Golden Age Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Centerville, Iowa.
- Location
- 1915 South 18th Street, Centerville, Iowa 52544
- CMS Provider Number
- 165257
- Inspections on file
- 24
- Latest survey
- October 21, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Golden Age Care Center during CMS and state inspections, most recent first.
A controlled pain medication was removed from locked storage by an LPN and left unattended in a resident's room, resulting in the medication going missing. The resident had moderate cognitive impairment and multiple diagnoses. Facility policy and staff interviews confirmed that medications should not be left unsecured or unattended.
Several residents with chronic conditions were not offered the pneumococcal vaccine as required by CDC guidelines and facility policy. The DON confirmed that eligible residents had not been assessed or offered the vaccine, and documentation was lacking or inconsistent across records. Some residents had received earlier vaccines but were not offered updated versions, and staff interviews confirmed the deficiency.
A resident with diabetes, hypertension, and Parkinson's disease was allowed to self-administer insulin without thorough documentation of an assessment to determine clinical appropriateness. Despite staff facilitating the resident's self-administration and a note indicating he managed the task, the care plan and records lacked comprehensive assessment details as required by facility policy.
A resident with diabetes, hypertension, and Parkinson's disease, who was cognitively intact, reported being left in soiled briefs for hours and missing insulin administration. Multiple staff confirmed the resident voiced these concerns and some reported them to nursing leadership, but there was no documentation that the facility's grievance process was initiated or followed, in violation of policy.
Two residents with significant medical needs experienced delays in receiving assistance due to a malfunctioning call system that failed to alert staff at the nurse's station. Staff and administrator interviews confirmed the system was old, unreliable, and did not consistently provide sound or visual alerts, resulting in prolonged wait times for residents needing help.
A resident with a history of falls, diabetes, and a humerus fracture developed deep tissue injuries on both heels. Required wound care treatments, including application of skin prep, Santyl, and dressings, were not consistently documented or completed as ordered. Staff interviews revealed that missed treatments were due to staffing issues, and an order for PT positioning was not carried out. The DON confirmed that treatments and therapy orders should be completed as ordered.
A resident with diabetes did not receive prescribed insulin or blood sugar checks on two occasions, with medication records and progress notes lacking documentation of administration or refusal. Staff interviews confirmed the omission, and the DON acknowledged that refusals should be documented and the physician notified, but this was not done according to facility policy.
A facility failed to provide consistent restorative therapy for a resident, leading to a deficiency in maintaining the resident's ability to perform activities of daily living. Despite the resident's intact cognitive status and prioritization of improving ambulation, several planned restorative tasks were not completed over a three-month period. Interviews revealed that the restorative aide was often pulled to other duties, and there was a lack of a designated restorative nurse to ensure the program was followed.
A resident with cognitive intactness and requiring assistance with daily activities experienced prolonged discomfort due to a sore groin and peri area. Despite complaints and visible symptoms, staff failed to utilize available barrier creams and instead applied an antifungal powder without an order. The resident's discomfort persisted for eight days before appropriate treatment was ordered, highlighting a lapse in timely intervention and assessment by the facility staff.
A resident with multiple health issues developed a blister on their foot, which was not reported to the physician or family by the nursing staff. Despite the blister's growth and a noticeable odor, the facility failed to communicate the condition's severity, leading to a deficiency in notification protocol.
A resident with multiple comorbidities developed a new blister on the foot, which was treated by a nurse without obtaining physician orders or notifying the power of attorney. The blister worsened, and the treatment was changed without proper authorization. The Advanced Practice Nurse Practitioner was unaware of the issue until later, highlighting a deficiency in communication and protocol adherence.
Controlled Medication Left Unattended and Unsecured
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to keep a controlled medication, Hydrocodone-Acetaminophen, secured and properly administered to a resident with moderate cognitive impairment and diagnoses including non-Alzheimer's dementia, diabetes, and depression. The LPN removed the medication from a locked storage and left it unattended in the resident's room on the bedside table while stepping out to attend to another task, without observing the resident take the medication as required. Upon returning, the LPN discovered the medication was missing and could not be located after searching the room and trash bins. The Director of Nursing confirmed that the expectation was for the medication to be administered immediately after removal from storage and not left unattended. The facility's policy also required medications to be administered as ordered and not left unsecured. Staff interviews corroborated that the medication was left unattended and subsequently went missing.
