Garden View Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Shenandoah, Iowa.
- Location
- 1200 West Nishna Road, Shenandoah, Iowa 51601
- CMS Provider Number
- 165531
- Inspections on file
- 32
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 45 (2 serious)
Citation history
Health deficiencies cited at Garden View Care Center during CMS and state inspections, most recent first.
The facility failed to maintain a comprehensive, effective QAPI program, as evidenced by repeated deficiencies over multiple surveys in areas including failure to report, protection of resident-identifiable information, infection prevention and control, environmental cleanliness and comfort, and ADL care for dependent residents. Although a written QAPI policy described broad data monitoring and committee review processes, survey history showed that these processes were not effectively implemented to prevent recurrence of the same problems, and leadership acknowledged only recent efforts to change QAPI activities.
The facility failed to maintain a safe, clean, and homelike environment when a resident’s room had a cracked, drafty window and nonfunctional closet doors that had remained unrepaired for many months, and the outside door contained a hole. Surveyors also observed multiple stained, split, or holed ceiling tiles in several halls and near the nurse’s station, bent ceiling hardware, and walls with paint chipping and dark marks above grab bars. The Maintenance Director reported he was unaware of the resident’s closet issues and acknowledged ongoing problems with stained ceiling tiles related to a leaking roof and limited replacement supplies.
Surveyors found unsecured resident medical records in an unlocked conference room and resident-identifiable documents stored in an easily accessible garage trash can, while the Administrator acknowledged records were also kept off campus with known payment issues for the storage unit. In addition, a resident with multiple comorbidities and a left BKA had a physician-ordered follow-up appointment that was missed after the facility’s transportation staff was terminated and an Assistant Administrator, who was uncomfortable driving the large van out of town, assumed transport duties. No progress note or documentation of the missed appointment was found in the resident’s chart, contrary to facility policy requiring all services and changes to be recorded in the medical record.
The facility failed to implement its infection prevention and control program by not correcting ongoing water intrusion and black, mold-like substances in the laundry room and basement. Surveyors observed cracked paint and a black fuzzy substance on a wall near the laundry floorboard, along with stagnant water behind a water heater and near washers, which the Maintenance Director attributed to periodically clogged drainage hoses. In the basement, there was a strong mildew/musty odor, stagnant water along walls and at a sealed window, mud under the water, and wooden work benches standing in the water, as well as an exposed lower wall area with a large black substance. The ground outside sloped toward the building, contributing to repeated water seepage during heavy rain, and leadership staff were initially unaware of the basement water problem despite a written IPC policy requiring a safe, sanitary environment and surveillance for infection risks.
A resident with no cognitive impairment, bowel incontinence, and dependence on staff for toileting requested a bedpan for a bowel movement, consistent with his usual practice due to a leg amputation. A CNA, who reported being unable to find an appropriate bedpan and did not obtain one from storage, told the resident to defecate in his incontinence brief instead, reportedly using crude language. Other staff later confirmed that a bedpan was available in the resident’s bathroom and that fracture pans were available in storage. This conduct conflicted with the resident’s care plan, which called for assistance with toileting and consideration of his preferences, and with the facility’s policy on promoting and maintaining resident dignity and respecting resident rights.
A resident with mild cognitive impairment, multiple chronic conditions, and a left BKA had physician orders for daily dressing changes, non-weight bearing status, and a scheduled out-of-town follow-up appointment. Due to the termination of the prior transportation staff and reassignment of transport duties to an Assistant Administrator who was uncomfortable driving the large van out of town, the resident was not transported and missed the scheduled clinic visit. The clinical record contained no progress notes documenting the follow-up appointment, and staff interviews confirmed the appointment was missed because no appropriate transportation was provided.
A resident with intact cognition, multiple medical conditions, and dependence on staff for toileting requested assistance to have a bowel movement, and a CNA told the resident to defecate in an adult brief instead of assisting with a bedpan, despite a bedpan being available. A CMA overheard the exchange, later found the resident’s brief soiled, and provided care but did not report the concern until the next day. The DON and ADON interviewed the CNA, who admitted telling the resident to use the brief, and the resident confirmed being told to go in the diaper against his preference. Although facility policy required immediate reporting of abuse allegations to the Administrator and notification of the state within 2 hours of an allegation, the incident was not reported to the state agency until the following day, outside the required timeframe.
A resident with intact cognition, bilateral extremity impairment, and dependence on staff for toileting requested a bedpan for a bowel movement but was reportedly told by a staff member to defecate in his brief when the bedpan could not be found. The resident, who typically used a bedpan and was only sporadically incontinent, subsequently soiled his brief and required cleanup by a CMA who responded to his call light. Staff interviews confirmed the resident’s usual toileting pattern and the reported statement by the staff member, while facility policy required appropriate ADL support, including toileting assistance, in accordance with the care plan.
A resident dependent on staff for tracheostomy care experienced repeated delays and refusals of suctioning by an LPN, despite physician orders for as-needed suctioning. The resident reported severe anxiety and fear due to these delays, and multiple CNAs confirmed the LPN's pattern of not responding promptly to requests. The DON was informed of concerns but did not initially identify any issues with the LPN's performance, and documentation of suctioning was lacking.
A resident dependent on staff for tracheostomy care reported that an LPN frequently refused or delayed suctioning, causing distress and anxiety. Multiple CNAs confirmed the LPN's refusal to provide care and reported these concerns to the DON, but no thorough investigation or separation of the LPN from the resident occurred. The resident's medical records showed no documentation of the suctioning order being followed, and the facility did not adhere to its abuse prevention and investigation policy.
A facility failed to maintain required 24-hour licensed nurse coverage when an LPN left the premises during an overnight shift, leaving no licensed nurse on site for several hours. Staff reported frequent absences by the LPN during overnight shifts, and documentation of concerns was lacking despite facility policy requiring continuous licensed nurse presence.
Nursing staff were assigned to work independently without documented orientation or competency-based training, as required by facility policy. Two LPNs reported not receiving an orientation checklist or formal training before caring for residents alone, and their files lacked evidence of completed orientation. A former RN and the administrator confirmed the absence of a formal orientation program, despite policy requiring a 10-hour orientation with a checklist.
Three cognitively intact residents who regularly received room trays reported that their meals were often cold upon delivery, with one noting the absence of heated carts and delays in tray delivery. Observation confirmed that at least one food item on a sample tray was below the required 135°F, and both dietary staff and facility policy affirmed that food should be served at or above this temperature.
Three residents who required staff assistance for bathing did not consistently receive scheduled baths or showers as outlined in their care plans, with EHR reviews showing significant gaps in care and a lack of documented refusals. Staff and DON interviews confirmed that missed baths were not always made up or properly documented, and that the facility's policy for regular bathing was not consistently followed.
The facility failed to follow physician orders, resulting in medication administration errors for multiple residents. A resident did not receive diabetes medication as ordered, and another resident's insulin was not administered per the sliding scale. Additionally, a resident's Oxycodone was destroyed without a discontinuation order. The facility's medication administration policy was not followed, leading to discrepancies in documentation and adherence to medication parameters.
A facility failed to properly assess and respond to an unwitnessed fall involving a resident with severe cognitive impairment, as neurological checks were not initiated immediately and the first set of vitals was delayed. Additionally, the facility did not conduct consistent respiratory assessments for residents who tested positive for COVID-19 and Influenza A, as required by protocol. These deficiencies highlight significant lapses in care and documentation.
The facility failed to maintain the required RN coverage for 8 consecutive hours, 7 days a week, as revealed by nursing schedules and staff interviews. The DON's frequent absences and reliance on a part-time RN contributed to inconsistent coverage. Staff reported communication issues and unresponsive management, leading to difficulties in scheduling RNs. Despite the facility's assessment claiming adequate coverage, the reality was insufficient, as indicated by staff comments and laughter about the ongoing issue.
The facility did not consistently update nurse staffing information daily for residents and visitors. Observations showed outdated postings on multiple occasions, with the DON indicating that night nurses were responsible for this task. The facility had a census of 37 residents.
A facility experienced a significant staffing deficiency when no licensed nurse was present for three hours, leaving the Administrator, who is not currently licensed, to oversee care. During this time, a resident fell, and proper protocols were not followed. The report also highlights a toxic work environment, with staff expressing frustration over the lack of support from the DON and ADON.
The facility's QAPI program was ineffective, as evidenced by repeated deficiencies in areas such as nursing staff sufficiency, quality of care, resident records, and infection control. Despite a revised QAPI plan, the facility continued to exhibit non-compliance, with the administrator acknowledging inconsistent corrective actions.
During an outbreak, a facility failed to enforce mask-wearing and proper infection control measures. Staff, including the Administrator and DON, were observed without masks, and masks were not available at the entrance. Additionally, a staff member did not use alcohol wipes before blood sugar checks or insulin administration, contrary to facility procedures. Residents and staff reported these issues, highlighting deficiencies in infection control and resident care.
The facility failed to update care plans for two residents, leading to deficiencies in their care. One resident's care plan did not reflect the presence of an indwelling catheter and ostomy, while another resident's care plan lacked instructions for using a fall mat, despite a history of falls. Staff observations and interviews confirmed these oversights, which were not aligned with the facility's policy requiring timely care plan revisions.
A facility failed to complete ordered treatments for a resident with pressure ulcers, as shown by incomplete treatment administration records and inconsistent skin assessments. The resident, who had no cognitive impairment, reported that treatments were sometimes skipped depending on the staff. The DON noted that measurements were not taken during weekly assessments, contrary to facility protocol, and mentioned that the resident often refused treatments, although this was not documented.
A resident with severe cognitive impairment and physical limitations fell out of bed and was assisted back into a wheelchair by staff without the use of a gait belt, contrary to facility policy. The incident occurred when no nurse was present, and the Administrator conducted an assessment without performing neurological checks. Staff interviews indicated confusion about the facility's lifting policy, and the DON confirmed that a gait belt should have been used.
A LTC facility experienced a lapse in nursing coverage when an LPN, who had been working extended hours, was advised by the Administrator to leave for rest and medication retrieval. This left the facility without a licensed nurse from 1:30 PM to 4:30 PM, despite the presence of high-risk residents. The Administrator, not currently licensed, attempted to fill the gap, but critical medical protocols were not followed, highlighting inadequate staffing contingency measures.
A resident with severe cognitive impairment fell out of bed when no licensed nurse was present. The Administrator, a former nurse without an active license, assessed the resident and assisted in transferring her without a gait belt. The facility lacked proper nursing coverage for three hours, and necessary neurological assessments were not conducted.
A resident with severe cognitive impairment and multiple health conditions was frequently administered a PRN narcotic pain medication without clear evidence of pain. Staff interviews revealed that the medication was often given to ensure a quieter night shift, despite the resident being on a sleeping pill. The facility's policy required re-evaluation of frequent PRN use, but no such re-evaluation was documented.
The facility failed to store medications properly after delivery, as observed when a bag containing various medications was left unattended on the nurse's station counter. Staff interviews confirmed that medications should be put away immediately, but the incident revealed a lapse in following the facility's storage policy.
The facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies in documentation and assessment. A resident with severe cognitive impairment experienced an unwitnessed fall that was not properly documented or assessed. Additionally, two residents' positive test results for Influenza A and COVID-19 were not recorded in their medical records, contrary to facility policy.
A CNA at a long-term care facility was found to have physically and verbally abused two residents with severe cognitive impairments. The abuse included rough handling and derogatory language, leading to bruises on one resident. Despite staff awareness, the incidents were not reported to the state agency, and the CNA was not immediately removed from resident care, resulting in Immediate Jeopardy.
A facility failed to report abuse allegations to the state agency within the required timeframe. A CNA witnessed another CNA abusing two residents, but the incident was not reported to the administration or state agency. One resident had severe cognitive impairment and was found with bruises consistent with fingerprint marks. Staff interviews revealed a history of abuse by the same CNA, but fear of retaliation and a belief that nothing would be done prevented reporting. The facility's policy for immediate reporting was not followed.
A facility failed to separate an alleged CNA abuser, resulting in continued verbal and physical abuse of two residents. Despite reports of abuse, the CNA continued working with residents, leading to Immediate Jeopardy. The facility's delayed investigation and failure to follow abuse prevention policies exposed residents to further harm.
A resident with a history of exit-seeking behavior eloped from the facility without triggering alarms due to a known door code and malfunctioning Wanderguard System. The facility failed to update the resident's Elopement Risk Assessment and did not ensure alarms were audible throughout the building. Staff were aware of the resident's behavior but did not prevent the elopement, and the facility's policies were not effectively implemented.
The facility failed to properly store and safeguard resident medical records, as observed in a basement room with significant water intrusion and mold growth. The Maintenance Director and Administrator were aware of the issues, but the records remained improperly stored, contrary to the facility's policy.
