Colonial Manor Of Elma
Inspection history, citations, penalties and survey trends for this long-term care facility in Elma, Iowa.
- Location
- 407 9th Street, Elma, Iowa 50628
- CMS Provider Number
- 165386
- Inspections on file
- 20
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Colonial Manor Of Elma during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dementia, hallucinations, delusions, and a documented pattern of physical and verbal aggression was allowed to ambulate freely and repeatedly exhibit disruptive and threatening behaviors toward others without behavior‑specific care plan interventions. This resident ultimately slapped another cognitively intact resident on the upper arm in a hallway confrontation, causing pain and a red mark, after staff were unable to separate them in time. Following this event, the assaulted resident, who had a history of anxiety and depression, reported increased anxiety, fear of being hit again, social withdrawal to her room, use of headphones during meals to block out the aggressive resident’s outbursts, and reduced meal intake, while staff observed her crying and avoiding interaction. Two other cognitively intact residents also reported being scared of the aggressive resident, limiting their time out of their rooms and declining activities due to her yelling, screaming, and perceived risk of being hit. Staff interviews and documentation confirmed that the aggressive resident’s behaviors had worsened over months, that other residents were fearful, and that the care plan did not include interventions for the known aggressive behaviors, despite an abuse policy prohibiting physical abuse such as hitting and slapping by other residents.
A resident with moderate cognitive impairment and chronic pain had an active order for fentanyl 25 mg patches when staff later discovered two patch packages in the resident’s supply that were empty, appeared cut open, and had been taped shut and returned to the box. Facility investigation records identified this as medication diversion involving the resident’s fentanyl patches, meaning the ordered opioid patches were removed from their packaging without the resident’s consent, resulting in misappropriation of the resident’s medication.
Failure to document non-pharmacological interventions before PRN lorazepam administration. A resident with severe cognitive loss, dementia, and anxiety had a PRN order for lorazepam for anxiety/restlessness, and the care plan directed staff to try measures such as 1:1 interaction, hydration, snacks, music, toileting, and other calming interventions before giving psychotropic meds. Progress notes and the psychotropic med review did not document those interventions before multiple PRN doses, and staff interviews confirmed the missing documentation.
Incorrect PASRR Level II Coding on MDS Assessments: The facility inaccurately coded 2 MDS assessments for residents with PASRR Level II outcomes. One resident had diagnoses including anxiety, depression, bipolar disorder, and schizophrenia, and another resident had moderate cognitive impairment on BIMS; however, both records showed PASRR Level II approval for mental illness, and the MDSs incorrectly indicated no Level II PASRR serious mental illness and/or intellectual disability or related condition.
A resident with diagnoses including anxiety, depression, bipolar disorder, and schizophrenia had a PASRR directing specialized services in the form of a behavior management plan for anxiety/worry, verbal aggression, irritability, and anger-related communication. However, the care plan lacked a behavior management plan, and the DON confirmed none was in place.
A resident with bowel and bladder incontinence, renal failure, DM, and recent UTI treatment received improper incontinent care when a CNA used soiled gloves to handle a clean brief and then fastened it without hand hygiene. The DON observed the error, and the resident’s care plan noted frequent UTIs and peri-care twice daily, but did not include EBP direction.
Failure to obtain ordered daily weights and report significant weight gains. A resident with severe cognitive impairment, aphasia, metabolic encephalopathy, and acute respiratory failure had a provider order for daily weights and notification for weight gains over 3 lb in a day, but the EHR showed multiple missing daily weights and 3-lb gains that were not documented as reported to the MD. The DON said daily weights had been started because of unexplained edema, and the Administrator said staff were expected to obtain and enter the weights daily.
Improper medication handling during a med pass: a CMA failed to perform hand hygiene and repeatedly touched medication cards, cart surfaces, and stock bottles with bare hands or gloves before preparing and administering meds to three residents. The DON, an LPN, and another CMA stated hand hygiene should occur between residents, and the facility policy directed hand hygiene before and after each resident’s med pass and said meds should not be touched.
