Concord Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Garner, Iowa.
- Location
- 490 West Lyons Street, Garner, Iowa 50438
- CMS Provider Number
- 165364
- Inspections on file
- 20
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Concord Care Center during CMS and state inspections, most recent first.
A resident with intact cognition but significant physical limitations from CVA, hemiplegia/hemiparesis, and limited ROM required substantial assistance with toileting and dressing and dependent transfers per the care plan. During morning care, a CNA told the resident it was time to get up, placed clothes in the wheelchair, and left without assisting, returning about 20 minutes later and stating she had other people to take care of when the resident asked for help. The resident, feeling upset and worthless, struggled to move furniture, dress, and transfer to the bathroom using grab bars without the required assistance, and later reported the CNA’s rude comments and lack of help to several staff. Another CNA observed the resident crying and striking the bed in frustration and viewed the situation as a respect and dignity issue. A trauma screening documented the resident’s history of prolonged verbal and physical abuse, but the care plan lacked a post-trauma focus or interventions despite this background and the resident’s distress.
A resident with dementia, chronic pain, and significant ADL dependence allegedly had their hands slapped by a CNA during incontinent care while the resident was yelling, crying, and swinging at staff. The witnessing CNA, despite having dependent adult abuse training and recent in‑service education on abuse reporting, did not immediately report the allegation to a charge nurse or Abuse Coordinator and instead waited and discussed it with another CNA later. The Administrator was not informed until much later, and the allegation was not reported to the state survey agency within the required 2‑hour timeframe, contrary to facility policy requiring immediate reporting of all abuse allegations.
A resident with CHF, renal failure, diabetes, and adult failure to thrive, who was care planned as at risk for ineffective breathing, developed a worsening cough, chest pain from coughing, fatigue, decreased appetite, and crackles in both lungs while using PRN albuterol nebulizers. Over the next shift the resident remained in bed, felt unwell, had poor intake, and later requested transfer to the hospital. Despite these changes, the clinical record contained no further assessment documentation, including no recorded lung sound assessments, even though abnormal respiratory findings were present. EMS later found the resident with labored breathing and an SpO2 of 83%, and the hospital documented acute hypoxic respiratory failure, suspected aspiration pneumonia, acute bronchitis with bronchospasm, RSV positivity, and generalized weakness. An RN acknowledged the lack of lung sound documentation despite it being an expected nursing practice and noted there was no specific assessment policy tied to change in condition.
A facility failed to complete a follow-up PASRR and resubmit it for reevaluation for a resident with mental disorders, including anxiety, depression, bipolar disorder, and schizophrenia. The resident's PASRR expired, and a subsequent Level 1 screen was submitted over four months late, causing a compliance issue. The delay was due to the Administrator performing dual roles, leading to the late resubmission of the PASRR.
The facility failed to provide adequate staffing, resulting in delayed call light responses for three residents. A resident with intact cognition reported waiting up to 45 minutes for assistance, risking incontinence. Another resident with moderate cognitive impairment experienced anxiety due to long wait times, particularly on weekends. A third resident, requiring assistance for transfers and toileting, reported inconsistent response times, leading to incontinence. Staff interviews confirmed that staffing levels and response times varied, with some acknowledging the delays.
The facility did not comply with regulatory requirements for QAA meetings due to the absence of the Infection Preventionist (IP) on multiple occasions. The IP's signature was missing from meeting documents, and the Administrator confirmed the IP was working on the floor during these meetings, despite the facility's QAPI Plan requiring their attendance.
A resident with a pressure ulcer did not have enhanced barrier precautions in place, and staff failed to wear gowns during high-contact care activities. Additionally, a staff member did not perform hand hygiene after removing gloves following peri care. The DON confirmed these lapses, which were against the facility's infection prevention policy.
A resident with severe cognitive impairment and multiple health conditions experienced repeated falls due to the facility's failure to implement effective interventions and provide necessary assistance as outlined in the care plan. Despite being at risk for falls, the resident was left unattended in the dining room, leading to multiple incidents and injuries. The facility's policy required fall risk assessments and communication of interventions, but these were not effectively followed.