The facility has repeatedly failed to systematically identify, report, and prevent adverse events, with deficiencies noted in reporting alleged violations, maintaining sufficient nursing staff, and infection prevention. The Administrator cited inconsistent nursing leadership and staffing challenges, including reliance on agency employees, as contributing factors. The facility's QAPI policy was not effectively implemented, and individual performance improvement plans were not available for review.
The facility failed to maintain a safe and comfortable environment by not providing sufficient linens and ensuring residents' beds were consistently made. Multiple residents reported issues with bed linens, including shortages of bed soakers and unmade beds. Staff confirmed the shortage of linens and improvised with available supplies. Despite suggestions to purchase more linens, administration delayed ordering until the beginning of the month.
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. A resident with intact cognition and a history of falls was not provided with a timely care plan for wandering behavior. Another resident with severe cognitive impairment was not consistently transferred to a stationary chair during meals as per the care plan. Additionally, a resident with multiple diagnoses lacked a care plan focus on enhanced barrier precautions. The facility's administrator acknowledged potential gaps in care plans due to changes in nursing leadership.
The facility failed to provide adequate nursing staff, resulting in delayed care and unmet resident needs. Staffing schedules showed consistent understaffing, confirmed by staff and resident interviews. A CNA reported working alone with a nurse on overnight shifts, while an LPN noted that low staffing prevented completion of treatments. Residents experienced long wait times for call lights, with one resident soiling herself due to delays. The administrator acknowledged the issue, aiming for two staff on overnight shifts.
The facility failed to address water intrusion and a black substance in the basement, which may have contributed to respiratory issues in a resident with pre-existing conditions. Despite awareness of these issues, no structural assessment or root cause analysis was conducted, and the infection prevention staff did not investigate the potential link between the basement conditions and residents' symptoms.
The facility failed to protect residents from accidents, as evidenced by incidents involving two residents. One resident, who required a non-weight-bearing mechanical lift, was improperly transferred by a CNA without a gait belt, resulting in a fall and fractures. Another resident, with a moderate cognitive deficit, experienced multiple falls due to inadequate interventions and care planning. The facility's policies on fall risk reduction and clinical change management were not adequately followed.
The facility failed to provide adequate staffing, resulting in delayed call light responses and unmet resident needs. A resident with quadriplegia reported hour-long waits for assistance, especially at night. Staff confirmed insufficient staffing, particularly during night shifts, impacting care delivery. The DON expressed concerns about staffing cuts due to budget constraints, which were deemed unsafe given the high needs of residents.
The facility failed to provide the required 8-hour RN coverage daily, as revealed by a review of the nursing schedule for June and July 2024. During a transition with the DON, LPNs covered shifts, leading to gaps in RN coverage. Staff reported feeling overwhelmed due to insufficient staffing, particularly when residents required two-person assistance. The facility's assessment indicated that staffing should ensure professional guidance, but actual levels were inadequate.
The facility failed to update comprehensive care plans for four residents, resulting in discrepancies between care plans and current needs. A resident's care plan did not reflect the need for a non-weight-bearing mechanical lift, while another's fluid restriction was outdated. Additionally, wound care instructions and fluid intake monitoring were not accurately documented, leading to inconsistencies in care.
The facility failed to maintain proper hand hygiene and glove use during food preparation and service. Staff did not clean thermometers between food items, moved between tasks without washing hands, and handled food with improper glove use. Despite training, the facility lacked a specific kitchen hygiene policy.
Two residents with chronic skin ulcers did not receive timely and accurate assessments and interventions. One resident, with impaired cognitive skills and multiple health conditions, had missed treatments and incomplete skin assessments. Another resident, with normal cognition and a history of ulcers, also experienced lapses in wound care and incomplete assessments. The facility's policies on skin and wound care management were not followed, and care plans did not reflect the residents' current needs.
The facility failed to consistently perform pre and post dialysis assessments for two residents with chronic kidney disease and end-stage renal disease. Incomplete documentation and assessments were noted, with staff acknowledging the deficiency. The facility's policy required specific assessments, which were not consistently followed.
The facility failed to implement proper hand hygiene and infection control practices during wound care for two residents. A resident with cognitive impairments and venous stasis ulcers received treatment without hand hygiene by an RN, contrary to the facility's policy. Another resident, at risk for pressure ulcers, also experienced inadequate hand hygiene during wound care, with the RN failing to clean a tape measure between wounds and not separating cleaning from wound management. The DON acknowledged these deficiencies.
A resident with multiple medical conditions did not receive the influenza vaccine despite signing a consent form. The facility's immunization process failed due to a breakdown in communication between the social worker and nursing staff, leading to a lack of documentation and administration of the vaccine.
The facility failed to report a verbal abuse incident involving an LPN and a paralyzed resident in a timely manner. The incident occurred but was not reported until several days later due to the reporting staff member's uncertainty and concerns about favoritism. The facility's policy requires immediate reporting, which was not followed.
The facility failed to allow a resident to return after a transfer to an acute setting due to behavioral issues. Despite the resident's history of behaviors, there was no documentation of PRN medication administration or the transfer to the ER. The emergency discharge was issued without proper documentation and procedures.
Repeated Deficiencies Reveal Ineffective QAPI Program
Penalty
Summary
The deficiency involves the facility’s failure to provide a comprehensive and effective Quality Assessment and Performance Improvement (QAPI) program despite having a written QAPI policy. Review of the state agency’s website showed repeated deficient practices cited over multiple complaint investigations and recertification surveys from early 2024 through late 2025, including failures related to reporting requirements, protection of resident-identifiable information in records, infection prevention and control, maintaining a safe, clean, comfortable, homelike environment, and provision of ADL care for dependent residents. QAPI-specific deficiencies were cited on several surveys, indicating that the facility’s QAPI program and plan were not effectively implemented to prevent recurrence of these issues. During an interview, the Administrator, who began as Interim Administrator in February 2026, stated he could only speak to what had been started since his arrival and that he planned to revamp QAPI. He described a general process of reviewing CMS Form 2567, discussing it with the QAPI team and departments, developing plans of correction, and initiating audits to prevent repeat deficiencies, but the survey findings showed that repeated deficiencies continued to occur over time. The facility’s written QAPI policy, updated in early 2025, described broad goals such as developing a culture of proactive leadership, using multiple data sources (including surveys, grievances, adverse events, and performance audits), and having the QAPI committee review findings against benchmarks. However, the persistence of repeated citations in areas such as reporting, resident records confidentiality, infection control, environment, ADL care, and QAPI itself demonstrated that the described processes were not effectively carried out to ensure a comprehensive, functioning QAPI program.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment for residents. One resident’s room had a cracked window and broken closet doors that had been in disrepair since her admission, which she reported was for nearly a year. The resident stated the window rattled when doors opened and closed and that her room became chilly in the winter when the wind blew, while she sat in a recliner positioned next to the window. Both closet doors in her room did not open or close properly and were not secured on the track, and the outside door had a hole approximately the size of a half dollar. Additional environmental concerns were observed throughout the facility’s hallways and common areas. Multiple ceiling tiles in various hall locations had brown to light brown circular or linear stains of various sizes, and one ceiling tile was beige with a large split, with an adjacent tile having a hole. A ceiling tile bracket in one hall appeared bent downward. Walls in several halls and near the nurse’s station had paint chipping, and one hall had a long light black line on the wall above the grab bars with paint chipping. The nurse’s station ceiling also had a tile with a hole in it. The Maintenance Director reported he was not aware of the resident’s closet door issues and acknowledged awareness of the stained ceiling tiles, which he attributed to a leaking roof and limited availability of replacement tiles within his budget.
Failure to Secure Medical Records and Incomplete Documentation of Missed Medical Appointment
Penalty
Summary
The deficiency involves the facility’s failure to secure and properly maintain resident medical records and other resident-identifiable documents. Surveyors observed an unlocked conference room near the main entrance containing a file cabinet with resident medical records and no locking mechanisms. Outside, in a garage with doors that could be opened without unlocking, they found a 60-gallon trash can filled with resident documents with visible identifiers. The Administrator stated that medical records were stored off campus at a storage unit company and acknowledged there was an issue with non-payment, and also acknowledged that the documents in the garage were records that needed to be shredded but were not secured. The deficiency also includes the facility’s failure to ensure a resident’s medical record was complete and accurate. A resident with heart failure, renal insufficiency, non-Alzheimer’s dementia, anxiety, depression, and a left below-knee amputation had a physician order dated 3/27/2026 for daily dry dressing changes, non-weight bearing to the left leg, and a follow-up appointment on 4/3/2026 at 9:30 AM. Review of the progress notes on 4/7/2026 showed no documentation related to the scheduled follow-up appointment. The former DON stated the resident missed the appointment and that she only became aware of it shortly before the scheduled time, after the facility’s transportation staff member had been let go and the Assistant Administrator had been asked to take residents to appointments. The Assistant Administrator reported she was now providing transportation, did not feel comfortable driving the large van out of town, and confirmed that a resident missed an out-of-town appointment for that reason, with no corresponding documentation of the missed appointment in the medical record despite facility policy requiring all services and changes in condition to be documented.
Failure to Address Water Intrusion and Mold-Like Conditions in Laundry and Basement Areas
Penalty
Summary
The facility failed to provide appropriate infection prevention and control by not resolving ongoing water intrusion and the presence of a black substance in the basement and laundry room. Observations in the laundry room showed cracked paint on the wall between the washers and dryers, with a black fuzzy substance visible behind an area near the floorboard. Stagnant water was present behind the water heater and to the left of the first washer on the dirty side of the laundry room. The Maintenance Director reported that drainage hoses sometimes became clogged, causing water to overflow from the water compartment, and the water was observed pooling on a flat surface above the slope to the drain. In the basement, surveyors noted a heavy mildew/musty odor and stagnant water where the walls met the floor, with water draining from a sealed basement window and mud present under the water. Some rooms contained wooden work benches or storage shelves standing in the stagnant water. One room had a wall that appeared to have been removed about half a foot from the basement floor, exposing a large area of black substance. Outside the building, the ground near the problem window and wall sloped toward the building rather than away, and the Maintenance Director stated that during heavy rainfall the water had no place to go and that downspout extensions had not been sufficient. The Administrator and Clinical Services Director were initially unaware of the water in the basement; when later observing the area, the mildew/musty smell persisted and rainwater, though receded, remained with mud present. These conditions occurred despite the facility’s written Infection Prevention and Control Program policy stating it would maintain a safe, sanitary, and comfortable environment and use a system of surveillance to prevent, identify, report, investigate, and control infections and communicable diseases.
Failure to Provide Dignified Toileting Assistance and Respect Resident Preferences
Penalty
Summary
The deficiency involves a failure to treat a resident with dignity during assistance with Activities of Daily Living (ADLs), specifically toileting. The resident had a BIMS score of 13, indicating no cognitive impairment, and was dependent on staff for toileting hygiene and transfers, with documented bowel incontinence and multiple medical diagnoses including atrial fibrillation, heart failure, renal failure, urinary retention, insomnia, and acute pain. His care plan documented a self-care deficit, the need for assistance of one staff for toileting, and his preference for having a urinal at the bedside, as well as staff responsibilities to check him every two hours, assist with toileting as needed, and provide peri-care after incontinent episodes. The resident reported that on one occasion, when he requested a bedpan because he needed to have a bowel movement, a staff member told him to defecate in his adult brief instead, which made him feel bad. He usually used a bedpan due to an amputation of one leg, having previously been able to use the toilet. Interviews with facility staff confirmed that a CNA told the resident to soil his brief rather than use a bedpan. The ADON reported being present when the former DON interviewed the CNA, who acknowledged telling the resident to soil his brief and later justified it by saying that was what briefs were for. The CNA stated she could not find an appropriate bedpan and did not go to the main storage to obtain another one. Another staff member (a CMA) informed the DON that the CNA had told the resident he could "sh*t himself" when he requested a bedpan. The DON stated that the CNA reported looking for a fracture bedpan in a storage closet and then telling the resident to use his brief because that is what briefs are for, while other staff later found a bedpan in the resident’s bathroom and the DON knew fracture pans were available in storage. The facility’s written policy on promoting and maintaining resident dignity states that residents are to be treated in a manner that maintains or enhances quality of life, recognizes individuality, and respects resident rights and personal choices.
