Bishop Drumm Retirement Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Johnston, Iowa.
- Location
- 5837 Winwood Drive, Johnston, Iowa 50131
- CMS Provider Number
- 165448
- Inspections on file
- 34
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 43
Citation history
Health deficiencies cited at Bishop Drumm Retirement Center during CMS and state inspections, most recent first.
Surveyors found that inadequate staffing led to prolonged call-light response times, closure of a dining room due to low staffing, and the DON working as a charge nurse despite a high census. Continuous observation showed a resident repeatedly using the call light for about an hour while staff briefly entered the room, turned off the light, and left without addressing her request for a bath. Multiple residents with intact or moderately impaired cognition reported waiting 30 minutes to several hours for help, especially at night and on weekends, including long waits for incontinence care and assistance from the toilet, and reported seeing staff sleeping on duty. Staff interviews confirmed frequent short staffing, particularly on nights and weekends, frequent call-ins, reports of staff sleeping, and that the DON had been working the floor to cover open shifts, contrary to regulatory limits. Resident Council minutes documented ongoing complaints about missed showers, lack of fresh water, staff cell phone use, and long call-light times.
The facility failed to prevent the DON from serving as a charge nurse when the average daily census exceeded 60 residents. Multiple RNs and CNAs reported that, due to staffing shortages, the DON regularly worked nights and overnight shifts on the floor in a charge nurse role, including shortly before going on maternity leave. Staffing logs confirmed specific dates when the DON functioned as a floor nurse. The Assistant Executive Director acknowledged that the DON had been used as a charge nurse despite knowing this was not permitted, and no relevant policy was available for review.
The facility was cited for failing to implement an effective QAPI/QAA process to correct ongoing insufficient nursing staff deficiencies. State survey records showed multiple prior surveys over about two years with repeated staffing-related citations, culminating in a fifth Insufficient Nursing Staff deficiency. Although the facility’s QAPI plan identified staff retention as an improvement focus and described a process for identifying issues, leadership reported that no Performance Improvement Plan (PIP) addressing staffing was in place at the time of the survey.
Surveyors identified multiple infection control failures, including a resident with an indwelling catheter whose drainage tubing was repeatedly observed resting on a trashcan, with staff giving conflicting statements about whether this practice was acceptable. A housekeeper was seen using a cart repaired with partially detached duct tape, leaving exposed adhesive surfaces that could harbor contaminants. In addition, an in-home nurse performed wound care on a cognitively impaired resident with chronic conditions and a right foot ulcer under EBP without donning a required gown, despite posted EBP instructions and an active order, and then used the same gloved hands to handle the resident’s drinking cup.
A resident with CAD, DM, depression, and generalized weakness, who required substantial assistance with personal hygiene, had a care plan specifying daily hair brushing and daily shaving. Despite this, the resident was observed with a long beard and matted, unwashed hair and reported repeatedly asking staff to shave her, being told they could not do so because of her diabetes and that only a barber or nurse could shave her. Facility records showed no refusals of bathing or personal care and documented daily bathing with extensive assistance, while staff interviews revealed uncertainty about whether CNAs could shave a diabetic resident and reports that grooming requests, including beard trimming, were not consistently honored, contrary to facility expectations and policy requiring documentation of refusals.
A resident with moderately impaired cognition and multiple medical conditions became lethargic at the dining table, required repeated tactile stimulation to respond, and was found to have a temperature of 100.4°F. An LPN directed staff to obtain vitals and attempt Tylenol administration, which the resident refused, and then had the resident returned to her room. Documentation showed the resident was semi-responsive with a fever and refusal of Tylenol, but the LPN left for lunch without promptly notifying another nurse, the provider, or the resident’s family, despite staff acknowledging that this represented a change in condition requiring immediate provider and family notification and completion of an electronic change-in-condition form, as required by facility policy.
A resident with moderately impaired cognition, diabetes, partial paralysis, and non-traumatic brain dysfunction became lethargic and semi-responsive, requiring repeated tactile stimulation to arouse, and was found to have a temperature of 100.4°F. An LPN requested vital signs, instructed a CMA to give Tylenol (which the resident refused twice), and then had a CNA return the resident to the room before leaving the unit for lunch without notifying a provider or arranging further monitoring. Documentation noted the semi-responsive state, fever, and refusal of Tylenol, but an eINTERACT change-in-condition evaluation lacked interventions and there were no follow-up assessments. Other nursing staff stated that such findings represented a significant change in condition requiring provider notification and ongoing assessment, and the resident’s care plan and facility policies did not address staff directives for mental status changes.
A resident with moderately impaired cognition, partial paralysis, and extensive mobility assistance needs was transported in a wheelchair without foot pedals by an LPN, despite staff acknowledging that wheelchair foot pedals should always be used during transport unless the resident is self-propelling. The resident, who was lethargic at the time and required repeated stimulation to respond, was moved from the dining room to a hallway area, and later interviews with nursing staff and the ADON confirmed this practice was inconsistent with their expectations. The facility lacked a written policy providing directives for safe wheelchair transport.
Surveyors found that an LPN failed to follow safe medication practices for multiple residents, including not priming a newly attached insulin pen needle before injection, using insulin pens that lacked documented open dates, and directing a CMA to administer PRN acetaminophen for fever when the existing order was only for mild pain and on hold. These actions involved residents with diabetes and other chronic conditions who were receiving insulin injections with FlexPens and one resident who was lethargic with an elevated temperature, leading to attempts to administer medication without a corresponding physician order for that indication.
A resident with moderately impaired cognition and multiple diagnoses became lethargic and semi-responsive, with a temperature of 100.4°F. An LPN directed a CMA to obtain vital signs and administer Tylenol, which the resident refused, and a CNA was instructed to return the resident to her room. A progress note documented the semi-responsive state, fever, and refusal of Tylenol, but the subsequent change-in-condition evaluation recorded family and provider notification at a time when the LPN reported being away at lunch. This resulted in documentation that did not accurately reflect the timing of events, contrary to facility policy requiring complete, accurate, and timely medical records.
A resident with severe cognitive impairment and multiple health conditions developed an unstageable pressure ulcer on the left heel, but the care plan did not address this wound or include interventions such as repositioning or heel floating. Clinical records showed repeated failures to assess, document, and treat the ulcer, with wound care not initiated until weeks after identification. Facility staff and documentation confirmed that required interventions for pressure ulcer prevention and management were not consistently implemented or recorded.
The facility experienced ongoing deficiencies in pressure sore management, professional standards of care, nursing staffing, and infection control, as evidenced by repeated citations over multiple surveys. Despite having a QAPI plan and implementing various tracking and auditing measures, the same issues continued to recur, indicating that the facility's quality assurance processes were not effective in preventing or correcting these problems.
A resident with severe cognitive impairment and multiple medical conditions experienced significant weight loss over several months, prompting dietary recommendations to adjust tube feeding. However, there was no documentation that the family or emergency contact was notified of these changes, despite facility policy requiring such notification. The DON confirmed that conversations with the family were not documented.
The facility did not consistently obtain weekly weights as ordered for three residents with feeding tubes, all of whom had complex medical conditions requiring close nutritional monitoring. Despite care plans and physician orders specifying regular weight checks, documentation showed missed or infrequent weights, and staff interviews confirmed ongoing issues with equipment and adherence to protocols. This failure to follow professional standards resulted in inadequate monitoring of residents' nutritional status.
A nurse failed to change gloves between wound and suprapubic catheter care for a resident with complex medical needs, and did not use proper technique when cleaning the catheter site. This improper care was followed by the resident developing a urinary tract infection, as confirmed by lab results.
A resident with a g-tube and multiple complex medical conditions did not receive required water flushes before and after medication administration, as a nurse administered medications through the g-tube without following facility policy for flushing. The nurse used an unspecified amount of water and did not adhere to the protocol, which was confirmed by the DON.
Surveyors found that staff did not consistently respond to call lights within the facility's 15-minute standard, with some residents reporting waits of up to 40 minutes, especially at night. Two residents with significant physical and cognitive impairments were observed without call lights within reach for extended periods, despite multiple staff being present in their rooms. Facility policy requires call lights to be accessible, but this was not consistently followed.
A resident with multiple medical devices and wounds did not receive care in accordance with Enhanced Barrier Precautions, as staff failed to consistently use gowns and gloves during high-contact care and did not perform hand hygiene or change gloves between dressing changes, contrary to facility policy.
Surveyors found that several room doors could not be closed, a board for a window sill remained on the floor for over a month, a bathroom call light was not working, and an electrical outlet sparked when used, despite residents and staff reporting these issues. Work orders were not consistently open or active for these problems, and maintenance requests were not addressed in a timely manner, resulting in an environment that was not safe, clean, or homelike.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors.
Residents and family members reported significant delays in call light responses, with some waiting 20 to 50 minutes for assistance. Multiple cognitively intact residents and a family member confirmed these delays, and Resident Council Minutes documented ongoing concerns. The DON acknowledged the expectation for responses within 15 minutes, but the facility did not consistently meet this standard.
Staff did not adhere to infection control protocols for two residents with medical devices. One resident with a feeding tube received care from staff who failed to perform hand hygiene between glove changes and did not sanitize equipment or change gloves as required by EBP. Another resident with a catheter had their catheter bag observed on the floor with the drain port touching the ground on multiple occasions. The DON confirmed these practices did not meet facility policy.
A resident with diabetes, stroke, and aphasia experienced persistently high blood glucose and elevated heart rate over several days without timely provider notification or additional insulin administration. Nursing documentation was lacking, and staff did not escalate care until the resident's condition became critical, resulting in hospitalization for DKA, sepsis, and pneumonia.
A resident with severe cognitive impairment and a history of falls, who required substantial assistance with transfers and toileting, was left to ambulate independently from the bathroom, resulting in a fall and injury. Staff were inconsistent in following the care plan, and there was confusion regarding the resident's required level of assistance. The care plan was not updated to reflect the resident's current needs, and staff did not provide the supervision necessary to prevent the accident.
The facility failed to perform and document required post-dialysis assessments and follow-up for missed medications for a resident with complex medical needs, resulting in a hospital transfer for abnormal vital signs and lethargy. Additionally, the facility did not document a post-fall assessment within 24 hours for another resident after a witnessed fall, with required information only entered as a late entry the next day.
Two residents dependent on staff for transfers did not receive adequate supervision or proper use of assistance devices. One was transferred using improper technique, with staff lifting by the pants instead of solely using a gait belt, contrary to the care plan. Another was injured when a CNA used a sit-to-stand lift instead of a full body lift and failed to provide the required two-person assistance. Additionally, a sit-to-stand lift in use was found to have damaged handles with exposed metal, in violation of facility policy.
