Good Samaritan - Indianola
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianola, Iowa.
- Location
- 708 South Jefferson, Indianola, Iowa 50125
- CMS Provider Number
- 165186
- Inspections on file
- 27
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Good Samaritan - Indianola during CMS and state inspections, most recent first.
The facility failed to provide adequate nursing staff, particularly on night and weekend shifts, resulting in prolonged call light response times for multiple cognitively intact residents. With only three to four CNAs and two nurses caring for 82 residents across four halls, including an isolated rehab hall, residents reported routinely waiting 45 minutes to over an hour for assistance with toileting, hygiene, and going to bed, and some reduced their use of call lights because help did not arrive. Call light logs documented numerous delays ranging from about 18 minutes to more than two hours. Resident council minutes repeatedly noted concerns about insufficient staffing and delayed call light responses, while CNAs, an RN, and an LPN consistently described the facility as chronically short staffed at night and on weekends. The DON confirmed that the facility expected five CNAs on nights, a 15-minute call light response time, and acknowledged that current staffing and call light times were inadequate, with no clear chain-of-command process when the on-call manager was unavailable.
The facility was cited for repeatedly failing over several survey cycles to correct known staffing deficiencies despite an active QAPI focus on assuring appropriate staffing. Public state survey records showed multiple surveys over a multi-year period with cited staffing violations while the facility maintained a census of 82 residents. QAPI notes identified staffing as an ongoing action item, and the Administrator acknowledged that leadership had been aware of staffing needs prior to his tenure and that the issue represented a repeat failure, though earlier QAPI documentation was unavailable.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required. Surveyors found gaps in staffing and leadership coverage during their review.
Staff failed to maintain the dignity of two residents by not promptly changing a stained shirt and by responding abruptly to a request, leaving one resident feeling insignificant. Another resident with quadriplegia experienced repeated delays in receiving feeding assistance, often being the last to be served meals due to staff unavailability, despite her dependence on staff for eating. These deficiencies were confirmed through observations, resident and staff interviews, and review of facility policies.
A CMA left a cup containing a Senna tablet unattended on a locked medication cart while administering medications, with a resident in a wheelchair nearby. Facility policy requires all medications to be secured and not left accessible when staff are not present. The DON confirmed that medications should not be left unattended.
Staff did not disinfect a mechanical lift between uses for two residents, with CNAs transferring one resident and then another using the same lift without cleaning it in between. Disinfectant wipes were not available on the equipment or in resident rooms, and staff interviews revealed inconsistent disinfection practices and a lack of a specific written policy for cleaning reusable equipment.
A male resident with dementia and a history of hypersexual behaviors was able to enter a female resident's room and inappropriately touch her, despite known risks and prior incidents. The female resident, who had limited mobility and required assistance with ADLs, was asleep during the incident and did not recall it. Staff interventions, including monitoring and alarms, were not sufficient to prevent the abuse, and the care plan for the female resident did not address the risk of resident-to-resident incidents.
Staff did not have access to an accurate code status for a resident with multiple diagnoses and moderately impaired cognition. The binder at the nursing station contained an IPOST form directing CPR, while both the EHR and the IPOST indicated the resident wished to be DNR. The DON confirmed that IPOSTs in the binders were expected to be accurate.
A resident with impaired cognition and physical limitations experienced an incident where another resident entered her room and touched her inappropriately. The care plan was not updated to reflect the incident or to include interventions for her psychosocial and mental health needs, despite facility policy requiring such updates after changes in resident status.
Staff did not follow infection control protocols during incontinence care for a resident, allowing a clean brief to come into contact with urine-soiled bedding. In a separate case, staff failed to use required gowns during high-contact care activities for a resident with a suprapubic catheter and quadriplegia, despite facility policy and care plan directives for Enhanced Barrier Precautions (EBP).
A resident's bathroom floor remained persistently sticky over several days, with shoes sticking to the surface during multiple observations. Despite a policy requiring daily and routine thorough cleaning, the floor was not properly maintained, and staff were aware of issues with the cleaning solution concentration.
A resident with cognitive and physical impairments did not receive timely assistance with incontinence care or nail hygiene, as required by their care plan and facility policy. Staff failed to check or change the resident's incontinence brief for several hours, resulting in a saturated brief and urine odor, and the resident's nails remained untrimmed and dirty despite policy requiring regular care.
Staff failed to respond to call lights within the expected timeframe, with a resident waiting at least 10 minutes and staff repeatedly turning off the call light without providing assistance. Multiple residents reported long waits and inadequate responses. Additionally, a resident with cognitive and physical impairments did not receive timely incontinence care, remaining in a saturated brief for several hours despite care plan directives and facility policy. Staffing shortages contributed to these deficiencies.
The facility failed to provide sufficient staffing, leading to delays in resident care. Residents reported long wait times for assistance, and staff expressed being overworked and unable to take breaks. The facility was often short-staffed, contributing to increased falls and UTIs among residents.
The facility failed to maintain adequate nursing staff, resulting in the DON and ADON working the floor despite a census of 78 residents, exceeding the regulatory limit for a DON to serve as a charge nurse. Staffing files showed the DON worked the floor frequently, leading to her resignation due to burnout. The facility had a staffing contract with an agency but failed to utilize it, contributing to the staffing issues.