Failure to Provide Transportation for Out-of-Town Medical Appointment
Penalty
Summary
The facility failed to reasonably accommodate a resident’s need for transportation to an out-of-town medical follow-up appointment, resulting in the resident missing the scheduled visit. The resident had a Significant Change MDS with a BIMS score of 9, indicating mild cognitive impairment, and diagnoses including heart failure, renal insufficiency, non-Alzheimer’s dementia, anxiety, depression, and a left leg below-knee amputation. Physician orders and progress notes dated 3/27/2026 directed daily dry dressing changes to the left lower extremity, non-weight bearing status for the left leg, and a follow-up appointment on 4/3/2026 at 9:30 AM. Review of the clinical record showed no progress notes related to this follow-up appointment, and the resident did not attend the scheduled visit. Staff interviews revealed that the previous transportation staff member had been let go, and the Assistant Administrator had been assigned to transport residents to appointments. The Assistant Administrator reported she did not feel comfortable driving the large van for out-of-town appointments and informed the Administrator of her discomfort. On the day of the scheduled follow-up, the DON learned shortly before the appointment time that the resident would miss the visit because the Assistant Administrator was unwilling to drive out of town. The Assistant Administrator acknowledged that a resident missed their appointment that morning for this reason and that, at that time, she was the only person covered under the facility’s insurance to drive the transportation van.
Failure to Timely Report Allegation of Verbal Abuse and Dignity Violation
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse within 2 hours of the alleged incident, as required by policy. Resident #1, who had a BIMS score of 13 indicating no cognitive impairment, was dependent on staff for toileting hygiene and transfers, was always incontinent of stool, and had multiple diagnoses including atrial fibrillation, heart failure, renal failure, urinary retention, insomnia, and acute pain. His care plans documented a self-care deficit, the need for assistance of one staff for toileting, use of a bedside urinal, and that staff were to check him every two hours, assist with toileting as needed, and provide peri-care after incontinent episodes. On the evening of 2/19/2026, between approximately 6:00 PM and 10:00 PM, Staff C, a CMA, heard Resident #1 ask Staff B, a CNA, to be taken to the bathroom to have a bowel movement. Staff C reported that Staff B told the resident to “just sh*t himself.” Staff C later entered the room, noted the resident’s call light was on, found his brief full, and provided hygiene care. Staff C did not report this concern until the following day, 2/20/2026, when she informed the DON (Staff A), describing the incident as a dignity issue. The facility’s investigative file shows that Staff A and the ADON interviewed Staff B on 2/20/2026; Staff B acknowledged telling the resident to go in his brief, stating that is what briefs are for, and reported difficulty finding an appropriate bedpan. Other staff later confirmed that a bedpan was present in the resident’s bathroom and that fracture pans were available in storage. At approximately 3:30 PM on 2/20/2026, Resident #1 was interviewed by the DON and Scheduler. He confirmed that when he requested to go to the bathroom the previous night, the staff member told him to go in his diaper, stating there were no bedpans, and he denied that this was his preference. He pointed out a bedpan visible in his room. Subsequent interviews with the ADON and Staff A confirmed that Staff B admitted telling the resident to soil his brief and that Staff C and another CNA should have reported the incident immediately. The Administrator stated that staff should have immediately reported this incident. Despite the facility’s written policy requiring all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation to be reported immediately to the Administrator and to the state entity not later than two hours after the allegation is made, the allegation from 2/19/2026 was not reported to the state agency until 4:08 PM on 2/20/2026, exceeding the required 2-hour reporting timeframe.
Failure to Provide Required Toileting Assistance and Respect Resident’s ADL Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate assistance with activities of daily living (ADLs), specifically toileting and elimination support, for one resident who required staff help. The resident had a BIMS score of 13, indicating no cognitive impairment, and his MDS documented dependence on staff for toileting hygiene and toilet transfers, with a pattern of always being incontinent of stool. His care plan identified a self-care deficit, impaired balance, incontinence, and the need for assistance of one staff for toileting, including the use of a bedpan or urinal at the bedside. The resident had multiple medical diagnoses, including atrial fibrillation, heart failure, renal failure, urinary retention, insomnia, and acute pain, and used a wheelchair due to bilateral extremity impairment and a leg amputation. According to the resident, on one occasion when he requested a bedpan because he needed to have a bowel movement, a staff member told him to “poop in his pants” after being unable to locate the bedpan, and he subsequently defecated in his adult brief. He reported that this made him feel very bad. A CMA stated she believed she heard the same staff member tell the resident to “sh*t himself” when he asked to go to the bathroom; shortly afterward, the CMA responded to the resident’s call light, found that he had soiled his brief, and assisted with cleaning and changing him. Staff interviews indicated that the resident usually requested a bedpan, was only sporadically incontinent, and knew when he needed to use the bathroom. Facility policy on Supporting ADLs required that residents who are unable to carry out ADLs independently receive appropriate care and services, including support and assistance with elimination and toileting, in accordance with their care plan.
Failure to Provide Timely Tracheostomy Suctioning Results in Resident Neglect
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN), identified as Staff A, repeatedly refused or delayed providing suctioning care for a resident who was dependent on staff for tracheostomy management. The resident had physician orders for deep suctioning as needed, with specific instructions for frequency and technique. Despite these orders, documentation revealed that Staff A did not record performing suctioning during his shifts, and multiple staff and the resident reported that Staff A would not respond promptly to requests for suctioning, often requiring the resident to activate the call light multiple times and for certified nursing assistants (CNAs) to repeatedly notify Staff A before the care was provided. The resident, who had diagnoses including acute and chronic respiratory failure with hypoxia, functional quadriplegia, and a tracheostomy, reported experiencing severe anxiety and fear for his life when suctioning was not performed as needed. The resident stated that this neglect occurred nearly every night Staff A worked, and that all overnight CNAs were aware of Staff A's refusal to provide timely suctioning. Staff interviews corroborated the resident's account, with CNAs stating that Staff A would often refuse to suction the resident, sometimes claiming he had already done so or was busy, and that the resident appeared scared and anxious as a result. The director of nursing (DON) was made aware of concerns regarding the frequency and timeliness of suctioning, including receiving calls and text messages from staff about the issue. However, the DON did not identify or document any concerns with Staff A's performance at the time, and there was no evidence that the DON was aware of the ongoing pattern of neglect until later. Staff A denied refusing care and claimed to have provided suctioning as needed, but this was contradicted by multiple staff and the resident's statements, as well as the lack of documentation in the medical record.
Failure to Investigate and Respond to Alleged Neglect of Tracheostomy Care
Penalty
Summary
The facility failed to investigate an allegation of neglect involving a resident who was dependent on staff for tracheostomy care. The resident reported that an LPN frequently refused or delayed providing suctioning, despite having physician orders for deep suctioning as needed every 20 minutes. The resident described having to activate the call light multiple times and rely on CNAs to communicate his needs to the LPN, resulting in significant anxiety and feelings of neglect. Multiple CNAs corroborated the resident's account, stating that the LPN routinely refused to suction the resident's tracheostomy when requested, and that these concerns were reported to the DON both verbally and via text message. Despite these reports, there was no evidence that the facility conducted a thorough investigation into the allegations. Documentation and interviews revealed that the DON was made aware of the situation through staff communications, including text messages and phone calls, but did not initiate a formal investigation or separate the LPN from the resident during the period in question. The DON acknowledged receiving concerns about the frequency of suctioning and the LPN's response but did not document any follow-up actions or witness statements related to the alleged neglect. The clinical record lacked documentation of the suctioning order being utilized by the LPN, and there was no evidence of a comprehensive review of the resident's care or staff performance regarding the allegations. The resident involved had a history of acute and chronic respiratory failure with hypoxia, functional quadriplegia, and a tracheostomy, making timely and appropriate suctioning critical to his well-being. The failure to respond appropriately to the resident's needs and to staff reports of neglect constituted a deficiency in the facility's abuse prevention, identification, and investigation procedures. The facility's policy required immediate notification, investigation, and documentation of alleged abuse or neglect, but these steps were not followed in this case.
Failure to Maintain 24-Hour Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide a licensed nurse on the premises on a 24-hour basis, specifically during the overnight shift from 11/11/25 to 11/12/25, when the only scheduled LPN left the facility. Review of staffing records and timecards confirmed that the LPN clocked out at 1:15 AM, leaving the facility without a licensed nurse on site for several hours while 37 residents were present. Staff interviews revealed that the LPN had a pattern of leaving the building or being unaccounted for during overnight shifts, often leaving his phone at the nurses' station and instructing CNAs to call him if needed, though he was sometimes unreachable. On the night in question, the LPN left the facility to get gas and was subsequently detained by law enforcement after a traffic stop. CNAs reported being unaware that the LPN had left the premises and were unable to locate him when needed for resident care, including when a resident developed a fever. The DON was notified by staff and law enforcement after the LPN was taken into custody, and EMS was dispatched to the facility to provide medical coverage until the DON arrived. Staff interviews indicated that concerns about the LPN's absences had been previously reported to the DON, but there was no documentation of disciplinary action or ongoing concerns in the staff records. Facility policy and the facility assessment both required a licensed nurse to be present 24 hours a day to provide direct resident care. Despite this, the LPN was the only nurse scheduled for the overnight shift and left the premises, resulting in a period where no licensed nurse was available to meet residents' needs. Staff and resident interviews corroborated that the LPN was frequently absent from the building during his shifts, and the facility lacked documentation or monitoring to address these concerns.
Failure to Provide Adequate Orientation and Competency Training for Nursing Staff
Penalty
Summary
Nursing staff at the facility were scheduled to work independently with residents without adequate orientation or competency-based training. Two LPNs reported that they did not receive an orientation checklist or formal training before being assigned to care for residents on their own. One LPN stated he did not follow another nurse or complete any orientation checklist, and his personnel file lacked documentation of orientation or training. Another LPN reported receiving some instruction on medication times and paperwork but did not receive competency-based training on specific clinical skills such as catheter care, enteral tubes, or tracheostomy care, despite being expected to perform these tasks. His personnel file also lacked an orientation or training checklist. A former RN at the facility confirmed that there was no checklist for orienting new staff and expressed concerns about the competency and readiness of new hires, specifically noting that one LPN was allowed to work independently despite her concerns about his abilities. The facility administrator acknowledged the absence of a formal orientation or training program, and the DON stated that while a process was being developed, there was no formal orientation list in place. Facility policy required a 10-hour orientation program with a checklist for all new hires, but this was not followed or documented for the staff reviewed.
Failure to Serve Room Trays at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing and safe temperature to three residents who consistently received room trays. All three residents were cognitively intact and reported that their meals were often cold upon delivery to their rooms. One resident specifically noted that the facility did not use heated carts for room tray delivery and expressed concern that food sat too long before being brought to her room. Another resident stated that every meal delivered to her room was cold, while a third resident mentioned that food was sometimes served cold and she would request reheating if needed. Observation of the meal delivery process revealed that room trays were loaded onto a cart and delivered to resident rooms, with a sample tray temperature check showing that one of the food items, pepper steak, was below the facility's required minimum temperature of 135 degrees Fahrenheit. Both the kitchen manager and consulting dietitian confirmed that food should be delivered at or above 135 degrees. Facility policy also indicated that potentially hazardous foods must be maintained above 135 degrees to prevent the growth of harmful pathogens, and the administrator confirmed the expectation for food temperature compliance.
Failure to Provide Scheduled Baths or Showers to Multiple Residents
Penalty
Summary
The facility failed to provide scheduled baths or showers to three out of four residents reviewed, despite care plans and facility protocols indicating the required frequency. Electronic Health Record (EHR) reviews showed that one resident, who was cognitively intact and required substantial assistance, was scheduled for three baths per week but only received 30 out of 48 expected baths over a four-month period. Staff interviews confirmed that baths were sometimes missed due to staffing shortages, and there was no documentation of resident refusals for the missed baths in the EHR or on bath sheets, despite staff claims that refusals would be recorded. Another resident, also cognitively intact and dependent on staff for bathing, received only 8 out of 18 scheduled baths over a two-month period, with no refusals documented in the EHR. A third resident, similarly dependent, received 17 out of 33 scheduled baths over a four-month period, with only one refusal documented. The facility's policy required that residents be assisted with bathing according to their care plans and preferences, but the records and interviews indicated that this standard was not consistently met. The Director of Nursing (DON) and other staff acknowledged that baths were missed and that the facility had identified this as a concern. The DON confirmed that the expectation was for residents to receive at least two baths per week, and that the documentation did not reflect refusals for the missed baths. The administrator also acknowledged the issue, stating that resident preferences were considered in care planning, but that the scheduled baths were not consistently provided as required.