A resident with severe cognitive impairment and a history of falls did not have a care plan intervention—a chair alarm—implemented as required. Staff observed the resident stand up and fall from a wheelchair, and multiple staff members confirmed the chair alarm was not in place at the time, despite facility policy and the care plan specifying its use.
A resident with intact cognition reported that a CNA used offensive language in her presence, speaking derogatorily about an LPN. The CNA admitted to the behavior, which was confirmed by the LPN and other staff. The facility's policy on dignity and respect was violated, as staff are expected to provide considerate and respectful care.
The facility failed to follow CDC guidelines for Enhanced Barrier Precautions during catheter care for three residents, leading to a deficiency in infection prevention and control. Staff did not use isolation gowns as required, and there was a lack of proper signage and PPE availability. The Director of Nursing confirmed the need for EBP for residents with urinary catheters, but issues with staff awareness and equipment availability were evident.
A facility failed to complete a Significant Change Status Assessment (SCSA) MDS within 14 days for a resident who elected hospice care. The resident, with severe cognitive loss and multiple diagnoses, was signed into hospice care, but the MDS lacked documentation of hospice services. The MDS Coordinator was aware of the hospice admission but missed setting up the SCSA MDS, and the DON expected adherence to RAI guidelines.
A resident with a history of lower extremity impairment fell and was improperly assisted to a standing position by the ADON without a full assessment, leading to a diagnosis of a hip fracture. The ADON admitted to not performing a proper assessment and altering documentation. The facility had recently discontinued fall alarms, raising concerns from the resident's family.
The facility failed to ensure that the Dietary Service Manager had the required qualifications in the absence of a full-time dietician. The Dietary Manager was in the process of enrolling in dietary manager classes, and the Consultant Dietician confirmed that the manager was not yet certified. The employee file lacked documentation of a certificate of completion for the Dietary Manager courses.
The facility failed to follow physician orders for a resident with benign prostatic hyperplasia, anxiety, and hypertension. Despite a physician order for a Urology referral, no appointment was scheduled, and there was no documentation of any call to Urology. The DON confirmed the lapse and noted the absence of a policy for handling physician orders.
The facility failed to conduct proper assessments for a resident with impairments in both upper and lower extremities to determine if she remained at baseline or had experienced a decline in ROM and mobility. Staff acknowledged the resident's refusals for restorative care but did not document ongoing assessments or conduct a new therapy screen during the annual review as required.
Failure to Protect Residents From Aggressive Resident Leading to Abuse and Fear
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse and to implement appropriate care plan interventions for a resident with severe cognitive impairment and escalating aggressive behaviors, which resulted in a resident‑to‑resident physical altercation and fear among multiple residents. One resident with non‑Alzheimer’s dementia, severe cognitive impairment (BIMS scores of 2/15 and later 1/15), hallucinations, delusions, and documented physical and verbal aggression toward others repeatedly exhibited behaviors such as hitting, grabbing, scratching, threatening, wandering, entering other residents’ rooms, and attempting to elope. Despite a Significant Change MDS that identified these behaviors and documented that they significantly intruded on others, the resident’s plan of care contained focus areas for impaired cognition, elopement/wandering risk, and psychotropic medication use, but lacked behavior‑specific interventions addressing the aggressive and intrusive behaviors recorded on the MDS and in multiple behavior notes. Point of Care and nursing documentation throughout March detailed numerous episodes in which this cognitively impaired resident was physically and verbally aggressive toward staff and residents, including grabbing and hitting others, cursing, threatening to hurt people with objects, attempting to enter other residents’ rooms, and causing disruption in common areas. Notes described the resident as very difficult to redirect, verbally violent and threatening, talking about using a “2 by 4” to “woop” people, attempting to elope multiple times, trying to get into the kitchen and out fire doors, and waving a fork aggressively while threatening to hit staff. Staff documented that other residents did not want this resident near them due to her confusion, nonstop talking, physical closeness, and disruptive behaviors. A housekeeper and CNAs confirmed that the resident independently ambulated throughout the facility and displayed hitting, kicking, throwing items, and frequent verbal outbursts during meals and activities. On one occasion, this aggressive resident confronted two other residents in a hallway after misunderstanding their conversation. Staff attempted to separate them, but the aggressive resident slapped another resident on the left upper arm with an open hand while yelling and being combative with staff, causing a red mark and pain at the time of the incident. The assaulted resident, who had intact cognition and a history of