Good Samaritan - Red Oak
Inspection history, citations, penalties and survey trends for this long-term care facility in Red Oak, Iowa.
- Location
- 201 Alix Avenue, Red Oak, Iowa 51566
- CMS Provider Number
- 165191
- Inspections on file
- 21
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Good Samaritan - Red Oak during CMS and state inspections, most recent first.
Two residents with significant cardiopulmonary conditions did not receive timely assessment and intervention when experiencing respiratory compromise and possible bleeding. One resident with chronic respiratory failure, COPD, sleep apnea, and atrial fibrillation had documented low O2 saturations, complaints of shortness of breath, weakness, and hallucinations, yet staff did not complete or document a comprehensive respiratory assessment, did not administer or document PRN respiratory treatments, did not document oxygen adjustments and follow‑up vitals, and did not clearly communicate critically low O2 readings to the provider. The resident ultimately called 911, and EMS found severe hypoxia and respiratory distress requiring CPAP and ED transfer for suspected pneumonia and CHF exacerbation. Another resident with COPD and on apixaban for atrial fibrillation had care plans directing staff to monitor for respiratory distress and hemoptysis and to report bleeding‑related signs, but when the resident reportedly coughed or spat up blood, staff did not complete appropriate assessment or intervention consistent with those care plans and physician orders.
Two cognitively impaired residents were observed by a CNA with their hands in each other's pants at the nurses’ station and were separated, with a nurse documenting the event and notifying the DON, social services, and the Administrator. The Administrator, after a phone discussion with the nurse and without directly interviewing the CNA or reviewing video, concluded the residents had only been holding hands in laps and decided the incident was not reportable, and no formal abuse investigation or state notification was made. The DON, who was on vacation and received only limited information, did not report the incident either. This response conflicted with the facility’s abuse policy, which required immediate reporting and investigation of all alleged or suspected abuse, including resident-to-resident incidents.
Two cognitively impaired residents were observed by a CNA with their hands down each other’s pants at the nurses’ station, after which they were separated and a nurse documented no trauma and notified leadership. The Administrator, relying on second-hand clarification that the residents were only holding hands in a lap and noting both had dementia, decided the incident was not reportable and did not initiate a formal investigation. The DON was not fully informed of the specific allegation, Social Services did not document the event, and no comprehensive abuse investigation consistent with the facility’s abuse/neglect policy was conducted, resulting in a failure to immediately and thoroughly investigate an allegation of potential abuse.
Two residents with cognitive impairment and a history of falls experienced repeated incidents due to the facility's failure to consistently implement and document fall prevention interventions, including not removing wheelchair pedals and not completing required assessments or care plan updates after falls. Staff interviews and record reviews confirmed lapses in supervision and adherence to facility policy.
Staff did not measure pureed foods before serving, resulting in incorrect portion sizes for residents requiring texture-modified diets. Despite facility policy and supervisory expectations to measure and divide pureed foods to ensure proper nutrition, pureed items were served without confirming correct serving sizes.
A staff member was observed handling food without proper hand hygiene, touching multiple surfaces and their own clothing before serving food with bare hands, and placing utensils on unclean surfaces between uses. These actions did not comply with the facility's infection control and hand hygiene policy.
Staff did not adhere to infection control protocols during care for three residents, including leaving an open pressure ulcer exposed during transfer and shower, failing to use gloves during enteral tube care, and not performing hand hygiene between glove changes or after catheter care. These lapses resulted in exposure of wounds to potential pathogens and improper handling of medical devices.
A resident with moderate cognitive impairment and total dependence on staff for personal hygiene did not receive oral care for at least 30 days, as shown by a lack of documentation and physical findings of poor oral hygiene upon hospital admission. Staff were unable to locate the resident's toothbrush, and there was uncertainty about oral care procedures and documentation, despite facility policy requiring both.
The facility did not ensure comprehensive care plans were developed and implemented for two residents: one who was a smoker and another with suicidal ideation. For the smoker, the care plan required cigarettes and a lighter to be stored at the nurse's station, but the resident kept the lighter in her pocket and staff were inconsistent about storage procedures. For the resident with depression and suicidal ideation, the care plan lacked documentation and interventions addressing her mental health crisis, even after an incident requiring emergency evaluation. The DON confirmed care plan interventions were not implemented for suicidal ideation.
A nurse left Nystatin suspension at a resident's bedside for self-administration without direct supervision, despite the resident not having an assessment, care plan, or provider order for self-administration. Facility policy required these steps, and the DON confirmed they were not completed.
A resident with a PEG tube received medications and water via a piston syringe using a slow push method, rather than by gravity as required by facility policy. The RN reported this was due to resistance in the tube and the resident's preference, but the method was not documented in the care plan. The DON confirmed the policy did not allow for pushing medications, resulting in a deficiency.
