Cedar Ridge Village
Inspection history, citations, penalties and survey trends for this long-term care facility in West Des Moines, Iowa.
- Location
- 8950 Coachlight Drive, West Des Moines, Iowa 50266
- CMS Provider Number
- 165790
- Inspections on file
- 16
- Latest survey
- August 12, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Cedar Ridge Village during CMS and state inspections, most recent first.
A resident was discharged without receiving the required ABN and NOMNC notifications regarding Medicare/Medicaid coverage and potential liability for non-covered services. Staff interviews confirmed that these notifications were not consistently provided, and the facility lacked a formal policy, relying instead on CMS guidelines.
A resident with an anxiety disorder received PRN clonazepam multiple times without staff documenting non-pharmacological interventions attempted prior to administration. The care plan lacked details on the use of anti-anxiety medication and interventions, and the facility had no policy or established process for such documentation until a recent system update.
Two residents prescribed psychotropic medications did not have their care plans updated to reflect new medication orders, monitoring for side effects, or non-pharmacological interventions. The MDS coordinator confirmed omissions in care plan documentation for both an antidepressant and an antianxiety medication.
Staff did not complete accurate assessments or provide timely interventions for two residents with complex medical needs. One resident continued to receive compression hose after the order was discontinued, with inconsistent documentation and confusion among staff about current orders. Another resident with cardiac conditions and on anti-coagulant therapy had chronic bruising that was not properly documented or tracked due to omissions in the initial assessment and unclear staff responsibilities.
A resident with a history of falls and cognitive impairment was observed multiple times in bed without required fall mats, despite care plan directives and recent injury. Staff interviews revealed inconsistent awareness and implementation of fall prevention measures, and documentation of interventions was not reliably completed. The DON confirmed the care plan was not followed, contrary to facility policy.
A resident with multiple cardiac and respiratory conditions did not receive oxygen therapy as ordered, with observations showing the oxygen flow rate set below prescribed levels and periods when oxygen was not administered at all. Staff interviews revealed inconsistent practices in monitoring and adjusting oxygen delivery, leading to a failure in providing safe and appropriate respiratory care.
Staff failed to follow infection prevention protocols for two residents: one with an indwelling catheter did not receive care using required EBP, including the use of gowns and proper disinfection after a spill, and another with respiratory symptoms was not promptly placed in appropriate isolation, resulting in continued participation in group activities while symptomatic. Staff interviews revealed inconsistent understanding and application of infection control policies.
The facility was found to have deficiencies in food storage and labeling practices. Open food items, such as planko crumbs, sugar, pancake mix, and taco shells, were undated and uncovered. Additionally, thawing meat was improperly stored above other food items in the refrigerator, contrary to the facility's policy. The Dietary Manager acknowledged these issues, which violate the facility's Food Receiving and Storage policy.
The dietary staff at the facility failed to properly execute the pureed food process for residents requiring a pureed diet. A cook was observed pureeing meals without measuring ingredients or using the correct scoop size, and admitted to not being trained on the process. The VP of Culinary stated that staff should follow specific recipes and use a graph to determine scoop size if changes are made, as per facility policy.
Failure to Provide Required Beneficiary Notifications at Discharge
Penalty
Summary
The facility failed to provide required beneficiary notifications regarding Medicaid/Medicare coverage and potential liability for non-covered services to a resident upon discharge. Specifically, clinical record review showed that a resident who was admitted and later discharged did not receive the Advanced Beneficiary Notification (ABN) or the Notice of Medicare Non-Coverage (NOMNC) as mandated by federal regulations. When surveyors requested documentation, the facility was unable to produce the required notifications for this resident, although notifications for two other residents were provided. Interviews with facility staff revealed that the Social Services Coordinator, who was newly hired, discovered the missing notifications while auditing previous work. She confirmed that the required notifications had not been given to some residents at discharge. The DON acknowledged awareness of the missing notifications but stated that overseeing this process was not within his responsibilities. The facility administrator reported that there was no formal policy on ABN/NOMNC notifications, but that the facility follows CMS guidelines.