anxiety, depression, and adjustment disorder, reported discomfort around loud and aggressive individuals and subsequently described increased anxiety about being around the aggressive resident, fear of being hit again, and a preference to stay in her room or wear headphones during meals to drown out the other resident’s outbursts. Documentation showed that after the incident, this resident spent more time isolated in her room, came out mainly for meals, avoided eye contact, cried due to fear, and had reduced nutritional intake compared to earlier in the month. Two additional cognitively intact residents also reported fear related to the aggressive resident’s behaviors. One resident stated she witnessed the hallway incident in which the aggressive resident hit another resident on the shoulder/upper arm and threatened to hit harder, and reported being scared and now only coming out for meals, no longer attending activities as before. She kept her room door open so she could see if the aggressive resident attempted to enter and stated she would chase her out if needed. Another resident reported being scared of the aggressive resident, describing that the aggressive resident would yell and scream during activities and meals and would “hit anyone,” leading her to avoid coming out for activities. Multiple CNAs and an LPN corroborated that these residents were fearful, cried in their rooms, came out only for meals or small groups, and declined activities due to fear of the aggressive resident. The facility’s abuse prevention policy stated that residents must not be subjected to abuse by anyone, including other residents, and defined physical abuse as hitting, slapping, and similar acts, yet the documented pattern of aggressive behavior and the lack of corresponding care plan interventions contributed to an environment in which one resident physically struck another and several residents experienced ongoing fear. A registered nurse acknowledged that the facility did not put interventions in place after the physical altercation and that the plan of care lacked interventions for the behaviors identified on the Significant Change MDS. The primary care physician for the assaulted resident later confirmed that they became aware of the incident through round‑table discussions and that the resident reported anxiety about going to the dining room and being around large groups following the event. Throughout this period, observations showed the fearful residents remaining in their rooms with doors closed or only briefly attending meals or limited activities, often wearing headphones and avoiding interaction, while the aggressive resident continued to ambulate freely, enter common areas, and assert that the facility belonged to her and that she would make others do what she said. These documented actions and omissions demonstrate that the facility did not ensure residents were free from abuse by other residents and did not adequately address known aggressive behaviors through individualized care planning and effective supervision. The facility’s own Abuse, Prevention, Reporting and Investigation Policy stated that residents must be free from abuse, including physical abuse such as hitting and slapping, and that residents must not be subjected to abuse by other residents. Despite this, the aggressive resident’s repeated physical and verbal behaviors toward others, the lack of corresponding care plan interventions, and the subsequent physical striking of another resident in the hallway show a failure to protect residents from abuse. The resulting fear, anxiety, social withdrawal, and decreased participation in activities and meals among multiple residents were documented by residents, staff, and clinical notes, all occurring in the context of the facility’s failure to implement behavior‑specific interventions for a resident with a clearly documented pattern of aggression and intrusion on others. Staff interviews further supported that the aggressive resident’s behaviors had worsened over the prior months and that other residents were fearful and scared. Housekeeping and CNA staff described residents crying in their rooms, expressing that they did not feel able to leave due to fear of being hit, and altering their daily routines to avoid contact with the aggressive resident. Observations by surveyors of residents remaining in their rooms with doors closed, wearing headphones, and avoiding eye contact aligned with these reports. Collectively, the documented behaviors, the absence of care plan interventions addressing those behaviors, the physical altercation, and the resulting psychosocial impact on multiple residents form the basis of the deficiency related to failure to protect residents from abuse and to maintain an environment free from resident‑to‑resident physical aggression. The facility census at the time was 32 residents, and six residents were reviewed, with one resident identified as the aggressor and three residents identified as experiencing fear related to that resident’s behaviors. The aggressive resident’s MDS and behavior documentation clearly showed severe cognitive impairment, psychotic symptoms, and a pattern of physical and verbal aggression that significantly intruded on others, yet the plan of care did not reflect interventions to manage these behaviors. This gap, combined with ongoing documentation of aggressive incidents and staff acknowledgment that interventions were not implemented after the physical altercation, directly contributed to the deficiency in protecting residents from abuse as required by facility policy and regulatory standards.