The facility failed to maintain appropriate food temperatures during meal service, as observed by surveyors. Residents reported receiving cold meals, linked to a malfunctioning steam table and non-operational plate warmer. The Dietary Cook and CDM confirmed these issues, which had been reported but not resolved. A sample tray showed food temperatures below required levels.
A resident with a high risk for falls experienced multiple falls due to inadequate supervision and care planning. The facility failed to perform a root cause analysis or update the care plan with fall interventions, resulting in repeated falls and a serious head injury. Staff interviews revealed issues with staffing levels and incident reporting, contributing to the deficiency.
A resident with severe cognitive impairment and multiple medical conditions did not receive prescribed lymphedema pump treatments due to the facility's failure to process and implement physician orders accurately. Despite the presence of the pump in the facility, the treatment was not administered, as confirmed by staff interviews and record reviews.
A LTC facility experienced significant medication errors involving two residents. One resident accidentally ingested another's medications, leading to a severe drop in blood pressure and emergency treatment. Another resident received incorrect doses of a pain medication over several instances. Additionally, a nurse was observed leaving a medication cart unattended, with insulin pens and supplies accessible. These incidents highlight failures in medication administration and supervision.
The facility failed to provide adequate staffing, resulting in residents being left unsupervised and experiencing neglect, such as missed baths and long call light response times. Staff reported being overburdened and unable to perform their duties effectively, particularly during the evening shift. Previous incidents of unsupervised residents led to a resident-to-resident encounter requiring investigation.
The facility failed to maintain complete and accurate medical records, delaying surveyor access to necessary documents. The DON manually entered data due to incomplete records, and a resident was left unobserved for 56 minutes despite being on 15-minute checks. Issues with the electronic health records system and incorrect instructions further complicated the survey process.
The facility failed to notify the Ombudsman of resident transfers to the hospital for five residents, as required by regulations. This deficiency was identified through record reviews and staff interviews, revealing that notifications had not been completed from December 2023 to March 2024. The facility's policy did not include the requirement for such notifications, contributing to the oversight.
The facility failed to investigate and document grievances regarding missing cigarettes for several residents. Despite reports to staff, including the DON, the facility's grievance documentation was incomplete, and residents feared losing smoking privileges if they continued to voice concerns. The facility's policy requires documentation and investigation of grievances, which was not followed, leading to a deficiency.
A resident with multiple pressure ulcers did not receive consistent wound care, as treatments were not documented in the TAR. The resident reported inconsistent dressing changes, leading to severe drainage. Staff acknowledged the resident's noncompliance and adjusted care times, but the DON confirmed that undocumented treatments were considered not done. Facility policies on systematic assessment and documentation were not followed.
A resident with Parkinson's Disease, dementia, and Tourette's syndrome was administered antipsychotic medications without documented non-pharmacological interventions, violating the facility's policy. Staff interviews revealed inconsistent documentation practices, and the Director of Nursing expected documentation of three non-pharmacological interventions prior to PRN medication administration.
A facility failed to accurately complete an MDS assessment for a resident with multiple mental health diagnoses. The MDS did not reflect the resident's status as determined by the state level II PASRR process, which recommended specific support services. The care plan lacked information about PASRR completion and recommended resources, despite facility policies requiring such documentation.
The facility failed to maintain an updated PASRR for a resident with schizophrenia and depression, and did not incorporate PASRR service recommendations into another resident's care plan. One resident's PASRR was outdated and lacked necessary diagnoses, while another's care plan did not reflect PASRR findings despite having multiple mental health diagnoses and using psychotropic medications.
Two residents in an LTC facility did not receive their scheduled baths and grooming. One resident with Parkinson's and dementia had unkempt fingernails and was unshaven, with inconsistent bath documentation. Another resident with a stroke and pressure ulcers reported not having a bath for ten days, despite a thrice-weekly schedule. Staff interviews revealed documentation gaps and potential staffing issues.
A resident with multiple wounds did not receive proper infection control during a dressing change. An LPN failed to change gloves and sanitize hands between handling soiled dressings and clean supplies, contrary to the facility's infection control policy. The DON confirmed the expectation for staff to perform hand hygiene when moving from dirty to clean areas.