Failure to Provide Dignified Morning Care and Respect Resident’s Need for Assistance
Penalty
Summary
The deficiency involves the facility’s failure to treat a cognitively intact resident with respect and dignity during morning care. The resident had a history of CVA with hemiplegia/hemiparesis, limited range of motion on one side, cataracts, and required substantial to maximal assistance for toileting hygiene and dressing, and was dependent for transfers. Her care plan called for staff assistance with ADLs, including one staff member to assist with dressing/grooming, assistance with toileting per her routine, and two staff with an EZ stand for transfers. Despite these documented needs, a CNA entered the resident’s room early in the morning, told her it was time to get up, placed her clothes in the wheelchair, and left without providing the needed assistance. According to the resident’s account, the CNA did not return for approximately 20 minutes. During this time, the resident, who required significant assistance, attempted to move her bedside table, sit at the edge of the bed, reach her wheelchair, and get herself dressed and to the bathroom without help. When the CNA returned and saw the resident was not yet up and dressed, the CNA reportedly told the resident she had other people to take care of and did not assist, leaving again. The resident reported feeling mad, worthless, and like “nothing and a nobody” as she struggled to get to the bathroom and use the grab bar to transfer herself to the toilet. When the CNA came back and found the resident in the bathroom, the CNA questioned what the resident was doing there by herself and then assisted with putting on the brief and pants. The resident reported this interaction to multiple staff members and described the CNA’s behavior and comments as rude and upsetting, though she did not personally label it as abuse. Another CNA reported that the resident was visibly upset, crying, and hitting the top of the bed in frustration while recounting the incident, and characterized the concern as one of respect and dignity. The facility’s own Resident Rights–Dignity and Respect policy states that each resident has the right to considerate and respectful care and to be treated with dignity and respect, with reasonable accommodation of individual needs. Additionally, a trauma screening documented that the resident had a history of verbal and physical abuse by her husband for 11 years, but the care plan did not include a post-trauma focus or related interventions, despite this history and the resident’s emotional response to the incident.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an allegation of abuse was reported to the state survey agency within the required 2-hour timeframe. The facility’s own policy, dated 9/2025, requires that all allegations of resident abuse be reported immediately to the charge nurse, who must immediately notify the Administrator or designee, and that all allegations be reported to the Iowa Department of Inspection and Appeals and Licensing immediately and not later than two hours. In this case, an alleged incident of mistreatment involving verbal and physical abuse occurred on 3/10/26 during evening shift care for Resident #10, but the allegation was not brought to the Administrator’s attention until 4/11/26 and was not reported to the state agency until 4/12/26. Resident #10 had non-Alzheimer’s dementia, hypertension, heart failure, anxiety, depression, adult failure to thrive, chronic lower back pain, and moderate cognitive impairment with a BIMS score of 10. The resident required partial to moderate assistance with all ADLs, substantial to maximal assistance for bed mobility, and had a history of being impulsive and at times resistive to care, including hitting, screaming, and biting at staff during care or transfers. On 3/10/26, while two CNAs were providing incontinent care, one CNA later reported that the other CNA was very fast and rough when rolling the resident, and that the resident was yelling, screaming, and crying. The reporting CNA stated that the other CNA took the resident’s hands and slapped them while telling the resident that cares needed to be completed, during a time when the resident was hitting and swinging at staff. Despite having completed dependent adult abuse reporting training and facility education on abuse reporting on 4/10/26, the CNA who witnessed the alleged slapping did not immediately report the incident to a charge nurse or Abuse Coordinator. Instead, she waited until 4/11/26 to call another CNA to discuss the situation, at which point she was told it needed to be reported to the Administrator. The Administrator was then notified, and the allegation was reported to the state agency on 4/12/26, more than a month after the alleged incident and well beyond the 2-hour reporting requirement. Interviews with staff and review of the facility’s policy confirmed that all allegations or accusations of abuse were expected to be reported right away, but this did not occur in this case, resulting in the cited deficiency for failure to timely report suspected abuse.
Failure to Assess and Document Respiratory Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide and document appropriate assessment and care for a resident experiencing a change in condition. The resident had intact cognition, multiple chronic diagnoses including CHF, renal failure, diabetes, and adult failure to thrive, and a care plan identifying risk for ineffective breathing pattern related to CHF with interventions such as evaluating for shortness of breath, respiratory rate, and effort. Health Status Notes show that the resident requested cough medicine for a dry cough, later reported a productive cough with chest pain from coughing all night, difficulty getting comfortable, decreased appetite, fatigue, and crackles in bilateral lung lobes, and had been using PRN albuterol nebulizers. Later documentation indicated the resident had not been feeling well, remained in bed, refused to get out of bed except for the bathroom, had poor appetite, and staff were encouraging fluids. In the early morning, the resident requested to go to the hospital, and the provider ordered transfer by ambulance. However, the clinical record lacked documentation of any further assessment of the resident’s change in condition, including the absence of documented lung sound assessments despite abnormal respiratory symptoms. EMS records described the resident as in a lateral recovery position, holding a garbage can off the side of the bed, having labored breathing, and an oxygen saturation of 83%. The hospital encounter documented shortness of breath, generalized weakness, coughing with sputum, RSV positivity, hypoxia, and principal problems including acute hypoxic respiratory failure, suspected aspiration pneumonia, acute bronchitis with bronchospasm, and generalized weakness. A facility RN acknowledged that the clinical record lacked documentation of lung sounds and confirmed that documenting abnormal lung sounds is an expectation of nursing practice, and that while the facility had a change of condition policy, it did not have a specific policy for assessments to be completed.