Multiple residents experienced significant delays in call light response and assistance with care needs, with some waiting up to 40 minutes for staff to respond. Residents dependent on staff for mobility, toileting, and personal care were left unattended or in soiled clothing for extended periods, and staff attributed these delays to short staffing. These actions were inconsistent with the facility's policy requiring call lights to be answered within 15 minutes.
Two residents reported ongoing mouse activity in their rooms, with one resident experiencing the issue for several months and another noting a mouse living in his closet. Staff interviews confirmed that complaints were made, but the pest control company had not been notified or conducted inspections for mice. Observations revealed mouse droppings and structural gaps at an exit door, contributing to the deficiency in pest control.
A resident experienced significant weight loss due to the facility's failure to provide adequate nutritional interventions. Despite the resident's preference for Bosnian food and a care plan intervention to provide Glucerna, no additional measures were taken to address the weight loss. Meals were not individualized, and the resident often slept through meal times, leaving food untouched. The facility's policies on nutritional management were not adequately followed, resulting in a lack of timely interventions.
A facility failed to maintain resident dignity when two staff members argued loudly in front of nine residents in the dining room. Additionally, a CNA charting monitor was left open and unattended, compromising resident confidentiality. The Executive Director acknowledged that monitors should be locked when not in use to protect privacy.
The facility failed to implement proper infection control practices, as observed in multiple instances. CNAs improperly positioned a resident's catheter bag, and a CMA entered a resident's room on contact isolation without PPE or hand hygiene. Additional observations revealed staff failing to perform hand hygiene before and after tasks, contrary to facility policies.
The facility did not secure Electronic Health Record information for 16 residents. A report sheet with 21 residents' information was found face up on a medication cart, contrary to the facility's confidentiality policy. The DON confirmed that the information should have been kept under a binder.
A resident with existing Stage IV pressure ulcer and comorbidities developed a second Stage IV ulcer due to the facility's failure to provide consistent repositioning and wound care. The care plan lacked a specific repositioning schedule, and there were gaps in treatment documentation, leading to the resident's hospitalization.
Two residents at an LTC facility developed pressure ulcers due to inadequate care and interventions. One resident, with a history of septicemia and dementia, developed unstageable deep tissue injuries on both heels and a skin tear on the buttock, leading to hospitalization for septic shock. Another resident, with a history of stroke and diabetes, developed a Stage IV pressure ulcer on the sacrum, resulting in a hospital transfer and subsequent death. Staff interviews revealed systemic issues, including inadequate staffing, contributing to delays in repositioning and care.
The facility failed to provide adequate staffing, resulting in delayed responses to call lights and unmet resident care needs. Observations and interviews revealed that residents often waited up to two hours for assistance, with administrative staff stepping in to help during state surveys. Staffing levels were insufficient, particularly on the night shift, leading to issues such as delayed repositioning, increased skin problems, and weight loss among residents. Despite a policy for timely call light response, the facility's practice did not meet these standards.
The facility failed to maintain an effective QA program, resulting in repeated deficiencies, including F725 and F686, as identified in surveys and complaint investigations. Despite implementing a QAPI change process, systemic issues persisted, and the new Administrator acknowledged the need for improvement, particularly in areas affecting the facility's 5-Star Rating Scale, such as pressure ulcers.
A resident with severe cognitive impairment and incontinence was observed sitting in the commons area with her adult brief exposed on two occasions. Staff acknowledged the issue but did not consistently ensure the resident was covered, contrary to the facility's dignity policy.
The facility failed to initiate physician's orders for two residents, leading to deficiencies in their care. One resident did not receive recommended wound care, and another experienced seizures due to delayed medication administration.
A resident with severe cognitive impairment and total dependence on staff for personal hygiene was observed in a state of neglect, with unkempt hair and exposed adult brief, due to inconsistent care and staffing issues. Staff interviews and observations revealed failures in adhering to the facility's grooming and dignity policies.
Inadequate Staffing Leading to Prolonged Call-Light Delays and DON Working as Charge Nurse
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nursing staff on a daily basis to meet resident needs and to ensure appropriate licensed nurse coverage on each shift. Surveyors documented prolonged call-light response times, closure of a dining room due to low staffing, reports of staff sleeping while on duty, and the DON functioning as a charge nurse despite a census over 60 residents. The facility census was 124. Multiple residents with varying levels of cognition, as measured by BIMS scores ranging from moderate impairment to fully intact cognition, reported frequent and extended delays in receiving assistance, particularly during nights and weekends. Direct observation on one evening showed a resident’s call light in a specific room being activated repeatedly over more than an hour, with staff entering the room briefly several times, turning off the call light, and leaving within seconds without addressing the resident’s needs. When interviewed, the resident in that room stated that staff had not addressed her request for a bath or bed bath and that she had been using her call light for about an hour without receiving help or an explanation. She reported that staff entered only to turn off the call light without speaking to her and expressed frustration with this pattern. Resident Council minutes over several months documented repeated concerns about missed showers/baths, lack of fresh water, staff using cell phones while on duty, and long call-light response times. Multiple residents reported that call-light response times were frequently 30 minutes to several hours, with nights and weekends identified as the worst periods. Several residents described waiting one to three hours for assistance with changing soiled incontinence briefs or getting off the toilet, and two residents reported that the North East dining room was closed on a recent weekend due to insufficient staff, resulting in residents being required to eat in their rooms. Residents also reported directly observing staff members sleeping on the job, including specific times and locations, and stated they had repeatedly reported these issues to administration and through Resident Council without perceiving improvement. Staff interviews corroborated that staffing was often inadequate, especially on nights and weekends, that call-light response could take hours, and that call-ins were frequent. Staff members, including CNAs and RNs, reported working short-handed once or twice a week or more, particularly on overnight and weekend shifts, and stated that the DON had been working the floor to cover open shifts. Review of staffing records confirmed that the DON worked the floor on at least two dates, despite regulations prohibiting the DON from serving as a charge nurse when the average daily census exceeds 60 residents. Several staff and residents reported staff sleeping on duty or appearing to sleep at the nurses’ station, and some staff stated they had reported these incidents to the DON. The facility’s Rules of Conduct policy identified sleeping or giving the appearance of sleeping on the job as an unsatisfactory behavior warranting termination. The ADON stated that staff were prohibited from sleeping on the job and that the expectation was for call lights to be answered within 15 minutes, but the observed and reported delays and staffing practices demonstrated that this expectation was not being met.
DON Inappropriately Used as Charge Nurse When Census Exceeded 60
Penalty
Summary
The deficiency involves the facility’s failure to prevent the Director of Nursing (DON) from serving as a charge nurse despite a reported census of 124 residents, which exceeds the regulatory threshold of 60 residents. Multiple staff interviews on 02/12/2026 confirmed that the facility was understaffed and that the DON had been working nights and overnight shifts on the floor in a charge nurse role to cover staffing shortages. Staff P, an RN, stated the facility was understaffed and that the DON was serving as a charge nurse. Staff Q, an RN, reported that the DON had been working as a charge nurse alongside the Assistant Executive Director and other nursing leadership to address staffing shortfalls and that the DON was working the floor the week she left for maternity leave. Additional staff corroborated that the DON had been functioning as a floor nurse. Staff R, a CNA, confirmed the DON had been working the floor as a nurse leading up to her maternity leave due to staffing shortages. Staff L, a CNA, similarly confirmed that the DON was working the floor in a nurse leadership capacity and stated this last occurred in January. Review of the last 30 days of staffing logs showed the DON worked as a floor nurse on 01/11/2026 and 01/21/2026. In an interview, the Assistant Executive Director confirmed the DON had been serving as a charge nurse on the floor and acknowledged awareness that this was prohibited. A policy addressing this issue was unavailable for review.
Repeated Staffing Deficiencies Not Addressed Through QAPI/PIP
Penalty
Summary
The deficiency involves the facility’s failure to ensure an effective QAPI/QAA process to address previously identified quality deficiencies related to insufficient nursing staff. Review of the State Survey Agency’s public website showed that the facility had been cited for staffing deficiencies on four separate surveys within a roughly two-year period, with survey end dates of 06/27/2024, 04/03/2025, 07/21/2025, and 09/17/2025, resulting in an Insufficient Nursing Staff deficiency for the fifth time in that timeframe. The facility’s QAPI plan, created on 02/26/2025, outlined how the QAPI team would identify issues and specifically listed staff retention as a QAPI improvement focus. However, during an interview with the Executive Director and Assistant Executive Director, they acknowledged that the QAPI plan did not currently include a Performance Improvement Plan (PIP) related to staffing, despite the repeated staffing-related deficiencies identified by surveyors.
Infection Control Failures in Catheter Care, Equipment Maintenance, and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices related to indwelling catheter management, equipment maintenance, and adherence to Enhanced Barrier Precautions (EBP). Surveyors observed a resident with chronic kidney disease, neurogenic bladder, paraplegia, and an indwelling catheter whose drainage bag was hanging on a wall hook with the catheter tubing lying across the top of the resident’s trashcan on two consecutive days. The resident’s care plan directed staff to check the tubing for kinks and keep the bag lower than the bladder, but did not address securing the tubing away from contaminated surfaces. Staff interviews revealed inconsistent understanding of whether it was acceptable to use a trashcan to keep catheter tubing off the floor, with some CNAs stating it was not acceptable and a CMA stating it was acceptable. A second deficiency was identified in the maintenance of housekeeping equipment. A housekeeper was observed using a housekeeping cart that had silver duct tape lining both sides of the top rolling door and the back access door. The tape was not fully affixed, leaving exposed adhesive that could harbor bacteria. The housekeeper reported the cart was new but had broken about a month earlier. The Environmental Services Director stated that housekeeping staff report repair needs to him and that equipment is replaced when damaged, and he acknowledged he was aware of the taped cart but did not realize the tape was being used as a repair method. A third deficiency involved failure to follow EBP requirements for a resident with chronic kidney disease, non-Alzheimer’s dementia, heart failure, diabetes, and a chronic right foot ulcer who required EBP due to wounds. An in-home nurse entered the resident’s room, removed the right foot dressings, and took pictures of the wound without wearing a gown, despite an active physician’s order for EBP and a posted EBP sign at the door specifying that gloves and a gown must be worn for wound care and other high-contact care activities. The nurse acknowledged receiving infection prevention education, noticed the resident was on EBP, and admitted he did not refer to the posted sign and refused to don a gown when prompted because he believed he was already finished in the room. During this interaction, he also held the resident’s drinking cup with the same gloved hands used for wound care.
