body dressing, and used a wheelchair for mobility. Despite having an order for Desitin and Mepilex to be applied to the affected area on specific days, the treatment was not documented as completed on one occasion. The resident reported discomfort and pain due to the lack of treatment, particularly after dialysis sessions when he was left sitting for extended periods. During an observation, a CNA discovered that the resident had a reddened, raw area on the right gluteal without any cream or Mepilex padding. The resident expressed that the area hurt and requested the salve. The CNA was unable to find the cream and sought assistance from an RN, who then applied the necessary treatment. The Director of Nursing later stated that the sore was caused by moisture and had healed, indicating that the issue was not a pressure injury but rather a result of moisture-associated skin damage.
Failure to Implement Resident-Centered Activities for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement resident-centered activities for a resident with severe cognitive impairment, as evidenced by a lack of a care plan for activities tailored to the resident's interests and needs. Observations revealed that the resident was often left unengaged during activities, such as sitting alone at bingo without participation or sleeping in the dayroom. Despite staff knowledge of the resident's preferences for coffee, movies with a specific actress, and sitting outside, these interests were not incorporated into a structured activity plan. Interviews with staff and the Director of Nursing confirmed the absence of a care plan for activities, with staff acknowledging the resident's limited participation in exercise activities and a lack of engagement in other interests. The facility's policy on activity programs emphasizes the need to meet the interests and support the well-being of each resident, yet this was not reflected in the care provided to the resident in question. The deficiency highlights a gap between the facility's policy and its implementation, particularly in addressing the psychosocial needs of residents with cognitive impairments.
Failure to Provide Restorative Therapy for Resident with Hemiplegia
Penalty
Summary
The facility failed to provide services to maintain or improve the range of motion for a resident diagnosed with hemiplegia following a cerebral infarction. The resident, who had intact cognition, was supposed to receive restorative therapy using an omni cycle or nu step for 10-15 minutes three times weekly, as per the care plan. However, there was no documentation of the therapy being provided in May, and the resident reported that the facility lacked a restorative staff member at the time. Interviews with the resident and staff revealed that the resident was discharged from therapy at the beginning of May after reaching maximum potential, according to the physical therapist. The Director of Nursing confirmed that the facility's full-time restorative aide had recently left, and the expectation was for restorative therapy to be completed as ordered. The facility's policy stated that residents should receive restorative nursing care to promote optimal safety and independence, which was not adhered to in this case.
Failure to Follow Feeding Tube Protocols
Penalty
Summary
The facility failed to adhere to policies and procedures regarding the administration of feeding tubes for Resident #59, who has a percutaneous endoscopic gastrostomy (PEG) tube for nutrition. The resident's physician orders specified a continuous feed of Osmolite 1.5 Cal at 60 mL/hr over 12 hours, with a tap water flush every hour. However, an observation revealed that the feeding was set at 70 mL/hr, contrary to the physician's orders. This discrepancy was acknowledged by Staff U, a Registered Nurse, who had set up the resident's feedings multiple times. The Director of Nursing confirmed that the physician's orders should have been followed, indicating that 720 mL of formula and water should have been administered, but only 414 mL of formula was given. Additionally, the facility did not follow the policy for administering medications through an enteral tube. Staff L, another Registered Nurse, was observed crushing medications, mixing them with water, and administering them via a piston syringe instead of by gravity flow, as per the facility's policy. The feeding pump history showed no hourly flush set for water, and the total water administered was not in accordance with the physician's orders. These actions demonstrate a failure to implement the technical aspects of feeding tube care as per the established policies and physician's directives.
Failure to Conduct Post-Dialysis Assessments
Penalty
Summary
The facility failed to conduct post-dialysis assessments for a resident who required such services. Resident #57, who had intact cognitive ability, was admitted to the facility after an acute hospital stay and had a diagnosis that included diabetes mellitus, anxiety, depression, chronic kidney disease, nutritional deficiency, acute pain, gangrene, and necrosis of the lung. The resident received hemodialysis treatments at the facility. The care plan indicated that the resident was at increased nutritional risk due to chronic kidney disease and diabetes, and staff were directed to monitor and report any signs or symptoms of renal insufficiency. However, post-dialysis assessments were not completed on several occasions, specifically on 5/16, 5/23, 5/30, and 6/1. The Assistant Director of Nursing acknowledged the absence of post-dialysis assessments on these dates, despite the requirement for both pre and post-dialysis assessments on dialysis days.