Failure to Document Non-Pharmacological Interventions Before PRN Anti-Anxiety Medication
Penalty
Summary
Facility staff failed to document non-pharmacological interventions attempted prior to administering anti-anxiety (AA) medication to a resident diagnosed with anxiety disorder. The resident was admitted with a diagnosis of anxiety disorder and was prescribed clonazepam 0.5 mg every 8 hours as needed. Over the course of two months, the medication was administered multiple times, but the clinical record and Medication Administration Record (MAR) lacked documentation of non-pharmacological interventions attempted before each administration. The resident's care plan did not include information about the use of AA medication or the non-pharmacological interventions used or attempted prior to administration. Interviews with staff revealed that, until recently, there was no process in place for documenting non-pharmacological interventions prior to PRN AA medication administration. The electronic MAR system had only recently been updated to prompt staff to document such interventions, but prior to this update, no documentation was required or completed. Additionally, the Director of Nursing confirmed that the facility did not have a policy regarding psychotropic medication use and non-pharmacological interventions.
Failure to Update Care Plans for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for two residents who were prescribed psychotropic medications. For one resident, the care plan initiated did not document the use of an antidepressant or provide directives for staff regarding monitoring for medication side effects, despite physician orders indicating the resident was started on Lexapro for depression. The MDS coordinator confirmed that the antidepressant was not added back to the care plan after the resident returned from the hospital and the medication was prescribed. For another resident with diagnoses of anxiety disorder and depression, the care plan was missing information about the use of an antianxiety medication, non-pharmacological interventions attempted prior to administration, and monitoring for side effects or symptoms related to the medication. The resident's order summary showed a PRN order for clonazepam for anxiety, but this was not reflected in the care plan. The MDS coordinator acknowledged that the antianxiety medication was not listed in the care plan at the time of review.
Failure to Complete Accurate Assessments and Provide Timely Interventions for Residents with Edema and Skin Conditions
Penalty
Summary
Staff failed to appropriately complete resident assessments and provide timely interventions for two residents with significant medical needs. For one resident with a history of coronary artery disease, hypertension, heart failure, localized edema, and acute respiratory failure, the care plan did not document the use of compression hose as ordered. Despite a physician's order discontinuing the use of compression hose, staff continued to apply them, and there was confusion among staff regarding whether the resident should be wearing them. Documentation in the electronic health record and medication administration record was inconsistent, with staff unsure about current orders and responsibilities for monitoring and documenting the use of compression hose. For another resident with multiple cardiac diagnoses and long-term use of anti-coagulant therapy, the initial assessment failed to document the presence of purpura or chronic bruising on the forearms and hands. The care plan instructed staff to monitor for bruising due to anti-coagulant use, but there was no ongoing documentation of bruising in the medication administration record or nursing progress notes after the initial mention. Staff interviews revealed a lack of clarity regarding who was responsible for tracking and documenting the bruising, and the initial assessment's omission led to the absence of a tracking task for this condition. Both deficiencies were identified through clinical record review, observations, resident and staff interviews, and policy review. The findings indicate that the facility did not ensure accurate and complete assessments or timely interventions according to physician orders and resident needs, resulting in lapses in care planning, documentation, and monitoring for residents with complex medical conditions.
Failure to Implement Care Planned Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and maintain care planned interventions to prevent and mitigate falls for a resident with a history of falls and significant cognitive impairment. The resident, who had diagnoses including atrial fibrillation, stroke, a displaced fracture of the right femur, and senile degeneration of the brain, was care planned to have fall mats on both sides of the bed, the bed in the lowest position, non-skid footwear, and a clutter-free environment. Despite these documented interventions, multiple direct observations revealed that the resident was in bed without fall mats in place on several occasions. Staff members, including a registered nurse and certified nurse aides, did not consistently recognize or implement the requirement for fall mats, and documentation in the electronic health record was not reliably completed to confirm that interventions were in place. Interviews with staff indicated a lack of awareness or understanding of the resident's care plan requirements, with some staff unaware that fall mats were needed and others confirming that documentation of interventions was expected but not always performed. The Director of Nursing acknowledged that the care plan was not being followed and expressed concern about the potential for harm, especially given the resident's recent femur fracture. Review of facility policy confirmed that the nursing team is responsible for communicating and implementing fall prevention interventions for residents with a history of falls.