Failure to Provide Dignified Grooming and Shaving as Requested
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide dignified grooming and personal hygiene assistance as care-planned and requested for one resident. The resident’s quarterly MDS documented multiple diagnoses including coronary artery disease, diabetes mellitus, anxiety disorder, depression, a left hip fracture, and generalized muscle weakness, and indicated the resident required substantial or maximal assistance with personal hygiene. The resident’s care plan, last revised on 02/13/2026, specified that she preferred her hair to remain long and brushed daily and that she requested to be shaved daily, with this shaving preference initiated in the care plan on 02/22/2025. Despite this, direct observation on 02/10/2026 at 11:36 AM showed the resident with a long, substantial beard and matted, unwashed hair. During interviews, the resident reported she requested staff to help her shave whenever they offered a shower, preferred bed baths, and was told by staff they could not shave her because she was diabetic and that only a barber or nurse could shave her due to her diabetic status. She stated this lack of assistance increased her feelings of depression. Review of the Kardex for personal hygiene and bathing from 01/13/2026 to 02/11/2026 showed no documented refusals for showers, personal cares, or bathing, and indicated bathing was documented as occurring every day with extensive assistance provided on more than half of the opportunities. A facility barber reported hearing from other residents that staff refused to trim or cut facial hair and believed CNAs and shower aides could cut hair but that this was not regularly done due to staffing shortages. An RN confirmed the resident had been asking to have her facial hair removed for several days and was unsure if CNAs could shave a resident with diabetes. A CNA familiar with the resident confirmed the resident preferred to be clean shaven and that refusals would be documented in the EHR. The ADON confirmed shaving is provided for residents who request it and that staff are expected to provide this service, and facility policy on shaving required refusals to be reported to a nurse supervisor and documented in the medical record.
Failure to Timely Notify Physician and Family After Resident Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide timely physician and family notification when a resident experienced a change in condition. The resident had moderately impaired cognition, diabetes mellitus, partial paralysis, and non-traumatic brain dysfunction, and required varying levels of assistance with activities of daily living. Her care plan directed staff to involve her family with decisions and medical updates. On the day of the incident, an LPN attempted to wake the resident while she was seated in her wheelchair at the dining room table; the resident was lethargic and required multiple taps or grabs of her arm to respond. The LPN moved the resident to a sunnier area and asked a CMA to obtain vital signs, which showed a temperature of 100.4°F. The LPN instructed the CMA to administer Tylenol, but the resident refused the medication twice, pulling her head back and saying no. The LPN then instructed a CNA to return the resident to her room. A nursing progress note documented at 12:05 PM that the resident was semi-responsive, responding only to touch and voice, and had a temperature of 100.4°F with refusal of Tylenol. Staff interviews, including RNs and LPNs, confirmed that a temperature of 100.4°F in a typically responsive resident who becomes lethargic and requires loud voice or touch to respond constitutes a change in condition that requires provider notification and documentation on an electronic change in condition form and in progress notes. The involved LPN acknowledged that the event was a change in condition and that the change-in-condition form should have been completed at that time, but she went to lunch at 12:19 PM without notifying another nurse and did not contact the resident’s brother and provider until after returning from lunch at 1:25 PM. An eINTERACT Change in Condition Evaluation later documented family and provider notification at 1:00 PM. The facility’s Notification of Changes policy required informing the resident, consulting with the physician, and/or notifying the family or legal representative when there is a significant change in the resident’s physical, mental, or psychosocial condition, such as deterioration in health or status, which did not occur in a timely manner in this case.
Failure to Assess and Intervene for Resident With Fever and Mental Status Change
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and intervene when a resident exhibited an elevated temperature and a change in mental status. The resident had moderately impaired cognition, diabetes mellitus, partial paralysis, and non-traumatic brain dysfunction, and required varying levels of assistance with activities of daily living. The care plan noted memory problems but did not include directives for staff response to a mental status change. During observation, an LPN attempted to wake the resident, who was lethargic and required repeated tactile stimulation to respond. The LPN moved the resident to a brighter area and requested a CMA to obtain vital signs, which showed a temperature of 100.4°F. The LPN instructed the CMA to administer Tylenol, but the resident refused the medication twice. The LPN then directed a CNA to return the resident to her room. Despite recognizing that the resident was semi-responsive, with a temperature of 100.4°F and refusal of Tylenol, the LPN left the unit for lunch without contacting the provider or arranging for further assessment or monitoring by another nurse. A progress note documented the resident as semi-responsive, responding only to touch and voice, with a temperature of 100.4°F and refusal of Tylenol. Interviews with other nursing staff indicated that a temperature of 100.4°F and decreased responsiveness constituted a significant change in condition that warranted provider notification, frequent reassessment, and documentation. The LPN later acknowledged that the event was a change in condition and that she did not contact the provider until after returning from lunch. An eINTERACT Change in Condition Evaluation was completed but did not include any interventions, and the progress notes lacked follow-up assessments or interventions. The facility did not have a policy directly addressing assessment and interventions for such changes in condition.
Failure to Use Wheelchair Foot Pedals During Resident Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe wheelchair transport by not using foot pedals for a resident who required assistance with mobility. Resident #8 had moderately impaired cognition, with a BIMS score of 12/15, and diagnoses including diabetes mellitus, partial paralysis, and non-traumatic brain dysfunction. The resident’s MDS indicated dependence or need for assistance with most mobility tasks, including transfers, bed mobility, and all other forms of mobility, and documented use of a wheelchair and walker. The resident’s care plan did not identify any non-compliance with wheelchair foot pedal use. On the observed date and time, an LPN (Staff A) attempted to wake the resident, who was seated in a wheelchair at the dining room table and was lethargic, requiring multiple taps or grabs of the left arm to elicit a response. Staff A then transported the resident in the wheelchair without foot pedals to a hallway area with more sunlight. Subsequent interviews with an RN (Staff D), another LPN (Staff E), and the ADON confirmed that staff understood residents should not be transported in wheelchairs without foot pedals and that feet should be on the pedals during transport unless the resident is self-propelling. Staff A acknowledged that foot pedals should have been applied during the transport. The facility did not have a policy that provided staff directives for transporting residents in wheelchairs.
Failure to Safely Administer Insulin and PRN Acetaminophen
Penalty
Summary
The deficiency involves failures in safe medication administration, particularly with insulin and acetaminophen. For one resident with chronic kidney disease and diabetes who required extensive assistance with ADLs and received insulin injections daily, an LPN prepared a fast-acting insulin FlexPen by attaching a needle and injecting the insulin into the resident’s abdomen without priming the pen to remove air. The LPN later acknowledged that the insulin pen should have been primed and that she had forgotten to do so. She also confirmed that the insulin pen was considered good for 30 days after opening but admitted there was no documented open date on the pen and that she had not noticed the blank date label before administering the dose. A second resident, who had chronic kidney disease, diabetes, heart failure, and morbid obesity and was cognitively intact but dependent for most ADLs, also received fast-acting insulin via FlexPen three times daily with meals. During observation, the same LPN correctly primed the insulin pen and administered the injection into the resident’s abdomen. However, after administration, the LPN stated she did not know when the insulin pen had been opened because it was not dated and admitted she had not checked the date-opened label before giving the insulin. Facility nursing staff, including an RN and another LPN, later stated that insulin pens should not be used if the date opened is not documented and that such insulin should be discarded and replaced. A third resident with diabetes, partial paralysis, and non-traumatic brain dysfunction, who required varying levels of assistance with mobility and ADLs, had a care plan for chronic pain directing staff to administer pain medication as ordered and monitor pain on a 0–10 scale. The resident’s physician order included acetaminophen 650 mg every six hours as needed for mild pain, and the order was on hold and did not include use for fever. When this resident was observed to be lethargic in a wheelchair at the dining table, staff obtained vital signs and reported a temperature of 100.4°F. The LPN instructed a CMA to administer acetaminophen, and the CMA attempted to give two acetaminophen tablets, but the resident refused by pulling her head back and saying no, at which point the CMA stopped. The LPN later acknowledged it was not acceptable to use a medication for a reason not included in the physician’s order and admitted she did not know the acetaminophen order did not include use for fever.
Inaccurate Documentation of Change in Condition and Notifications
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate health record for a resident who experienced a change in condition. The resident had moderately impaired cognition with a BIMS score of 12, and diagnoses including diabetes mellitus, partial paralysis, and non-traumatic brain dysfunction. The resident required varying levels of assistance with activities of daily living and had a care plan directing staff to involve her family in decisions and medical updates. On the day of the incident, an LPN attempted to wake the resident, who was lethargic and only responded after multiple taps to her arm. The resident’s temperature was obtained by a CMA and found to be 100.4°F, and the LPN instructed the CMA to administer Tylenol. The resident refused the Tylenol, pulling her head back and saying “no” twice. The LPN then directed a CNA to return the resident to her room. A nurse’s progress note entered at 12:05 PM documented that the resident was semi-responsive, responded to touch and voice only, had a temperature of 100.4°F, and refused Tylenol. The LPN left the unit for lunch at 12:19 PM and returned at 1:25 PM, stating she did not perform any work-related duties while at lunch. She later confirmed that the resident’s condition constituted a change in condition and acknowledged that a change-of-condition form should have been completed at that time. An eINTERACT Change in Condition Evaluation dated the same day documented family and provider notification at 1:00 PM, a time when the LPN reported she was at lunch. The ADON stated staff should not be backdating and should accurately record events to reflect the time they occurred. Facility policy on documentation required each resident’s medical record to be complete, accurate, and timely, containing an accurate representation of the resident’s actual experiences, which was not followed in this instance.
Failure to Identify and Treat Unstageable Pressure Ulcer
Penalty
Summary
A resident with severe cognitive impairment, multiple comorbidities including anemia, diabetes, traumatic brain injury, malnutrition, and respiratory failure, was identified as being at very high risk for pressure ulcers. The resident was dependent on staff for bed mobility and transfers, and the care plan acknowledged risk factors such as impaired mobility, cognition, incontinence, and high-risk medications. However, the care plan failed to address an unstageable pressure ulcer on the left heel and lacked specific interventions for repositioning, turning, or floating the heels to prevent further breakdown or promote healing. Clinical documentation revealed repeated failures to assess, document, and treat the left heel pressure ulcer. Upon multiple admissions and readmissions, progress notes and skin assessments either omitted mention of the wound or lacked essential details such as wound measurements, characteristics, and treatment interventions. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not reflect any wound care or new interventions for the left heel ulcer until several weeks after the wound was first identified. Even after wound care orders were received from the hospital, there was no documentation of consistent implementation of repositioning, turning, or heel floating as required by facility policy. Interviews with the DON and NP confirmed gaps in wound assessment, documentation, and intervention. The DON acknowledged omissions in skin assessments and was uncertain about the timing of heel protector use. Facility policies required regular turning, repositioning, and heel floating for residents at risk of or with pressure ulcers, but these interventions were not documented in the care plan or medical record. The lack of prompt assessment, documentation, and implementation of appropriate interventions contributed to the failure to provide care consistent with professional standards for pressure ulcer prevention and management.