Two residents with significant cognitive and physical impairments did not receive proper pressure ulcer care, including missed or undocumented wound treatments, failure to apply ordered dressings, and lack of documentation and measurement of new skin breakdowns. Facility staff did not consistently follow wound care policies, resulting in inadequate treatment and monitoring of pressure injuries.
The facility failed to maintain sanitary conditions in food storage and preparation, as observed with improper food storage, undated items, and inadequate hand hygiene practices by staff. The kitchen's refrigerator had a black fuzzy area, and food items were found uncovered and undated. Staff did not follow proper glove use and handwashing protocols during meal preparation, contributing to the deficiency.
The facility failed to serve food at safe and appetizing temperatures to three residents. A resident reported that baked potatoes were served raw and food was not always warm. Observations showed room trays left on a cart for extended periods, resulting in food temperatures outside safety standards. Another resident reported food frequently served cold, and a third resident noted a pork sandwich was not hot and coleslaw was not cold. The facility's policy required periodic temperature checks, which were not followed.
The facility failed to implement proper infection control practices, leading to potential cross-contamination of invasive medical devices. A resident with an indwelling catheter had the drainage bag improperly positioned, and staff failed to perform hand hygiene during catheter care. Another resident with a supra pubic catheter experienced similar issues, with staff not adhering to hand hygiene protocols.
The facility did not update the daily nursing staffing data as required, with outdated information observed on two consecutive days. The DON identified an LPN as responsible for updating the staffing sheet, which was expected to be changed daily. The facility's policy mandates daily posting of current staffing data, including staff hours and resident census.
The facility failed to notify a resident's family when a large bruise developed on the resident's right thigh. Despite the resident's pain and the bruise being documented by staff, the family was not informed until the resident's condition declined the following day. Staff interviews revealed a lack of clear recollection and absence of a specific policy for family notification.
A facility failed to notify management in a timely manner when a resident was found to have a large, painful bruise on her right hip/thigh. The bruise was first documented by an RN, but management was not informed until the following day. The resident had a history of heart failure, stroke, hemiplegia, and depression, and required substantial assistance with mobility. Staff interviews revealed uncertainty about reporting the bruise, and the facility's policy on immediate reporting was not followed.
The facility staff failed to supervise medication administration by leaving a resident's medication on their bedside table. The resident, with severe cognitive impairment, was observed with TUMS on two occasions without an order for self-administration. The resident's son also reported finding multiple pills in a medication cup during his visits. The DON and Administrator acknowledged the issue, which had been a problem in past surveys.
A resident with no cognitive impairment and limited mobility due to a stroke reported pain and bruising, which was first documented by an RN but not followed up. The bruise was present for about a month before the resident's passing, and multiple CNAs reported it to nurses who did not document or assess it further. The DON and Administrator acknowledged that incidents should be reported and investigated promptly, but this protocol was not followed.
A facility failed to notify hospice when a resident with no cognitive impairment and requiring substantial assistance was found with a large, painful bruise on her right thigh. Despite documentation and family-provided photos showing extensive bruising, there was no record of hospice being informed. Staff interviews revealed a lack of communication regarding the resident's condition, contrary to the facility's agreement with the hospice provider.
Failure to Assess and Intervene for Respiratory Distress and Hemoptysis
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and thorough assessment and intervention for residents experiencing significant respiratory changes and possible bleeding while on anticoagulant therapy. For Resident #16, who had chronic respiratory failure with hypoxia, COPD, obstructive sleep apnea, atrial fibrillation, and sleep‑related hypoventilation, the care plan directed staff to monitor for signs and symptoms of respiratory distress and to report changes to the provider as needed. Physician orders included PRN albuterol nebulizer, PRN albuterol‑budesonide inhaler, and oxygen at 2 L/min via nasal cannula to maintain oxygen saturation above 92%, with documentation of oxygen saturation, pulse, respirations, and lung sounds pre‑ and post‑administration when PRN treatments were used. The April MAR/TAR showed no documentation that PRN respiratory medications were administered, and the electronic record for 4/15/26 contained only a weekly skin assessment and an infection assessment, with no documented respiratory assessment despite multiple indications of respiratory compromise. On 4/15/26, Resident #16’s oxygen saturation readings included 96% on room air at 4:29 AM and 90% on BiPAP at 8:11 AM, with later readings of 93% on BiPAP. Staff G, the RN caring for the resident that morning, reported that when therapy sat the resident on the side of the bed, she could not get enough air and her oxygen saturation was 68%, prompting staff to put her back on BiPAP, after which the saturation reportedly increased to 94%. Staff G stated she completed an assessment, repeatedly checked oxygen saturation, and listened to