Inadequate Night and Weekend Staffing Leading to Prolonged Call Light Response Times
Penalty
Summary
The deficiency involves the facility’s failure to maintain adequate nursing staff on the overnight and weekend shifts, resulting in prolonged call light response times for multiple residents. Surveyors observed that during an overnight shift there were only three CNAs and two nurses in the building until an additional CNA arrived, bringing the CNA count to four for a building with four halls, including an isolated rehab hall staffed by only one person. The facility census was 82 residents. The DON later confirmed that the facility’s expectation was to have five CNAs on the overnight shift, and acknowledged that recent resignations and staff on paternity and maternity leave had led to operating with fewer staff than typical. The facility assessment stated that staffing was to be based on resident acuity and needs, feedback, and use of pool and agency staff as needed. Multiple cognitively intact residents reported long waits for assistance via call lights, particularly at night and on weekends. One resident who could not get to the bathroom independently stated that while daytime staffing was often sufficient, nighttime staffing was inadequate and call lights were not answered in a timely manner, leading him to feel he had to advocate for other residents. Another resident who was dependent for care reported waiting at least 45 minutes, and possibly over an hour, for assistance after soiling herself, describing this as a daily and nightly occurrence and noting that she felt miserable and ashamed having to sit in urine and feces. A third resident reported that call light response times were usually 45 minutes or longer, especially on nights and weekends, and that she had reduced how often she used her call light because help did not come; she also reported not reliably receiving water at night. Another resident stated that staffing was usually bad at night and that she typically waited over an hour for assistance with going to bed, with night and weekend staff frequently reporting they were short staffed. Objective call light response logs for several residents over a three-day period showed numerous instances of call lights remaining unanswered for extended periods, including times ranging from approximately 18 minutes to over two hours. Resident council minutes from two separate months documented ongoing resident concerns about insufficient staffing and a desire for call lights to be answered within 15 minutes, showing the facility had been made aware of these issues over time. Staff interviews across multiple CNAs, an RN, and an LPN consistently described the facility as always or frequently short staffed, especially at night and on weekends, with reports of operating with only one CNA per hall and sometimes only two to three CNAs total. Staff stated that the low staffing levels caused slow call light response times and made it impossible to be everywhere they were needed, with one nurse reporting that it could take 45 minutes or more to answer other call lights when they were already responding to one. The DON confirmed the expectation of a 15-minute call light response time and acknowledged that the recent call light times were unacceptable, and also stated there was no chain-of-command protocol when the manager on call was unavailable.
Repeated Failure to Correct Ongoing Staffing Deficiencies
Penalty
Summary
The deficiency involves the facility’s failure to make a good faith effort to correct ongoing deficient practices related to sufficient staffing over a three-year period. Review of the state agency’s public website showed multiple surveys ending on 07/29/2025, 04/24/2025, 01/30/2025, and 06/18/2025, each resulting in a deficiency cited for staffing while the facility reported a census of 82 residents. Quality Assurance and Performance Improvement (QAPI) meeting notes dated 12/15/2025 identified assuring appropriate staffing as an active area of the QAPI action plan, indicating that staffing concerns were formally recognized within the facility’s quality program. In an interview on 01/14/2026, the Administrator stated the facility had been aware of the need for more staff since before he assumed the role in November and acknowledged that the staffing issues were a repeat facility failure, though he could not explain why the failure persisted due to his limited tenure. He also reported that QAPI meeting notes from before December were unavailable, but that facility leadership had known about staffing issues for some time. No specific residents, clinical conditions, or direct resident care events are described in the report; the deficiency centers on repeated staffing violations and the facility’s failure over multiple survey cycles to effectively address and correct these known staffing problems through its QAPI and QAA processes.
Insufficient Nursing Staff and Lack of Licensed Nurse in Charge
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through surveyor observation and review of facility staffing practices. The report specifically notes the absence of adequate nursing coverage and the lack of a licensed nurse in charge during certain shifts, which did not meet regulatory requirements.
Failure to Maintain Resident Dignity and Timely Assistance with Meals
Penalty
Summary
Surveyors identified that staff failed to maintain resident dignity and timely care in several instances. One resident with intact cognition and a history of stroke, hemiplegia, and COPD was observed wearing a shirt stained with food after breakfast. The resident expressed discomfort about being in public with the stained shirt and stated she would have preferred to have it changed. Staff acknowledged the stain but did not change the shirt after transferring the resident to bed, and the resident remained in the stained shirt for an extended period. Additionally, when the resident requested to go outside to smoke, a staff member responded abruptly and dismissively, which made the resident feel insignificant. Another resident, also with intact cognition and diagnosed with multiple sclerosis and quadriplegia, required maximal assistance for eating. This resident routinely experienced delays in receiving assistance with meals, often being the last to be served because staff were not available to help her eat when she arrived in the dining room. The resident reported feeling neglected and believed staff prioritized other residents over her, particularly after the departure of a staff member who previously assisted her regularly. The issue was corroborated by interviews with dietary and clinical staff, who confirmed that the resident's meal was withheld until a staff member was available to assist, resulting in frequent delays. Facility records and staff interviews confirmed that both residents' concerns had been raised to management, and the issues persisted despite awareness among leadership. The facility's own policy emphasized the importance of maintaining resident dignity and providing necessary assistance, but observations and interviews demonstrated that these standards were not consistently upheld for the affected residents.
Unattended Medication Left Accessible on Medication Cart
Penalty
Summary
A Certified Medication Aide (CMA) was observed administering medications and left an opaque medication cup containing an orange, round pill (identified as Senna, a stool softener) unattended on top of a locked medication cart. During this time, the CMA walked away from the cart and into a resident's room, leaving the medication accessible. A resident in a wheelchair was observed nearby, three doors away from the unattended medication cart. The pill remained on the cart for several minutes while the CMA was away. Facility policy requires that all medications be secured in a locked medication cart, drawer, or cupboard, and not left accessible when staff are not present. The CMA confirmed that the medication should have been disposed of and not left unattended. The Director of Nursing (DON) also stated that medications should be secured in the medication cart or appropriately disposed of, and not left unattended.