Failure to Offer Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
The facility failed to offer the pneumococcal vaccine to four out of five sampled residents reviewed for immunizations, despite CDC guidelines and facility policy requiring assessment and offering of the vaccine within 30 days of admission. The Director of Nursing (DON) acknowledged that some residents were eligible for the vaccine but had not been offered it, citing issues such as difficulty accessing the Iowa Immunization Registry Information (IRIS) account and discrepancies between hard chart, electronic records, and a separate file maintained by the DON. A recent pharmacy audit had also identified residents in need of vaccines, but the necessary follow-up had not occurred. Clinical record reviews revealed that several residents, including those with significant medical histories such as diabetes, dementia, coronary artery disease, COPD, and heart failure, either lacked documentation of being offered or receiving the appropriate pneumococcal vaccines per current CDC guidelines. In some cases, residents had received earlier versions of the vaccine but had not been offered the updated vaccines as recommended. Interviews with residents and staff confirmed that eligible residents had not been offered the vaccine, and the facility's policy, last updated in 2017, was not being followed as required.
Failure to Document Assessment for Self-Administration of Insulin
Penalty
Summary
The facility failed to ensure thorough documentation of an assessment regarding a resident's ability to self-administer insulin. Clinical record review, policy review, and staff interviews revealed that a resident with diagnoses including diabetes, hypertension, and Parkinson's disease was self-administering insulin without comprehensive documentation of an assessment to determine if this was clinically appropriate. Although the resident had an intact cognitive status as indicated by a perfect BIMS score, the care plan did not document the resident's ability to self-administer insulin, and the facility's policy required such an assessment. Staff interviews indicated that nursing staff either handed the insulin to the resident or left it on his table, and the resident administered it himself, particularly after refusing to have certain staff administer his insulin. The Director of Nursing was unaware if a formal assessment had been documented, and only a brief handwritten note was found stating the resident had self-administered insulin and "did fine." No further details or formal assessments were available, and it was unclear if staff observation was required during administration. The lack of detailed documentation and assessment constituted the deficiency.
Failure to Promptly Address Resident Grievances
Penalty
Summary
The facility failed to promptly address and resolve grievances raised by a resident with diagnoses including diabetes, hypertension, and Parkinson's disease, who was cognitively intact. The resident reported having to remain in soiled briefs for extended periods, specifically stating that on one occasion he sat in his own waste for 4-5 hours before being changed, and described this as humiliating. Additionally, the resident reported that staff failed to check his blood sugar or administer insulin on a previous occasion. Multiple staff members confirmed that the resident had voiced these concerns to them, and some reported relaying the complaints to nursing leadership or social services. Despite these reports, there was no documentation indicating that the facility's grievance process was initiated or followed in response to the resident's complaints. The facility's grievance policy required prompt efforts to resolve issues, but the administrator stated she was unaware of the concerns and would have expected the grievance process to be carried out if staff had reported them. The lack of documented follow-up or resolution demonstrates a failure to honor the resident's right to voice grievances without discrimination or reprisal, as required by facility policy.
Failure to Maintain Functioning Call System in Resident Areas
Penalty
Summary
The facility failed to provide a properly functioning call system in resident bathrooms and bathing areas for two residents. One resident, with diagnoses including traumatic brain injury, heart disease, renal insufficiency, neurogenic bladder, and reduced mobility, required substantial assistance for transfers and was instructed to use the call light for help. This resident reported waiting up to forty-five minutes for staff assistance, attributing the delay to the malfunctioning call system, which was not visible or audible at the nurse's station. Another resident, with diabetes, depression, vision deficits, and heart disease, used a walker and required prompt staff response. This resident confirmed awareness of the call system malfunction and described having to search for staff when assistance was needed, as the call light in their room was not detected at the nurse's station unless staff happened to walk by and see the overhead light. Staff interviews confirmed the call system was old, frequently malfunctioned, and did not consistently activate sound or light at the nurse's station for several halls. Staff reported that only one hall had a functioning sound system, while others relied solely on overhead lights, which could be missed if not directly observed. The administrator acknowledged ongoing issues with the system, frequent repairs, and the need for replacement. Facility policy required each resident room to have a functioning call light system, but observations and interviews demonstrated that this standard was not met for the affected residents.
Failure to Complete Ordered Pressure Ulcer Treatments and Interventions
Penalty
Summary
The facility failed to carry out ordered interventions and treatments for a resident with pressure ulcers. Clinical record review showed that the resident, who had a history of humerus fracture, falls, and diabetes, was at risk for pressure ulcers and developed deep purple, boggy blisters on both heels, later assessed as suspected deep tissue injuries. The Treatment Administration Records (TARs) indicated multiple instances where required wound care treatments, such as application of skin prep, Santyl ointment, and dressings, were not documented as completed on several dates. Additionally, an order for Physical Therapy for positioning related to heel wounds was not documented as carried out. Staff interviews confirmed that due to staffing issues, some dressing changes and treatments were not completed as ordered, with some shifts failing to follow up on missed treatments. Nursing staff acknowledged that there were times when wound care was not performed as scheduled, and the DON stated that staff are expected to carry out treatments and therapy orders in a timely manner. The lack of documentation and completion of ordered treatments and interventions led to the deficiency in pressure ulcer care for the resident.