Failure to Protect Resident from Misappropriation of Fentanyl Patches
Penalty
Summary
The facility failed to protect a resident’s property by not preventing the misappropriation of the resident’s prescribed opioid pain medication patches. The resident had moderate cognitive impairment, with a BIMS score of 9, and diagnoses including low back pain, age-related osteoporosis, and limitation of activities due to disability. Her MDS documented opioid use, and her physician’s orders and EHR reflected an active order for a 25 mg fentanyl patch over a specified period. During this time, staff later identified that two fentanyl patch packages associated with this resident were found empty, with the packages appearing to have been cut open, the patches removed, and the packages placed back into the box and taped shut. The facility’s own investigation documentation, titled as a criminal act and medication diversion investigation, confirmed that on a specific date an RN discovered the two empty fentanyl patch packages that appeared tampered with. This discovery led to the determination that the resident’s fentanyl patches were missing from their packaging, indicating misappropriation of the resident’s medication. The facility’s abuse prevention, reporting, and investigation policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a patient’s belongings or money without consent, and required immediate measures upon receiving such a report. The events described show that the resident’s ordered fentanyl patches were wrongfully removed from their packaging without the resident’s consent, constituting misappropriation of the resident’s belongings.
Failure to Document Non-Pharmacological Interventions Before PRN Lorazepam
Penalty
Summary
The facility failed to document non-pharmacological interventions before administering PRN lorazepam for anxiety and restlessness to one resident with severe cognitive loss. Resident #35 had diagnoses of non-Alzheimer's dementia and anxiety, and the MDS showed a BIMS score of 00. The resident had an order for lorazepam 0.5 mg, 0.5 tablet by mouth every 2 hours as needed for anxiety/restlessness, and the care plan identified use of an anti-anxiety psychotropic medication related to agitation and anxiety. The resident's care plan intervention directed staff to attempt non-pharmacological measures before giving psychotropic medications, including one-to-one interaction, hydration, snacks, television, music, toileting, going outside, hand massage, gentle touch, shoulder rub, deep breathing, family visits, and phone calls. However, the psychotropic medication monthly review lacked documentation of these interventions, and progress notes showed multiple PRN lorazepam administrations without documentation that non-pharmacological interventions were attempted first. Staff interviews confirmed that the required interventions were not documented in the progress notes for most of the January 2026 administrations.
Incorrect PASRR Level II Coding on MDS Assessments
Penalty
Summary
The facility failed to accurately code 2 of 2 MDS assessments for residents with PASRR Level II outcomes. Resident #4’s MDS, dated [DATE], indicated she did not have a state Level II PASRR serious mental illness and/or intellectual disability or related condition, even though her record included diagnoses of anxiety, depression, bipolar disorder, and schizophrenia. Her MDS also documented a BIMS score of 15, indicating no cognitive impairment, while her PASRR notice of nursing facility approval dated 12/2/15 showed she met the criteria for mental illness as defined by PASRR. Resident #32’s MDS, dated [DATE], also indicated he did not have a state Level II PASRR serious mental illness and/or intellectual disability or related condition. His MDS documented a BIMS score of 12, indicating moderate cognitive impairment. However, his PASRR dated 8/10/17 reflected that he met the criteria for mental illness as defined by PASRR, and an addendum to the PASRR summary of findings dated 12/20/17 documented a Level II approval with specialized services. During interview, the MDS Coordinator confirmed the annual MDS was coded incorrectly for Resident #32 as he was a Level II PASRR resident.
Failure to Provide PASRR-Directed Behavior Management Plan
Penalty
Summary
The facility failed to provide specialized services for Resident #4 as directed by the resident's PASRR. Resident #4's MDS documented a BIMS score of 15, indicating no cognitive impairment, and listed diagnoses of anxiety, depression, bipolar disorder, and schizophrenia. The PASRR dated 12/2/15 directed that the resident required specialized services of a behavior management plan to address anxiety/worry, verbal aggression, abrasiveness/irritable behaviors, and inappropriate communication of anger. However, review of the resident's care plan on 2/17/16 showed that no behavior management plan was in place. During an interview on 2/19/26, the DON stated that there was no behavior management plan for Resident #4, and the Administrator stated in an e-mail that the facility followed the PASRR provider's guidelines for completing PASRRs.