Failure to Ensure Safe and Accurate Oxygen Therapy Delivery
Penalty
Summary
The facility failed to ensure safe and accurate delivery of oxygen therapy for a resident with significant cardiac and respiratory diagnoses, including coronary artery disease, heart failure, and acute respiratory failure with hypoxia. The resident's care plan and physician's orders specified continuous oxygen therapy at 2-3 liters via nasal cannula to maintain oxygen saturation above 88%. However, multiple observations revealed that the oxygen concentrator was set below the ordered range, at 1 1/2 and 1 3/4 liters, and at one point, the resident was found without oxygen, with both the concentrator and portable tank turned off and the tubing stored away. The resident had to request staff assistance to have her oxygen reapplied. Staff interviews indicated a lack of clarity and consistency in following the oxygen therapy orders. A CNA reported that she only turns the oxygen on or off and does not adjust the flow rate, while an RN initially believed the oxygen was set correctly but, upon closer inspection, found it was below the ordered rate and adjusted it. These actions and inactions resulted in the resident not receiving oxygen therapy as ordered, constituting a failure to provide safe and appropriate respiratory care.
Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for residents requiring enhanced barrier precautions (EBP) and droplet/contact precautions. For one resident with obstructive uropathy and an indwelling catheter, staff did not follow EBP guidelines as outlined in the care plan and facility policy. During an observed catheter care procedure, the certified nursing assistant (CNA) wore gloves but did not don a gown as required. Additionally, after urine was spilled on the floor, the CNA cleaned the area with a paper towel instead of using an appropriate disinfectant, contrary to the infection preventionist's expectations and facility policy. Staff interviews revealed inconsistent understanding and application of EBP protocols. One CNA believed EBP was only necessary for residents with certain infections like influenza, COVID, or C. difficile, while another stated she would use a gown and gloves for catheter care if an EBP sign was posted. The infection preventionist clarified that a gown and gloves should always be used for catheter care and that contaminated surfaces must be disinfected with approved wipes, not just wiped with a paper towel. In a separate incident, another resident with respiratory symptoms and a diagnosis of Parainfluenza Type 2 was not placed in transmission-based precautions (TBP) until after returning from the emergency department, despite having symptoms for several days. Staff interviews indicated a lack of clarity regarding when to initiate isolation and which type of precautions to use. The care plan was not updated to reflect the resident's symptoms or need for TBP until after the diagnosis was confirmed, and the resident continued to participate in communal dining while symptomatic.
Improper Food Storage and Labeling
Penalty
Summary
The facility failed to adhere to proper food storage and labeling protocols, as observed during a survey. In the main kitchen, several open food items, including a 25-pound bag of planko crumbs, a 25-pound bag of sugar, two boxes of pancake mix, and packages of hard and soft taco shells, were found undated and uncovered. Additionally, a tray of frozen meat was improperly stored on a middle shelf in the walk-in refrigerator, thawing above a pie, which violates the facility's policy of storing thawing meat separately and on the bottom shelf to prevent cross-contamination. During an interview, the Dietary Manager acknowledged the expectation that dry food should be stored in sealed containers and that open food should be sealed, labeled, and dated. The facility's Food Receiving and Storage policy, revised in October 2018, requires dry foods to be removed from original packaging, labeled, and dated, and mandates that uncooked and raw animal products be stored separately in drip-proof containers below fruits, vegetables, and other ready-to-eat foods. The policy also specifies that opened containers must be dated and sealed or covered during storage.
Deficiency in Pureed Food Preparation Process
Penalty
Summary
The facility's dietary staff failed to properly execute the pureed food process for three residents requiring a pureed diet. During an observation, a cook, identified as Staff A, was seen pureeing chicken fried steak, corn, and strawberry shortcake without measuring the ingredients or using the appropriate scoop size as per the facility's guidelines. Staff A admitted to not being trained on the puree process and was uncertain about the correct scoop size to use for serving the residents. In an interview, Staff B, the VP of Culinary, stated that kitchen staff are expected to follow specific recipes from [NAME] Brothers, which include exact measurements for food, fluids, and thickeners, as well as the correct scoop size for serving. Staff B emphasized that if any changes are made to the recipe, the graph should be used to determine the appropriate scoop size, and the serving staff should be informed of any changes. The facility's policy on Appealing Pureed Foods also documented the need to follow the correct amounts of food as noted in the recipe.
Latest citations in Iowa
An LPN, unfamiliar with residents on a medication cart and faced with two residents sharing the same first name, failed to correctly identify a resident and administered a full set of another resident’s medications in addition to the resident’s own ordered morning medications, including PRN oxycodone. The resident, who had severe cognitive impairment and multiple diagnoses including hypertension and Alzheimer’s disease, subsequently experienced declining BP, reported not feeling well, and became increasingly fatigued. The facility’s policy required resident identification before medication administration, and the LPN acknowledged not knowing the residents and finding the EHR photos too small, despite their availability. Hospital records later documented hypotension, treatment with IV fluids, and a drug overdose after accidental ingestion of another resident’s medications plus the resident’s own, with persistent sinus bradycardia requiring admission for further hemodynamic monitoring.