Medication Administration Errors and Documentation Issues
Penalty
Summary
The facility failed to follow physician orders for two residents, leading to medication administration errors. Resident #2, who had no cognitive impairment, did not receive her diabetes medication, Mounjaro, on a specified date, and her antihypertensive medication, Hydralazine, was administered outside the ordered parameters. Additionally, her weekly weight monitoring was not completed as ordered. There were no progress notes documenting the reasons for these discrepancies. Resident #2 reported that the Assistant Director of Nursing (ADON) did not administer medications to several residents, including herself, on a particular day, and there was a discrepancy in the administration of her insulin, Tresiba. Resident #3, also without cognitive impairment, did not receive his insulin as per the sliding scale order, and there were no notes explaining the deviation. On another occasion, the ADON documented that Resident #3 refused his morning medications, which he stated was due to the late administration time, advised by his doctor. Staff confirmed that Resident #3 had never refused his medications before, indicating a possible error in documentation or communication. Resident #6's medication, Oxycodone, was destroyed without obtaining a discontinuation order from the physician. The medication had not been used for several months, and there was no documentation explaining the destruction. The Director of Nursing was unsure why the medication was destroyed without an order. The facility's policy on medication administration was not followed, as medications were not signed out immediately after administration, and parameters for holding medications were not adhered to.
Deficiencies in Fall and Infection Assessment Protocols
Penalty
Summary
The facility failed to adequately assess and respond to an unwitnessed fall involving Resident #5, who had severe cognitive impairment and a history of falls. On 2/12/2025, Resident #5 was found on the floor next to her bed without her fall mat in place, and no call light was activated. The Interim Administrator, who was not a licensed nurse, conducted an initial assessment and assisted the resident into a wheelchair without using a gait belt. Neurological checks were not initiated immediately, and the first set of vitals was delayed by 30 minutes. The facility's protocol for neurological assessments following an unwitnessed fall was not followed, as confirmed by staff interviews and the Director of Nursing. Additionally, the facility failed to conduct appropriate assessments for residents who tested positive for COVID-19 and Influenza A. Residents #1, #8, #11, #12, #13, and #14, who tested positive for COVID-19, did not receive consistent respiratory assessments every shift as required. Their clinical records lacked documentation of regular COVID-19 Observation assessments and vital signs monitoring. Similarly, Resident #9, who tested positive for Influenza A, did not have consistent vital signs and respiratory assessments documented in their clinical record. The facility's failure to adhere to established protocols for post-fall assessments and monitoring of residents with infectious diseases highlights significant lapses in care. The lack of timely and thorough assessments, as well as the absence of consistent documentation, contributed to the deficiencies identified during the survey. These actions and inactions demonstrate a failure to provide appropriate treatment and care according to orders, resident preferences, and goals.
Inadequate RN Coverage in Facility
Penalty
Summary
The facility failed to maintain the required Registered Nurse (RN) coverage for 8 consecutive hours, 7 days a week, as evidenced by the review of nursing schedules, staffing sheets, and Payroll Based Journal (PBJ) reports. Specific dates in January and February 2025, as well as several dates in late 2024, were identified where the facility did not have the necessary RN coverage. Interviews with staff, including Licensed Practical Nurses (LPNs) and Certified Medication Aides (CMAs), revealed that the facility struggled with consistent RN coverage, often relying on the Director of Nursing (DON) and a part-time RN who worked weekends. However, the DON's frequent absences due to vacation, illness, or hospitalization further exacerbated the issue. Staff interviews highlighted a lack of communication and coordination in scheduling RNs, with some RNs expressing difficulty in picking up shifts due to unresponsive management. The facility's assessment claimed to maintain 24-hour licensed nurse coverage, but the reality, as reported by staff, was inconsistent and insufficient. The DON and Assistant Director of Nursing (ADON) were often unavailable, and agency staff were sometimes used to fill gaps, but this did not ensure the required coverage. The deficiency was further underscored by staff laughter and comments about the ongoing issue, indicating a lack of confidence in the facility's ability to meet regulatory requirements for RN coverage.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily with accurate and updated details for residents and visitors to see. Observations on multiple dates revealed that the daily staff postings were not updated consistently. On February 13, 2025, the postings were dated February 11, 2025, and on February 19, 2025, the postings were dated February 18, 2025. The Director of Nursing (DON) stated that night nurses were responsible for filling out the staff postings. The facility reported a census of 37 residents at the time of the survey.
Staffing and Management Deficiencies Lead to Unsafe Conditions
Penalty
Summary
The deficiency report highlights a significant lapse in staffing and management at the facility, which led to a period where no licensed nurse was present to care for the residents. On the day in question, the facility was left without a nurse for approximately three hours due to a combination of staff illness, weather conditions, and scheduling issues. During this time, the Administrator, who is not currently licensed to practice as a nurse, attempted to fill the gap by overseeing the medication cart and assessing a resident who had fallen. However, this was not sufficient to meet the facility's needs, as the absence of a licensed nurse left the staff feeling unsupported and concerned for resident safety. The report details an incident involving a resident who fell out of bed during the period without a nurse. The resident was assessed by the Administrator, who determined there were no injuries, but the assessment was not conducted by a licensed nurse, and proper protocols, such as using a gait belt for lifting, were not followed. Additionally, neurological assessments were not initiated despite the fall being unwitnessed. This incident underscores the facility's failure to ensure adequate staffing and appropriate care for residents, as the Administrator's actions, while well-intentioned, did not comply with standard nursing practices. The report also reveals a broader issue of poor management and a toxic work environment, as staff members expressed frustration with the lack of support from the Director of Nursing (DON) and Assistant Director of Nursing (ADON). The DON and ADON were reported to have remained in their offices rather than assisting with resident care, contributing to a hostile work environment. Staff members reported feeling unsupported and retaliated against for raising concerns, further exacerbating the facility's challenges in maintaining a safe and effective care environment.
Repeated Deficiencies in QAPI Program
Penalty
Summary
The facility failed to ensure a comprehensive and effective Quality Assessment and Performance Improvement (QAPI) program, as evidenced by repeated deficiencies identified in multiple surveys. The Department of Inspections, Appeals and Licensing (DIAL) website revealed that the facility had a history of deficiencies, including insufficient nursing staff, inadequate quality of care, issues with resident records, and infection control problems. These deficiencies were noted across several surveys, including complaint surveys and the annual recertification survey, indicating a pattern of non-compliance with regulatory standards. The facility's QAPI plan, revised in January 2025, aimed to foster a culture of proactive leadership and systematic improvement. However, the plan's implementation appeared ineffective, as evidenced by the recurrence of deficiencies. The administrator acknowledged that after surveys, results are shared with the management team to develop a plan of correction. However, the approach to preventing recurrence seemed inconsistent, relying on actions such as staff demotion, audits, and training, which may not have been sufficient to address the underlying issues. The repeated deficiencies suggest that the facility's QAPI efforts were not adequately addressing the root causes of the problems identified in the surveys.
Infection Control and Insulin Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures during an outbreak status, as observed by surveyors. Despite a sign on the front entrance indicating that masks were required, masks were not readily available at the entrance, and staff, including the Administrator and Director of Nursing (DON), were frequently observed without masks. This non-compliance with mask-wearing protocols was consistent across multiple days and involved various staff members, including the Activity Director and Transportation staff, who were seen with masks improperly worn or not worn at all. The facility was in outbreak status due to COVID-19, with several staff and residents testing positive, yet routine testing and mask enforcement were not adequately implemented. Additionally, the facility failed to adhere to proper procedures for obtaining blood sugar levels and administering insulin to residents. Multiple residents reported that Staff A did not use alcohol wipes before performing finger sticks for blood sugar checks or before administering insulin injections. This was corroborated by other staff members who were aware of the issue but did not take corrective action. Residents expressed concern over this practice, which was contrary to the facility's established procedures for blood sampling and insulin administration. The facility's COVID-19 policy guidelines and procedures for blood sampling and insulin administration were not followed, leading to deficiencies in infection control and resident care. Staff interviews revealed a lack of consistent testing and mask-wearing, with some staff unaware of the current protocols. The DON acknowledged the issues but did not ensure compliance with the facility's policies, contributing to the ongoing deficiencies during the outbreak status.
Care Plan Deficiencies for Two Residents
Penalty
Summary
The facility failed to update the care plans for two residents, leading to deficiencies in their care. Resident #4, who had no cognitive impairment, was documented to have an indwelling catheter, ostomy, and received tracheostomy care. However, the care plan, last revised in November 2024, did not reflect these medical devices or provide directives for their care. This oversight was confirmed by staff observations and record reviews, indicating a lack of necessary updates to the resident's care plan to address their current medical needs. Resident #5, with severe cognitive impairment, had a history of falls and required a fall mat when in bed. Despite this, the care plan did not instruct staff to use a fall mat, and staff interviews confirmed that the mat was not in place during a recent fall. The Director of Nursing acknowledged the oversight, noting that the care plan should have included the use of a fall mat. The facility's policy requires care plans to be revised with significant changes in a resident's condition, but this was not adhered to, resulting in inadequate care planning for the residents involved.
Failure to Complete Ordered Treatments for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to complete treatments as ordered for a resident with pressure ulcers, as observed through clinical record reviews, resident and staff interviews, and facility policy review. The resident, who had a BIMS score of 15 indicating no cognitive impairment, was at risk for developing pressure ulcers and had existing stage two pressure ulcers and venous and arterial ulcers. Despite having a care plan that directed staff to follow doctor's orders for treatment and to monitor and document the location, size, and treatment of skin injuries, the facility did not consistently complete these tasks. The resident's treatment administration records (TAR) for December 2024, January 2025, and February 2025 showed multiple instances where orders for wound care and skin assessments were not signed out as completed. This included the application of dressings, ointments, and other treatments, as well as weekly skin assessments and the elevation of the resident's legs. The resident reported that while treatments generally got done, there were times when nurses skipped them, sometimes for two days at a time, depending on which staff were working. The Director of Nursing (DON) stated that measurements were not obtained during weekly skin assessments because they were done monthly at the wound clinic. However, the facility's protocol required full assessment and documentation of pressure sores, including measurements. The DON also mentioned that the resident often refused treatments, although this was not documented as required by the facility's procedures. The facility's failure to consistently follow treatment orders and document assessments and refusals contributed to the deficiency.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure the use of a gait belt for a resident with severe cognitive impairment and physical limitations during a transfer after a fall. The resident, who had a history of stroke, dementia, and other medical conditions, required extensive assistance for transfers. On the day of the incident, the resident fell out of bed, and the staff, including the Administrator, assisted the resident back into a wheelchair without using a gait belt, contrary to the facility's policy. The resident's fall was unwitnessed, and although the Administrator assessed the resident for pain and injuries, no neurological assessments were conducted. Staff interviews revealed confusion regarding the facility's policy on lifting residents, with some staff unsure if a mechanical lift was required. The Director of Nursing acknowledged that a gait belt should have been used during the transfer. The facility's policy on safe lifting and movement of residents emphasized the use of appropriate techniques and devices, including gait belts, to ensure resident safety and comfort. However, the staff did not adhere to this policy during the incident, leading to the deficiency.
Nursing Coverage Lapse in LTC Facility
Penalty
Summary
The facility failed to provide adequate nursing coverage on a specific date, resulting in a period from approximately 1:30 PM to 4:30 PM where no licensed nurse was present in the building. This occurred after an LPN, who had been working extended hours due to another staff member calling in sick, was advised by the Administrator to leave the facility to rest and retrieve her medications. The absence of a licensed nurse during this time left the facility without the necessary medical oversight, despite the presence of high-risk residents, including one with complex medical needs such as a tracheostomy, indwelling catheter, and a history of frequent hospitalizations. During the period without nursing coverage, the facility had several CNAs and CMAs on duty, but no licensed nurse to oversee care or respond to medical emergencies. The Administrator, who was not currently licensed as a nurse, assumed some responsibilities, including taking charge of the medication cart keys and assessing a resident who had fallen. However, the lack of a licensed nurse meant that certain medical protocols, such as neurological assessments following an unwitnessed fall, were not completed. Staff interviews revealed that this situation was unprecedented in the facility, causing concern and anxiety among the staff. The facility's staffing plan and contingency measures were insufficient to address the sudden shortage, despite having partnerships with staffing agencies. The Administrator's actions, including advising the LPN to leave and attempting to fill the gap himself, were inadequate to meet regulatory requirements for nursing coverage. The absence of a licensed nurse during this critical period posed a significant risk to resident safety, particularly for those with complex medical needs and those in isolation due to infectious diseases.