Failure to Document Vital Signs After Resident Fall
Penalty
Summary
The facility failed to document accurate information in the electronic medical records of a resident who experienced an unwitnessed fall. The resident, who had severe cognitive deficits and required assistance with daily activities, was found on the floor with a laceration on her eyebrow. Although the incident report indicated that vital signs were taken and a neurological assessment was completed, the clinical records lacked documentation of the vital signs on multiple occasions following the fall. The facility's policy required that vital signs be taken and documented during neurological assessments after an unwitnessed fall. However, the records for the resident did not include the necessary vital signs on several dates, despite the expectation that staff would obtain and record new vital signs with each assessment. This discrepancy was confirmed by the Director of Nursing and Corporate Nurse, who noted that the vital signs should have been documented in the resident's file.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity and respect, as evidenced by the experiences of two residents. Resident #57, who had intact cognitive ability and was dependent on staff for toileting and transfers, reported being left on a bedpan for over 50 minutes, which caused him distress due to a sore on his bottom. Despite his request for assistance, a registered nurse responded sarcastically and did not provide the needed help. This incident occurred after the resident returned from dialysis and was not promptly attended to by the staff. Resident #35, also with intact cognitive ability, reported being scolded by staff for drinking too much water and urinating in bed. The resident's care plan lacked interventions for her water-seeking behavior, and staff were instructed to provide her with water and ice. However, a certified nurse aide reportedly withheld water from the resident overnight, and the resident was found without bedding on multiple occasions. The resident's friend corroborated these claims, noting the staff's rude behavior and neglect in providing basic care. Additionally, a grievance form documented an incident involving an Emergency Medical Technician who reported rude behavior from a male staff member when a resident was in distress. The staff member made sarcastic remarks about the resident's belongings during a hospital transfer. This staff member, identified as Staff S, was temporarily suspended pending investigation. The facility's policy emphasizes the residents' right to be free from abuse and neglect, yet these incidents indicate a failure to uphold these standards.
Latest citations in Iowa
An LPN, unfamiliar with residents on a medication cart and faced with two residents sharing the same first name, failed to correctly identify a resident and administered a full set of another resident’s medications in addition to the resident’s own ordered morning medications, including PRN oxycodone. The resident, who had severe cognitive impairment and multiple diagnoses including hypertension and Alzheimer’s disease, subsequently experienced declining BP, reported not feeling well, and became increasingly fatigued. The facility’s policy required resident identification before medication administration, and the LPN acknowledged not knowing the residents and finding the EHR photos too small, despite their availability. Hospital records later documented hypotension, treatment with IV fluids, and a drug overdose after accidental ingestion of another resident’s medications plus the resident’s own, with persistent sinus bradycardia requiring admission for further hemodynamic monitoring.
A cognitively impaired, wandering resident with Alzheimer’s disease and behavioral symptoms was care planned as an elopement risk but was able to leave the memory care unit by holding an emergency exit door bar for 15 seconds and exiting into a stairwell and then to the employee parking lot. The door alarm functioned, but staff in the noisy dining room did not hear it while they were feeding multiple residents, including several needing extensive assistance, and only realized the resident was missing when another staff member encountered him outside and brought him back. In addition, several residents who required staff assistance for transfers and toileting experienced prolonged call light response times well beyond the facility’s 15‑minute expectation, including one who reported waiting up to an hour during meals and having an in‑room accident, another observed waiting about 25 minutes while calling out for help, and a third waiting about 17 minutes before a CNA responded.
A cognitively intact resident reported that a CNA ripped her incontinence brief during care and then refused to change it, despite the resident stating she could not wear it due to the tear. The resident became upset and informed housekeeping staff, who then asked an LPN to assist. On assessment, the LPN observed a large rip extending around the back of the brief, changed the brief, and provided peri care at the resident’s request. The resident stated the ripped brief was uncomfortable and that she did not feel treated with dignity or respect. In interviews, the CNA acknowledged telling the resident the torn brief would still work and did not change it, while the DON confirmed the CNA had refused the resident’s request for a brief change, in conflict with the facility’s dignity policy.