Repeated Deficiencies in QAPI, Pressure Sores, Staffing, and Infection Control
Penalty
Summary
The facility failed to correct its own deficiencies and did not maintain an effective quality assurance program to ensure quality care for its residents and compliance with federal and state regulations. Over the past two and a half years, repeated deficiencies were cited in areas including pressure sores (F686), services to meet professional standards (F658), sufficient nursing staffing (F725), and infection control (F880). These deficiencies were identified during multiple surveys, including recertification, complaint, and incident surveys, with the same issues recurring across several survey cycles. The facility's QAPI plan outlined a systematic approach for identifying and addressing problems, but the repeated citations indicate that these processes were not effective in preventing recurrence of the same issues. Despite documentation of a QAPI plan and acknowledgment from the Administrator that various measures had been implemented, the facility continued to experience repeat deficiencies in critical areas affecting resident care. The Administrator confirmed that the facility had ongoing issues with pressure wounds, infection control, and staffing, and that these concerns persisted despite efforts to track and address them. The repeated nature of these deficiencies suggests that the facility's quality assurance activities were insufficient to achieve and sustain compliance with regulatory requirements.
Failure to Notify Family of Significant Weight Loss and Dietary Changes
Penalty
Summary
The facility failed to notify the family or emergency contact of a resident who experienced significant weight loss and changes in nutritional management. Clinical record review and staff interviews revealed that a resident with severe cognitive impairment, multiple diagnoses including anemia, diabetes mellitus, traumatic brain injury, malnutrition, and respiratory failure, experienced notable weight loss over several months. The resident was dependent on staff for eating and received the majority of their nutrition via a feeding tube. Progress notes documented an 8.8-pound (5%) weight loss in one week and an 11.9-pound (7.3%) weight loss in one month, with a total loss of 21.4 pounds (12.4%) over three months. The dietician made recommendations to adjust tube feeding to address the weight loss. Despite these significant changes, there was no documentation in the clinical record that the resident's family or emergency contact was notified about the weight loss or the dietary recommendations. The DON confirmed that she could not locate any documentation of family notification and acknowledged that, although she had multiple conversations with the family, these were not documented. Facility policy required prompt notification of the resident's representative in the event of significant changes in the resident's condition, but this was not followed in this case.
Failure to Obtain Weekly Weights for Residents with Feeding Tubes
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice by not obtaining weekly weights as ordered by physicians for three residents with feeding tubes. Clinical record reviews, staff interviews, and policy review revealed that physician orders for weekly weight monitoring were not followed for these residents, despite their high risk for nutritional issues due to conditions such as malnutrition, anemia, diabetes, traumatic brain injury, cerebrovascular accident, and respiratory failure. Care plans for these residents specifically identified the need for close nutritional monitoring, including regular weights, due to their dependence on tube feeding and other complex medical needs. For one resident, only a single weight was documented in the month of May, despite a physician order for daily weights for three days followed by weekly weights. Progress notes indicated significant weight fluctuations and insufficient documentation of weights, with the dietician noting the lack of weekly weights and recommending changes to tube feeding due to observed weight loss. Another resident had multiple missed weekly weights over several months, as shown in the weight summary and treatment administration records. Staff interviews confirmed ongoing issues with obtaining accurate and timely weights, with equipment problems and staff performance cited as contributing factors. A third resident with multiple complex medical diagnoses, including muscular dystrophy, respiratory failure, and malnutrition, also had physician orders for daily and weekly weights that were not consistently followed. Medication administration records and weight logs showed only sporadic documentation of weights over a two-month period. Facility policy required implementation of a weight monitoring schedule and timely recording of weights, but this was not adhered to for these residents, resulting in a failure to meet professional standards of quality for monitoring nutritional status.
Failure to Follow Infection Control Protocol During Suprapubic Catheter Care
Penalty
Summary
A deficiency was identified when a registered nurse failed to follow proper infection control procedures while providing wound and suprapubic catheter care to a resident with multiple complex medical conditions, including muscular dystrophy, respiratory failure, dysphagia, malnutrition, and a suprapubic catheter. During observation, the nurse performed two wound treatments and then proceeded to change the suprapubic catheter dressing without changing gloves between procedures. The nurse also cleansed the catheter insertion site by repeatedly wiping the same area with the same part of the gauze pad, contrary to facility policy, which requires using a new cotton ball or applicator for each outward stroke from the stoma. The resident's clinical record revealed an incident where the resident was found with blood in the urine and large sediment in the catheter tubing, resulting in a transfer to the emergency room. Subsequent laboratory testing confirmed a urinary tract infection with a high bacterial count. Facility policy and infection control expectations, as confirmed by the Infection Control Preventionist, require hand hygiene, glove changes, and proper technique when cleaning the suprapubic catheter site, which were not followed during the observed care.
Failure to Flush G-Tube Before and After Medication Administration
Penalty
Summary
A deficiency occurred when a registered nurse failed to follow facility policy regarding the administration of medication through a gastrostomy tube (g-tube) for a resident with multiple complex medical conditions, including muscular dystrophy, respiratory failure, dysphagia, malnutrition, a suprapubic catheter, and a tracheostomy. The nurse administered a syringe containing three medications mixed with an unspecified amount of water directly into the resident's g-tube without flushing the tube with water before or after the medication administration, as required by facility policy. Facility policy, revised on 9/16/25, specifies that the enteral tube should be flushed with at least 15 ml of water prior to and after administering medications. The nurse stated there was no set amount for the water flush and indicated it did not matter, which was inconsistent with both the policy and the Director of Nursing's expectations. The Director of Nursing confirmed that, in the absence of a specific physician order, the protocol is to flush with 30 or 60 ml of water before and after medication administration.
Delayed Call Light Response and Inaccessible Call Lights
Penalty
Summary
The facility failed to provide timely responses to resident call lights and did not ensure call lights were within reach for certain residents. Resident council minutes documented ongoing concerns about delayed call light responses, with residents reporting that response times often exceeded the facility's standard of 15 minutes, particularly during the night shift when waits could reach up to 40 minutes. Interviews with cognitively intact residents confirmed these delays, and the Director of Nursing acknowledged the expectation for call lights to be answered within 15 minutes. Additionally, observations revealed that two residents with significant physical and cognitive impairments did not have their call lights within reach for extended periods. One resident, dependent on staff for transfers and toileting due to hemiplegia and dementia, was observed unable to access the call light, which was placed approximately five feet away. Another resident with muscular dystrophy, respiratory failure, and a tracheostomy was observed in bed for over two hours with the call light on the floor, out of reach, despite multiple staff entering the room during that time. Facility policy requires call lights to be accessible to all residents, but this was not consistently followed.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident with multiple complex medical needs, including a g-tube, suprapubic catheter, and tracheostomy. The resident was care planned for Enhanced Barrier Precautions (EBP) due to the presence of a catheter. Observations revealed that the Infection Control Preventionist provided oral care to the resident wearing only gloves and no gown, contrary to EBP requirements. Additionally, a registered nurse performed multiple dressing changes on the resident's wounds, catheter, g-tube, and tracheostomy without changing gloves or performing hand hygiene between sites, as required by facility policy. Further observation showed the same nurse administering medication via the resident's g-tube without wearing gloves or a gown. Review of facility policies confirmed that EBP requires gown and glove use during high-contact care activities, including device care and wound care, and that hand hygiene must be performed after handling contaminated objects and between dressing changes. The Infection Control Preventionist acknowledged these lapses in infection control practices during an interview.
Failure to Maintain Safe and Homelike Environment Due to Unresolved Maintenance Issues
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to provide a safe, clean, comfortable, and homelike environment for its residents. Several room doors could not be properly closed, even after repeated attempts by staff and surveyors. In one room, a board intended for the window sill was found lying on the floor by the resident's bed for over a month, and the platform for the window sill had hard, dried glue and a rough surface. Additionally, the bathroom call light in one room was not functioning, and a 4-plex electrical outlet was being used to power a dorm-sized refrigerator, a charger for a motorized wheelchair, and a charger for electronic devices, with reports of the outlet sparking when used. Review of facility work orders revealed that there were no open or active work orders for the affected rooms during the survey period, despite ongoing issues. Interviews with residents confirmed that maintenance requests had been made but not addressed in a timely manner. Staff interviews indicated that work orders were entered into the facility's TELS system, but repairs were not always completed promptly. The maintenance director confirmed that work orders were prioritized by urgency, but some issues, such as the broken windowsill and malfunctioning electrical outlet, persisted for extended periods before being addressed.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. Specific details regarding the resident's medical history or condition at the time of the deficiency are not provided in the report.
Delayed Call Light Response Across Multiple Units
Penalty
Summary
The facility failed to provide timely responses to resident call lights on three of four units, as evidenced by multiple resident and family interviews, as well as documentation in Resident Council Minutes. Residents consistently reported waiting 20 to 50 minutes for staff to respond to call lights, with some instances where staff turned off the call light and did not return for an extended period. Resident Council Minutes from April, May, and June 2025 documented ongoing concerns about delayed call light responses, and several cognitively intact residents confirmed these delays during interviews. A family member also reported frequent delays of 30 minutes or more for call light responses. The Director of Nursing acknowledged awareness of the issue and stated that the facility's standard is to answer call lights within 15 minutes. Despite this expectation, the reported experiences indicate that the facility did not consistently meet the needs of residents for timely assistance, as required.
Failure to Follow Infection Control Practices for Residents with Medical Devices
Penalty
Summary
Staff failed to follow infection control practices for a resident with a feeding tube and another with a catheter. For the resident with a feeding tube, a registered nurse donned gloves and gown for Enhanced Barrier Precautions (EBP) but did not perform hand hygiene or remove gloves between tasks such as obtaining vital signs, administering insulin, handling medication packaging, and documenting care. Equipment used for blood sugar, blood pressure, and pulse oximetry was placed back into the medication cart without being sanitized. The nurse continued to access the medication cart and administer medications via gastrostomy tube without changing gloves or performing hand hygiene, only removing gloves and gown at the end of the process. Additionally, certified nursing assistants providing hygiene and transfer for the same resident donned gowns and gloves but failed to perform hand hygiene between glove changes and did not consistently don new gowns as required by EBP protocols. For the resident with an indwelling catheter, observations on three separate occasions revealed that the catheter bag was lying on the floor with the drain port touching the floor. The Director of Nursing confirmed during an interview that the catheter bag should not be on the floor. These findings were based on direct observation, staff interviews, and policy review, and indicate lapses in adherence to established infection prevention and control procedures for residents with medical devices.