Inadequate Staffing and Competency in Resident Care
Penalty
Summary
The facility failed to ensure that licensed staff were competent to complete an assessment after a resident experienced an unwitnessed fall. The resident, who had severe cognitive impairment and required extensive assistance for transfers due to a history of stroke and other medical conditions, fell out of bed when there was no licensed nurse present in the building. The Administrator, who was a former nurse but did not have an active license, assessed the resident for pain and injuries and assisted in transferring her to a wheelchair without using a gait belt. During the time of the incident, the facility was without a licensed nurse for approximately three hours. Staff members, including a Certified Medication Aide, were present but were not licensed to perform the necessary assessments. The Administrator, who was aware of the situation, instructed a nurse to take a break due to exhaustion, leaving the facility without proper nursing coverage. The Director of Nursing eventually arrived later in the afternoon. The incident highlighted a lapse in staffing and competency, as the necessary neurological assessments were not conducted following the unwitnessed fall. Additionally, the transfer of the resident was performed without the use of a gait belt, which is against standard protocol for ensuring resident safety during transfers. The facility's failure to maintain adequate licensed nursing staff and ensure proper assessment and transfer procedures contributed to the deficiency.
Unnecessary Administration of PRN Narcotic Pain Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically the administration of a PRN narcotic pain medication, Oxycodone, without clear evidence of pain. The resident, who had severe cognitive impairment and a history of stroke, cancer, heart failure, and dementia, was documented to have received the narcotic on several occasions despite staff observations that he did not appear to be in pain. The resident's care plan included directives to administer analgesic medications as ordered and to anticipate and respond to his pain needs, but there was no consistent evidence of pain that justified the frequent administration of the narcotic. Staff interviews revealed discrepancies in the administration of the PRN narcotic. Several staff members, including LPNs and CNAs, reported that the resident often moaned and groaned but did not exhibit behaviors consistent with significant pain. Some staff indicated that the narcotic was given to help the resident sleep, despite the resident being on a sleeping pill, and one staff member admitted to administering the medication to ensure a quieter night shift. The resident's Medication Administration Record (MAR) showed frequent administration of the narcotic by a specific LPN, raising concerns about the necessity of the medication. The facility's policy on administering medications required re-evaluation of frequent PRN medication use by the attending physician and care team, with input from a consultant pharmacist. However, there was no documentation of such re-evaluation or clinical justification for the frequent use of the narcotic. The Director of Nursing and other staff members acknowledged the resident's behaviors were more related to agitation than pain, further questioning the appropriateness of the narcotic administration.
Failure to Properly Store Delivered Medications
Penalty
Summary
The facility failed to appropriately store medications after they were delivered from the pharmacy, as observed on two separate occasions. On February 13, 2025, a blue plastic bag containing medication cards for sertraline, oseltamivir, Lisinopril, pyridostigmine, Eliquis, and metoprolol was found opened and unattended on the counter at the nurse's station for 30 minutes. This was contrary to the facility's policy, which requires medications to be stored in locked compartments. Staff interviews revealed that medications are usually delivered in white or blue bags and should be put away immediately by the nurse or Certified Medication Aide (CMA) present at the time of delivery. The Director of Nursing (DON) confirmed the procedure for handling delivered medications, which involves checking the packing slip, signing forms, and storing the medications in the cart. However, the incident on February 13, 2025, indicated a lapse in this procedure, as the medications were left unattended on the counter. Staff members, including a Licensed Practical Nurse (LPN) and a CMA, acknowledged that medications should not be left on the counter unattended, highlighting a failure in adhering to the facility's medication storage policy.
Incomplete Medical Records and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies in documentation and assessment. Resident #5, who had severe cognitive impairment and a history of falls, experienced an unwitnessed fall that was not properly documented or assessed. The incident report for the fall was delayed, and a post-fall assessment was not conducted immediately. The Administrator, who was present during the fall, did not perform a neurological assessment, and the Director of Nursing acknowledged the delay in completing the incident report due to her absence from the facility. Additionally, the facility did not document positive test results for Influenza A and COVID-19 for Residents #9 and #10, respectively, in their medical records. Both residents were placed in isolation due to their positive test results, but the documentation in their progress notes was incomplete. The Director of Nursing admitted that the staff failed to chart these test results, which was contrary to the facility's policy guidelines that required all test results to be recorded in the residents' permanent medical records.
Failure to Prevent Abuse of Residents by CNA
Penalty
Summary
The facility failed to prevent physical and verbal abuse of two residents, identified as Resident #2 and Resident #5, by a Certified Nursing Assistant (CNA) known as Staff U. The abuse was witnessed by another CNA and involved both physical and verbal aggression. Resident #2, who had a severe cognitive impairment with a BIMS score of 3, was found with bruises on her chest that resembled fingerprints. These bruises were discovered during a skin assessment conducted by a Licensed Practical Nurse (LPN). Staff interviews revealed that Staff U had a history of being rough with Resident #2, including pushing her down into a chair and using derogatory language. Resident #5, also with severe cognitive impairment and a BIMS score of 6, was similarly subjected to rough handling and verbal abuse by Staff U. Witnesses reported that Staff U aggressively moved Resident #5 by grabbing his feet and pulling him up by his arms. Staff U was also reported to have used offensive language towards Resident #5, threatening to hit him. Multiple staff members corroborated these incidents, indicating a pattern of abusive behavior by Staff U towards both residents. The facility's administration acknowledged that the abuse incidents were not reported to the state agency as required. The Administrator admitted that the facility's expectation was for all possible abuse to be reported, but this did not occur. The investigation revealed that Staff U's negative attitude and rough handling of residents were known issues, yet she was not immediately separated from resident care. This oversight allowed the abuse to continue, resulting in an Immediate Jeopardy situation for the residents involved.
Removal Plan
- Resident and staff interviews to determine any unreported incidence of abuse conducted.
- All Staff are educated on Abuse types, Reporting Requirements, and Requirement of immediate separation with all employees being educated on the abuse policy prior to working with residents.
- The Administrator has been identified as the Abuse Coordinator and signage for phone number/contact for reporting has been placed conspicuously in the facility.
Failure to Report Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within the required 2-hour timeframe. On August 26, 2024, between 5:00 pm and 5:30 pm, a CNA witnessed another CNA physically and verbally abusing two residents. Despite reporting the incident to a nurse, neither the CNA nor the nurse reported the abuse to the state agency or the administration. This failure resulted in residents being exposed to actual abuse and the potential for further abuse, creating an Immediate Jeopardy to their health, safety, and security. Resident #2, who had a severe cognitive impairment with a BIMS score of 3, was found to have three bruises on her chest, which were documented by a Licensed Practical Nurse (LPN) during a skin assessment on August 27, 2024. The bruises were consistent with fingerprint marks, suggesting physical abuse. Additionally, Resident #5, also severely cognitively impaired with a BIMS score of 6, was dependent on staff for dressing and toileting. Staff interviews revealed that the same CNA had a history of verbally and physically abusing these residents, but these allegations were not reported. The investigation uncovered that multiple staff members had witnessed or were aware of the abusive behavior by the CNA, identified as Staff U, but failed to report it due to fear of retaliation or a belief that nothing would be done. The facility's policy required immediate reporting of suspected abuse to the Administrator and Director of Nursing, but this protocol was not followed. The Administrator acknowledged that the allegations should have been reported to the state agency and that Staff U should have been immediately separated from resident care, which did not occur.
Removal Plan
- Resident and staff interviews to determine any unreported incidence of abuse.
- All Staff are educated on Abuse types, Reporting Requirements, and Requirement of immediate separation with all employees being educated on the abuse policy prior to working with residents.
- The Administrator has been identified as the Abuse Coordinator and signage for phone #/contact for 24/7 reporting has been placed conspicuously in the facility.
Failure to Separate Alleged Abuser Leads to Continued Resident Abuse
Penalty
Summary
The facility failed to separate an alleged CNA abuser, resulting in continued verbal and physical abuse of two residents. On August 26, 2024, a CNA witnessed another CNA physically and verbally abusing two residents. Despite reporting the incident to a nurse, the alleged abuser continued to work with the residents. The following day, staff identified a bruise on one resident's chest, shaped like fingers, indicating physical abuse. The investigation revealed that the same CNA had a history of abusing these residents, which was not immediately addressed, leading to an Immediate Jeopardy situation. The facility's investigation into the incidents was delayed and incomplete. The Administrator was informed of verbal abuse by the alleged CNA but did not immediately separate the CNA from resident care. Staff interviews revealed that the CNA had been verbally abusive and physically rough with residents, including pulling a resident's legs aggressively and using inappropriate language. Despite multiple staff members witnessing and reporting these behaviors, the facility did not take immediate action to protect the residents or report the incidents to the state agency. The facility's policy on abuse prevention and reporting was not followed, as staff failed to report the abuse immediately, and the alleged abuser was not separated from resident care. The facility's failure to act promptly and comprehensively investigate the allegations exposed residents to further abuse and created an Immediate Jeopardy to their health and safety. The facility's inaction and lack of adherence to its abuse prevention policy contributed to the deficiency.
Removal Plan
- Resident and staff interviews to determine any unreported incidence of abuse.
- All Staff are educated on Abuse types, Reporting Requirements, and Requirement of immediate separation with all employees being educated on the abuse policy prior to working with residents.
- The Administrator has been identified as the Abuse Coordinator and signage for phone #/contact for reporting has been placed conspicuously in the facility.
Failure to Prevent Resident Elopement and Ensure Safety
Penalty
Summary
The facility failed to protect residents from potential accidents and injuries, particularly for two residents identified as having wandering and elopement risks. One resident, with a history of exit-seeking behavior, was able to leave the facility without triggering the door alarm, as the door code had not been changed despite the resident knowing it. The resident was found at a nearby Walmart by police after being missing for over an hour. The facility's Wanderguard System (WGS) was not functioning properly, and the resident's bracelet had not been checked for functionality. The facility's failure to conduct an updated Elopement Risk Assessment after previous exit-seeking incidents contributed to the deficiency. The resident had been demonstrating exit-seeking behaviors earlier in the day and had a history of wandering and exit-seeking, yet the care plan did not include interventions for wandering until after the incident. Staff interviews revealed that the door alarm and WGS alarm were not audible from the back of the building, and the front door code was known by several residents, further compromising security. Additionally, observations showed that the facility was located near busy roads without sidewalks, increasing the risk for residents who eloped. Staff were aware of the resident's exit-seeking behavior but did not take adequate measures to prevent elopement. The facility's policies on elopement and missing resident protocols were not effectively implemented, as evidenced by the lack of an overhead announcement when the resident was discovered missing.
Removal Plan
- The code to the door was changed.
- All Residents had Elopement Risk Assessments reviewed and/or completed.
- Elopement Binders were updated with current at risk residents and care plans were added to the binders regarding the resident's individual supervision needs.
- Residents with WGS had Sensor Checks added to the Electronic Medication Administration Record (EMAR) for placement and function daily.
- The WGS door alarm checks were to be completed daily and audited by the Administrator.
- The facility provided education to the staff on Elopement Procedures/Protocols.
- Additional education was provided regarding supervision levels of residents per care plan and the removal plan. Employees will be educated prior to the start of their next shift.
- Code to the front door was changed and staff educated that only staff members were to have the code.
- No family members, residents, or visitors were to know the code for exiting the building.
- The resident smoking area moved to the back of the facility.
- Staff were re-educated on the elopement policy and not sharing the front door code.
Failure to Safeguard and Properly Store Resident Medical Records
Penalty
Summary
The facility failed to maintain and safeguard resident medical records in accordance with accepted professional standards. During an observation, it was noted that the basement of the facility had significant issues with water intrusion, particularly in a room where resident records were stored. The room had a window well with washed away soil, and the walls were covered with a black fuzzy substance, indicating mold growth. The paint on the walls was chipping, loose, and bubbled, and there were signs of water damage to the boxes and resident records stored in the basement. Staff interviews revealed that the Maintenance Director was aware of the water intrusion issues and had informed the Administrator. The Administrator acknowledged being aware of the conditions and the improper storage of medical records but had not yet taken action to address the situation. The facility's policy on the location and storage of medical records stated that records should be protected from fire, water damage, insects, and theft, and stored in a locked room, which was not adhered to in this case.
Repeated Deficiencies in Reporting, Staffing, and Infection Control
Penalty
Summary
The facility failed to demonstrate evidence of systematic identification, reporting, investigation, analysis, and prevention of adverse events, as well as the development, implementation, and evaluation of corrective actions or performance improvement activities. The facility has a history of repeated deficiencies in several areas, including F609 (reporting alleged violations), F689 (free of accidents/hazards and supervision), F725 (sufficient nursing staff), and F880 (infection prevention and control). These deficiencies have been noted in multiple surveys over the years, with some resulting in harm level deficiencies. The Administrator acknowledged the lack of a performance improvement plan (PIP) for F609, citing inconsistent nursing leadership and challenges in developing a comprehensive plan due to the varied nature of the violations. The Administrator also highlighted staffing issues, including reliance on agency employees who sometimes cancel, leading to insufficient staffing levels. There was no current PIP related to staffing, and the facility's corporate office handled onboarding, which the Administrator believed could be more efficient if done in-house. Additionally, the facility had issues with infection prevention and control, particularly with hand hygiene and water intrusion concerns, which were not logged or analyzed due to the absence of consistent nursing leadership. The facility's QAPI policy outlined a process for identifying and prioritizing performance improvement plans, but the Administrator admitted that individual PIPs were not readily available for the survey team.