Failure to Timely Resubmit PASRR for Resident with Mental Disorders
Penalty
Summary
The facility failed to complete a follow-up Preadmission Screening and Resident Review (PASRR) and resubmit it to ASCEND for reevaluation for a resident with mental disorders and intellectual disabilities. The resident, who was diagnosed with anxiety disorder, depression, bipolar disorder, and schizophrenia, had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. The resident was admitted to the facility with a Level 1 PASRR that expired after 60 days, and a subsequent Level 1 PASRR indicated the need for a Level II onsite evaluation. However, the Level 1 screen was submitted over four months after the prior PASRR expired, leading to a compliance issue. The facility's failure to timely resubmit the PASRR was attributed to the Administrator, who was also performing the duties of a Social Worker during the period in question. This dual role led to delays in the resubmission process, resulting in the resident's PASRR being completed after the expiration of the short-term approval period. The facility's procedures required the Level I screen to be electronically submitted before admission to a Medicaid-certified nursing facility and prior to the conclusion of an assigned time-limited stay, which was not adhered to in this case.
Inadequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by prolonged call light response times for three residents. Resident #24, with intact cognition, reported waiting up to 45 minutes for assistance, risking incontinence. The call light report confirmed multiple instances where response times exceeded 15 minutes, with some reaching up to 45 minutes. Resident #22, with moderately impaired cognition, also experienced long call light response times, particularly on weekends, which contributed to her anxiety. Her niece expressed concerns about the staffing levels and the impact on her aunt's well-being. The facility's call light report corroborated these delays, with several instances exceeding 30 minutes. Resident #3, who required assistance for transfers and toileting, reported inconsistent call light response times, leading to incontinence. The call light report showed numerous instances where response times were significantly delayed, with some exceeding 30 minutes. Interviews with staff indicated that staffing levels and call light response times varied, with some staff acknowledging the delays.
Infection Preventionist Absence in QAA Meetings
Penalty
Summary
The facility failed to meet the regulatory requirements for their Quality Assessment and Assurance (QAA) meetings by not having the minimum number of required members present. Specifically, the Infection Preventionist (IP) was absent from the QAA meetings held on multiple occasions, as evidenced by the lack of the IP's signature on documents dated 5/7/24, 6/2024, 7/2024, 9/10/24, and 10/8/24. The facility's Quality Assurance Performance Improvement (QAPI) Plan, effective March 1, 2024, mandates that the IP, along with other key personnel, attend these meetings at least quarterly. During an interview, the Administrator confirmed the absence of the IP, attributing it to the IP's responsibilities on the floor during the meetings, although the IP's information was reportedly discussed in their absence.
Infection Control Deficiency in Resident Care
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections, specifically in the care of a resident with a pressure ulcer. The resident, who had severely impaired cognition and required assistance with transfers and toileting, was observed without an enhanced barrier precaution sign on their door. During care activities, staff members did not adhere to the facility's infection prevention and control guidelines. Specifically, staff did not wear gowns during high-contact activities, such as transferring and providing hygiene care to the resident with a chronic pressure ulcer. Additionally, there were lapses in hand hygiene practices. After providing peri care and removing gloves, a staff member did not perform hand hygiene before continuing with other care tasks. The Director of Nursing acknowledged these deficiencies, confirming that enhanced barrier precautions were not in place and that hand hygiene should have been performed after glove removal. The facility's policy required hand hygiene before and after assisting a resident with toileting and after removing gloves, as well as the use of gowns and gloves during high-contact care activities for residents with chronic wounds.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement effective interventions and provide the necessary assistance as outlined in the care plan for a resident with severe cognitive impairment and multiple health conditions, including Alzheimer's Disease, depression, heart failure, and hypertension. The resident was assessed as requiring partial or moderate assistance for transfers, ambulation, and toilet transfers. Despite being identified as at risk for falls due to gait and balance problems, the resident experienced multiple falls over a period of time, including incidents in the dining room where the resident was left unattended, contrary to the care plan directives. The care plan included specific interventions such as attaching a call-sensitive light to the resident's blanket, ensuring appropriate footwear, frequent visual checks, and not leaving the resident unattended in the dining room. However, these interventions were not effectively implemented, as evidenced by the resident's repeated falls and injuries, including a laceration and hematoma from an unwitnessed fall. The facility's policy required fall risk assessments and the communication of interventions to staff, but the repeated falls suggest a failure to adhere to these protocols and adequately supervise the resident to prevent accidents.
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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