Failure to Notify Provider of Change in Condition for Resident with Hyperglycemia and Tachycardia
Penalty
Summary
The facility failed to promptly notify a medical provider of a significant change in condition for a resident with multiple complex medical diagnoses, including diabetes, stroke, aphasia, and seizure disorders. The resident, who was nonverbal and received the majority of her nutrition via tube feeding, exhibited persistently elevated blood glucose levels over several days, with readings as high as 437, 413, and 397. Additionally, the resident's heart rate was consistently elevated, reaching up to 126 beats per minute, and her blood pressure was trending below baseline. Despite these abnormal findings, there was no documentation that a medical provider was notified of the resident's high blood sugars or tachycardia prior to her acute deterioration. Nursing documentation was notably lacking, with no progress notes entered for a period of nearly two weeks, and the only note during that time referencing a physician note with no new orders. Staff interviews revealed that while some staff recognized the abnormal blood sugar levels and vital signs, there was inconsistency in when to notify a provider, and no action was taken until the resident's condition became critical. When the resident's blood glucose became unreadable by the glucometer, a provider was contacted but did not give orders for insulin, only for tube feeding to be stopped and labs to be drawn. The resident was ultimately sent to the emergency department after further decline, where she was diagnosed with diabetic ketoacidosis, sepsis, and pneumonia. The lack of timely provider notification and absence of additional insulin administration outside of scheduled doses contributed to a delay in appropriate medical intervention. The facility's documentation and communication practices did not reflect prompt recognition or escalation of the resident's deteriorating condition, despite clear evidence of significant changes in vital signs and blood glucose levels.
Failure to Provide Adequate Supervision and Follow Care Plan Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and follow the care plan for a resident with severe cognitive impairment, resulting in a fall. The resident had a history of dementia, anxiety disorder, a prior humerus fracture, and required substantial to maximal assistance with transfers and toileting according to the most recent MDS and care plan. Despite these documented needs, the resident was allowed to ambulate independently from the bathroom to her chair, during which she fell and sustained a significant skin tear and bruising, and later complained of pain in her right big toe and left arm. Staff interviews and documentation revealed inconsistencies in the assignment and supervision of care for the resident on the day of the fall. The care plan directed staff to provide assistance with transfers and all toileting tasks, but staff accounts indicated that the resident was often left to use the bathroom independently for privacy, with staff only nearby rather than providing direct assistance. There was also confusion among staff regarding the resident's level of independence, with some believing she was care planned to be independent for transfers and toileting, while others stated she required assistance. The care plan had not been updated to reflect changes in the resident's condition, and staff were not consistently following the documented interventions. Further, the facility's policies required ongoing assessment and adjustment of interventions for residents at risk of falls, as well as accurate documentation and communication among staff. However, the care plan was outdated, and staff were unclear about the resident's needs and the required level of supervision. The lack of direct supervision and failure to adhere to the care plan led to the resident's fall and injury, demonstrating a breakdown in communication, care planning, and implementation of fall prevention strategies.
Failure to Perform Post-Dialysis and Post-Fall Assessments and Document Missed Medications
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for two residents. For one resident with multiple complex diagnoses, including end stage renal disease, diabetes, and heart failure, staff did not perform a post-dialysis assessment or assess for side effects after missed medication doses. The resident returned from a scheduled hemodialysis appointment, but there was no documentation of post-dialysis weight, vital signs, or assessment of the dialysis access site. Additionally, several scheduled medications were not administered because the resident was away from the facility, but there was no evidence of physician notification or follow-up assessment for potential side effects related to the missed doses. Later that day, the resident exhibited abnormal vital signs, lethargy, and hypothermia, and was transferred to the hospital. The review of facility records and staff interviews revealed that the facility's care plan and medication administration records lacked specific instructions and documentation regarding fluid restriction amounts and post-dialysis assessments. Staff confirmed that post-dialysis assessments were not consistently documented, and that there was no process in place to ensure communication with the dialysis center if documentation was missing. The facility's own policies required coordination with the dialysis center, monitoring and documentation of the access site, and timely communication regarding medication administration, but these were not followed in this case. For another resident at risk for falls, the facility failed to document a post-fall assessment within 24 hours after a witnessed fall. Although staff reported assessing the resident's vitals, pain, and orientation after the fall, this information was not entered into the medical record until the following day as a late entry. The facility's policies required timely documentation of incidents and assessments in the medical record, but this was not completed as required. The lack of timely documentation meant that pertinent information about the resident's condition and the circumstances of the fall were not available in the medical record as expected.
Failure to Ensure Safe Transfers and Equipment Use for Residents Requiring Mechanical Assistance
Penalty
Summary
The facility failed to provide adequate supervision and appropriate assistance devices to prevent accidents for two residents requiring mechanical equipment transfers. One resident, with no cognitive impairment and dependent on staff for transfers and activities of daily living, was observed being transferred by two staff members using a gait belt. However, one staff member lifted the resident by the waist of his pants and under his shoulder, rather than solely using the gait belt as required. The resident's care plan specified the use of a platform walker and one-person assistance for transfers, but this was not followed during the observed transfer. Another resident, with intact cognitive function and diagnoses including hemiplegia, dementia, cancer, anemia, and orthostatic hypotension, was totally dependent on staff for transfers. The resident sustained an injury during a transfer when a CNA used a sit-to-stand mechanical lift instead of the required full body mechanical lift, and only one staff member assisted instead of two as specified in the care plan. The resident, who was on blood thinners, developed a bruise and discomfort as a result of the improper transfer. Documentation confirmed that the CNA did not follow the plan of care, and the incident was reported to the family. Additionally, an observation of the sit-to-stand mechanical lift used in the facility revealed severely damaged foam padding on the handles, exposing sharp metal edges where hands are placed during use. This compromised equipment was confirmed by both the Administrator and the DON, who removed it from service. Facility policy clearly states that damaged or improperly functioning lift equipment should not be used, but this was not adhered to at the time of the incident.
Delayed Call Light Response and Inadequate Staffing
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure timely response to resident call lights and assistance with care needs for multiple residents. Observations and interviews revealed that several residents experienced significant delays in staff response, with call lights often going unanswered for 15 minutes or longer. One resident, who was on strict bedrest due to a lumbar fracture, reported frequent delays of up to 40 minutes and sometimes turned off the call light herself when it was not answered. Another resident, dependent on staff for mobility and personal care, stated that it could take up to an hour for staff to respond to his call light, particularly during peak times, and staff attributed the delays to being short-staffed. Additional observations documented a resident who was incontinent and dependent on staff for toileting was left in visibly wet clothing for at least 23 minutes before being assisted, despite staff being made aware of his condition. Another resident with an indwelling urinary catheter and at risk for skin breakdown activated his call light and waited 16 minutes before a nursing assistant responded, who then informed the resident that a nurse would be notified and assistance would be provided later. These delays were observed despite the facility's policy and staff expectations that call lights should be answered within 15 minutes. The facility's own policies required all staff to respond promptly to call lights and to ensure that residents' needs were met in a timely manner. However, both staff and residents reported and demonstrated through observation that call light response times frequently exceeded the facility's expectations, particularly during busy periods or when staffing was not optimal. The documented delays in responding to residents' needs resulted in residents remaining in uncomfortable or potentially unsafe situations for extended periods.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of mice in resident rooms for two of three residents reviewed. One resident reported seeing a mouse in her room for the past four months, with traps being set off but not catching the mouse, and sticky traps disappearing. Observations confirmed the presence of a mouse trap and possible mouse droppings in the resident's room. Another resident, living across the hall, reported a mouse living in his closet, which he stated to the Director of Maintenance. Staff interviews revealed that complaints about mice had been made to maintenance, but the pest control company had not received any reports of mice in the last six months and had not conducted any inspections or treatments for mice during that period. Further observations identified structural issues at an exit door near the affected rooms, including visible gaps and missing weather guard, which could allow pests to enter. Staff interviews indicated that complaints about mice had been ongoing, with the DON acknowledging reports for four months and entering them into the facility's reporting system. However, the Director of Maintenance denied receiving reports about mice and stated that only moths had been reported previously. The facility's policy required maintaining a report system for pest issues between scheduled pest control visits, but this was not effectively implemented, leading to a failure to address the pest problem.
Failure to Maintain Nutritional Status
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, resulting in a significant weight loss of 10.4% over approximately three months. The resident, who had moderate cognitive impairment and depression, was not on a physician-prescribed weight-loss regimen. Despite a care plan intervention to provide Glucerna with each meal, no additional interventions were documented to address the weight loss. Observations revealed that the resident's meals were not individualized or separated from other residents' trays, and the resident often slept through meal times, leaving meals untouched. The resident expressed a preference for Bosnian food, but no specific cultural dietary interventions were implemented. The facility's registered dietitian and director of nursing acknowledged the resident's significant weight loss and lack of interventions beyond Glucerna. The facility's policies on nutritional management and unplanned weight loss were not adequately followed, as evidenced by the lack of individualized interventions and monitoring of the resident's nutritional status. Despite awareness of the resident's weight loss, the facility did not implement additional supplements or fortified foods until much later, and there was no documentation of dietary notes with additional supplements until after the deficiency was identified.
Staff Argument and Privacy Breach in LTC Facility
Penalty
Summary
The facility failed to uphold the dignity of its residents when two staff members, a Dietary Attendant and Culinary Support, engaged in a loud argument in the presence of nine residents in the dining room. The incident occurred when the Dietary Attendant accused the Culinary Support of not helping and expressed frustration by yelling and throwing napkins. This behavior was witnessed by the residents and was audible from outside the dining room, indicating a breach of the facility's policy on treating residents with dignity and respect. Additionally, the facility did not adequately protect the confidentiality of resident information. A CNA charting monitor was left open and unattended in the hallway, displaying information for several residents. A Licensed Practical Nurse walked by without closing the screen, and another CNA accessed the monitor shortly after. The Executive Director confirmed that the monitors should be locked when not in use to protect resident privacy, as per the facility's policy on confidentiality and personal privacy.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to implement proper infection control practices during resident-staff interactions, as observed in multiple instances. In one case, two Certified Nurse Aides (CNAs) improperly positioned a resident's indwelling catheter bag above the bladder, contrary to the care plan and training, which directed that the bag should be below the bladder to prevent backflow of urine. Both CNAs acknowledged the mistake, and the Director of Nursing (DON) confirmed the correct procedure was not followed. In another instance, a Certified Medicine Aide (CMA) entered a resident's room, who was on contact isolation and Enhanced Barrier Precautions (EBP), without donning Personal Protective Equipment (PPE) or performing hand hygiene. The CMA handled items in the room and returned without following proper isolation protocols. The DON stated that PPE should have been applied before entering the room, as per the facility's policy on transmission-based precautions. Additional observations revealed multiple staff members failing to perform hand hygiene before and after various tasks, such as medication administration and catheter care. Staff members were seen not changing gloves between tasks or performing hand hygiene, which is against the facility's policies on hand hygiene and PPE use. The Executive Director acknowledged these lapses and stated that staff should adhere to the established protocols for hand hygiene and PPE use.