A cognitively impaired, wandering resident with Alzheimer’s disease and behavioral symptoms was care planned as an elopement risk but was able to leave the memory care unit by holding an emergency exit door bar for 15 seconds and exiting into a stairwell and then to the employee parking lot. The door alarm functioned, but staff in the noisy dining room did not hear it while they were feeding multiple residents, including several needing extensive assistance, and only realized the resident was missing when another staff member encountered him outside and brought him back. In addition, several residents who required staff assistance for transfers and toileting experienced prolonged call light response times well beyond the facility’s 15‑minute expectation, including one who reported waiting up to an hour during meals and having an in‑room accident, another observed waiting about 25 minutes while calling out for help, and a third waiting about 17 minutes before a CNA responded.
A cognitively intact resident reported that a CNA ripped her incontinence brief during care and then refused to change it, despite the resident stating she could not wear it due to the tear. The resident became upset and informed housekeeping staff, who then asked an LPN to assist. On assessment, the LPN observed a large rip extending around the back of the brief, changed the brief, and provided peri care at the resident’s request. The resident stated the ripped brief was uncomfortable and that she did not feel treated with dignity or respect. In interviews, the CNA acknowledged telling the resident the torn brief would still work and did not change it, while the DON confirmed the CNA had refused the resident’s request for a brief change, in conflict with the facility’s dignity policy.
A deficiency was identified when a CNA did not follow manufacturer instructions for a mechanical stand while transferring a resident with severe cognitive impairment, a history of hip fracture, dementia, and muscle wasting who required substantial assistance for transfers. The resident’s care plan called for use of a mechanical stand, but during observed toileting and return-to-chair transfers, the CNA repeatedly locked and unlocked only one wheel of the device and did not keep the brakes unlocked during the actual transfer, contrary to the operator’s instructions that brakes be locked only when raising and lowering the resident during ambulation. In an interview, the DON confirmed staff were expected to follow these operator instructions and keep the wheels unlocked during transfers.
A resident with dementia, behavioral symptoms, and multiple psychotropic and cardiovascular medications was discharged to another nursing facility without a thorough or accurate discharge summary. The care plan contained a discharge planning focus but was never updated to reflect the actual discharge, and the EHR lacked documentation of discharge planning, the reason for discharge, or a recapitulation of stay, despite a family member stating they initiated the discharge due to dissatisfaction with care. The discharge instructions contained multiple medication discrepancies and omissions, including missing drugs, incorrect dosages, and absent administration frequencies, and several PRN constipation medications were not listed, contrary to the facility’s written discharge planning policy.
A resident was admitted from a hospital without a completed Preadmission Screening and Resident Review (PASRR) in the medical record, as required prior to admission. The PASRR was only completed several days later by the Hospital Liaison/Admissions Coordinator after a call alerted staff that it was missing. Both the admissions coordinator and the Administrator acknowledged that the facility relies on the hospital to provide the PASRR and that, in this case, it was missed and not done before the resident’s admission.
A resident with Alzheimer's disease, severely impaired cognition, and documented nutrition/hydration risk required partial to moderate assistance with eating and was care planned for assisted feeding with a general diet and thin liquids. During a breakfast observation, the resident was seated in a reclined Broda chair while staff placed food and beverages on an overbed table and attempted to offer chocolate milk and hot cereal without first positioning the resident upright, causing the resident to struggle to reach the cup. Facility policy on feeding required residents needing assistance to be positioned comfortably in an upright position, and the DON stated she expected residents to be upright whenever food or drink was offered, but there was no separate positioning policy in place.
A resident with a left leg fracture, muscle wasting, and impaired mobility was dependent on a mechanical lift for transfers. Staff positioned the lift at the side of the wheelchair instead of straight on, and the lift tipped and struck the resident’s forehead with the sling-holding part, causing a bruise and protruding bump. Staff interviews confirmed the transfer was done from the side and that the resident’s care plan required straight-on positioning for the lift.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance: Several residents did not receive bathing and hygiene assistance as scheduled. One resident with intact cognition and a stroke history was observed unshaven and said staff did not always shave him during showers, while staff noted the bath sheets no longer tracked shaving or nail care. Other residents with severe cognitive impairment or dependence for bathing went extended periods without baths, and one cognitively intact resident reported missing baths and wanting them. Facility records and staff interviews showed bathing schedules were not consistently followed or documented as required.