Failure to Administer and Document Insulin for Diabetic Resident
Penalty
Summary
A deficiency occurred when a resident with diabetes, hypertension, and Parkinson's disease did not receive prescribed insulin and blood sugar checks as ordered. The resident's Minimum Data Set indicated insulin dependence, and the Medication Administration Records (MARs) showed orders for blood sugar checks and Novolog insulin administration three times daily. On two separate occasions, the MARs lacked documentation and staff initials for both insulin administration and blood sugar checks during evening shifts. Progress notes also did not indicate whether the resident received or refused insulin on those dates. Interviews with staff revealed that the DON discussed documenting a refusal for insulin, although staff accounts and the resident indicated that the insulin was not administered and the resident was upset about missing a dose. The DON stated that refusals should be documented with reasons and the physician notified, but there was no documentation to support that this process was followed. The facility's policy required accurate recording of physician orders and avoidance of medication errors, which was not adhered to in this instance.
Failure to Provide Consistent Restorative Therapy
Penalty
Summary
The facility failed to provide restorative activity as planned for a resident, leading to a deficiency in maintaining the resident's ability to perform activities of daily living. The resident, who had an intact cognitive status and required moderate assistance with various activities, was supposed to receive restorative tasks 3-6 times per week as part of a Nursing Restorative Care Program. However, documentation indicated that several tasks were not completed in January, February, and March 2025. Interviews with staff and the resident revealed inconsistencies in the provision of restorative therapy, with the restorative aide being pulled to other duties and not consistently providing the planned therapy. The resident, who had a history of a broken hip and other medical conditions, expressed frustration over the lack of progress in his mobility goals, attributing it to the insufficient restorative therapy. The Assistant Director of Nursing acknowledged the lack of a designated restorative nurse and the need for better tracking of the restorative programs. Despite the resident's prioritization of improving ambulation, the facility's failure to consistently implement the restorative care plan contributed to the deficiency.
Failure to Provide Timely Treatment for Resident's Skin Condition
Penalty
Summary
The facility failed to ensure that a resident was appropriately assessed and provided with timely interventions to maintain their optimal health and well-being. A resident with an intact cognitive status and requiring moderate assistance with daily activities, including having a catheter and occasional bowel incontinence, complained of a sore groin and peri area. Despite the resident's complaints of discomfort and visible redness and tenderness, the staff did not produce a skin sheet or provide immediate appropriate treatment. The resident's discomfort was not addressed promptly, as the staff failed to utilize available barrier creams listed in the Treatment Administration Record (TAR) and instead applied an antifungal powder without an order. The delay in obtaining a physician's order for a barrier cream resulted in the resident experiencing discomfort for eight days before receiving the appropriate treatment. Staff interviews revealed that the nurse on duty was aware of the resident's complaints but did not thoroughly review the TAR, which contained orders for barrier creams that could have alleviated the resident's discomfort. The Director of Nursing indicated that the process for addressing resident complaints involves assessing the resident and contacting the physician for necessary orders, with the only difference on weekends being the need to contact the on-call physician.
Failure to Notify Physician and Family of Resident's Blister
Penalty
Summary
The facility failed to notify a physician and the family representative of a resident upon the discovery of a blistered area on the resident's left foot. The resident, who had an intact cognitive status and required significant assistance with daily activities, was diagnosed with lymphedema, congestive heart failure, renal insufficiency, diabetes mellitus, and morbid obesity. On a skin assessment, a new blister was identified on the resident's left foot, measuring 6 cm by 3.5 cm. Staff A, a registered nurse, noted the blister in a progress note and indicated that the physician was updated, but later admitted in interviews that neither the physician nor the resident's power of attorney (POA) was contacted about the blister. Further interviews revealed that the blister had grown in size by the next assessment, yet there was still no notification to the physician or the POA. The Advanced Practice Nurse Practitioner (ARNP) was unaware of the blister until her return from vacation. The resident's POA discovered the blister's severity during a visit, noting a strong odor in the room attributed to the resident's wounds. The lack of communication regarding the resident's condition and the progression of the blister represents a deficiency in the facility's protocol for notifying relevant parties of changes in a resident's condition.