Failure to Secure Resident Information
Penalty
Summary
The facility failed to secure Electronic Health Record information for 16 residents, as observed during a survey. On the evening of September 17, 2024, a report sheet containing information for 21 residents was found laying face up on a medication cart in the northeast hall. This was contrary to the facility's policy, which requires such information to be kept under a binder to ensure confidentiality. The Director of Nursing acknowledged that the resident information should not have been left exposed on top of the cart. The facility's policy on Confidentiality of Information and Personal Privacy, revised in October 2017, mandates the safeguarding of personal privacy and confidentiality of all resident personal and medical records.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to prevent the development of a pressure ulcer for a resident who was admitted with a Stage IV pressure ulcer and had comorbidities making her susceptible to further skin integrity issues. The resident required assistance for repositioning and was dependent on staff for turning and transfers. Despite this, the facility did not provide the recommended every 2-hour repositioning, and there were lapses in the documentation of these activities. The resident's care plan did not include a specific turning/repositioning schedule, and the care plan had not been updated since 2023. The resident developed a second Stage IV pressure ulcer, which required medical intervention and hospitalization. The facility's records showed inconsistencies in the documentation of wound care treatments, with gaps in treatment administration for the sacral wound. The resident's skin condition worsened, leading to the development of an unstageable pressure ulcer, which was later identified as a Stage IV pressure injury. The facility's failure to consistently implement and document wound care treatments contributed to the deterioration of the resident's skin condition. Interviews with staff revealed that the resident occasionally refused repositioning, but this was not consistently documented. The facility's policy on turning and repositioning was not effectively implemented, and there was a lack of communication and follow-up on wound care orders. The resident expressed concerns about the timeliness of repositioning and the need for staff assistance, indicating that the facility did not adequately address her needs for pressure ulcer prevention.
Failure to Prevent Pressure Ulcers in At-Risk Residents
Penalty
Summary
The facility failed to provide adequate care and interventions to prevent the development of pressure ulcers for two residents identified as at risk. Resident #1, who was admitted with diagnoses including septicemia and dementia, was initially assessed as having intact skin but later developed unstageable deep tissue injuries on both heels and a skin tear on the right buttock. Despite being identified as high risk for pressure ulcers, the resident's care plan was not effectively implemented, as evidenced by the lack of timely application of heel protector boots and an air mattress, which were only provided after the wounds were discovered. The resident's condition deteriorated, leading to hospitalization for septic shock and respiratory failure. Resident #2, with a history of stroke, hemiplegia, diabetes, and malnutrition, was also at risk for pressure ulcers. Initially, the resident had intact skin, but over time developed a Stage IV pressure ulcer on the sacrum. The care plan included the use of pressure-reducing devices and frequent repositioning, but these measures were insufficient or not consistently applied, as indicated by the progression of the wound from a Stage III to a Stage IV ulcer. The resident's condition worsened, resulting in a transfer to the hospital, where the resident later passed away. Interviews with staff revealed systemic issues, including inadequate staffing levels, which contributed to delays in repositioning and changing residents, leading to the development of pressure ulcers. Staff reported challenges in maintaining consistent care due to high resident acuity and insufficient personnel, which hindered their ability to perform necessary interventions timely. The facility's failure to implement effective pressure ulcer prevention strategies and address staffing shortages directly contributed to the deficiencies observed.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staff to meet the needs of residents, as evidenced by observations, interviews, and record reviews. On multiple occasions, call lights were left unanswered for extended periods, with some residents waiting up to two hours for assistance. This lack of timely response was attributed to inadequate staffing levels, particularly on the night shift, where only three CNAs were available for 61 residents. Interviews with residents and family members revealed dissatisfaction with the care provided, citing delays in assistance, inadequate feeding support, and concerns about staff being too busy or distracted. The facility's staffing issues were further highlighted by the involvement of administrative staff in direct care tasks, such as passing meal trays and answering call lights, particularly when state surveyors were present. Staff interviews confirmed that the facility often operated with minimal staffing, leading to unmet care needs, such as delayed repositioning, increased skin issues, and weight loss among residents. The facility's reliance on a scheduling software, On-Shift, was noted, but discrepancies between scheduled and actual staffing levels were reported, with staff frequently calling in and shifts going unfilled. The facility's assessment and staffing plan indicated a need for more staff than were actually present, with a significant number of residents requiring assistance from two staff members for transfers. Despite the facility's policy for timely call light response, the actual practice fell short, with residents experiencing prolonged waits for assistance. The Director of Nursing and other staff expressed concerns about the facility's ability to meet residents' needs due to budget constraints and management's reluctance to approve overtime or use agency staff.
Facility Lacks Effective QA Program Leading to Repeated Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assurance (QA) program, which is essential for providing quality care to residents and ensuring compliance with Federal regulations and State rules. The facility, with a census of 116 residents, has a history of repeated deficiencies as identified in its annual surveys and complaint investigations. Specifically, deficiencies F725 and F686 were repeatedly cited during surveys conducted on various dates, indicating persistent issues that were not adequately addressed. The facility's QA program, which was supposed to be a systematic approach for performance improvement, failed to prevent or decrease the likelihood of problems. Despite implementing a Quality Assurance and Performance Improvement (QAPI) change process in October 2022, the facility continued to experience systemic problems. The new Administrator, who started in March 2024, acknowledged the ongoing issues and the need for improvement, particularly in areas affecting the facility's 5-Star Rating Scale, such as pressure ulcers. However, the report does not detail any specific actions taken by the previous administration to address these deficiencies, highlighting a lack of continuity and effectiveness in the facility's QA efforts.
Failure to Ensure Resident Dignity
Penalty
Summary
The facility failed to ensure the dignity of a resident who was observed sitting in the commons area with her adult brief completely exposed. The resident, who has severely impaired cognitive skills, is always incontinent of bowel and bladder, and requires total assistance with personal hygiene care, was seen without pants and with her adult brief exposed on two separate occasions. Staff interviews revealed that the resident only had dresses to wear, which were provided by her family, and that staff would usually cover her with a blanket or sheet, which she would sometimes remove. Despite this, the resident was left exposed in the commons area for extended periods. The Director of Nursing was informed of the situation but could not comment as she had not witnessed it herself. The facility's dignity policy, which emphasizes treating residents with dignity and respect at all times, was not adhered to in this instance. The policy aims to promote residents' well-being, satisfaction with life, and self-worth, but the observed actions and inactions of the staff failed to uphold these standards for the resident in question.
Failure to Initiate Physician's Orders and Administer Medications
Penalty
Summary
The facility failed to initiate physician's orders for two residents, leading to deficiencies in their care. Resident #1, who had a BIMS score of 12 indicating no cognitive impairment, was admitted with a Stage 2 pressure ulcer. Despite weekly recommendations from the wound physician to administer vitamin C 500 mg twice daily, the facility did not initiate this order from February to April 2024. The Director of Nursing acknowledged that the order should have been started, and the responsibility for initiating these recommendations was assigned to the wound nurse, Staff C Unit Manager. Resident #2, who had a BIMS score of 3 indicating severe cognitive impairment, was admitted from a hospital with multiple diagnoses including metabolic encephalopathy and seizures. The facility failed to administer his prescribed medications upon admission due to unavailability at the pharmacy. Despite attempts to obtain the medications in pill form, the resident experienced seizure episodes and was eventually sent to the emergency room. The Director of Nursing confirmed that the medications were not administered on the day of admission because they were delivered late, and staff did not seek an order to administer them late. The facility's policies on medication orders and admission orders were reviewed, revealing that the procedures for receiving and recording medication orders were not followed. The facility's failure to administer prescribed medications and initiate physician's orders for wound care led to significant deficiencies in the care provided to these residents.
Failure to Provide Adequate Assistance with ADLs
Penalty
Summary
The facility failed to ensure that a resident received appropriate assistance with their activities of daily living (ADLs). The resident, who has severely impaired cognitive skills, is non-verbal, and requires total assistance for personal hygiene and dressing, was observed multiple times over two days in a state of neglect. The resident was seen lying in bed for extended periods, wearing a hospital gown, and later sitting in a Broda chair in the commons area with no pants on, exposing her adult brief. Her hair was noted to be unkempt, oily, and balled up, indicating a lack of proper grooming and care as per the facility's policies on brushing and combing hair and maintaining resident dignity. Interviews with staff revealed inconsistencies in the care provided to the resident. Staff A, a CNA, admitted that the resident is usually checked every two hours and changed when needed but acknowledged that the resident had been left in bed until after lunch due to staffing issues. Staff B, another CNA, confirmed that the resident is typically up in her chair by 10:00 AM but also noted that the resident had been left in bed for longer periods recently. Both CNAs acknowledged the resident's unkempt hair and the difficulty in grooming it, with Staff B mentioning that the resident makes noises when they try to comb her hair, leading them to stop. The Director of Nursing (DON) confirmed that the resident's routine involves getting up once a day and sitting in the lobby area. The DON also acknowledged the issue with the resident's hair, attributing the knots to saliva pooling on the back of her head. Despite the facility's policies requiring daily grooming and maintaining resident dignity, the resident was observed in a state that did not meet these standards, indicating a failure in providing the necessary care and assistance with ADLs.
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An LPN, unfamiliar with residents on a medication cart and faced with two residents sharing the same first name, failed to correctly identify a resident and administered a full set of another resident’s medications in addition to the resident’s own ordered morning medications, including PRN oxycodone. The resident, who had severe cognitive impairment and multiple diagnoses including hypertension and Alzheimer’s disease, subsequently experienced declining BP, reported not feeling well, and became increasingly fatigued. The facility’s policy required resident identification before medication administration, and the LPN acknowledged not knowing the residents and finding the EHR photos too small, despite their availability. Hospital records later documented hypotension, treatment with IV fluids, and a drug overdose after accidental ingestion of another resident’s medications plus the resident’s own, with persistent sinus bradycardia requiring admission for further hemodynamic monitoring.