QAPI program failed to address repeated deficiencies. Review of the facility’s visit history showed repeated F689, Free of Accident Hazards/Supervision/Devices, and F880, Infection Prevention and Control, across multiple annual surveys and complaint investigations. The QAPI plan stated it would review sources of information for gaps or patterns in care systems, and the Administrator acknowledged the repeated deficiencies and said the facility would review and discuss plans to improve.
Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to follow the 5 rights of medication administration, resulting in one resident receiving another resident’s medications in addition to their own. The resident had diagnoses including hypertension, Alzheimer’s disease, and toxic encephalopathy, with a BIMS score of 3 indicating severe cognitive impairment. On the morning in question, review of the MAR showed the resident received their ordered medications, which included aspirin, calcium carbonate, vitamin C, vitamin D, fluoxetine 20 mg, furosemide 40 mg, galantamine, a lidocaine patch, memantine, acetaminophen, and PRN oxycodone around 8:00 a.m. According to the incident report and nursing progress notes, the LPN (Staff A) administered another resident’s full set of morning medications to this resident while the resident was in the dining room. These additional medications included metoprolol 60 mg, Lyrica 75 mg, oxycodone 7.5/325 mg, furosemide 40 mg, celecoxib 100 mg, Prozac 60 mg, hydroxyzine 10 mg, cetirizine 10 mg, Neuriva, Protonix 20 mg, potassium 99 mg, a multivitamin, and vitamin D3. These medications were given in addition to the resident’s own morning medications and PRN oxycodone. The nurse’s notes documented that the resident’s blood pressure readings declined from 100/50 to 85/48 and then to 73/48, and the resident complained of not feeling well and was increasingly fatigued. Staff A reported during interview that the resident had been screaming and yelling and that she did not realize there were two residents with the same first name in the back hallway. She stated it was her first time working in that hallway after training and that, although resident pictures were available in the EHR to assist with identification, she felt they were small and she did not know the residents. The facility’s medication management policy required staff to identify the resident before administering medications. Staff A’s employee record showed a prior medication occurrence in which she administered the wrong medications (including furosemide and potassium) to a resident, and she had documented previously that she was not familiar with residents when working on that cart. The resident was ultimately sent to the ER, where records documented hypotension on admission, treatment with IV fluids, and a chief complaint of drug overdose after accidental ingestion of another resident’s multiple medications in addition to the resident’s own medications, with continued sinus bradycardia requiring admission for further hemodynamic monitoring.
Elopement of Wandering Resident and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for a cognitively impaired, wandering resident and failure to respond to resident call lights within the facility’s stated 15‑minute expectation. One resident with Alzheimer’s disease, bipolar disorder, and anxiety disorder had a care plan identifying risk for elopement due to wandering and documented behaviors of agitation, aggression, restlessness, and continuous pacing/wandering within the unit. This resident ambulated independently with a walker and had a BIMS score indicating impaired cognition. On the evening of the incident, the resident finished supper in the memory care dining room and then repeatedly walked the hallway with his walker, eventually approaching an emergency exit door at the far end of the hall, away from the dining room. Video and documentation show that the resident stood at the emergency exit door, held the door bar down for the required 15 seconds to release the egress, and then exited through the door into a stairwell and out to the employee parking lot. The door alarm and 15‑second egress functioned, but staff in the dining room did not hear the alarm due to noise from residents, staff conversation, and the television. At the time, two CNAs and one LPN were in the dining room feeding multiple residents, including several who required assistance, and staff reported that the resident was very quick, wandered constantly, and was difficult to keep seated. Staff interviews revealed that one CNA noticed the resident was no longer in the dining room around the same time another staff member reported they were looking for him, and only then did staff recognize the back exit door alarm sounding. A nurse arriving for her shift in the parking lot encountered the resident outside with his walker and escorted him back inside, after which he was assessed and found in stable condition. The deficiency also includes failure to respond to resident call lights within the professional standard of 15 minutes for multiple residents. One resident with intact cognition but dependent or substantial/maximal assistance needs for toileting reported that during meal hours it could take up to an hour for staff to answer the call light, resulting in an in‑room accident. Another resident, alert and oriented but occasionally forgetful and requiring two‑person assistance for transfers, was observed with the call light on for approximately 25 minutes in the morning while repeatedly yelling for help; staff walked past in the hallway without answering the light until a staff member finally entered the room. A third resident, requiring one‑person assistance for transfers, was observed with the call light on for about 17 minutes before a CNA entered to assist. The DON stated that the facility’s expectation is that call lights