Failure to Disinfect Mechanical Lift Between Resident Uses
Penalty
Summary
Staff failed to implement the facility's infection control policy by not disinfecting a mechanical lift between uses for two residents. On the observed date, Certified Nurse Aides (CNAs) transferred one resident from a wheelchair to a bed using a mechanical lift, then placed the lift outside the room without disinfecting it. Later, the same lift was used to transfer another resident without being disinfected beforehand. The lift was again placed in the hallway after use, still without being cleaned. Staff interviews revealed that disinfectant wipes (Saniwipes) were not available in resident rooms and were supposed to be stored either at the nurses' station or in storage pouches on the equipment, but none were found on the lift at the time of observation. Further interviews with staff indicated inconsistent practices regarding when and where reusable equipment was disinfected, with some staff stating that equipment was wiped down in the hallway after use or during the night, but not before being used for another resident. The Director of Nursing confirmed that staff were expected to disinfect the equipment between uses, but there was no specific written policy addressing the disinfection of reusable equipment such as mechanical lifts.
Failure to Prevent Resident-to-Resident Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident from abuse when a male resident with a history of dementia, impaired cognition, and documented hypersexual behaviors was able to enter the room of a female resident and inappropriately touch her. The male resident had a known pattern of sexually inappropriate behaviors, including previous incidents of touching other residents and staff inappropriately, making sexual remarks, and being noncompliant with medications prescribed for hypersexuality. Despite these behaviors, the care plan interventions, such as monitoring in hallways and use of alarms, were not sufficient to prevent the male resident from accessing other residents' rooms unsupervised. On the day of the incident, staff observed the male resident wandering the halls and entering female residents' rooms. Staff redirected him to his room, but he was later found in the female resident's room, sitting at the foot of her bed with her brief undone and his hand between her legs. The female resident, who had limited mobility due to a stroke and required assistance with ADLs, was asleep at the time and did not recall the incident upon waking. Staff immediately separated the residents and notified appropriate personnel, but the incident revealed that existing monitoring and supervision measures were inadequate to prevent resident-to-resident abuse. The care plan for the female resident did not include information about the risk of resident-to-resident incidents, despite her vulnerability due to physical limitations. Interviews with other residents indicated concerns about male residents entering female residents' rooms and a perception that staff response was not always timely. The report documents that the male resident's behaviors were known to staff, and interventions such as medication adjustments and increased monitoring had been attempted, but these measures did not prevent the incident of abuse.
Failure to Ensure Accurate Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure that staff had access to an accurate code status for one resident reviewed for advance directives. Clinical record review showed that the resident had diagnoses including mild intellectual disabilities, heart failure, and depression, with a BIMS score indicating moderately impaired cognition. The facility's policy required advance directive orders to be kept in a binder accessible to nursing staff. During the survey, a registered nurse stated that code status would be checked first in the computer and then in the binder at the nursing station. However, the binder at the nursing station contained an IPOST form for the resident that directed staff to perform CPR, while both the electronic health record face sheet and the IPOST form itself indicated the resident wished to be DNR. The Director of Nursing confirmed that IPOSTs in the binders were expected to be accurate.
Failure to Update Care Plan After Resident-to-Resident Incident
Penalty
Summary
The facility failed to update and revise the care plan for a resident following a resident-to-resident incident involving inappropriate physical contact. The affected resident had a history of cerebrovascular accident (stroke), hemiplegia, muscle weakness, and impaired cognition, as indicated by a low BIMS score. The resident required significant assistance with activities of daily living and had documented symptoms of depression. Despite an incident in which another resident entered her room, undid her brief, and touched her inappropriately, the care plan was not updated to reflect this event or to include interventions addressing her psychosocial and mental health needs. Record review showed that the care plan, last revised after the incident, continued to focus on the resident's physical limitations and assistance needs but did not address the trauma or implement behavioral interventions related to the incident. Staff interviews confirmed that the care plan should have been updated to include the incident and related interventions. The facility's policy required care plans to be person-centered, updated as resident needs changed, and to include trauma-informed care, but these requirements were not met in this case.
Failure to Follow Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow proper infection control practices during incontinence care for a resident with mild intellectual disabilities, heart failure, and depression. The resident, who required partial to moderate assistance with toileting hygiene and was incontinent of bowel and bladder, was observed lying on a soiled fitted sheet and bed pad. During care, staff changed the resident's incontinence brief before changing the soiled sheets, resulting in the clean brief coming into contact with urine-soiled bedding. Both the CNA and RN involved acknowledged that the clean brief was in contact with soiled sheets, which was contrary to facility policy and infection control standards. In a separate incident, staff did not implement Enhanced Barrier Precautions (EBP) for a resident with multiple sclerosis, neurogenic bladder, and a suprapubic catheter, who was also quadriplegic and dependent on staff for activities of daily living. Despite the care plan and facility policy requiring staff to wear gowns and gloves during high-contact care activities such as catheter care, changing briefs, dressing, and transfers, staff were observed performing these tasks without donning gowns. Specifically, staff emptied the resident's catheter bag, changed the resident's brief, assisted with dressing, and transferred the resident using a mechanical lift, all without wearing the required gown, though gloves were used. Interviews with staff and the Director of Nursing confirmed that the expectation was for gowns and gloves to be worn during high-contact care for residents requiring EBP, particularly those with indwelling catheters. Facility policies reviewed also supported these requirements, but observations showed that staff did not consistently adhere to them during the care of the resident with a catheter.