A cognitively impaired, wandering resident with Alzheimer’s disease and behavioral symptoms was care planned as an elopement risk but was able to leave the memory care unit by holding an emergency exit door bar for 15 seconds and exiting into a stairwell and then to the employee parking lot. The door alarm functioned, but staff in the noisy dining room did not hear it while they were feeding multiple residents, including several needing extensive assistance, and only realized the resident was missing when another staff member encountered him outside and brought him back. In addition, several residents who required staff assistance for transfers and toileting experienced prolonged call light response times well beyond the facility’s 15‑minute expectation, including one who reported waiting up to an hour during meals and having an in‑room accident, another observed waiting about 25 minutes while calling out for help, and a third waiting about 17 minutes before a CNA responded.
A cognitively intact resident reported that a CNA ripped her incontinence brief during care and then refused to change it, despite the resident stating she could not wear it due to the tear. The resident became upset and informed housekeeping staff, who then asked an LPN to assist. On assessment, the LPN observed a large rip extending around the back of the brief, changed the brief, and provided peri care at the resident’s request. The resident stated the ripped brief was uncomfortable and that she did not feel treated with dignity or respect. In interviews, the CNA acknowledged telling the resident the torn brief would still work and did not change it, while the DON confirmed the CNA had refused the resident’s request for a brief change, in conflict with the facility’s dignity policy.
A deficiency was identified when a CNA did not follow manufacturer instructions for a mechanical stand while transferring a resident with severe cognitive impairment, a history of hip fracture, dementia, and muscle wasting who required substantial assistance for transfers. The resident’s care plan called for use of a mechanical stand, but during observed toileting and return-to-chair transfers, the CNA repeatedly locked and unlocked only one wheel of the device and did not keep the brakes unlocked during the actual transfer, contrary to the operator’s instructions that brakes be locked only when raising and lowering the resident during ambulation. In an interview, the DON confirmed staff were expected to follow these operator instructions and keep the wheels unlocked during transfers.
A resident with dementia, behavioral symptoms, and multiple psychotropic and cardiovascular medications was discharged to another nursing facility without a thorough or accurate discharge summary. The care plan contained a discharge planning focus but was never updated to reflect the actual discharge, and the EHR lacked documentation of discharge planning, the reason for discharge, or a recapitulation of stay, despite a family member stating they initiated the discharge due to dissatisfaction with care. The discharge instructions contained multiple medication discrepancies and omissions, including missing drugs, incorrect dosages, and absent administration frequencies, and several PRN constipation medications were not listed, contrary to the facility’s written discharge planning policy.
A resident was admitted from a hospital without a completed Preadmission Screening and Resident Review (PASRR) in the medical record, as required prior to admission. The PASRR was only completed several days later by the Hospital Liaison/Admissions Coordinator after a call alerted staff that it was missing. Both the admissions coordinator and the Administrator acknowledged that the facility relies on the hospital to provide the PASRR and that, in this case, it was missed and not done before the resident’s admission.
A resident with Alzheimer's disease, severely impaired cognition, and documented nutrition/hydration risk required partial to moderate assistance with eating and was care planned for assisted feeding with a general diet and thin liquids. During a breakfast observation, the resident was seated in a reclined Broda chair while staff placed food and beverages on an overbed table and attempted to offer chocolate milk and hot cereal without first positioning the resident upright, causing the resident to struggle to reach the cup. Facility policy on feeding required residents needing assistance to be positioned comfortably in an upright position, and the DON stated she expected residents to be upright whenever food or drink was offered, but there was no separate positioning policy in place.
A resident with a left leg fracture, muscle wasting, and impaired mobility was dependent on a mechanical lift for transfers. Staff positioned the lift at the side of the wheelchair instead of straight on, and the lift tipped and struck the resident’s forehead with the sling-holding part, causing a bruise and protruding bump. Staff interviews confirmed the transfer was done from the side and that the resident’s care plan required straight-on positioning for the lift.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance: Several residents did not receive bathing and hygiene assistance as scheduled. One resident with intact cognition and a stroke history was observed unshaven and said staff did not always shave him during showers, while staff noted the bath sheets no longer tracked shaving or nail care. Other residents with severe cognitive impairment or dependence for bathing went extended periods without baths, and one cognitively intact resident reported missing baths and wanting them. Facility records and staff interviews showed bathing schedules were not consistently followed or documented as required.
QAPI program failed to address repeated deficiencies. Review of the facility’s visit history showed repeated F689, Free of Accident Hazards/Supervision/Devices, and F880, Infection Prevention and Control, across multiple annual surveys and complaint investigations. The QAPI plan stated it would review sources of information for gaps or patterns in care systems, and the Administrator acknowledged the repeated deficiencies and said the facility would review and discuss plans to improve.
Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to follow the 5 rights of medication administration, resulting in one resident receiving another resident’s medications in addition to their own. The resident had diagnoses including hypertension, Alzheimer’s disease, and toxic encephalopathy, with a BIMS score of 3 indicating severe cognitive impairment. On the morning in question, review of the MAR showed the resident received their ordered medications, which included aspirin, calcium carbonate, vitamin C, vitamin D, fluoxetine 20 mg, furosemide 40 mg, galantamine, a lidocaine patch, memantine, acetaminophen, and PRN oxycodone around 8:00 a.m. According to the incident report and nursing progress notes, the LPN (Staff A) administered another resident’s full set of morning medications to this resident while the resident was in the dining room. These additional medications included metoprolol 60 mg, Lyrica 75 mg, oxycodone 7.5/325 mg, furosemide 40 mg, celecoxib 100 mg, Prozac 60 mg, hydroxyzine 10 mg, cetirizine 10 mg, Neuriva, Protonix 20 mg, potassium 99 mg, a multivitamin, and vitamin D3. These medications were given in addition to the resident’s own morning medications and PRN oxycodone. The nurse’s notes documented that the resident’s blood pressure readings declined from 100/50 to 85/48 and then to 73/48, and the resident complained of not feeling well and was increasingly fatigued. Staff A reported during interview that the resident had been screaming and yelling and that she did not realize there were two residents with the same first name in the back hallway. She stated it was her first time working in that hallway after training and that, although resident pictures were available in the EHR to assist with identification, she felt they were small and she did not know the residents. The facility’s medication management policy required staff to identify the resident before administering medications. Staff A’s employee record showed a prior medication occurrence in which she administered the wrong medications (including furosemide and potassium) to a resident, and she had documented previously that she was not familiar with residents when working on that cart. The resident was ultimately sent to the ER, where records documented hypotension on admission, treatment with IV fluids, and a chief complaint of drug overdose after accidental ingestion of another resident’s multiple medications in addition to the resident’s own medications, with continued sinus bradycardia requiring admission for further hemodynamic monitoring.
Elopement of Wandering Resident and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for a cognitively impaired, wandering resident and failure to respond to resident call lights within the facility’s stated 15‑minute expectation. One resident with Alzheimer’s disease, bipolar disorder, and anxiety disorder had a care plan identifying risk for elopement due to wandering and documented behaviors of agitation, aggression, restlessness, and continuous pacing/wandering within the unit. This resident ambulated independently with a walker and had a BIMS score indicating impaired cognition. On the evening of the incident, the resident finished supper in the memory care dining room and then repeatedly walked the hallway with his walker, eventually approaching an emergency exit door at the far end of the hall, away from the dining room. Video and documentation show that the resident stood at the emergency exit door, held the door bar down for the required 15 seconds to release the egress, and then exited through the door into a stairwell and out to the employee parking lot. The door alarm and 15‑second egress functioned, but staff in the dining room did not hear the alarm due to noise from residents, staff conversation, and the television. At the time, two CNAs and one LPN were in the dining room feeding multiple residents, including several who required assistance, and staff reported that the resident was very quick, wandered constantly, and was difficult to keep seated. Staff interviews revealed that one CNA noticed the resident was no longer in the dining room around the same time another staff member reported they were looking for him, and only then did staff recognize the back exit door alarm sounding. A nurse arriving for her shift in the parking lot encountered the resident outside with his walker and escorted him back inside, after which he was assessed and found in stable condition. The deficiency also includes failure to respond to resident call lights within the professional standard of 15 minutes for multiple residents. One resident with intact cognition but dependent or substantial/maximal assistance needs for toileting reported that during meal hours it could take up to an hour for staff to answer the call light, resulting in an in‑room accident. Another resident, alert and oriented but occasionally forgetful and requiring two‑person assistance for transfers, was observed with the call light on for approximately 25 minutes in the morning while repeatedly yelling for help; staff walked past in the hallway without answering the light until a staff member finally entered the room. A third resident, requiring one‑person assistance for transfers, was observed with the call light on for about 17 minutes before a CNA entered to assist. The DON stated that the facility’s expectation is that call lights be answered within 15 minutes, and the facility’s policy directs all staff from all departments to respond to call lights and either assist or obtain appropriate help, but the observed response times exceeded this standard for the residents involved. Staff interviews further described the conditions contributing to these call light delays and supervision gaps. Staff on the memory care unit reported that typical evening staffing consisted of one nurse, one CMA, and two CNAs, and that while this was manageable when routines went smoothly, it became inadequate when residents had behaviors, were sundowning, or when events such as falls or changes in condition occurred. A CMA stated that at least three CNAs were needed on the memory care unit due to multiple residents requiring two‑person assistance, noting that when two CNAs were in a room providing care, they could not monitor the rest of the unit. Staff also reported that the back exit door alarm was faint and difficult to hear from the dining room, and some staff were not fully aware of the configuration of the back stairwell and exit leading to the parking lot. These conditions, combined with high resident care needs and noise levels during meals, contributed to the resident’s elopement and to prolonged call light response times for several residents. Maintenance and administrative staff confirmed that the south/back exit door from the unit led to another unalarmed door and then to the outside employee parking lot, and that the facility did not receive system reports when door alarms were activated. The Administrator was unable to verify when a door alarm went off or when an exit door was breached. The facility’s Wandering Resident policy stated that residents at risk for elopement should receive adequate supervision to prevent accidents and that staff must be vigilant in responding to alarms in a timely manner, and the call light policy required prompt response by all staff. Despite these policies, the documented events show that the resident at risk for elopement was able to leave the secured unit and reach the parking lot without timely staff detection, and that multiple residents experienced call light response times significantly longer than the facility’s stated 15‑minute standard.