Facility Fails to Provide Sufficient Linens and Consistently Made Beds
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for its residents by not providing sufficient linens and ensuring that residents' beds were consistently made. Observations and interviews revealed that multiple residents, including those with normal cognition, reported issues with bed linens. Resident #6 mentioned frequent shortages of bed soakers, while Resident #10 and Resident #11 reported returning to unmade beds after dialysis and finding dirty, stained sheets, respectively. Resident #7, who has moderate cognitive impairment, was observed with an unmade bed lacking a fitted sheet. Staff interviews corroborated these findings, with several CNAs and LPNs acknowledging the shortage of bed pads, sheets, and other linens. Staff members reported improvising with available linens or repositioning when supplies were insufficient. The housekeeping assistant and laundry aide confirmed the low supply of linens and stated that restocking typically occurred by mid to late morning. Despite suggestions to purchase more linens, the administration's response was that ordering would be done at the beginning of the month. The facility's policy on maintaining a homelike environment emphasized the need for clean bed and bath linens in good condition, which was not consistently met.
Deficiencies in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop, implement, and follow comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. Resident #1, with intact cognition and a history of falls, was identified as a high risk for wandering. Despite having a Wanderguard System in place since February, the care plan did not include a focus area or interventions for wandering behavior until late August. This delay in updating the care plan left staff without specific guidance on managing the resident's wandering risk. Resident #2, with severe cognitive impairment and requiring substantial assistance, had a care plan that included transferring to a stationary chair during meals to improve eating. However, observations revealed that the resident was consistently left in a wheelchair during meals, contrary to the care plan's interventions. Staff admitted to not consistently following the care plan. Resident #11, with intact cognition and multiple diagnoses, had a care plan that lacked focus areas or interventions for enhanced barrier precautions, despite having a treatment regime for lower extremity wounds. The facility's administrator acknowledged that care plans might be lacking due to changes in directors of nursing.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure the safety and well-being of its residents, as evidenced by the staffing schedules and interviews with staff and residents. The August and September 2024 schedules revealed consistent understaffing across various shifts, with fewer Certified Nursing Assistants (CNAs) than required. Staff interviews confirmed that the shortage led to missed breaks and delayed resident care. A CNA reported working overnight shifts alone with a nurse, while a Licensed Practical Nurse (LPN) noted that low staffing levels prevented the completion of resident treatments as ordered. A Certified Medication Aide (CMA) expressed concerns about managing medication carts alone and being unable to respond to door alarms due to insufficient staffing. Residents also reported negative impacts due to the staffing deficiencies. One resident, who was dependent on staff for all activities of daily living and used a power wheelchair, stated that call lights could take up to an hour to be answered during overnight shifts. Another resident, who required substantial assistance for transfers and had bowel incontinence, reported long wait times for call lights, resulting in soiling herself. The facility's administrator acknowledged the longer call light response times, particularly after supper and during overnight shifts, and stated that the goal was to have two staff members on overnight shifts. The facility's policy indicated that staffing should be sufficient to meet residents' needs based on their care plans, but this was not achieved.
Inadequate Infection Control Due to Basement Conditions
Penalty
Summary
The facility failed to implement appropriate infection prevention practices, particularly in addressing water intrusion and a black substance in the basement. The Administrator acknowledged awareness of these issues, which included water entering through a wall and window well during heavy rainfall, causing mud on the floor and a black fuzzy substance on the wall. Despite these conditions, no structural integrity assessment was conducted, and the infection prevention staff did not perform a root cause analysis to determine if these environmental factors contributed to respiratory issues in residents. Resident #7, who had a history of respiratory problems, was hospitalized for acute hypoxic respiratory failure and later required supplemental oxygen. The Administrator noted that several residents exhibited flu-like symptoms in August, but none tested positive for COVID-19. The facility's infection prevention and control policy emphasized the importance of surveillance and data analysis to identify potential infection issues, but the facility did not adequately investigate the potential link between the basement conditions and the exacerbation of respiratory symptoms in residents.
Failure to Prevent Resident Falls and Injuries
Penalty
Summary
The facility failed to protect residents from possible accidents and injuries, as evidenced by the incidents involving two residents. Resident #13, who was cognitively intact and had a history of falls, was involved in an incident where a CNA attempted to transfer her to a wheelchair without a gait belt, resulting in a fall and subsequent fractures. The resident had been previously assessed as requiring a non-weight-bearing dependent mechanical lift for transfers, but the CNA was unaware of this requirement. The resident's care plan was not up to date, and the CNA did not have access to the necessary equipment, leading to the improper transfer attempt. Additionally, Resident #39, who had a moderate cognitive deficit and was a fall risk, experienced multiple falls over a period of time. Despite being identified as a fall risk, the facility failed to implement and document effective interventions to prevent these falls. Observations showed that the resident was often found in precarious positions, such as reaching for items on the floor, which contributed to the falls. The care plan for Resident #39 included frequent checks and removal of potential fall hazards, but these measures were not effectively carried out. The facility's policies on fall risk reduction and clinical change in condition management were not adequately followed. The Director of Nursing acknowledged the lack of implemented interventions and care planning for Resident #39's falls. The facility's failure to update care plans, communicate changes in resident status, and ensure staff were informed of and equipped to follow proper procedures contributed to the deficiencies observed.
Inadequate Staffing Leads to Delayed Call Light Response
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, resulting in delayed response times to call lights. Resident #35, who has a C5 level spinal injury and quadriplegia, reported that call lights could take up to an hour to be answered, particularly at night. This issue was consistently raised in Resident Council meetings, with concerns about inadequate staffing during evenings and weekends. Resident #14 and Resident #2 also reported long wait times for call lights, with instances of waiting up to an hour or more. The Director of Nursing expressed concerns about staffing cuts due to budget constraints, which she deemed unrealistic and unsafe given the high needs of the residents, including those requiring two-person assistance and extensive wound care. Staff interviews corroborated the residents' experiences, with reports of insufficient staffing, particularly during night shifts. Licensed Practical Nurses and Certified Medication Aides described situations where they were unable to complete all necessary treatments and tasks due to being understaffed. The facility's assessment indicated a staffing plan that was not being met, with only one nurse and two Certified Medication Aides on day shifts, and even fewer staff during evening and night shifts. This staffing shortage led to delays in care and unmet resident needs, particularly for those requiring two-person assistance.
Deficiency in RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours each day, as required. This deficiency was identified through a review of the nursing schedule for June and July 2024, which revealed multiple days without the mandated RN coverage. The facility had a census of 40 residents during this period. The gap in RN coverage occurred during a transition phase with the Director of Nursing (DON), leading to Licensed Practical Nurses (LPNs) covering the shifts. Staff interviews confirmed the absence of RN coverage, with LPNs stepping in to fill the gap. Staff reported feeling overwhelmed due to the increased expectations and insufficient staffing, particularly when residents required assistance from two staff members. The facility's assessment indicated that the staffing ratio should ensure professional guidance and supervision, but the actual staffing levels fell short of this requirement.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to revise and update the Comprehensive Care Plan for four residents, leading to discrepancies between the care plans and the residents' current needs and physician orders. For Resident #13, the care plan was outdated and did not reflect the resident's current need for a non-weight-bearing dependent mechanical lift due to hip precautions and pain. Despite the resident's return from the hospital with a left lower extremity immobilizer and non-weight-bearing status, the care plan still indicated the need for two staff for transfers, which was not aligned with the facility's no-lift policy. Resident #2's care plan contained outdated fluid restriction information, specifying a limit of 1500cc per day, while the physician's orders had been updated to allow 2000cc per day. This discrepancy was not addressed in the care plan, leading to potential inconsistencies in the resident's care. Similarly, Resident #6's care plan did not reflect the current treatment orders for wound care, which included specific instructions for dressing changes and wound management that were not updated in the care plan. For Resident #27, the care plan did not accurately document the monitoring and recording of fluid intake, as the electronic health record did not provide a location for recording fluids consumed at meals. Additionally, the care plan did not align with the physician's orders for fluid restrictions and weight monitoring. These deficiencies highlight the facility's failure to ensure that care plans are consistently updated to reflect the residents' current medical needs and physician directives.
Deficiency in Hand Hygiene and Glove Use During Food Service
Penalty
Summary
The facility failed to adhere to professional standards for hand hygiene and glove use during food preparation, serving, and distribution. During an observation, it was noted that the cook and dietary aide did not clean the thermometer between checking different food items and placed the uncovered thermometer on a countertop among various items, including trash. The dietary aide moved between the kitchen and dining room without performing hand hygiene, and the cook handled dirty dishes and returned to food preparation without washing hands. Additionally, the cook donned gloves without prior hand hygiene and handled food items, placing used gloves on the counter next to food items without washing hands. Furthermore, during meal service, the dietary aide discarded plates and continued serving without hand hygiene. Another staff member delivered room trays but only performed hand hygiene on two out of eleven opportunities. The facility's administrator acknowledged the need for improved hygiene practices in the kitchen, and although hand hygiene training had been provided, the facility lacked a specific policy for kitchen hygiene.
Deficiencies in Skin Ulcer Care and Assessment
Penalty
Summary
The facility failed to ensure accurate and timely assessment and interventions for two residents with chronic skin ulcers. Resident #40, who had moderately impaired cognitive skills and multiple health conditions, including heart failure and peripheral vascular disease, was observed with swollen and blotchy red lower limbs with open areas. Despite having treatment orders for his skin ulcers, the Treatment Administration Record (TAR) showed missed treatments on several dates in June, with no explanation in the nursing notes. Weekly skin assessments were incomplete, lacking mention of the legs or toes on several occasions, and there was a lack of documentation regarding the condition of the toes on his right foot. Resident #6, with normal cognition and a history of venous and arterial ulcers, also experienced lapses in care. The Treatment Administration Record (TAR) indicated that wound care was not signed off as completed on three occasions in July. The care plan for Resident #6 included specific interventions for skin integrity, but weekly skin assessments were incomplete, lacking measurements and site information. The Director of Nursing (DON) acknowledged that weekly skin assessments should be thoroughly completed and that treatments should be done daily as ordered. The facility's policies on skin and wound care management and clinical change in condition were not adhered to, as evidenced by the lack of weekly skin reports and daily observations. The DON stated that care plans should reflect the current needs of the residents, but the care plans were being completed by an off-site staff member, and a new Unit Manager had been hired to oversee MDS, care plans, and higher-need skin assessments.
Inconsistent Dialysis Care and Assessment
Penalty
Summary
The facility failed to provide consistent pre and post dialysis assessments for two residents requiring dialysis care. Resident #2, with a diagnosis of chronic kidney disease stage 5 and morbid obesity, had incomplete documentation for dialysis sessions in July 2024, with missing post-dialysis assessments on several occasions. On one instance, the resident ended dialysis early due to back pain and was taken to the hospital, yet the post-dialysis assessment was only partially completed upon return to the facility. The resident reported that staff did not consistently perform assessments before and after dialysis. Similarly, Resident #27, diagnosed with renal insufficiency and end-stage renal disease, also experienced incomplete documentation of dialysis assessments. The resident's care plan required monitoring for specific symptoms and conditions related to dialysis, but the facility failed to consistently complete these assessments. The Director of Nursing and a Nurse Consultant acknowledged the deficiency, confirming that assessments were not being completed as required. The facility's policy required specific pre and post-dialysis assessments, which were not consistently followed.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to implement appropriate hand hygiene and infection control practices during wound care treatments for two residents. Resident #40, who had moderately impaired cognitive skills and multiple health conditions including heart failure and venous stasis ulcers, was observed receiving wound care without proper hand hygiene by Staff A, a Registered Nurse. During the treatment, Staff A did not perform hand hygiene after removing gloves and before leaving the room, which is against the facility's infection prevention policy. Resident #6, who had normal cognition and was at risk for pressure ulcers, also received wound care from Staff A in the presence of the Director of Nursing (DON). Staff A failed to perform hand hygiene multiple times during the procedure, including after glove removal and before donning new gloves. Additionally, the tape measure used for measuring wounds was not cleaned between uses on different wounds, and there was no separation between cleaning and wound management of each lower extremity. The DON acknowledged the lack of proper hand hygiene and the need for better separation during the wound care process. These observations indicate a deficiency in the facility's infection prevention and control practices, specifically in the area of hand hygiene during wound care procedures. The facility's policy emphasizes the importance of hand hygiene to prevent the spread of infections, yet these practices were not followed by the staff, leading to potential risks for the residents involved.