Failure to Maintain Clean and Non-Sticky Resident Bathroom Floor
Penalty
Summary
The facility failed to maintain a clean and non-sticky floor in the bathroom of one resident's room, as required by its housekeeping policy. Observations over three consecutive days revealed that the bathroom floor remained very sticky, with shoes noticeably sticking to the surface while walking. The facility's policy specified a daily cleaning schedule with routine thorough cleaning, but the persistent stickiness indicated that this was not effectively implemented for the resident's bathroom. The issue was identified through direct observation and confirmed by staff interviews, which acknowledged awareness of the problem and previous discussions about the cleaning solution concentration.
Failure to Provide Timely Incontinence and Nail Care
Penalty
Summary
A deficiency occurred when a resident with mild intellectual disabilities, heart failure, and depression, who required partial to moderate assistance with toileting hygiene, did not receive timely incontinence and nail care as directed by their care plan and facility policy. The resident was observed over a period of several hours without being offered assistance with toileting or incontinence care, despite care plan instructions to check and assist every two hours. The resident was later found with a heavily saturated incontinence brief and urine odor, and staff only provided care after being prompted by the surveyor. Staff interviews confirmed that the resident was not checked or changed as frequently as required, with one CNA stating she was the only one working on the hall and another indicating changes were attempted only before lunch and supper. Additionally, the resident's nails were observed to be untrimmed and had a black substance under several nails on multiple occasions, contrary to the facility's nail care policy requiring nails to be kept clean and trimmed. Despite these observations, no staff were seen addressing the resident's nail hygiene during the survey period. The DON confirmed that staff are expected to check and change residents every two hours and maintain clean, trimmed nails, but these standards were not met for this resident.
Delayed Call Light Response and Incontinence Care
Penalty
Summary
Facility staff failed to respond to resident call lights in a timely manner, with observations showing that a resident's call light remained unanswered for at least 10 minutes on multiple occasions. Staff entered the resident's room, turned off the call light, and left without providing the requested assistance, causing the resident to repeatedly activate the call light. Interviews with residents revealed consistent concerns about delayed responses, with some reporting waits of up to an hour and instances where staff turned off call lights without assisting them. The facility's call light system did not record response times, preventing the administrator from obtaining call light reports. Additionally, staff failed to provide timely incontinence care for a resident with mild intellectual disabilities, heart failure, and depression, who required partial to moderate assistance with toileting. Despite care plan instructions to check and assist the resident every two hours, staff did not offer toileting or incontinence care for nearly three hours, resulting in the resident being observed with a heavily saturated brief and visible incontinence products. Staff interviews confirmed that only one CNA was working on the hall at the time, and that care routines were not consistently followed as directed by facility policy.
Staffing Deficiency Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by multiple resident and staff interviews, as well as facility document reviews. Resident interviews revealed that residents felt the facility was understaffed, leading to delays in care. One resident, who is ambulatory, reported having to leave her room to find staff to assist her non-ambulatory roommate. Another resident reported that call lights at night could take over 30 minutes to be answered, and staff expressed feeling overworked. A third resident, who requires assistance with toileting and personal hygiene, reported that staff did not have time to help her apply barrier cream, which was left unused on her nightstand. Staff interviews corroborated the residents' concerns, with several staff members stating that the facility did not have enough staff to adequately care for all residents. Staff reported being unable to take breaks due to insufficient staffing, leading to burnout and high turnover rates. Some staff members were written up for failing to take breaks, despite the lack of coverage to allow for breaks. The facility's staffing coordinator confirmed that the facility often worked short-staffed, with staffing sheets showing that the facility was short-staffed on 13 out of 26 days reviewed. The lack of adequate staffing was linked to an increase in falls and urinary tract infections among residents, as reported by a registered nurse. The facility was on a performance improvement plan to address these issues. The Advanced Registered Nurse Practitioner noted that the facility's layout made it difficult for the limited number of nurses to cover all areas effectively. Overall, the facility's inability to maintain adequate staffing levels resulted in compromised care for residents, as evidenced by the documented delays and omissions in care.
Inadequate Staffing Leads to DON Working the Floor
Penalty
Summary
The facility failed to maintain adequate nursing staff, resulting in the Director of Nursing (DON) and Assistant Director of Nursing (ADON) working the nursing floor on multiple occasions. This occurred despite the facility having a census of 78 residents, which exceeds the regulatory threshold of 60 residents for a DON to serve as a charge nurse. The staffing files from December 2024 revealed that the DON and ADON were scheduled to work the floor on ten occasions. The former DON reported working the floor three times a week or more from November to December 2024, leading to her resignation due to burnout and concerns about her professional license. Interviews with the former DON and the Regional Director of Clinical Services highlighted administrative failures in staffing management. The facility had a staffing contract with an agency, Grapetree, which was not utilized to address the staffing shortages. The facility's job description for the DON allowed for resident care on an as-needed basis but did not specify limits on floor work. The failure to utilize available agency staffing and the lack of clear guidelines contributed to the DON's excessive workload, ultimately leading to her departure.