Failure to Honor Resident Request for Brief Change and Maintain Dignity
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and respect when a cognitively intact resident’s request for a brief change was not honored. The resident, with a BIMS score of 15 indicating no cognitive impairment, reported being upset because a CNA (Staff N) ripped her brief during care and then refused to change it. The resident self-propelled down the hallway stating she was upset about the ripped brief and that staff would not change it. A housekeeping staff member (Staff M) observed the resident’s distress, was told that the CNA had refused to change the brief despite a large rip, and then asked an LPN (Staff O) to assist with changing it. During the subsequent brief change, Staff O performed hand hygiene, used gloves, removed the resident’s pants and brief, and provided peri care at the resident’s request before applying a new brief and redressing the resident. Observation of the removed brief revealed a large rip on the left side extending past the middle of the resident’s back. The resident stated the brief with the hole was uncomfortable and that she felt staff did not provide her with dignity and respect when her request for a new brief was not honored. Staff O confirmed that the brief had a very large hole and that the resident was very upset, reporting she did not feel treated with dignity or respect and that the ripped brief was uncomfortable. In an interview, Staff N acknowledged caring for the resident that day, stated the resident had been upset and had “behaviors,” and reported that when the resident said she wanted her brief changed because it was ripped, Staff N told her the brief would still work and that urine would not get everywhere, characterizing the tear as “just a little tear.” Staff N stated the resident did not explicitly ask her to change the brief. The DON later stated that Staff N had ripped the brief, the resident had requested a brief change, Staff N said she would not change it, and acknowledged that a lack of dignity occurred when Staff N refused to change the resident’s brief, contrary to the facility’s dignity policy.
Improper Use of Mechanical Stand Brakes During Resident Transfers
Penalty
Summary
Surveyors identified a deficiency related to accident prevention when staff failed to properly use a mechanical stand’s brakes during transfers for one resident. The resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment, required substantial assistance for transfers, and had diagnoses including hip fracture, dementia, and muscle wasting. The care plan documented initiation of a mechanical stand for transfers. During observation, a CNA applied a sling, locked the right wheel of the mechanical stand, lifted the resident from a chair, then unlocked the right wheel and positioned the resident over the toilet. The CNA then lowered the resident onto the toilet and locked the right wheel. After the resident finished, the CNA lifted the resident from the toilet, unlocked the right wheel, positioned the resident over the chair, locked the right wheel, and lowered the resident, thereby failing to keep the mechanical stand brakes unlocked during the transfer as required by the operator’s instructions, which specified that brakes should only be locked when raising and lowering the resident during ambulation. In an interview, the DON stated that staff were expected to follow the operator’s instructions and keep the wheels unlocked during transfers, confirming that the observed practice did not align with the manufacturer’s guidance for safe operation of the mechanical stand.
Failure to Complete Accurate and Thorough Discharge Summary and Documentation
Penalty
Summary
Surveyors identified a failure to complete a thorough and accurate discharge summary and related discharge documentation for one resident who was discharged from the facility. The resident was admitted in early March with moderate cognitive impairment, a Brief Interview for Mental Status (BIMS) score of 08, and documented delusions and behavioral symptoms. Diagnoses included dementia with agitation, anxiety disorder, and depression. Although the care plan contained a discharge planning focus initiated shortly after admission, it did not contain any updates or documentation related to the resident’s actual discharge later that month. The electronic health record (EHR) contained a communication note indicating that transport to another nursing facility was arranged and a health status note stating that the resident was discharged, with physician orders and a face sheet faxed and a report called to the receiving facility. The resident’s EHR did not contain documentation of the discharge planning process, the reason for the discharge, or a recapitulation of the resident’s stay. A family member reported that the family initiated the discharge due to dissatisfaction with care, but there was no documentation in the EHR reflecting that the family initiated the discharge. The Long Term Care Ombudsman reported that no one contacted her during the resident’s stay, although her office did receive notice of the transfer. The facility’s own discharge planning policy required that discharge planning begin on admission, be routinely updated in the comprehensive care plan, and that the evaluation of discharge needs and the final discharge plan be completely documented in the clinical record and discussed with the resident or representative. Review of the resident’s discharge instructions and March medication administration record revealed multiple discrepancies and omissions in the discharge summary. One medication (Amlodipine 10 mg) was listed without any frequency or time of administration. Several medications that the resident was receiving, including Donepezil 10 mg, Lisinopril 5 mg, and Buspirone 10 mg twice daily, were not included on the discharge summary. Other medications were inaccurately documented, such as Memantine, which was ordered as 20 mg once daily but listed as 10 mg twice daily, and Seroquel, ordered as 50 mg twice daily but listed as once daily. Several PRN constipation medications were also omitted. The Regional Nurse Consultant confirmed that the facility’s EHR contained a discharge assessment tool that was not completed for this resident and acknowledged the multiple medication discrepancies on the discharge summary form.
Failure to Complete PASRR Evaluation Prior to Admission
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) evaluation for a resident with an admission date of 4/22/26. The resident’s electronic health record documented admission from a hospital on 4/22/26, but review of the record showed no PASRR completed at the time of admission. A PASRR form for this resident was later obtained and showed it was completed on 4/27/26 by the Hospital Liaison/Admissions Coordinator, several days after the resident had already been admitted. During interview, the Hospital Liaison/Admissions Coordinator stated that the hospital usually completes the PASRR, acknowledged receiving a call the previous night that the PASRR was not in the chart, and admitted she had missed completing it prior to admission even though it should have been done. The Administrator similarly reported that the facility relies on receiving the PASRR from the hospital admission records and that, in this case, the PASRR was missed and not completed prior to the resident’s admission. This resulted in a deficiency for failure to ensure a PASRR evaluation was completed prior to admission for 1 of 3 reviewed residents, in accordance with PASRR requirements.
Failure to Properly Position Resident Upright During Assisted Feeding
Penalty
Summary
Surveyors identified a deficiency in resident positioning during mealtime for a resident with Alzheimer's disease and severely impaired cognition, as evidenced by a Brief Interview for Mental Status score of 2. The resident’s MDS indicated a need for partial to moderate assistance with eating, and the care plan documented nutrition and hydration risk related to end-stage diagnosis, cognitive limitations, and weakness, with directions for a general diet, thin liquids, and assistance with eating. During a breakfast observation on the Magnolia Unit, the resident was seated in a Broda chair that was reclined back. A dietary aide placed food on the table in front of the resident, and a CNA then placed beverages and food on an overbed table before walking away, while the resident remained reclined with eyes closed and the plate of food untouched. Later in the same observation period, another CNA offered the resident chocolate milk while the Broda chair remained tilted backward, and the resident had to struggle to move her head up and forward to reach the cup. The same CNA then offered hot cereal, which the resident declined by saying “later.” A different CNA subsequently offered another drink of chocolate milk, again without adjusting the reclined position of the Broda chair. Policy review showed the facility’s “Feeding of Residents by Staff” policy required that residents unable to feed themselves be assisted per their care plan and be positioned comfortably in an upright position. In an interview, the DON stated there was no specific positioning policy, that staff received positioning education in training, and that her expectation was that residents be placed in an upright position whenever food or drink was offered.
Mechanical Lift Transfer Caused Resident Forehead Injury
Penalty
Summary
The facility failed to provide a safe and adequate mechanical lift transfer for Resident #18, who had a left leg fracture, muscle wasting, and impaired gait and mobility, but no cognitive impairment based on a BIMS score of 15. The resident’s care plan required two staff members to use a mechanical lift for transfers because the resident was nonweight-bearing on the left leg. The care plan update also directed staff to approach the wheelchair straight on and not from the side, and to have the resident bend the right leg and turn away from the lift during transfers. During a wheelchair transfer, staff positioned the mechanical lift at the side of the wheelchair and began the transfer. The lift tipped and struck the resident’s forehead with the part that held the sling. The resident sustained a bruise and a protruding bump on the left forehead, and the incident documentation noted the resident’s head was hit on the lift. The resident later reported that the lift almost fell to the floor and that additional staff were needed to return it upright. Staff interviews confirmed that the transfer was performed from the side of the wheelchair. One CNA stated the lift may have caught on bars under the wheelchair and acknowledged that staff had been educated not to use the lift from the side. Another CNA stated the lift was used from the side because the resident did not want her leg hit by the lift, and identified the sling-holding part of the lift as the piece that struck the resident’s forehead. The DON stated the proper procedure was to position the mechanical lift directly in front of the wheelchair rather than to the side.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living for 5 of 8 residents reviewed, specifically related to bathing and shaving. Resident #3 had a BIMS score of 15 and was dependent on staff for personal hygiene, with diagnoses including renal insufficiency, stroke, hemiplegia, and seizure disorder. The resident was observed unshaven, stated he was getting showers but not shaved every time, and said he needed help shaving since his stroke. Facility records showed showers were documented without indicating whether shaving was completed, and staff interviews confirmed the bath sheets no longer tracked shaving or nail care, while the DON stated male residents should be offered shaving during showers and it should be documented if completed or refused. Resident #1 had a BIMS score of 4, diagnoses including muscle weakness, diabetes, and hip fracture, and was care planned as an extensive assist for bathing. Review of the follow-up report showed the resident went 17 days without a bath and later 19 days without a bath. Resident #11 had a BIMS score of 3, diagnoses including depression, hypertension, and anemia, and was scheduled for bathing on Wednesday morning and Friday afternoon, but the follow-up report showed gaps of 6 days, 6 days, and 18 days between baths. Resident #27 also had a BIMS score of 3 with depression, hypertension, and anemia, was scheduled for bathing on Monday and Thursday afternoon, and the follow-up report showed the resident went 19 days and then 20 days without a bath, with refusals documented on two occasions. Resident #85 had a BIMS score of 15, diagnoses including hypertension, depression, and need for assistance with personal care, and stated she did not get 2 baths the prior week and wanted them. Her care plan identified her as dependent for bathing, but lacked bathing frequency, and the task list scheduled bathing for Monday morning and Wednesday afternoon. The follow-up report showed multiple extended gaps between baths, including 12 days, 7 days, 18 days, and 7 days. Facility policy stated bathing is intended to promote cleanliness, provide comfort, and observe skin condition, and the Regional Nurse Consultant stated bathing should be completed as scheduled.
QAPI Program Failed to Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive and effective QAPI program and did not have a plan that described the process for conducting QAPI and QAA activities. Review of the DIAL website visit history showed repeated deficient practices identified during the facility’s annual survey and complaint investigation on 3/27/25 and during the annual survey, complaint, and facility-reported incident investigation on 4/19/26. The repeat deficiencies included F689, Free of Accident Hazards/Supervision/Devices, which had been repeated in the previous three consecutive annual surveys, and F880, Infection Prevention and Control, which had been repeated in the previous four consecutive annual surveys. The facility’s QAPI plan stated that it would review sources of information to determine whether gaps or patterns existed in systems of care that could result in quality problems or opportunities for improvement. During an interview on 4/23/26 at 1:28 PM, the Administrator acknowledged the repeated F689 and F880 deficiencies and stated the facility would review and discuss plans to improve.
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