Failure to Obtain Treatment Orders for New Wounds
Penalty
Summary
The facility failed to obtain treatment orders for a resident who developed new wounds. The resident, who had an intact cognitive status, required significant assistance with daily activities and had multiple diagnoses including lymphedema, congestive heart failure, renal insufficiency, diabetes mellitus, and morbid obesity. On a skin assessment, a new blister was identified on the resident's left foot, which was initially covered with Xeroform and cling wrap by a registered nurse. However, the nurse did not contact the physician to obtain an order for this treatment, nor did she notify the resident's power of attorney about the change in condition. The situation worsened when the blister increased in size, and the nurse changed the treatment to a non-stick telfa dressing without obtaining a physician's order. Again, the physician was not contacted, and the power of attorney was not informed of the condition's progression. The Advanced Practice Nurse Practitioner was unaware of the blister until after returning from vacation, despite the resident's multiple comorbidities that contributed to skin issues. This lack of communication and failure to obtain necessary treatment orders led to the deficiency identified in the report.
Latest citations in Iowa
An LPN, unfamiliar with residents on a medication cart and faced with two residents sharing the same first name, failed to correctly identify a resident and administered a full set of another resident’s medications in addition to the resident’s own ordered morning medications, including PRN oxycodone. The resident, who had severe cognitive impairment and multiple diagnoses including hypertension and Alzheimer’s disease, subsequently experienced declining BP, reported not feeling well, and became increasingly fatigued. The facility’s policy required resident identification before medication administration, and the LPN acknowledged not knowing the residents and finding the EHR photos too small, despite their availability. Hospital records later documented hypotension, treatment with IV fluids, and a drug overdose after accidental ingestion of another resident’s medications plus the resident’s own, with persistent sinus bradycardia requiring admission for further hemodynamic monitoring.
A cognitively impaired, wandering resident with Alzheimer’s disease and behavioral symptoms was care planned as an elopement risk but was able to leave the memory care unit by holding an emergency exit door bar for 15 seconds and exiting into a stairwell and then to the employee parking lot. The door alarm functioned, but staff in the noisy dining room did not hear it while they were feeding multiple residents, including several needing extensive assistance, and only realized the resident was missing when another staff member encountered him outside and brought him back. In addition, several residents who required staff assistance for transfers and toileting experienced prolonged call light response times well beyond the facility’s 15‑minute expectation, including one who reported waiting up to an hour during meals and having an in‑room accident, another observed waiting about 25 minutes while calling out for help, and a third waiting about 17 minutes before a CNA responded.
A cognitively intact resident reported that a CNA ripped her incontinence brief during care and then refused to change it, despite the resident stating she could not wear it due to the tear. The resident became upset and informed housekeeping staff, who then asked an LPN to assist. On assessment, the LPN observed a large rip extending around the back of the brief, changed the brief, and provided peri care at the resident’s request. The resident stated the ripped brief was uncomfortable and that she did not feel treated with dignity or respect. In interviews, the CNA acknowledged telling the resident the torn brief would still work and did not change it, while the DON confirmed the CNA had refused the resident’s request for a brief change, in conflict with the facility’s dignity policy.
A deficiency was identified when a CNA did not follow manufacturer instructions for a mechanical stand while transferring a resident with severe cognitive impairment, a history of hip fracture, dementia, and muscle wasting who required substantial assistance for transfers. The resident’s care plan called for use of a mechanical stand, but during observed toileting and return-to-chair transfers, the CNA repeatedly locked and unlocked only one wheel of the device and did not keep the brakes unlocked during the actual transfer, contrary to the operator’s instructions that brakes be locked only when raising and lowering the resident during ambulation. In an interview, the DON confirmed staff were expected to follow these operator instructions and keep the wheels unlocked during transfers.
A resident with dementia, behavioral symptoms, and multiple psychotropic and cardiovascular medications was discharged to another nursing facility without a thorough or accurate discharge summary. The care plan contained a discharge planning focus but was never updated to reflect the actual discharge, and the EHR lacked documentation of discharge planning, the reason for discharge, or a recapitulation of stay, despite a family member stating they initiated the discharge due to dissatisfaction with care. The discharge instructions contained multiple medication discrepancies and omissions, including missing drugs, incorrect dosages, and absent administration frequencies, and several PRN constipation medications were not listed, contrary to the facility’s written discharge planning policy.
A resident was admitted from a hospital without a completed Preadmission Screening and Resident Review (PASRR) in the medical record, as required prior to admission. The PASRR was only completed several days later by the Hospital Liaison/Admissions Coordinator after a call alerted staff that it was missing. Both the admissions coordinator and the Administrator acknowledged that the facility relies on the hospital to provide the PASRR and that, in this case, it was missed and not done before the resident’s admission.