be answered within 15 minutes, and the facility’s policy directs all staff from all departments to respond to call lights and either assist or obtain appropriate help, but the observed response times exceeded this standard for the residents involved. Staff interviews further described the conditions contributing to these call light delays and supervision gaps. Staff on the memory care unit reported that typical evening staffing consisted of one nurse, one CMA, and two CNAs, and that while this was manageable when routines went smoothly, it became inadequate when residents had behaviors, were sundowning, or when events such as falls or changes in condition occurred. A CMA stated that at least three CNAs were needed on the memory care unit due to multiple residents requiring two‑person assistance, noting that when two CNAs were in a room providing care, they could not monitor the rest of the unit. Staff also reported that the back exit door alarm was faint and difficult to hear from the dining room, and some staff were not fully aware of the configuration of the back stairwell and exit leading to the parking lot. These conditions, combined with high resident care needs and noise levels during meals, contributed to the resident’s elopement and to prolonged call light response times for several residents. Maintenance and administrative staff confirmed that the south/back exit door from the unit led to another unalarmed door and then to the outside employee parking lot, and that the facility did not receive system reports when door alarms were activated. The Administrator was unable to verify when a door alarm went off or when an exit door was breached. The facility’s Wandering Resident policy stated that residents at risk for elopement should receive adequate supervision to prevent accidents and that staff must be vigilant in responding to alarms in a timely manner, and the call light policy required prompt response by all staff. Despite these policies, the documented events show that the resident at risk for elopement was able to leave the secured unit and reach the parking lot without timely staff detection, and that multiple residents experienced call light response times significantly longer than the facility’s stated 15‑minute standard.
Failure to Honor Resident Request for Brief Change and Maintain Dignity
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and respect when a cognitively intact resident’s request for a brief change was not honored. The resident, with a BIMS score of 15 indicating no cognitive impairment, reported being upset because a CNA (Staff N) ripped her brief during care and then refused to change it. The resident self-propelled down the hallway stating she was upset about the ripped brief and that staff would not change it. A housekeeping staff member (Staff M) observed the resident’s distress, was told that the CNA had refused to change the brief despite a large rip, and then asked an LPN (Staff O) to assist with changing it. During the subsequent brief change, Staff O performed hand hygiene, used gloves, removed the resident’s pants and brief, and provided peri care at the resident’s request before applying a new brief and redressing the resident. Observation of the removed brief revealed a large rip on the left side extending past the middle of the resident’s back. The resident stated the brief with the hole was uncomfortable and that she felt staff did not provide her with dignity and respect when her request for a new brief was not honored. Staff O confirmed that the brief had a very large hole and that the resident was very upset, reporting she did not feel treated with dignity or respect and that the ripped brief was uncomfortable. In an interview, Staff N acknowledged caring for the resident that day, stated the resident had been upset and had “behaviors,” and reported that when the resident said she wanted her brief changed because it was ripped, Staff N told her the brief would still work and that urine would not get everywhere, characterizing the tear as “just a little tear.” Staff N stated the resident did not explicitly ask her to change the brief. The DON later stated that Staff N had ripped the brief, the resident had requested a brief change, Staff N said she would not change it, and acknowledged that a lack of dignity occurred when Staff N refused to change the resident’s brief, contrary to the facility’s dignity policy.
Improper Use of Mechanical Stand Brakes During Resident Transfers
Penalty
Summary
Surveyors identified a deficiency related to accident prevention when staff failed to properly use a mechanical stand’s brakes during transfers for one resident. The resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment, required substantial assistance for transfers, and had diagnoses including hip fracture, dementia, and muscle wasting. The care plan documented initiation of a mechanical stand for transfers. During observation, a CNA applied a sling, locked the right wheel of the mechanical stand, lifted the resident from a chair, then unlocked the right wheel and positioned the resident over the toilet. The CNA then lowered the resident onto the toilet and locked the right wheel. After the resident finished, the CNA lifted the resident from the toilet, unlocked the right wheel, positioned the resident over the chair, locked the right wheel, and lowered the resident, thereby failing to keep the mechanical stand brakes unlocked during the transfer as required by the operator’s instructions, which specified that brakes should only be locked when raising and lowering the resident during ambulation. In an interview, the DON stated that staff were expected to follow the operator’s instructions and keep the wheels unlocked during transfers, confirming that the observed practice did not align with the manufacturer’s guidance for safe operation of the mechanical stand.