A deficiency was identified when a CNA did not follow manufacturer instructions for a mechanical stand while transferring a resident with severe cognitive impairment, a history of hip fracture, dementia, and muscle wasting who required substantial assistance for transfers. The resident’s care plan called for use of a mechanical stand, but during observed toileting and return-to-chair transfers, the CNA repeatedly locked and unlocked only one wheel of the device and did not keep the brakes unlocked during the actual transfer, contrary to the operator’s instructions that brakes be locked only when raising and lowering the resident during ambulation. In an interview, the DON confirmed staff were expected to follow these operator instructions and keep the wheels unlocked during transfers.
A resident with dementia, behavioral symptoms, and multiple psychotropic and cardiovascular medications was discharged to another nursing facility without a thorough or accurate discharge summary. The care plan contained a discharge planning focus but was never updated to reflect the actual discharge, and the EHR lacked documentation of discharge planning, the reason for discharge, or a recapitulation of stay, despite a family member stating they initiated the discharge due to dissatisfaction with care. The discharge instructions contained multiple medication discrepancies and omissions, including missing drugs, incorrect dosages, and absent administration frequencies, and several PRN constipation medications were not listed, contrary to the facility’s written discharge planning policy.
A resident was admitted from a hospital without a completed Preadmission Screening and Resident Review (PASRR) in the medical record, as required prior to admission. The PASRR was only completed several days later by the Hospital Liaison/Admissions Coordinator after a call alerted staff that it was missing. Both the admissions coordinator and the Administrator acknowledged that the facility relies on the hospital to provide the PASRR and that, in this case, it was missed and not done before the resident’s admission.
A resident with Alzheimer's disease, severely impaired cognition, and documented nutrition/hydration risk required partial to moderate assistance with eating and was care planned for assisted feeding with a general diet and thin liquids. During a breakfast observation, the resident was seated in a reclined Broda chair while staff placed food and beverages on an overbed table and attempted to offer chocolate milk and hot cereal without first positioning the resident upright, causing the resident to struggle to reach the cup. Facility policy on feeding required residents needing assistance to be positioned comfortably in an upright position, and the DON stated she expected residents to be upright whenever food or drink was offered, but there was no separate positioning policy in place.
A resident with a left leg fracture, muscle wasting, and impaired mobility was dependent on a mechanical lift for transfers. Staff positioned the lift at the side of the wheelchair instead of straight on, and the lift tipped and struck the resident’s forehead with the sling-holding part, causing a bruise and protruding bump. Staff interviews confirmed the transfer was done from the side and that the resident’s care plan required straight-on positioning for the lift.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance: Several residents did not receive bathing and hygiene assistance as scheduled. One resident with intact cognition and a stroke history was observed unshaven and said staff did not always shave him during showers, while staff noted the bath sheets no longer tracked shaving or nail care. Other residents with severe cognitive impairment or dependence for bathing went extended periods without baths, and one cognitively intact resident reported missing baths and wanting them. Facility records and staff interviews showed bathing schedules were not consistently followed or documented as required.
QAPI program failed to address repeated deficiencies. Review of the facility’s visit history showed repeated F689, Free of Accident Hazards/Supervision/Devices, and F880, Infection Prevention and Control, across multiple annual surveys and complaint investigations. The QAPI plan stated it would review sources of information for gaps or patterns in care systems, and the Administrator acknowledged the repeated deficiencies and said the facility would review and discuss plans to improve.
Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to follow the 5 rights of medication administration, resulting in one resident receiving another resident’s medications in addition to their own. The resident had diagnoses including hypertension, Alzheimer’s disease, and toxic encephalopathy, with a BIMS score of 3 indicating severe cognitive impairment. On the morning in question, review of the MAR showed the resident received their ordered medications, which included aspirin, calcium carbonate, vitamin C, vitamin D, fluoxetine 20 mg, furosemide 40 mg, galantamine, a lidocaine patch, memantine, acetaminophen, and PRN oxycodone around 8:00 a.m. According to the incident report and nursing progress notes, the LPN (Staff A) administered another resident’s full set of morning medications to this resident while the resident was in the dining room. These additional medications included metoprolol 60 mg, Lyrica 75 mg, oxycodone 7.5/325 mg, furosemide 40 mg, celecoxib 100 mg, Prozac 60 mg, hydroxyzine 10 mg, cetirizine 10 mg, Neuriva, Protonix 20 mg, potassium 99 mg, a multivitamin, and vitamin D3. These medications were given in addition to the resident’s own morning medications and PRN oxycodone. The nurse’s notes documented that the resident’s blood pressure readings declined from 100/50 to 85/48 and then to 73/48, and the resident complained of not feeling well and was increasingly fatigued. Staff A reported during interview that the resident had been screaming and yelling and that she did not realize there were two residents with the same first name in the back hallway. She stated it was her first time working in that hallway after training and that, although resident pictures were available in the EHR to assist with identification, she felt they were small and she did not know the residents. The facility’s medication management policy required staff to identify the resident before administering medications. Staff A’s employee record showed a prior medication occurrence in which she administered the wrong medications (including furosemide and potassium) to a resident, and she had documented previously that she was not familiar with residents when working on that cart. The resident was ultimately sent to the ER, where records documented hypotension on admission, treatment with IV fluids, and a chief complaint of drug overdose after accidental ingestion of another resident’s multiple medications in addition to the resident’s own medications, with continued sinus bradycardia requiring admission for further hemodynamic monitoring.
Elopement of Wandering Resident and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for a cognitively impaired, wandering resident and failure to respond to resident call lights within the facility’s stated 15‑minute expectation. One resident with Alzheimer’s disease, bipolar disorder, and anxiety disorder had a care plan identifying risk for elopement due to wandering and documented behaviors of agitation, aggression, restlessness, and continuous pacing/wandering within the unit. This resident ambulated independently with a walker and had a BIMS score indicating impaired cognition. On the evening of the incident, the resident finished supper in the memory care dining room and then repeatedly walked the hallway with his walker, eventually approaching an emergency exit door at the far end of the hall, away from the dining room. Video and documentation show that the resident stood at the emergency exit door, held the door bar down for the required 15 seconds to release the egress, and then exited through the door into a stairwell and out to the employee parking lot. The door alarm and 15‑second egress functioned, but staff in the dining room did not hear the alarm due to noise from residents, staff conversation, and the television. At the time, two CNAs and one LPN were in the dining room feeding multiple residents, including several who required assistance, and staff reported that the resident was very quick, wandered constantly, and was difficult to keep seated. Staff interviews revealed that one CNA noticed the resident was no longer in the dining room around the same time another staff member reported they were looking for him, and only then did staff recognize the back exit door alarm sounding. A nurse arriving for her shift in the parking lot encountered the resident outside with his walker and escorted him back inside, after which he was assessed and found in stable condition. The deficiency also includes failure to respond to resident call lights within the professional standard of 15 minutes for multiple residents. One resident with intact cognition but dependent or substantial/maximal assistance needs for toileting reported that during meal hours it could take up to an hour for staff to answer the call light, resulting in an in‑room accident. Another resident, alert and oriented but occasionally forgetful and requiring two‑person assistance for transfers, was observed with the call light on for approximately 25 minutes in the morning while repeatedly yelling for help; staff walked past in the hallway without answering the light until a staff member finally entered the room. A third resident, requiring one‑person assistance for transfers, was observed with the call light on for about 17 minutes before a CNA entered to assist. The DON stated that the facility’s expectation is that call lights be answered within 15 minutes, and the facility’s policy directs all staff from all departments to respond to call lights and either assist or obtain appropriate help, but the observed response times exceeded this standard for the residents involved. Staff interviews further described the conditions contributing to these call light delays and supervision gaps. Staff on the memory care unit reported that typical evening staffing consisted of one nurse, one CMA, and two CNAs, and that while this was manageable when routines went smoothly, it became inadequate when residents had behaviors, were sundowning, or when events such as falls or changes in condition occurred. A CMA stated that at least three CNAs were needed on the memory care unit due to multiple residents requiring two‑person assistance, noting that when two CNAs were in a room providing care, they could not monitor the rest of the unit. Staff also reported that the back exit door alarm was faint and difficult to hear from the dining room, and some staff were not fully aware of the configuration of the back stairwell and exit leading to the parking lot. These conditions, combined with high resident care needs and noise levels during meals, contributed to the resident’s elopement and to prolonged call light response times for several residents. Maintenance and administrative staff confirmed that the south/back exit door from the unit led to another unalarmed door and then to the outside employee parking lot, and that the facility did not receive system reports when door alarms were activated. The Administrator was unable to verify when a door alarm went off or when an exit door was breached. The facility’s Wandering Resident policy stated that residents at risk for elopement should receive adequate supervision to prevent accidents and that staff must be vigilant in responding to alarms in a timely manner, and the call light policy required prompt response by all staff. Despite these policies, the documented events show that the resident at risk for elopement was able to leave the secured unit and reach the parking lot without timely staff detection, and that multiple residents experienced call light response times significantly longer than the facility’s stated 15‑minute standard.