A resident with Alzheimer's disease, severely impaired cognition, and documented nutrition/hydration risk required partial to moderate assistance with eating and was care planned for assisted feeding with a general diet and thin liquids. During a breakfast observation, the resident was seated in a reclined Broda chair while staff placed food and beverages on an overbed table and attempted to offer chocolate milk and hot cereal without first positioning the resident upright, causing the resident to struggle to reach the cup. Facility policy on feeding required residents needing assistance to be positioned comfortably in an upright position, and the DON stated she expected residents to be upright whenever food or drink was offered, but there was no separate positioning policy in place.
A resident with a left leg fracture, muscle wasting, and impaired mobility was dependent on a mechanical lift for transfers. Staff positioned the lift at the side of the wheelchair instead of straight on, and the lift tipped and struck the resident’s forehead with the sling-holding part, causing a bruise and protruding bump. Staff interviews confirmed the transfer was done from the side and that the resident’s care plan required straight-on positioning for the lift.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance: Several residents did not receive bathing and hygiene assistance as scheduled. One resident with intact cognition and a stroke history was observed unshaven and said staff did not always shave him during showers, while staff noted the bath sheets no longer tracked shaving or nail care. Other residents with severe cognitive impairment or dependence for bathing went extended periods without baths, and one cognitively intact resident reported missing baths and wanting them. Facility records and staff interviews showed bathing schedules were not consistently followed or documented as required.
QAPI program failed to address repeated deficiencies. Review of the facility’s visit history showed repeated F689, Free of Accident Hazards/Supervision/Devices, and F880, Infection Prevention and Control, across multiple annual surveys and complaint investigations. The QAPI plan stated it would review sources of information for gaps or patterns in care systems, and the Administrator acknowledged the repeated deficiencies and said the facility would review and discuss plans to improve.
Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to follow the 5 rights of medication administration, resulting in one resident receiving another resident’s medications in addition to their own. The resident had diagnoses including hypertension, Alzheimer’s disease, and toxic encephalopathy, with a BIMS score of 3 indicating severe cognitive impairment. On the morning in question, review of the MAR showed the resident received their ordered medications, which included aspirin, calcium carbonate, vitamin C, vitamin D, fluoxetine 20 mg, furosemide 40 mg, galantamine, a lidocaine patch, memantine, acetaminophen, and PRN oxycodone around 8:00 a.m. According to the incident report and nursing progress notes, the LPN (Staff A) administered another resident’s full set of morning medications to this resident while the resident was in the dining room. These additional medications included metoprolol 60 mg, Lyrica 75 mg, oxycodone 7.5/325 mg, furosemide 40 mg, celecoxib 100 mg, Prozac 60 mg, hydroxyzine 10 mg, cetirizine 10 mg, Neuriva, Protonix 20 mg, potassium 99 mg, a multivitamin, and vitamin D3. These medications were given in addition to the resident’s own morning medications and PRN oxycodone. The nurse’s notes documented that the resident’s blood pressure readings declined from 100/50 to 85/48 and then to 73/48, and the resident complained of not feeling well and was increasingly fatigued. Staff A reported during interview that the resident had been screaming and yelling and that she did not realize there were two residents with the same first name in the back hallway. She stated it was her first time working in that hallway after training and that, although resident pictures were available in the EHR to assist with identification, she felt they were small and she did not know the residents. The facility’s medication management policy required staff to identify the resident before administering medications. Staff A’s employee record showed a prior medication occurrence in which she administered the wrong medications (including furosemide and potassium) to a resident, and she had documented previously that she was not familiar with residents when working on that cart. The resident was ultimately sent to the ER, where records documented hypotension on admission, treatment with IV fluids, and a chief complaint of drug overdose after accidental ingestion of another resident’s multiple medications in addition to the resident’s own medications, with continued sinus bradycardia requiring admission for further hemodynamic monitoring.