Improper Incontinent Care and Infection Control During Brief Change
Penalty
Summary
Appropriate care for residents who are continent or incontinent of bowel and bladder, appropriate catheter care, and appropriate care to prevent UTIs was not provided when staff failed to follow infection control practices during incontinent care for Resident #7. Resident #7 had a BIMS score of 13, required partial/moderate assistance with lower body dressing and toileting hygiene, was frequently incontinent of bowel and bladder, and had diagnoses including renal failure, diabetes mellitus, and hypertension. Her care plan identified bowel and bladder incontinence related to cognitive impairment and mobility and noted she got frequent UTIs, with peri-care to be focused on twice per day. The care plan did not include direction for enhanced barrier precautions during care. During observation, Staff F and Staff E donned EBP and explained incontinent care would be provided. After Staff F completed the resident’s incontinence care, she used dirty gloves to open a clean brief and place it under the resident. Staff F then removed her dirty gloves and fastened the brief without performing hand hygiene. Staff F later stated she should have removed her gloves and performed hand hygiene before placing the clean brief, and the DON acknowledged observing the improper incontinent care. The resident had recently been treated for a UTI, with a physician note documenting flank pain, later ER transfer, and return to the facility with orders for cefdinir and ondansetron; the final urine culture showed >100,000 CFU/ml E. coli mixed growth.
Failure to Obtain Ordered Daily Weights and Report Weight Gains
Penalty
Summary
The facility failed to obtain daily weights and failed to notify the doctor of 3-pound weight gains in a day as ordered for one resident reviewed for nutrition. The resident had severe cognitive impairment with a BIMS score of 6 and diagnoses including aphasia, metabolic encephalopathy, and acute respiratory failure. The doctor’s order, signed on 11/25/25, directed staff to obtain daily weights and notify the doctor of weight greater than 3 lb. in a day and 5 lb. in a week starting 9/12/25. Review of the resident’s EHR showed 3-pound weight gains from the prior day on 11/24/25, 12/11/25, and 12/25/25, but progress notes did not show notification to the doctor for those gains. The weight record also lacked daily weights on multiple dates, including 11/21/25, 11/29/25, 11/26/25, 1/3/26, 1/8/26, 1/12/26, 1/19/26, 1/27/26, 1/29/26, 2/4/26, 2/7/26, and 2/14/26. The DON stated the resident had significant edema without a cause a few months earlier, which was why daily weights were started, and the Administrator stated staff were expected to obtain the weight daily and enter it into the system for review.
Improper Medication Handling During Pass
Penalty
Summary
The facility failed to ensure infection control prevention and practices to prevent touching medication with bare hands or dirty gloves during medication administration for 3 of 5 residents observed, including Residents #27, #1, and #11. During the medication administration task, Staff B, a CMA, did not perform hand hygiene before beginning the pass, applied gloves, opened the double-lock narcotic drawer, touched the computer mouse with a gloved hand, handled multiple resident medication cards, and retrieved Resident #27’s methadone card before punching the pill into her gloved hand and placing it into a medication cup. Staff B then administered the medication to Resident #27. Staff B also handled Resident #1’s Eliquis, metoprolol, omeprazole, spironolactone, and stock acetaminophen by popping pills directly into her hand and placing them into a medication cup, including shaking acetaminophen into the palm of her left hand. For Resident #11, Staff B again failed to perform hand hygiene, placed her fingers inside a plastic cup, handled multiple drawers and bottles on the medication cart, shook aspirin, multivitamins, and Senokot S into her hand, and prepared Miralax in a plastic cup before administering the medications. Staff C, Staff D, and the DON stated hand hygiene should be performed between residents’ medication passes, and the facility policy directed hand hygiene before and after each resident’s medication pass and stated medications should not be touched.