Failure to Honor Resident Request for Brief Change and Maintain Dignity
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and respect when a cognitively intact resident’s request for a brief change was not honored. The resident, with a BIMS score of 15 indicating no cognitive impairment, reported being upset because a CNA (Staff N) ripped her brief during care and then refused to change it. The resident self-propelled down the hallway stating she was upset about the ripped brief and that staff would not change it. A housekeeping staff member (Staff M) observed the resident’s distress, was told that the CNA had refused to change the brief despite a large rip, and then asked an LPN (Staff O) to assist with changing it. During the subsequent brief change, Staff O performed hand hygiene, used gloves, removed the resident’s pants and brief, and provided peri care at the resident’s request before applying a new brief and redressing the resident. Observation of the removed brief revealed a large rip on the left side extending past the middle of the resident’s back. The resident stated the brief with the hole was uncomfortable and that she felt staff did not provide her with dignity and respect when her request for a new brief was not honored. Staff O confirmed that the brief had a very large hole and that the resident was very upset, reporting she did not feel treated with dignity or respect and that the ripped brief was uncomfortable. In an interview, Staff N acknowledged caring for the resident that day, stated the resident had been upset and had “behaviors,” and reported that when the resident said she wanted her brief changed because it was ripped, Staff N told her the brief would still work and that urine would not get everywhere, characterizing the tear as “just a little tear.” Staff N stated the resident did not explicitly ask her to change the brief. The DON later stated that Staff N had ripped the brief, the resident had requested a brief change, Staff N said she would not change it, and acknowledged that a lack of dignity occurred when Staff N refused to change the resident’s brief, contrary to the facility’s dignity policy.
Improper Use of Mechanical Stand Brakes During Resident Transfers
Penalty
Summary
Surveyors identified a deficiency related to accident prevention when staff failed to properly use a mechanical stand’s brakes during transfers for one resident. The resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment, required substantial assistance for transfers, and had diagnoses including hip fracture, dementia, and muscle wasting. The care plan documented initiation of a mechanical stand for transfers. During observation, a CNA applied a sling, locked the right wheel of the mechanical stand, lifted the resident from a chair, then unlocked the right wheel and positioned the resident over the toilet. The CNA then lowered the resident onto the toilet and locked the right wheel. After the resident finished, the CNA lifted the resident from the toilet, unlocked the right wheel, positioned the resident over the chair, locked the right wheel, and lowered the resident, thereby failing to keep the mechanical stand brakes unlocked during the transfer as required by the operator’s instructions, which specified that brakes should only be locked when raising and lowering the resident during ambulation. In an interview, the DON stated that staff were expected to follow the operator’s instructions and keep the wheels unlocked during transfers, confirming that the observed practice did not align with the manufacturer’s guidance for safe operation of the mechanical stand.