Elopement of Wandering Resident and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for a cognitively impaired, wandering resident and failure to respond to resident call lights within the facility’s stated 15‑minute expectation. One resident with Alzheimer’s disease, bipolar disorder, and anxiety disorder had a care plan identifying risk for elopement due to wandering and documented behaviors of agitation, aggression, restlessness, and continuous pacing/wandering within the unit. This resident ambulated independently with a walker and had a BIMS score indicating impaired cognition. On the evening of the incident, the resident finished supper in the memory care dining room and then repeatedly walked the hallway with his walker, eventually approaching an emergency exit door at the far end of the hall, away from the dining room. Video and documentation show that the resident stood at the emergency exit door, held the door bar down for the required 15 seconds to release the egress, and then exited through the door into a stairwell and out to the employee parking lot. The door alarm and 15‑second egress functioned, but staff in the dining room did not hear the alarm due to noise from residents, staff conversation, and the television. At the time, two CNAs and one LPN were in the dining room feeding multiple residents, including several who required assistance, and staff reported that the resident was very quick, wandered constantly, and was difficult to keep seated. Staff interviews revealed that one CNA noticed the resident was no longer in the dining room around the same time another staff member reported they were looking for him, and only then did staff recognize the back exit door alarm sounding. A nurse arriving for her shift in the parking lot encountered the resident outside with his walker and escorted him back inside, after which he was assessed and found in stable condition. The deficiency also includes failure to respond to resident call lights within the professional standard of 15 minutes for multiple residents. One resident with intact cognition but dependent or substantial/maximal assistance needs for toileting reported that during meal hours it could take up to an hour for staff to answer the call light, resulting in an in‑room accident. Another resident, alert and oriented but occasionally forgetful and requiring two‑person assistance for transfers, was observed with the call light on for approximately 25 minutes in the morning while repeatedly yelling for help; staff walked past in the hallway without answering the light until a staff member finally entered the room. A third resident, requiring one‑person assistance for transfers, was observed with the call light on for about 17 minutes before a CNA entered to assist. The DON stated that the facility’s expectation is that call lights be answered within 15 minutes, and the facility’s policy directs all staff from all departments to respond to call lights and either assist or obtain appropriate help, but the observed response times exceeded this standard for the residents involved. Staff interviews further described the conditions contributing to these call light delays and supervision gaps. Staff on the memory care unit reported that typical evening staffing consisted of one nurse, one CMA, and two CNAs, and that while this was manageable when routines went smoothly, it became inadequate when residents had behaviors, were sundowning, or when events such as falls or changes in condition occurred. A CMA stated that at least three CNAs were needed on the memory care unit due to multiple residents requiring two‑person assistance, noting that when two CNAs were in a room providing care, they could not monitor the rest of the unit. Staff also reported that the back exit door alarm was faint and difficult to hear from the dining room, and some staff were not fully aware of the configuration of the back stairwell and exit leading to the parking lot. These conditions, combined with high resident care needs and noise levels during meals, contributed to the resident’s elopement and to prolonged call light response times for several residents. Maintenance and administrative staff confirmed that the south/back exit door from the unit led to another unalarmed door and then to the outside employee parking lot, and that the facility did not receive system reports when door alarms were activated. The Administrator was unable to verify when a door alarm went off or when an exit door was breached. The facility’s Wandering Resident policy stated that residents at risk for elopement should receive adequate supervision to prevent accidents and that staff must be vigilant in responding to alarms in a timely manner, and the call light policy required prompt response by all staff. Despite these policies, the documented events show that the resident at risk for elopement was able to leave the secured unit and reach the parking lot without timely staff detection, and that multiple residents experienced call light response times significantly longer than the facility’s stated 15‑minute standard.
Failure to Honor Resident Request for Brief Change and Maintain Dignity
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and respect when a cognitively intact resident’s request for a brief change was not honored. The resident, with a BIMS score of 15 indicating no cognitive impairment, reported being upset because a CNA (Staff N) ripped her brief during care and then refused to change it. The resident self-propelled down the hallway stating she was upset about the ripped brief and that staff would not change it. A housekeeping staff member (Staff M) observed the resident’s distress, was told that the CNA had refused to change the brief despite a large rip, and then asked an LPN (Staff O) to assist with changing it. During the subsequent brief change, Staff O performed hand hygiene, used gloves, removed the resident’s pants and brief, and provided peri care at the resident’s request before applying a new brief and redressing the resident. Observation of the removed brief revealed a large rip on the left side extending past the middle of the resident’s back. The resident stated the brief with the hole was uncomfortable and that she felt staff did not provide her with dignity and respect when her request for a new brief was not honored. Staff O confirmed that the brief had a very large hole and that the resident was very upset, reporting she did not feel treated with dignity or respect and that the ripped brief was uncomfortable. In an interview, Staff N acknowledged caring for the resident that day, stated the resident had been upset and had “behaviors,” and reported that when the resident said she wanted her brief changed because it was ripped, Staff N told her the brief would still work and that urine would not get everywhere, characterizing the tear as “just a little tear.” Staff N stated the resident did not explicitly ask her to change the brief. The DON later stated that Staff N had ripped the brief, the resident had requested a brief change, Staff N said she would not change it, and acknowledged that a lack of dignity occurred when Staff N refused to change the resident’s brief, contrary to the facility’s dignity policy.