Failure to Administer Influenza Vaccine
Penalty
Summary
The facility failed to offer an influenza immunization to a resident, despite the resident having signed a consent form for the vaccine. The resident, who had intact cognitive ability with a BIMS score of 15, was totally dependent on staff for certain activities of daily living and had multiple medical diagnoses, including anemia, heart failure, renal insufficiency, pneumonia, septicemia, and chronic respiratory failure. The resident's care plan indicated the presence of a tracheostomy and cardiac devices, highlighting the importance of receiving the influenza vaccine. The deficiency occurred due to a breakdown in the facility's immunization process. The Infection Preventionist confirmed that there was no documentation of the resident receiving the influenza vaccine, despite the signed consent. The facility's policy required all residents to receive the influenza vaccine annually, barring any contraindications or refusals. The process involved the social worker handling paperwork and consents, which were then passed to nursing for follow-up with a doctor's order and administration of the vaccine. However, the communication and procedural steps failed, resulting in the resident not receiving the vaccine.
Failure to Timely Report Verbal Abuse Incident
Penalty
Summary
The facility failed to report a reportable event in a timely manner for one resident. The incident involved a Licensed Practical Nurse (LPN) verbally abusing a paralyzed resident by making derogatory comments about the resident's hygiene and mobility. The incident occurred on 3/23/24 but was not reported to the facility's compliance hotline until 3/27/24. The delay in reporting was due to the reporting staff member's uncertainty about the consequences and whether the incident constituted abuse. The staff member also expressed concerns about the Administrator's favoritism towards the offending LPN. The facility's policy requires immediate reporting of suspected abuse, but this protocol was not followed. The Regional Director of Clinical Services and the Administrator both confirmed that staff are expected to report abuse allegations immediately. The Administrator acknowledged that not all staff had been educated on the reporting procedures, particularly those who had not worked recently or were PRN staff members. The facility's Abuse Prevention Program and Reporting Policy mandates immediate notification to the shift supervisor, Administrator, and Director of Nursing (DON) for any suspected abuse, neglect, mistreatment, or misappropriation of property.
Failure to Allow Resident Return After Transfer
Penalty
Summary
The facility failed to allow a resident to return after a facility-initiated transfer to an acute setting. Resident #2, who had no cognitive impairment and was actively planning to discharge to the community, exhibited behaviors such as cursing, yelling, and throwing items. Despite these behaviors, there was no documentation of PRN medication administration to manage his anxiousness since 3/21/24. The facility's records lacked documentation of the behaviors and the transfer to the ER on 3/27/24. On 3/27/24, the Administrator presented Resident #2 with an emergency discharge letter at the hospital ER, citing aggressive and violent behaviors as the reason for discharge. The hospital staff reported that Resident #2 had no behavioral issues while admitted and noted the lack of PRN medication administration. The Administrator admitted that staff likely did not document the behaviors because they were accustomed to Resident #2's actions. The facility's Discharge Management policy requires documentation and written notice for transfers, which was not adequately followed in this case. The Administrator stated that Resident #2 was sent to the hospital due to increased behaviors and the inability to calm him down. The facility called 911, and the police and EMS were involved in transferring him to the hospital. The Administrator acknowledged that there was no documentation in the resident's EHR to reflect the behaviors leading to the transfer. The emergency discharge was issued for the safety of staff and residents, but the facility failed to provide sufficient documentation and follow proper procedures for the transfer and discharge.
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An LPN, unfamiliar with residents on a medication cart and faced with two residents sharing the same first name, failed to correctly identify a resident and administered a full set of another resident’s medications in addition to the resident’s own ordered morning medications, including PRN oxycodone. The resident, who had severe cognitive impairment and multiple diagnoses including hypertension and Alzheimer’s disease, subsequently experienced declining BP, reported not feeling well, and became increasingly fatigued. The facility’s policy required resident identification before medication administration, and the LPN acknowledged not knowing the residents and finding the EHR photos too small, despite their availability. Hospital records later documented hypotension, treatment with IV fluids, and a drug overdose after accidental ingestion of another resident’s medications plus the resident’s own, with persistent sinus bradycardia requiring admission for further hemodynamic monitoring.
A cognitively impaired, wandering resident with Alzheimer’s disease and behavioral symptoms was care planned as an elopement risk but was able to leave the memory care unit by holding an emergency exit door bar for 15 seconds and exiting into a stairwell and then to the employee parking lot. The door alarm functioned, but staff in the noisy dining room did not hear it while they were feeding multiple residents, including several needing extensive assistance, and only realized the resident was missing when another staff member encountered him outside and brought him back. In addition, several residents who required staff assistance for transfers and toileting experienced prolonged call light response times well beyond the facility’s 15‑minute expectation, including one who reported waiting up to an hour during meals and having an in‑room accident, another observed waiting about 25 minutes while calling out for help, and a third waiting about 17 minutes before a CNA responded.
A cognitively intact resident reported that a CNA ripped her incontinence brief during care and then refused to change it, despite the resident stating she could not wear it due to the tear. The resident became upset and informed housekeeping staff, who then asked an LPN to assist. On assessment, the LPN observed a large rip extending around the back of the brief, changed the brief, and provided peri care at the resident’s request. The resident stated the ripped brief was uncomfortable and that she did not feel treated with dignity or respect. In interviews, the CNA acknowledged telling the resident the torn brief would still work and did not change it, while the DON confirmed the CNA had refused the resident’s request for a brief change, in conflict with the facility’s dignity policy.
A deficiency was identified when a CNA did not follow manufacturer instructions for a mechanical stand while transferring a resident with severe cognitive impairment, a history of hip fracture, dementia, and muscle wasting who required substantial assistance for transfers. The resident’s care plan called for use of a mechanical stand, but during observed toileting and return-to-chair transfers, the CNA repeatedly locked and unlocked only one wheel of the device and did not keep the brakes unlocked during the actual transfer, contrary to the operator’s instructions that brakes be locked only when raising and lowering the resident during ambulation. In an interview, the DON confirmed staff were expected to follow these operator instructions and keep the wheels unlocked during transfers.
A resident with dementia, behavioral symptoms, and multiple psychotropic and cardiovascular medications was discharged to another nursing facility without a thorough or accurate discharge summary. The care plan contained a discharge planning focus but was never updated to reflect the actual discharge, and the EHR lacked documentation of discharge planning, the reason for discharge, or a recapitulation of stay, despite a family member stating they initiated the discharge due to dissatisfaction with care. The discharge instructions contained multiple medication discrepancies and omissions, including missing drugs, incorrect dosages, and absent administration frequencies, and several PRN constipation medications were not listed, contrary to the facility’s written discharge planning policy.
A resident was admitted from a hospital without a completed Preadmission Screening and Resident Review (PASRR) in the medical record, as required prior to admission. The PASRR was only completed several days later by the Hospital Liaison/Admissions Coordinator after a call alerted staff that it was missing. Both the admissions coordinator and the Administrator acknowledged that the facility relies on the hospital to provide the PASRR and that, in this case, it was missed and not done before the resident’s admission.
A resident with Alzheimer's disease, severely impaired cognition, and documented nutrition/hydration risk required partial to moderate assistance with eating and was care planned for assisted feeding with a general diet and thin liquids. During a breakfast observation, the resident was seated in a reclined Broda chair while staff placed food and beverages on an overbed table and attempted to offer chocolate milk and hot cereal without first positioning the resident upright, causing the resident to struggle to reach the cup. Facility policy on feeding required residents needing assistance to be positioned comfortably in an upright position, and the DON stated she expected residents to be upright whenever food or drink was offered, but there was no separate positioning policy in place.
A resident with a left leg fracture, muscle wasting, and impaired mobility was dependent on a mechanical lift for transfers. Staff positioned the lift at the side of the wheelchair instead of straight on, and the lift tipped and struck the resident’s forehead with the sling-holding part, causing a bruise and protruding bump. Staff interviews confirmed the transfer was done from the side and that the resident’s care plan required straight-on positioning for the lift.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance: Several residents did not receive bathing and hygiene assistance as scheduled. One resident with intact cognition and a stroke history was observed unshaven and said staff did not always shave him during showers, while staff noted the bath sheets no longer tracked shaving or nail care. Other residents with severe cognitive impairment or dependence for bathing went extended periods without baths, and one cognitively intact resident reported missing baths and wanting them. Facility records and staff interviews showed bathing schedules were not consistently followed or documented as required.
QAPI program failed to address repeated deficiencies. Review of the facility’s visit history showed repeated F689, Free of Accident Hazards/Supervision/Devices, and F880, Infection Prevention and Control, across multiple annual surveys and complaint investigations. The QAPI plan stated it would review sources of information for gaps or patterns in care systems, and the Administrator acknowledged the repeated deficiencies and said the facility would review and discuss plans to improve.
Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to follow the 5 rights of medication administration, resulting in one resident receiving another resident’s medications in addition to their own. The resident had diagnoses including hypertension, Alzheimer’s disease, and toxic encephalopathy, with a BIMS score of 3 indicating severe cognitive impairment. On the morning in question, review of the MAR showed the resident received their ordered medications, which included aspirin, calcium carbonate, vitamin C, vitamin D, fluoxetine 20 mg, furosemide 40 mg, galantamine, a lidocaine patch, memantine, acetaminophen, and PRN oxycodone around 8:00 a.m. According to the incident report and nursing progress notes, the LPN (Staff A) administered another resident’s full set of morning medications to this resident while the resident was in the dining room. These additional medications included metoprolol 60 mg, Lyrica 75 mg, oxycodone 7.5/325 mg, furosemide 40 mg, celecoxib 100 mg, Prozac 60 mg, hydroxyzine 10 mg, cetirizine 10 mg, Neuriva, Protonix 20 mg, potassium 99 mg, a multivitamin, and vitamin D3. These medications were given in addition to the resident’s own morning medications and PRN oxycodone. The nurse’s notes documented that the resident’s blood pressure readings declined from 100/50 to 85/48 and then to 73/48, and the resident complained of not feeling well and was increasingly fatigued. Staff A reported during interview that the resident had been screaming and yelling and that she did not realize there were two residents with the same first name in the back hallway. She stated it was her first time working in that hallway after training and that, although resident pictures were available in the EHR to assist with identification, she felt they were small and she did not know the residents. The facility’s medication management policy required staff to identify the resident before administering medications. Staff A’s employee record showed a prior medication occurrence in which she administered the wrong medications (including furosemide and potassium) to a resident, and she had documented previously that she was not familiar with residents when working on that cart. The resident was ultimately sent to the ER, where records documented hypotension on admission, treatment with IV fluids, and a chief complaint of drug overdose after accidental ingestion of another resident’s multiple medications in addition to the resident’s own medications, with continued sinus bradycardia requiring admission for further hemodynamic monitoring.
Elopement of Wandering Resident and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for a cognitively impaired, wandering resident and failure to respond to resident call lights within the facility’s stated 15‑minute expectation. One resident with Alzheimer’s disease, bipolar disorder, and anxiety disorder had a care plan identifying risk for elopement due to wandering and documented behaviors of agitation, aggression, restlessness, and continuous pacing/wandering within the unit. This resident ambulated independently with a walker and had a BIMS score indicating impaired cognition. On the evening of the incident, the resident finished supper in the memory care dining room and then repeatedly walked the hallway with his walker, eventually approaching an emergency exit door at the far end of the hall, away from the dining room. Video and documentation show that the resident stood at the emergency exit door, held the door bar down for the required 15 seconds to release the egress, and then exited through the door into a stairwell and out to the employee parking lot. The door alarm and 15‑second egress functioned, but staff in the dining room did not hear the alarm due to noise from residents, staff conversation, and the television. At the time, two CNAs and one LPN were in the dining room feeding multiple residents, including several who required assistance, and staff reported that the resident was very quick, wandered constantly, and was difficult to keep seated. Staff interviews revealed that one CNA noticed the resident was no longer in the dining room around the same time another staff member reported they were looking for him, and only then did staff recognize the back exit door alarm sounding. A nurse arriving for her shift in the parking lot encountered the resident outside with his walker and escorted him back inside, after which he was assessed and found in stable condition. The deficiency also includes failure to respond to resident call lights within the professional standard of 15 minutes for multiple residents. One resident with intact cognition but dependent or substantial/maximal assistance needs for toileting reported that during meal hours it could take up to an hour for staff to answer the call light, resulting in an in‑room accident. Another resident, alert and oriented but occasionally forgetful and requiring two‑person assistance for transfers, was observed with the call light on for approximately 25 minutes in the morning while repeatedly yelling for help; staff walked past in the hallway without answering the light until a staff member finally entered the room. A third resident, requiring one‑person assistance for transfers, was observed with the call light on for about 17 minutes before a CNA entered to assist. The DON stated that the facility’s expectation is that call lights be answered within 15 minutes, and the facility’s policy directs all staff from all departments to respond to call lights and either assist or obtain appropriate help, but the observed response times exceeded this standard for the residents involved. Staff interviews further described the conditions contributing to these call light delays and supervision gaps. Staff on the memory care unit reported that typical evening staffing consisted of one nurse, one CMA, and two CNAs, and that while this was manageable when routines went smoothly, it became inadequate when residents had behaviors, were sundowning, or when events such as falls or changes in condition occurred. A CMA stated that at least three CNAs were needed on the memory care unit due to multiple residents requiring two‑person assistance, noting that when two CNAs were in a room providing care, they could not monitor the rest of the unit. Staff also reported that the back exit door alarm was faint and difficult to hear from the dining room, and some staff were not fully aware of the configuration of the back stairwell and exit leading to the parking lot. These conditions, combined with high resident care needs and noise levels during meals, contributed to the resident’s elopement and to prolonged call light response times for several residents. Maintenance and administrative staff confirmed that the south/back exit door from the unit led to another unalarmed door and then to the outside employee parking lot, and that the facility did not receive system reports when door alarms were activated. The Administrator was unable to verify when a door alarm went off or when an exit door was breached. The facility’s Wandering Resident policy stated that residents at risk for elopement should receive adequate supervision to prevent accidents and that staff must be vigilant in responding to alarms in a timely manner, and the call light policy required prompt response by all staff. Despite these policies, the documented events show that the resident at risk for elopement was able to leave the secured unit and reach the parking lot without timely staff detection, and that multiple residents experienced call light response times significantly longer than the facility’s stated 15‑minute standard.