Failure to Maintain Appropriate Food Temperatures
Penalty
Summary
The facility failed to serve food within appropriate temperature ranges during a meal service, as observed by surveyors. Multiple residents reported that their meals were often served cold, with one resident expressing concern for others who might not be able to reheat their food. The residents interviewed had intact cognition, as indicated by their BIMS scores. The issue was linked to a malfunctioning steam table and a non-operational plate warmer, which were unable to maintain the required food temperatures during service. The Dietary Cook and Certified Dietary Manager confirmed the problems with the steam table and plate warmer, which had been reported to maintenance but remained unresolved. The steam table was observed to lose significant heat over the course of service, and the plate warmer was not functioning at all. A sample tray prepared for surveyors showed food temperatures below the required levels, with the main dish and vegetables being lukewarm. The facility's policy on food temperature monitoring did not specify target temperatures for serving, contributing to the deficiency.
Inadequate Supervision and Care Planning for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate nursing supervision and care planning for a resident identified as having a high risk for falls. The resident, who had a history of repeated falls, anemia, atrial fibrillation, and severely impaired cognition, experienced multiple falls during their stay. Despite these incidents, the facility did not perform a root cause analysis to determine the reasons for the falls, nor did they update the resident's care plan with appropriate fall interventions. The resident's care plan, initiated upon admission, lacked specific interventions to prevent falls, even after the resident experienced several falls. The facility's documentation revealed that the resident had multiple falls, some resulting in injuries, including a head injury that led to a hospital admission for a brain bleed. The facility's incident reports and progress notes indicated that the resident was often found on the floor, attempting to transfer or move without assistance, and was not consistently using the call light system. Interviews with staff highlighted issues with staffing levels and the completion of incident reports. Some nurses failed to fill out incident reports for each fall, and there was a lack of timely documentation and follow-up on the resident's care plan. The Director of Clinical Services acknowledged the high number of falls and the need for improved incident reporting and care planning. Despite these acknowledgments, the facility did not adequately address the resident's fall risk, leading to repeated incidents and a serious injury.
Failure to Administer Lymphedema Treatment as Ordered
Penalty
Summary
The facility failed to provide treatments as ordered for a resident with severe cognitive impairment and multiple medical conditions, including non-Alzheimer's dementia, atrial fibrillation, congestive heart failure, and chronic lymphedema. The resident was admitted to the facility after a hospitalization for a pubic fracture, with discharge orders that included the use of lymphedema pumps. However, the facility did not implement these orders, as evidenced by the absence of the lymphedema pump in the resident's room and the lack of documentation in the Medication Administration Record (MAR) and Treatment Administration Record (TAR). The Director of Nursing (DON) acknowledged that the lymphedema pump order was not processed accurately upon the resident's admission and subsequent hospital discharge. Despite the presence of the lymphedema pump in the facility, the treatment was not administered as ordered. This oversight was confirmed through staff interviews and record reviews, revealing a failure to accurately review, process, and implement the physician's orders for the resident's care.
Medication Errors and Unattended Medications in LTC Facility
Penalty
Summary
The facility failed to administer medications correctly, resulting in significant medication errors involving two residents. Resident #87, who had intact cognition and multiple medical conditions, accidentally ingested medications intended for another resident, Resident #188. This occurred after a registered nurse left the medication cup unattended on a bedside table. As a result, Resident #87 experienced a severe drop in blood pressure and pulse rate, necessitating emergency room treatment for a beta blocker overdose. The incident was documented in progress notes and a facility incident report, highlighting the nurse's error in leaving medications unsupervised. Additionally, the facility failed to administer the correct dose of a pain medication to Resident #3, who suffered from multiple sclerosis, malnutrition, and chronic pain. The resident's medication administration records revealed that the prescribed Fentanyl patch was not administered on the scheduled date, and subsequent doses were incorrect. The facility's records showed repeated administration of a lower dose than prescribed, without proper documentation or notification to the family and physician. This oversight was acknowledged by the facility administrator as a significant medication error. Observations during a medication administration round revealed further issues with medication management. A registered nurse was seen leaving a medication cart unattended while administering medications to residents, with insulin pens and diabetic supplies left accessible on the cart. Interviews with staff confirmed this practice, despite the facility's policy against leaving medications unattended. The Director of Nursing acknowledged that medications should not have been left unsupervised, indicating a systemic issue with medication administration practices.