Failure to Complete Accurate and Thorough Discharge Summary and Documentation
Penalty
Summary
Surveyors identified a failure to complete a thorough and accurate discharge summary and related discharge documentation for one resident who was discharged from the facility. The resident was admitted in early March with moderate cognitive impairment, a Brief Interview for Mental Status (BIMS) score of 08, and documented delusions and behavioral symptoms. Diagnoses included dementia with agitation, anxiety disorder, and depression. Although the care plan contained a discharge planning focus initiated shortly after admission, it did not contain any updates or documentation related to the resident’s actual discharge later that month. The electronic health record (EHR) contained a communication note indicating that transport to another nursing facility was arranged and a health status note stating that the resident was discharged, with physician orders and a face sheet faxed and a report called to the receiving facility. The resident’s EHR did not contain documentation of the discharge planning process, the reason for the discharge, or a recapitulation of the resident’s stay. A family member reported that the family initiated the discharge due to dissatisfaction with care, but there was no documentation in the EHR reflecting that the family initiated the discharge. The Long Term Care Ombudsman reported that no one contacted her during the resident’s stay, although her office did receive notice of the transfer. The facility’s own discharge planning policy required that discharge planning begin on admission, be routinely updated in the comprehensive care plan, and that the evaluation of discharge needs and the final discharge plan be completely documented in the clinical record and discussed with the resident or representative. Review of the resident’s discharge instructions and March medication administration record revealed multiple discrepancies and omissions in the discharge summary. One medication (Amlodipine 10 mg) was listed without any frequency or time of administration. Several medications that the resident was receiving, including Donepezil 10 mg, Lisinopril 5 mg, and Buspirone 10 mg twice daily, were not included on the discharge summary. Other medications were inaccurately documented, such as Memantine, which was ordered as 20 mg once daily but listed as 10 mg twice daily, and Seroquel, ordered as 50 mg twice daily but listed as once daily. Several PRN constipation medications were also omitted. The Regional Nurse Consultant confirmed that the facility’s EHR contained a discharge assessment tool that was not completed for this resident and acknowledged the multiple medication discrepancies on the discharge summary form.
Failure to Complete PASRR Evaluation Prior to Admission
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) evaluation for a resident with an admission date of 4/22/26. The resident’s electronic health record documented admission from a hospital on 4/22/26, but review of the record showed no PASRR completed at the time of admission. A PASRR form for this resident was later obtained and showed it was completed on 4/27/26 by the Hospital Liaison/Admissions Coordinator, several days after the resident had already been admitted. During interview, the Hospital Liaison/Admissions Coordinator stated that the hospital usually completes the PASRR, acknowledged receiving a call the previous night that the PASRR was not in the chart, and admitted she had missed completing it prior to admission even though it should have been done. The Administrator similarly reported that the facility relies on receiving the PASRR from the hospital admission records and that, in this case, the PASRR was missed and not completed prior to the resident’s admission. This resulted in a deficiency for failure to ensure a PASRR evaluation was completed prior to admission for 1 of 3 reviewed residents, in accordance with PASRR requirements.
Failure to Properly Position Resident Upright During Assisted Feeding
Penalty
Summary
Surveyors identified a deficiency in resident positioning during mealtime for a resident with Alzheimer's disease and severely impaired cognition, as evidenced by a Brief Interview for Mental Status score of 2. The resident’s MDS indicated a need for partial to moderate assistance with eating, and the care plan documented nutrition and hydration risk related to end-stage diagnosis, cognitive limitations, and weakness, with directions for a general diet, thin liquids, and assistance with eating. During a breakfast observation on the Magnolia Unit, the resident was seated in a Broda chair that was reclined back. A dietary aide placed food on the table in front of the resident, and a CNA then placed beverages and food on an overbed table before walking away, while the resident remained reclined with eyes closed and the plate of food untouched. Later in the same observation period, another CNA offered the resident chocolate milk while the Broda chair remained tilted backward, and the resident had to struggle to move her head up and forward to reach the cup. The same CNA then offered hot cereal, which the resident declined by saying “later.” A different CNA subsequently offered another drink of chocolate milk, again without adjusting the reclined position of the Broda chair. Policy review showed the facility’s “Feeding of Residents by Staff” policy required that residents unable to feed themselves be assisted per their care plan and be positioned comfortably in an upright position. In an interview, the DON stated there was no specific positioning policy, that staff received positioning education in training, and that her expectation was that residents be placed in an upright position whenever food or drink was offered.