Failure to Implement Care Plan Chair Alarm Intervention for Fall Risk Resident
Penalty
Summary
The facility failed to implement a care plan intervention for a resident identified as being at risk for falls. The resident, who had severe cognitive impairment as indicated by a BIMS score of 2 out of 15, required substantial to maximal assistance for transfers and ambulation. The care plan, created in February and updated in March, included the use of a chair alarm to alert staff when the resident attempted to self-transfer. However, on the date of the incident, staff observed the resident stand up impulsively from a wheelchair and immediately fall. Multiple staff members present during the fall did not recall a chair alarm being in place at the time. Interviews with staff, including the staffing coordinator, activities director, social services designee, and DON, confirmed that the chair alarm, as specified in the care plan, was not in use during the fall. The facility's policy required the use of alarming devices to alert staff of position changes for residents with diminished cognition. Despite this policy and the care plan intervention, the chair alarm was not implemented at the time of the incident, resulting in a failure to follow the established care plan for fall prevention.
Resident Dignity Compromised by Staff's Use of Profanity
Penalty
Summary
The facility failed to treat a resident with dignity and respect, as evidenced by an incident involving a Certified Nursing Assistant (CNA), referred to as Staff B, who used offensive language in the presence of a resident, identified as Resident #4. Resident #4, who has intact cognition as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, reported that Staff B entered her room during the night and began yelling about a Licensed Practical Nurse (LPN), referred to as Staff A, using derogatory language. Resident #4 expressed discomfort with Staff B's behavior, noting that it was inappropriate for Staff B to speak negatively about other staff members in her presence. Staff B admitted to using profanity and acknowledged that it was inappropriate to do so in front of a resident. The Director of Nursing (DON) and other staff members, including a Registered Nurse (RN), confirmed that the use of profanity in front of residents is unacceptable and violates the facility's policy on resident rights, which emphasizes treating residents with dignity and respect. The incident was corroborated by Staff A, who reported previous altercations with Staff B and confirmed that Resident #4 had informed him of the incident. The facility's policy on dignity and respect outlines the expectation for staff to provide considerate and respectful care, which was not upheld in this instance.
Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to adhere to the Centers for Disease Control and Prevention (CDC) guidelines for Enhanced Barrier Precautions (EBP) during catheter care for three residents, leading to a deficiency in infection prevention and control. Resident #5, who has moderate cognitive impairment and uses an indwelling catheter due to neurogenic bladder, was observed receiving catheter care without the use of an isolation gown by Staff G, CNA. Despite the care plan indicating the need for EBP, including the use of gowns, no EBP sign was present in or outside the resident's room, and staff were unaware of the requirement. Similarly, Resident #4, with intact cognition and an indwelling catheter for neurogenic bladder, was observed receiving catheter care from Staff D, CNA, without the use of an isolation gown, despite the presence of a CDC sign indicating the need for such precautions. Interviews with staff revealed a misunderstanding of the requirement for gowns, with some staff believing their use was optional. The Director of Nursing (DON) confirmed that all residents with urinary catheters should be on EBP, but acknowledged issues with signage and PPE availability. Resident #10, who has intact cognition and uses an indwelling catheter for benign prostatic hyperplasia and obstructive uropathy, also received catheter care without the use of an isolation gown by Staff E. The DON confirmed the absence of a PPE isolation bin and EBP sign in Resident #10's room. The facility's failure to consistently implement EBP as per CDC guidelines and their own policy resulted in a deficiency in infection prevention and control measures.
Failure to Complete SCSA MDS for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change Status Assessment (SCSA) Minimum Data Set (MDS) within 14 days of a resident's hospice election. Resident #23, who was reviewed for hospice care, had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive loss and was dependent on staff for activities of daily living. The resident had diagnoses of cancer, end-stage renal disease, diabetes mellitus, and Non-Alzheimer's Dementia. Despite being signed into hospice care by a family representative, the MDS lacked documentation of hospice care services, and the SCSA MDS was not set up within the required timeframe. The MDS Coordinator acknowledged awareness of the resident's hospice admission but admitted that the SCSA MDS was missed. The Director of Nursing (DON) reported that hospice admissions are communicated via slips, which are not retained, and expected the MDS Coordinator to complete the SCSA MDS as per the Resident Assessment Instrument (RAI) guidelines. The RAI manual specifies that the SCSA MDS must be completed within 14 days from the determination of a significant change in resident status, such as enrollment in a hospice program, which was not adhered to in this case.