Inadequate Staffing Leads to Resident Neglect
Penalty
Summary
The facility failed to provide sufficient staff to meet the needs of its residents, as evidenced by multiple observations and interviews. A notable incident involved a resident who was left unsupervised for 56 minutes, despite being on 15-minute checks, which was acknowledged by the Director of Nursing (DON). The facility's documentation inaccurately reflected that the resident was checked every 30 minutes, contradicting the observed evidence. Interviews with residents revealed dissatisfaction with staffing levels, citing long call light response times, missed baths, and inadequate care, particularly during the second and overnight shifts. Staff interviews corroborated the residents' concerns, with several staff members expressing that the facility was understaffed, especially during the evening shift. Certified Medication Aides (CMAs) and Licensed Practical Nurses (LPNs) reported being forced to perform duties outside their roles due to insufficient staffing, which affected their ability to perform their primary responsibilities effectively. Staff also expressed fear of retribution for voicing concerns about staffing levels. The facility's internal documents and interviews with the administration indicated that staffing decisions were based on a facility assessment and feedback from staff, residents, and families. However, the facility had previously reported incidents of residents being left unsupervised, leading to a resident-to-resident sexual encounter that required investigation. The administration acknowledged the need to increase staffing during certain shifts but continued to rely on pool and agency staff as needed.
Deficiencies in Record-Keeping and Resident Monitoring
Penalty
Summary
The facility failed to maintain complete and accurate medical records and did not provide timely access to electronic health records, which hindered the survey process. The Director of Nursing (DON) initially stated that the On-Base software system was used for storing resident documents and promised to set up facility computers for surveyors. However, there were delays in providing access to these records, as the Administrator struggled to make computers available due to security concerns and staff taking computers home. This resulted in surveyors not having access to necessary records, such as advanced directives and PASRR documentation, in a timely manner. During the survey, it was observed that the DON was manually entering information from skin monitoring forms because nurses did not have time to do so, indicating incomplete record-keeping. Additionally, the facility's electronic health records system lacked a PASRR document for a resident, which was later found to have been completed but not included in the resident's records. The facility's entrance conference worksheet also contained incorrect instructions for locating certain documents, further complicating the survey process. Furthermore, a resident was observed wandering the hallway unobserved for 56 minutes, despite their care plan indicating they were on 15-minute checks. The DON later provided resident check forms that inaccurately indicated the resident was checked every 30 minutes. The Health Information Management (HIM) Manager reported issues with indexing and uploading documents into the On-Base system, and a personnel change was made in the HIM department. The facility's policy required medical records to be complete, accurately documented, and readily accessible, but these standards were not met.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Ombudsman of resident transfers to the hospital for five residents, as required by regulations. The deficiency was identified through a review of facility records, staff interviews, and policy review. The residents involved were hospitalized and readmitted to the facility without the required notification to the Ombudsman. Specifically, Resident #29, #9, #57, #50, and #85 were transferred to the hospital, and the facility did not provide proof of notification to the Ombudsman for any of these cases. The facility's policy did not indicate that such notifications were required, contributing to the oversight. Interviews with the facility's Administrator and Social Services Director revealed that the lack of notifications was due to staff not following the ombudsman notification process. This issue was discovered during a mock survey, indicating that notifications had not been completed from at least December 2023 until the end of March 2024. The facility's policy, last reviewed in December 2023, did not include the requirement for ombudsman notifications upon resident discharge or transfer, which may have contributed to the deficiency.
Failure to Investigate and Document Grievances on Missing Cigarettes
Penalty
Summary
The facility failed to adequately investigate and follow up on residents' grievances regarding missing cigarettes. Multiple residents reported their cigarettes were missing, which were supposed to be stored securely at the nurse's station. Despite these reports, the facility's grievance documentation was incomplete, with only one grievance form filled out for a resident's missing cigarettes. This indicates a lack of proper documentation and follow-up on the residents' concerns. Interviews with residents revealed that they had reported their missing cigarettes to various staff members, including the social worker and the Director of Nursing (DON). However, the residents felt that their concerns were not being addressed, and there was a fear that their smoking privileges might be revoked if they continued to voice their grievances. The facility's staff, including CNAs and the social worker, acknowledged that they did not consistently fill out grievance forms when residents reported missing items, further contributing to the lack of resolution. The facility's policy on grievances requires that all grievances be documented and investigated, but this was not adhered to in the case of the missing cigarettes. The Administrator and DON were aware of some reports of missing cigarettes but did not have a comprehensive system in place to track and resolve these issues. The facility's failure to properly document and investigate the grievances led to a deficiency in honoring residents' rights to voice grievances without reprisal and ensuring their concerns were promptly addressed.
Failure to Document and Perform Consistent Wound Care
Penalty
Summary
The facility failed to document assessments, interventions, and treatments for a resident with skin management concerns, specifically pressure ulcers. Resident #64, who had diagnoses including sepsis, diabetes, and multiple pressure ulcers, was not consistently receiving documented wound care as per the treatment administration record (TAR). The TAR from April to June showed multiple instances where treatments were not documented for the resident's left toes, right plantar foot, and left heel. Additionally, there was a lack of documentation regarding the resident's refusal of wound care and the re-approach to offer dressing changes after a missed wound clinic appointment. Interviews with the resident and staff revealed inconsistencies in wound care practices. The resident reported that the dressing changes were not consistently performed, leading to severe drainage from the wounds. Staff A, a registered nurse, acknowledged the resident's noncompliance and stated that they adjusted care times to accommodate the resident's preferences. The Director of Nursing (DON) confirmed that if treatments were not documented, they were considered not done. The facility's policies required systematic assessment and accurate documentation of residents' skin conditions, which were not adhered to in this case.