Improper Use of Mechanical Stand Brakes During Resident Transfers
Penalty
Summary
Surveyors identified a deficiency related to accident prevention when staff failed to properly use a mechanical stand’s brakes during transfers for one resident. The resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment, required substantial assistance for transfers, and had diagnoses including hip fracture, dementia, and muscle wasting. The care plan documented initiation of a mechanical stand for transfers. During observation, a CNA applied a sling, locked the right wheel of the mechanical stand, lifted the resident from a chair, then unlocked the right wheel and positioned the resident over the toilet. The CNA then lowered the resident onto the toilet and locked the right wheel. After the resident finished, the CNA lifted the resident from the toilet, unlocked the right wheel, positioned the resident over the chair, locked the right wheel, and lowered the resident, thereby failing to keep the mechanical stand brakes unlocked during the transfer as required by the operator’s instructions, which specified that brakes should only be locked when raising and lowering the resident during ambulation. In an interview, the DON stated that staff were expected to follow the operator’s instructions and keep the wheels unlocked during transfers, confirming that the observed practice did not align with the manufacturer’s guidance for safe operation of the mechanical stand.
Failure to Complete Accurate and Thorough Discharge Summary and Documentation
Penalty
Summary
Surveyors identified a failure to complete a thorough and accurate discharge summary and related discharge documentation for one resident who was discharged from the facility. The resident was admitted in early March with moderate cognitive impairment, a Brief Interview for Mental Status (BIMS) score of 08, and documented delusions and behavioral symptoms. Diagnoses included dementia with agitation, anxiety disorder, and depression. Although the care plan contained a discharge planning focus initiated shortly after admission, it did not contain any updates or documentation related to the resident’s actual discharge later that month. The electronic health record (EHR) contained a communication note indicating that transport to another nursing facility was arranged and a health status note stating that the resident was discharged, with physician orders and a face sheet faxed and a report called to the receiving facility. The resident’s EHR did not contain documentation of the discharge planning process, the reason for the discharge, or a recapitulation of the resident’s stay. A family member reported that the family initiated the discharge due to dissatisfaction with care, but there was no documentation in the EHR reflecting that the family initiated the discharge. The Long Term Care Ombudsman reported that no one contacted her during the resident’s stay, although her office did receive notice of the transfer. The facility’s own discharge planning policy required that discharge planning begin on admission, be routinely updated in the comprehensive care plan, and that the evaluation of discharge needs and the final discharge plan be completely documented in the clinical record and discussed with the resident or representative. Review of the resident’s discharge instructions and March medication administration record revealed multiple discrepancies and omissions in the discharge summary. One medication (Amlodipine 10 mg) was listed without any frequency or time of administration. Several medications that the resident was receiving, including Donepezil 10 mg, Lisinopril 5 mg, and Buspirone 10 mg twice daily, were not included on the discharge summary. Other medications were inaccurately documented, such as Memantine, which was ordered as 20 mg once daily but listed as 10 mg twice daily, and Seroquel, ordered as 50 mg twice daily but listed as once daily. Several PRN constipation medications were also omitted. The Regional Nurse Consultant confirmed that the facility’s EHR contained a discharge assessment tool that was not completed for this resident and acknowledged the multiple medication discrepancies on the discharge summary form.
Failure to Complete PASRR Evaluation Prior to Admission
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) evaluation for a resident with an admission date of 4/22/26. The resident’s electronic health record documented admission from a hospital on 4/22/26, but review of the record showed no PASRR completed at the time of admission. A PASRR form for this resident was later obtained and showed it was completed on 4/27/26 by the Hospital Liaison/Admissions Coordinator, several days after the resident had already been admitted. During interview, the Hospital Liaison/Admissions Coordinator stated that the hospital usually completes the PASRR, acknowledged receiving a call the previous night that the PASRR was not in the chart, and admitted she had missed completing it prior to admission even though it should have been done. The Administrator similarly reported that the facility relies on receiving the PASRR from the hospital admission records and that, in this case, the PASRR was missed and not completed prior to the resident’s admission. This resulted in a deficiency for failure to ensure a PASRR evaluation was completed prior to admission for 1 of 3 reviewed residents, in accordance with PASRR requirements.
Failure to Properly Position Resident Upright During Assisted Feeding
Penalty
Summary
Surveyors identified a deficiency in resident positioning during mealtime for a resident with Alzheimer's disease and severely impaired cognition, as evidenced by a Brief Interview for Mental Status score of 2. The resident’s MDS indicated a need for partial to moderate assistance with eating, and the care plan documented nutrition and hydration risk related to end-stage diagnosis, cognitive limitations, and weakness, with directions for a general diet, thin liquids, and assistance with eating. During a breakfast observation on the Magnolia Unit, the resident was seated in a Broda chair that was reclined back. A dietary aide placed food on the table in front of the resident, and a CNA then placed beverages and food on an overbed table before walking away, while the resident remained reclined with eyes closed and the plate of food untouched. Later in the same observation period, another CNA offered the resident chocolate milk while the Broda chair remained tilted backward, and the resident had to struggle to move her head up and forward to reach the cup. The same CNA then offered hot cereal, which the resident declined by saying “later.” A different CNA subsequently offered another drink of chocolate milk, again without adjusting the reclined position of the Broda chair. Policy review showed the facility’s “Feeding of Residents by Staff” policy required that residents unable to feed themselves be assisted per their care plan and be positioned comfortably in an upright position. In an interview, the DON stated there was no specific positioning policy, that staff received positioning education in training, and that her expectation was that residents be placed in an upright position whenever food or drink was offered.