Failure to Honor Resident Request for Brief Change and Maintain Dignity
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and respect when a cognitively intact resident’s request for a brief change was not honored. The resident, with a BIMS score of 15 indicating no cognitive impairment, reported being upset because a CNA (Staff N) ripped her brief during care and then refused to change it. The resident self-propelled down the hallway stating she was upset about the ripped brief and that staff would not change it. A housekeeping staff member (Staff M) observed the resident’s distress, was told that the CNA had refused to change the brief despite a large rip, and then asked an LPN (Staff O) to assist with changing it. During the subsequent brief change, Staff O performed hand hygiene, used gloves, removed the resident’s pants and brief, and provided peri care at the resident’s request before applying a new brief and redressing the resident. Observation of the removed brief revealed a large rip on the left side extending past the middle of the resident’s back. The resident stated the brief with the hole was uncomfortable and that she felt staff did not provide her with dignity and respect when her request for a new brief was not honored. Staff O confirmed that the brief had a very large hole and that the resident was very upset, reporting she did not feel treated with dignity or respect and that the ripped brief was uncomfortable. In an interview, Staff N acknowledged caring for the resident that day, stated the resident had been upset and had “behaviors,” and reported that when the resident said she wanted her brief changed because it was ripped, Staff N told her the brief would still work and that urine would not get everywhere, characterizing the tear as “just a little tear.” Staff N stated the resident did not explicitly ask her to change the brief. The DON later stated that Staff N had ripped the brief, the resident had requested a brief change, Staff N said she would not change it, and acknowledged that a lack of dignity occurred when Staff N refused to change the resident’s brief, contrary to the facility’s dignity policy.
Improper Use of Mechanical Stand Brakes During Resident Transfers
Penalty
Summary
Surveyors identified a deficiency related to accident prevention when staff failed to properly use a mechanical stand’s brakes during transfers for one resident. The resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment, required substantial assistance for transfers, and had diagnoses including hip fracture, dementia, and muscle wasting. The care plan documented initiation of a mechanical stand for transfers. During observation, a CNA applied a sling, locked the right wheel of the mechanical stand, lifted the resident from a chair, then unlocked the right wheel and positioned the resident over the toilet. The CNA then lowered the resident onto the toilet and locked the right wheel. After the resident finished, the CNA lifted the resident from the toilet, unlocked the right wheel, positioned the resident over the chair, locked the right wheel, and lowered the resident, thereby failing to keep the mechanical stand brakes unlocked during the transfer as required by the operator’s instructions, which specified that brakes should only be locked when raising and lowering the resident during ambulation. In an interview, the DON stated that staff were expected to follow the operator’s instructions and keep the wheels unlocked during transfers, confirming that the observed practice did not align with the manufacturer’s guidance for safe operation of the mechanical stand.
Failure to Complete Accurate and Thorough Discharge Summary and Documentation
Penalty
Summary
Surveyors identified a failure to complete a thorough and accurate discharge summary and related discharge documentation for one resident who was discharged from the facility. The resident was admitted in early March with moderate cognitive impairment, a Brief Interview for Mental Status (BIMS) score of 08, and documented delusions and behavioral symptoms. Diagnoses included dementia with agitation, anxiety disorder, and depression. Although the care plan contained a discharge planning focus initiated shortly after admission, it did not contain any updates or documentation related to the resident’s actual discharge later that month. The electronic health record (EHR) contained a communication note indicating that transport to another nursing facility was arranged and a health status note stating that the resident was discharged, with physician orders and a face sheet faxed and a report called to the receiving facility. The resident’s EHR did not contain documentation of the discharge planning process, the reason for the discharge, or a recapitulation of the resident’s stay. A family member reported that the family initiated the discharge due to dissatisfaction with care, but there was no documentation in the EHR reflecting that the family initiated the discharge. The Long Term Care Ombudsman reported that no one contacted her during the resident’s stay, although her office did receive notice of the transfer. The facility’s own discharge planning policy required that discharge planning begin on admission, be routinely updated in the comprehensive care plan, and that the evaluation of discharge needs and the final discharge plan be completely documented in the clinical record and discussed with the resident or representative. Review of the resident’s discharge instructions and March medication administration record revealed multiple discrepancies and omissions in the discharge summary. One medication (Amlodipine 10 mg) was listed without any frequency or time of administration. Several medications that the resident was receiving, including Donepezil 10 mg, Lisinopril 5 mg, and Buspirone 10 mg twice daily, were not included on the discharge summary. Other medications were inaccurately documented, such as Memantine, which was ordered as 20 mg once daily but listed as 10 mg twice daily, and Seroquel, ordered as 50 mg twice daily but listed as once daily. Several PRN constipation medications were also omitted. The Regional Nurse Consultant confirmed that the facility’s EHR contained a discharge assessment tool that was not completed for this resident and acknowledged the multiple medication discrepancies on the discharge summary form.
Failure to Complete PASRR Evaluation Prior to Admission
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) evaluation for a resident with an admission date of 4/22/26. The resident’s electronic health record documented admission from a hospital on 4/22/26, but review of the record showed no PASRR completed at the time of admission. A PASRR form for this resident was later obtained and showed it was completed on 4/27/26 by the Hospital Liaison/Admissions Coordinator, several days after the resident had already been admitted. During interview, the Hospital Liaison/Admissions Coordinator stated that the hospital usually completes the PASRR, acknowledged receiving a call the previous night that the PASRR was not in the chart, and admitted she had missed completing it prior to admission even though it should have been done. The Administrator similarly reported that the facility relies on receiving the PASRR from the hospital admission records and that, in this case, the PASRR was missed and not completed prior to the resident’s admission. This resulted in a deficiency for failure to ensure a PASRR evaluation was completed prior to admission for 1 of 3 reviewed residents, in accordance with PASRR requirements.
Failure to Properly Position Resident Upright During Assisted Feeding
Penalty
Summary
Surveyors identified a deficiency in resident positioning during mealtime for a resident with Alzheimer's disease and severely impaired cognition, as evidenced by a Brief Interview for Mental Status score of 2. The resident’s MDS indicated a need for partial to moderate assistance with eating, and the care plan documented nutrition and hydration risk related to end-stage diagnosis, cognitive limitations, and weakness, with directions for a general diet, thin liquids, and assistance with eating. During a breakfast observation on the Magnolia Unit, the resident was seated in a Broda chair that was reclined back. A dietary aide placed food on the table in front of the resident, and a CNA then placed beverages and food on an overbed table before walking away, while the resident remained reclined with eyes closed and the plate of food untouched. Later in the same observation period, another CNA offered the resident chocolate milk while the Broda chair remained tilted backward, and the resident had to struggle to move her head up and forward to reach the cup. The same CNA then offered hot cereal, which the resident declined by saying “later.” A different CNA subsequently offered another drink of chocolate milk, again without adjusting the reclined position of the Broda chair. Policy review showed the facility’s “Feeding of Residents by Staff” policy required that residents unable to feed themselves be assisted per their care plan and be positioned comfortably in an upright position. In an interview, the DON stated there was no specific positioning policy, that staff received positioning education in training, and that her expectation was that residents be placed in an upright position whenever food or drink was offered.
Mechanical Lift Transfer Caused Resident Forehead Injury
Penalty
Summary
The facility failed to provide a safe and adequate mechanical lift transfer for Resident #18, who had a left leg fracture, muscle wasting, and impaired gait and mobility, but no cognitive impairment based on a BIMS score of 15. The resident’s care plan required two staff members to use a mechanical lift for transfers because the resident was nonweight-bearing on the left leg. The care plan update also directed staff to approach the wheelchair straight on and not from the side, and to have the resident bend the right leg and turn away from the lift during transfers. During a wheelchair transfer, staff positioned the mechanical lift at the side of the wheelchair and began the transfer. The lift tipped and struck the resident’s forehead with the part that held the sling. The resident sustained a bruise and a protruding bump on the left forehead, and the incident documentation noted the resident’s head was hit on the lift. The resident later reported that the lift almost fell to the floor and that additional staff were needed to return it upright. Staff interviews confirmed that the transfer was performed from the side of the wheelchair. One CNA stated the lift may have caught on bars under the wheelchair and acknowledged that staff had been educated not to use the lift from the side. Another CNA stated the lift was used from the side because the resident did not want her leg hit by the lift, and identified the sling-holding part of the lift as the piece that struck the resident’s forehead. The DON stated the proper procedure was to position the mechanical lift directly in front of the wheelchair rather than to the side.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living for 5 of 8 residents reviewed, specifically related to bathing and shaving. Resident #3 had a BIMS score of 15 and was dependent on staff for personal hygiene, with diagnoses including renal insufficiency, stroke, hemiplegia, and seizure disorder. The resident was observed unshaven, stated he was getting showers but not shaved every time, and said he needed help shaving since his stroke. Facility records showed showers were documented without indicating whether shaving was completed, and staff interviews confirmed the bath sheets no longer tracked shaving or nail care, while the DON stated male residents should be offered shaving during showers and it should be documented if completed or refused. Resident #1 had a BIMS score of 4, diagnoses including muscle weakness, diabetes, and hip fracture, and was care planned as an extensive assist for bathing. Review of the follow-up report showed the resident went 17 days without a bath and later 19 days without a bath. Resident #11 had a BIMS score of 3, diagnoses including depression, hypertension, and anemia, and was scheduled for bathing on Wednesday morning and Friday afternoon, but the follow-up report showed gaps of 6 days, 6 days, and 18 days between baths. Resident #27 also had a BIMS score of 3 with depression, hypertension, and anemia, was scheduled for bathing on Monday and Thursday afternoon, and the follow-up report showed the resident went 19 days and then 20 days without a bath, with refusals documented on two occasions. Resident #85 had a BIMS score of 15, diagnoses including hypertension, depression, and need for assistance with personal care, and stated she did not get 2 baths the prior week and wanted them. Her care plan identified her as dependent for bathing, but lacked bathing frequency, and the task list scheduled bathing for Monday morning and Wednesday afternoon. The follow-up report showed multiple extended gaps between baths, including 12 days, 7 days, 18 days, and 7 days. Facility policy stated bathing is intended to promote cleanliness, provide comfort, and observe skin condition, and the Regional Nurse Consultant stated bathing should be completed as scheduled.
QAPI Program Failed to Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive and effective QAPI program and did not have a plan that described the process for conducting QAPI and QAA activities. Review of the DIAL website visit history showed repeated deficient practices identified during the facility’s annual survey and complaint investigation on 3/27/25 and during the annual survey, complaint, and facility-reported incident investigation on 4/19/26. The repeat deficiencies included F689, Free of Accident Hazards/Supervision/Devices, which had been repeated in the previous three consecutive annual surveys, and F880, Infection Prevention and Control, which had been repeated in the previous four consecutive annual surveys. The facility’s QAPI plan stated that it would review sources of information to determine whether gaps or patterns existed in systems of care that could result in quality problems or opportunities for improvement. During an interview on 4/23/26 at 1:28 PM, the Administrator acknowledged the repeated F689 and F880 deficiencies and stated the facility would review and discuss plans to improve.
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