Failure to Implement Non-Pharmacological Interventions Before Medication
Penalty
Summary
The facility failed to implement non-pharmacological and behavioral interventions before administering antipsychotic medications to a resident, leading to a deficiency in the resident's drug regimen. The resident, who had diagnoses of Parkinson's Disease, dementia, Tourette's syndrome, and repeated falls, was documented to have no hallucinations, delusions, or behaviors according to the Annual Minimum Data Set (MDS) assessment. Despite this, the resident was administered Hydroxyzine and Lorazepam without documented attempts of non-pharmacological interventions prior to medication administration on several occasions. Interviews with staff revealed that while they documented the administration of PRN medications on the Medication Administration Record (MAR), they did not consistently document non-pharmacological interventions in the progress notes. The Director of Nursing (DON) expected staff to document three non-pharmacological interventions in the resident's progress notes whenever a PRN medication was administered. The facility's Psychotropic Medication policy also required that alternative behavioral interventions be evaluated and documented before administering psychotropic medications.
Inaccurate MDS Assessment and PASRR Documentation
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for a resident, identified as Resident #64, who was part of a sample of eighteen residents reviewed. The resident had multiple diagnoses, including adjustment disorder with anxiety, mood disorder, bipolar disorder, and depression. The MDS assessment did not reflect the resident's status as determined by the state level II PASRR process, which identified the resident as having a serious mental illness and recommended specific support services. The care plan for the resident, revised on April 1, 2024, included various diagnoses and behaviors but lacked information about the PASRR completion and the recommended resources. The facility's PASRR policy, revised in November 2022, required that PASRR determinations and evaluation reports be included in the resident's assessment and care plans. However, this was not adhered to in the case of Resident #64. The MDS 3.0 / RAI policy indicated that social services were responsible for completing Section A of the MDS assessment, and the resident's electronic medical record should be reviewed to ensure documentation accuracy. An interview with the Administrator revealed that the social worker filled out Section A of the MDS, but the necessary PASRR information was not incorporated, leading to the deficiency.
Failure to Maintain and Implement PASRR for Residents
Penalty
Summary
The facility failed to maintain a valid Pre-admission Screening and Resident Review (PASRR) for one resident and did not incorporate PASRR service recommendations into another resident's comprehensive care plan. For Resident #37, the Minimum Data Set (MDS) dated 06/11/24 indicated that a Brief Interview for Mental Status (BIMS) could not be completed due to communication difficulties, and the resident had diagnoses including schizophrenia and depression. However, the PASRR dated 10/09/2019 did not include these diagnoses. The Social Services Director acknowledged that the PASRR had not been updated, which was a lapse from previous staff. For Resident #64, the MDS assessments revealed multiple mental health diagnoses and the use of psychotropic medications. Despite this, the care plan lacked documentation of a PASRR completion and the recommended resources. The facility's records did not initially contain a PASRR for this resident, but a PASRR notice dated 7/3/23 was later found, indicating a Level II determination with recommended services such as psychiatric evaluation and therapy. The facility's policy required PASRR findings to be included in the resident's care plan, which was not done in this case.
Failure to Provide Scheduled Baths and Grooming
Penalty
Summary
The facility failed to ensure that residents received their scheduled baths and grooming, as evidenced by the cases of two residents. Resident #50, who has Parkinson's Disease, diabetes, and dementia, required substantial assistance for bathing and personal hygiene. Observations revealed that the resident had uneven and jagged fingernails with brown debris and appeared unshaven. The facility's records showed inconsistencies in documenting the type of bath provided, and there was a lack of documentation for a period between May 21 and June 6. Interviews with staff confirmed that the paper skin sheets used did not indicate the type of bath given, and there was no section for fingernail care. Resident #64, diagnosed with a cerebrovascular accident, dementia, and pressure ulcers, reported not having a bath for ten days, despite being scheduled for baths three times a week. The facility's records showed a lack of documentation for the type of bath provided and missing skin measurements. Interviews with the resident and staff indicated that staffing issues might have contributed to the failure to provide scheduled baths. The facility's bathing policy required documentation of baths in the electronic health record, but the current system did not adequately capture the necessary details.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control techniques were followed during a dressing change for a resident with multiple wounds. The resident, who had diagnoses including sepsis, diabetes, and chronic ulcers, required Enhanced Barrier Precautions. During an observation, a Licensed Practical Nurse (LPN) did not change gloves or sanitize hands appropriately between handling soiled dressings and clean supplies. The LPN opened the resident's room door with a gloved hand, retrieved supplies, and continued the dressing change without performing hand hygiene as required by the facility's infection control policy. The Director of Nursing (DON) confirmed that staff are expected to change gloves and sanitize hands when moving from dirty to clean areas during treatments. The facility's infection control policy mandates glove removal and hand hygiene after handling soiled dressings and before proceeding with treatment. The observed actions of the LPN did not align with these procedures, leading to a deficiency in infection prevention and control practices.
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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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