Failure to Complete Accurate and Thorough Discharge Summary and Documentation
Penalty
Summary
Surveyors identified a failure to complete a thorough and accurate discharge summary and related discharge documentation for one resident who was discharged from the facility. The resident was admitted in early March with moderate cognitive impairment, a Brief Interview for Mental Status (BIMS) score of 08, and documented delusions and behavioral symptoms. Diagnoses included dementia with agitation, anxiety disorder, and depression. Although the care plan contained a discharge planning focus initiated shortly after admission, it did not contain any updates or documentation related to the resident’s actual discharge later that month. The electronic health record (EHR) contained a communication note indicating that transport to another nursing facility was arranged and a health status note stating that the resident was discharged, with physician orders and a face sheet faxed and a report called to the receiving facility. The resident’s EHR did not contain documentation of the discharge planning process, the reason for the discharge, or a recapitulation of the resident’s stay. A family member reported that the family initiated the discharge due to dissatisfaction with care, but there was no documentation in the EHR reflecting that the family initiated the discharge. The Long Term Care Ombudsman reported that no one contacted her during the resident’s stay, although her office did receive notice of the transfer. The facility’s own discharge planning policy required that discharge planning begin on admission, be routinely updated in the comprehensive care plan, and that the evaluation of discharge needs and the final discharge plan be completely documented in the clinical record and discussed with the resident or representative. Review of the resident’s discharge instructions and March medication administration record revealed multiple discrepancies and omissions in the discharge summary. One medication (Amlodipine 10 mg) was listed without any frequency or time of administration. Several medications that the resident was receiving, including Donepezil 10 mg, Lisinopril 5 mg, and Buspirone 10 mg twice daily, were not included on the discharge summary. Other medications were inaccurately documented, such as Memantine, which was ordered as 20 mg once daily but listed as 10 mg twice daily, and Seroquel, ordered as 50 mg twice daily but listed as once daily. Several PRN constipation medications were also omitted. The Regional Nurse Consultant confirmed that the facility’s EHR contained a discharge assessment tool that was not completed for this resident and acknowledged the multiple medication discrepancies on the discharge summary form.
Failure to Complete PASRR Evaluation Prior to Admission
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) evaluation for a resident with an admission date of 4/22/26. The resident’s electronic health record documented admission from a hospital on 4/22/26, but review of the record showed no PASRR completed at the time of admission. A PASRR form for this resident was later obtained and showed it was completed on 4/27/26 by the Hospital Liaison/Admissions Coordinator, several days after the resident had already been admitted. During interview, the Hospital Liaison/Admissions Coordinator stated that the hospital usually completes the PASRR, acknowledged receiving a call the previous night that the PASRR was not in the chart, and admitted she had missed completing it prior to admission even though it should have been done. The Administrator similarly reported that the facility relies on receiving the PASRR from the hospital admission records and that, in this case, the PASRR was missed and not completed prior to the resident’s admission. This resulted in a deficiency for failure to ensure a PASRR evaluation was completed prior to admission for 1 of 3 reviewed residents, in accordance with PASRR requirements.
Failure to Properly Position Resident Upright During Assisted Feeding
Penalty
Summary
Surveyors identified a deficiency in resident positioning during mealtime for a resident with Alzheimer's disease and severely impaired cognition, as evidenced by a Brief Interview for Mental Status score of 2. The resident’s MDS indicated a need for partial to moderate assistance with eating, and the care plan documented nutrition and hydration risk related to end-stage diagnosis, cognitive limitations, and weakness, with directions for a general diet, thin liquids, and assistance with eating. During a breakfast observation on the Magnolia Unit, the resident was seated in a Broda chair that was reclined back. A dietary aide placed food on the table in front of the resident, and a CNA then placed beverages and food on an overbed table before walking away, while the resident remained reclined with eyes closed and the plate of food untouched. Later in the same observation period, another CNA offered the resident chocolate milk while the Broda chair remained tilted backward, and the resident had to struggle to move her head up and forward to reach the cup. The same CNA then offered hot cereal, which the resident declined by saying “later.” A different CNA subsequently offered another drink of chocolate milk, again without adjusting the reclined position of the Broda chair. Policy review showed the facility’s “Feeding of Residents by Staff” policy required that residents unable to feed themselves be assisted per their care plan and be positioned comfortably in an upright position. In an interview, the DON stated there was no specific positioning policy, that staff received positioning education in training, and that her expectation was that residents be placed in an upright position whenever food or drink was offered.