Mechanical Lift Transfer Caused Resident Forehead Injury
Penalty
Summary
The facility failed to provide a safe and adequate mechanical lift transfer for Resident #18, who had a left leg fracture, muscle wasting, and impaired gait and mobility, but no cognitive impairment based on a BIMS score of 15. The resident’s care plan required two staff members to use a mechanical lift for transfers because the resident was nonweight-bearing on the left leg. The care plan update also directed staff to approach the wheelchair straight on and not from the side, and to have the resident bend the right leg and turn away from the lift during transfers. During a wheelchair transfer, staff positioned the mechanical lift at the side of the wheelchair and began the transfer. The lift tipped and struck the resident’s forehead with the part that held the sling. The resident sustained a bruise and a protruding bump on the left forehead, and the incident documentation noted the resident’s head was hit on the lift. The resident later reported that the lift almost fell to the floor and that additional staff were needed to return it upright. Staff interviews confirmed that the transfer was performed from the side of the wheelchair. One CNA stated the lift may have caught on bars under the wheelchair and acknowledged that staff had been educated not to use the lift from the side. Another CNA stated the lift was used from the side because the resident did not want her leg hit by the lift, and identified the sling-holding part of the lift as the piece that struck the resident’s forehead. The DON stated the proper procedure was to position the mechanical lift directly in front of the wheelchair rather than to the side.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living for 5 of 8 residents reviewed, specifically related to bathing and shaving. Resident #3 had a BIMS score of 15 and was dependent on staff for personal hygiene, with diagnoses including renal insufficiency, stroke, hemiplegia, and seizure disorder. The resident was observed unshaven, stated he was getting showers but not shaved every time, and said he needed help shaving since his stroke. Facility records showed showers were documented without indicating whether shaving was completed, and staff interviews confirmed the bath sheets no longer tracked shaving or nail care, while the DON stated male residents should be offered shaving during showers and it should be documented if completed or refused. Resident #1 had a BIMS score of 4, diagnoses including muscle weakness, diabetes, and hip fracture, and was care planned as an extensive assist for bathing. Review of the follow-up report showed the resident went 17 days without a bath and later 19 days without a bath. Resident #11 had a BIMS score of 3, diagnoses including depression, hypertension, and anemia, and was scheduled for bathing on Wednesday morning and Friday afternoon, but the follow-up report showed gaps of 6 days, 6 days, and 18 days between baths. Resident #27 also had a BIMS score of 3 with depression, hypertension, and anemia, was scheduled for bathing on Monday and Thursday afternoon, and the follow-up report showed the resident went 19 days and then 20 days without a bath, with refusals documented on two occasions. Resident #85 had a BIMS score of 15, diagnoses including hypertension, depression, and need for assistance with personal care, and stated she did not get 2 baths the prior week and wanted them. Her care plan identified her as dependent for bathing, but lacked bathing frequency, and the task list scheduled bathing for Monday morning and Wednesday afternoon. The follow-up report showed multiple extended gaps between baths, including 12 days, 7 days, 18 days, and 7 days. Facility policy stated bathing is intended to promote cleanliness, provide comfort, and observe skin condition, and the Regional Nurse Consultant stated bathing should be completed as scheduled.
QAPI Program Failed to Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive and effective QAPI program and did not have a plan that described the process for conducting QAPI and QAA activities. Review of the DIAL website visit history showed repeated deficient practices identified during the facility’s annual survey and complaint investigation on 3/27/25 and during the annual survey, complaint, and facility-reported incident investigation on 4/19/26. The repeat deficiencies included F689, Free of Accident Hazards/Supervision/Devices, which had been repeated in the previous three consecutive annual surveys, and F880, Infection Prevention and Control, which had been repeated in the previous four consecutive annual surveys. The facility’s QAPI plan stated that it would review sources of information to determine whether gaps or patterns existed in systems of care that could result in quality problems or opportunities for improvement. During an interview on 4/23/26 at 1:28 PM, the Administrator acknowledged the repeated F689 and F880 deficiencies and stated the facility would review and discuss plans to improve.
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