Failure to Assess Resident After Fall
Penalty
Summary
The facility failed to provide a full assessment for a resident who was involved in a fall incident. The resident, who had a history of functional impairment in both lower extremities and used a walker, fell and was found by the Assistant Director of Nursing (ADON) exhibiting signs of a left hip injury. Despite the resident's inability to bear weight on the left leg and the presence of pain, the ADON assisted the resident to a standing position without conducting a proper assessment, including vital signs and range of motion (ROM) evaluation. The incident report initially documented by the ADON was later amended, revealing discrepancies in the account of the fall and the actions taken. The ADON admitted to not performing a full assessment before moving the resident and acknowledged altering the documentation. The resident was eventually diagnosed with a left hip fracture and later found to have additional rib fractures. The facility's investigation concluded that the fall was unavoidable, but the lack of proper assessment and documentation by the ADON was evident. Interviews with staff and the Director of Nursing (DON) confirmed that the ADON did not follow the facility's fall care path, which requires a complete assessment before moving a resident after a fall. The DON and Administrator noted the absence of vital signs and ROM assessment in the incident report. The ADON was suspended and later terminated for falsifying documentation. The facility had recently discontinued the use of fall alarms, which was a concern for the resident's family, and staff were instructed to increase monitoring of residents.
Dietary Service Manager Lacks Required Qualifications
Penalty
Summary
The facility failed to ensure that the Dietary Service Manager had the required qualifications in the absence of a full-time dietician. The facility, which had a census of 35 residents, was found to be non-compliant during a survey. During an interview, the Dietary Manager mentioned that she was in the process of enrolling in dietary manager classes. Another interview with the Consultant Dietician revealed that the Dietary Manager was not certified but was currently taking the course. The review of the Dietary Manager's employee file confirmed the absence of a certificate of completion for the Dietary Manager courses.
Failure to Follow Physician Orders for Urology Referral
Penalty
Summary
The facility failed to follow physician orders for a resident with intact cognition, as indicated by a BIMS score of 15. The resident had diagnoses of benign prostatic hyperplasia, anxiety, and hypertension. A physician order for a referral to Urology was made on 1/22/24, but the facility's Electronic Health Record and Progress Notes lacked documentation of an appointment being made or a call to schedule the appointment. The Director of Nursing confirmed that no appointment was scheduled and that there was no documentation of any call to Urology. The facility did not have a policy for handling physician orders and claimed to follow professional standards.
Failure to Conduct Proper Assessments for Resident's Range of Motion and Mobility
Penalty
Summary
The facility failed to ensure proper assessments were conducted for a resident to determine if she remained at baseline or had experienced a decline in her range of motion (ROM) and mobility. Resident #15, who had impairments on both sides of her upper and lower extremities, was not included in a restorative care program. Observations revealed that the resident was often left unattended and without a call light, and staff only responded after she had been yelling for help for several minutes. The Director of Nursing (DON) and other staff members acknowledged that the resident had refused restorative care in the past, but there was no documentation of ongoing assessments to confirm her baseline status or need for therapy. The last documented therapy screen was outdated, and the facility did not conduct a new assessment during the resident's annual review as required. Interviews with the DON, MDS Coordinator, Assistant Director of Nursing (ADON), and Occupational Therapist (OT) revealed a lack of clarity and communication regarding the responsibility for conducting ROM assessments and therapy screens. The MDS Coordinator was unaware of the need to check ROM during annual assessments, and the ADON admitted to not performing the required annual therapy screens. The OT confirmed that therapy staff were not informed of residents' annual assessment schedules and relied on weekly Medicare meetings for referrals. The facility's process for ensuring therapy evaluations was not followed, resulting in missed assessments and a failure to document the resident's refusals and baseline status accurately.
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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