Mechanical Lift Transfer Caused Resident Forehead Injury
Penalty
Summary
The facility failed to provide a safe and adequate mechanical lift transfer for Resident #18, who had a left leg fracture, muscle wasting, and impaired gait and mobility, but no cognitive impairment based on a BIMS score of 15. The resident’s care plan required two staff members to use a mechanical lift for transfers because the resident was nonweight-bearing on the left leg. The care plan update also directed staff to approach the wheelchair straight on and not from the side, and to have the resident bend the right leg and turn away from the lift during transfers. During a wheelchair transfer, staff positioned the mechanical lift at the side of the wheelchair and began the transfer. The lift tipped and struck the resident’s forehead with the part that held the sling. The resident sustained a bruise and a protruding bump on the left forehead, and the incident documentation noted the resident’s head was hit on the lift. The resident later reported that the lift almost fell to the floor and that additional staff were needed to return it upright. Staff interviews confirmed that the transfer was performed from the side of the wheelchair. One CNA stated the lift may have caught on bars under the wheelchair and acknowledged that staff had been educated not to use the lift from the side. Another CNA stated the lift was used from the side because the resident did not want her leg hit by the lift, and identified the sling-holding part of the lift as the piece that struck the resident’s forehead. The DON stated the proper procedure was to position the mechanical lift directly in front of the wheelchair rather than to the side.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living for 5 of 8 residents reviewed, specifically related to bathing and shaving. Resident #3 had a BIMS score of 15 and was dependent on staff for personal hygiene, with diagnoses including renal insufficiency, stroke, hemiplegia, and seizure disorder. The resident was observed unshaven, stated he was getting showers but not shaved every time, and said he needed help shaving since his stroke. Facility records showed showers were documented without indicating whether shaving was completed, and staff interviews confirmed the bath sheets no longer tracked shaving or nail care, while the DON stated male residents should be offered shaving during showers and it should be documented if completed or refused. Resident #1 had a BIMS score of 4, diagnoses including muscle weakness, diabetes, and hip fracture, and was care planned as an extensive assist for bathing. Review of the follow-up report showed the resident went 17 days without a bath and later 19 days without a bath. Resident #11 had a BIMS score of 3, diagnoses including depression, hypertension, and anemia, and was scheduled for bathing on Wednesday morning and Friday afternoon, but the follow-up report showed gaps of 6 days, 6 days, and 18 days between baths. Resident #27 also had a BIMS score of 3 with depression, hypertension, and anemia, was scheduled for bathing on Monday and Thursday afternoon, and the follow-up report showed the resident went 19 days and then 20 days without a bath, with refusals documented on two occasions. Resident #85 had a BIMS score of 15, diagnoses including hypertension, depression, and need for assistance with personal care, and stated she did not get 2 baths the prior week and wanted them. Her care plan identified her as dependent for bathing, but lacked bathing frequency, and the task list scheduled bathing for Monday morning and Wednesday afternoon. The follow-up report showed multiple extended gaps between baths, including 12 days, 7 days, 18 days, and 7 days. Facility policy stated bathing is intended to promote cleanliness, provide comfort, and observe skin condition, and the Regional Nurse Consultant stated bathing should be completed as scheduled.
QAPI Program Failed to Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive and effective QAPI program and did not have a plan that described the process for conducting QAPI and QAA activities. Review of the DIAL website visit history showed repeated deficient practices identified during the facility’s annual survey and complaint investigation on 3/27/25 and during the annual survey, complaint, and facility-reported incident investigation on 4/19/26. The repeat deficiencies included F689, Free of Accident Hazards/Supervision/Devices, which had been repeated in the previous three consecutive annual surveys, and F880, Infection Prevention and Control, which had been repeated in the previous four consecutive annual surveys. The facility’s QAPI plan stated that it would review sources of information to determine whether gaps or patterns existed in systems of care that could result in quality problems or opportunities for improvement. During an interview on 4/23/26 at 1:28 PM, the Administrator acknowledged the repeated F689 and F880 deficiencies and stated the facility would review and discuss plans to improve.
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