Mechanical Lift Transfer Caused Resident Forehead Injury
Penalty
Summary
The facility failed to provide a safe and adequate mechanical lift transfer for Resident #18, who had a left leg fracture, muscle wasting, and impaired gait and mobility, but no cognitive impairment based on a BIMS score of 15. The resident’s care plan required two staff members to use a mechanical lift for transfers because the resident was nonweight-bearing on the left leg. The care plan update also directed staff to approach the wheelchair straight on and not from the side, and to have the resident bend the right leg and turn away from the lift during transfers. During a wheelchair transfer, staff positioned the mechanical lift at the side of the wheelchair and began the transfer. The lift tipped and struck the resident’s forehead with the part that held the sling. The resident sustained a bruise and a protruding bump on the left forehead, and the incident documentation noted the resident’s head was hit on the lift. The resident later reported that the lift almost fell to the floor and that additional staff were needed to return it upright. Staff interviews confirmed that the transfer was performed from the side of the wheelchair. One CNA stated the lift may have caught on bars under the wheelchair and acknowledged that staff had been educated not to use the lift from the side. Another CNA stated the lift was used from the side because the resident did not want her leg hit by the lift, and identified the sling-holding part of the lift as the piece that struck the resident’s forehead. The DON stated the proper procedure was to position the mechanical lift directly in front of the wheelchair rather than to the side.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living for 5 of 8 residents reviewed, specifically related to bathing and shaving. Resident #3 had a BIMS score of 15 and was dependent on staff for personal hygiene, with diagnoses including renal insufficiency, stroke, hemiplegia, and seizure disorder. The resident was observed unshaven, stated he was getting showers but not shaved every time, and said he needed help shaving since his stroke. Facility records showed showers were documented without indicating whether shaving was completed, and staff interviews confirmed the bath sheets no longer tracked shaving or nail care, while the DON stated male residents should be offered shaving during showers and it should be documented if completed or refused. Resident #1 had a BIMS score of 4, diagnoses including muscle weakness, diabetes, and hip fracture, and was care planned as an extensive assist for bathing. Review of the follow-up report showed the resident went 17 days without a bath and later 19 days without a bath. Resident #11 had a BIMS score of 3, diagnoses including depression, hypertension, and anemia, and was scheduled for bathing on Wednesday morning and Friday afternoon, but the follow-up report showed gaps of 6 days, 6 days, and 18 days between baths. Resident #27 also had a BIMS score of 3 with depression, hypertension, and anemia, was scheduled for bathing on Monday and Thursday afternoon, and the follow-up report showed the resident went 19 days and then 20 days without a bath, with refusals documented on two occasions. Resident #85 had a BIMS score of 15, diagnoses including hypertension, depression, and need for assistance with personal care, and stated she did not get 2 baths the prior week and wanted them. Her care plan identified her as dependent for bathing, but lacked bathing frequency, and the task list scheduled bathing for Monday morning and Wednesday afternoon. The follow-up report showed multiple extended gaps between baths, including 12 days, 7 days, 18 days, and 7 days. Facility policy stated bathing is intended to promote cleanliness, provide comfort, and observe skin condition, and the Regional Nurse Consultant stated bathing should be completed as scheduled.
QAPI Program Failed to Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive and effective QAPI program and did not have a plan that described the process for conducting QAPI and QAA activities. Review of the DIAL website visit history showed repeated deficient practices identified during the facility’s annual survey and complaint investigation on 3/27/25 and during the annual survey, complaint, and facility-reported incident investigation on 4/19/26. The repeat deficiencies included F689, Free of Accident Hazards/Supervision/Devices, which had been repeated in the previous three consecutive annual surveys, and F880, Infection Prevention and Control, which had been repeated in the previous four consecutive annual surveys. The facility’s QAPI plan stated that it would review sources of information to determine whether gaps or patterns existed in systems of care that could result in quality problems or opportunities for improvement. During an interview on 4/23/26 at 1:28 PM, the Administrator acknowledged the repeated F689 and F880 deficiencies and stated the facility would review and discuss plans to improve.
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