lung sounds, but she did not document these assessments or the subsequent oxygen readings. She also stated she increased oxygen to 2.5 L when the saturation was 90%, but did not document the change or obtain a corresponding physician order, despite saying she notified the physician. The clinic nurse later stated she was not told about an oxygen saturation of 68% and that, had she known, the physician would likely have ordered ED evaluation. The DON acknowledged that Staff G noted a low oxygen level of 68% and applied BiPAP but did not document interventions or use of PRN albuterol as expected. Throughout the day, Resident #16 and her husband reported that she felt ill for several days, complained of fluid overload, shortness of breath, and difficulty breathing, and that she was gasping for air during therapy. The husband and resident both stated that staff did not appear concerned, did not perform assessments when she reported feeling ill, did not offer PRN breathing treatments, and did not increase oxygen. Staff D, a CNA, confirmed that during an attempted transfer with therapy, the resident said she could not breathe, took long deep breaths between words, seemed weak and tired, and insisted on lying back down; he recalled that her oxygen was low but did not remember the exact number. Despite these reports, there was no documented comprehensive respiratory assessment on 4/15/26. Later that evening, the resident called 911 herself, reporting someone nearby was having a stroke. EMS found her pale, cool, confused, and hallucinating, with oxygen saturation in the high 60s to low 70s and respirations of 36. EMS documented rales bilaterally, initiated CPAP with escalating PEEP due to persistent respiratory distress, and transported her to the ED, where she was diagnosed with possible pneumonia and CHF exacerbation. The primary care physician stated he was not informed of oxygen saturations in the 60s or 70s and that such values would have warranted notification and ED evaluation. For Resident #41, the report identifies another failure to follow care plan directives related to respiratory status and anticoagulant use. This resident had intact cognition, diagnoses including hypertension, pneumonia, COPD, and atrial fibrillation, and was receiving apixaban 5 mg twice daily. The care plan for altered respiratory status directed staff to monitor for and report signs and symptoms of respiratory distress, including hemoptysis, and the anticoagulant care plan directed staff to report blood‑tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle/joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, and significant or sudden changes in vital signs. The report notes that this resident was reviewed in the context of coughing/spitting up blood while on an anticoagulant, indicating that staff did not complete appropriate assessment or intervention in response to hemoptysis as required by the care plan and physician orders. Specific details of the communication to the physician are referenced in a fax communication dated 3/30/26, but the excerpt provided ends before the content of that fax is fully described, leaving the documented deficiency focused on the failure to adequately assess and respond to the resident’s reported coughing/spitting up blood. Collectively, the findings show that for two of three residents reviewed, staff did not complete timely, comprehensive assessments or implement ordered or care‑planned interventions when residents exhibited low oxygen saturation or hemoptysis. For Resident #16, this included lack of documented respiratory assessments, failure to use or document PRN respiratory medications, failure to document oxygen adjustments and subsequent vital signs, and failure to communicate critical oxygen saturation values to the physician or clinic nurse. For Resident #41, this included failure to follow care plan directives to assess and report hemoptysis in the context of COPD and anticoagulant therapy. These actions and omissions occurred despite clear care plan instructions and physician orders directing staff to monitor for and respond to respiratory changes and bleeding‑related signs and symptoms.
Failure to Report Alleged Resident-to-Resident Sexual Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents who were observed inappropriately touching each other. Resident #1 had moderate cognitive impairment with a BIMS score of 11 and a diagnosis of early-onset Alzheimer's disease. Resident #2 had severe cognitive impairment with a BIMS score of 3 and a diagnosis of vascular dementia with behavioral disturbance. On 12/20/26, a CNA (Staff H) observed Resident #1 and Resident #2 sitting at the nurses’ station with their hands down each other's pants. Staff H separated the residents, assisted Resident #2 back to his room, and reported the incident to the nurse (Staff A) and another nurse (Staff I). A progress note entered by Staff A documented that both residents were assessed for trauma and none was observed, and that the DON, Social Services Director (Staff G), and the Administrator were aware of the incident. The Administrator later stated that he determined the incident was not reportable because both residents had documented dementia. He reported that, after speaking with Staff A, he understood the situation as the residents holding hands in each other's laps rather than having hands down each other's pants, and on that basis decided not to report the incident to the state agency or conduct a formal investigation. The Administrator acknowledged that he did not interview the CNA or nurse directly at the time and did not review available camera footage from the lobby for the date of the incident. The DON stated she was on vacation at the time, was only told there was an “incident” without details, and believed the Administrator handled the situation. She also stated she was not aware that Resident #2 had his hands down another resident’s pants and therefore did not report the incident to the state agency. Staff H consistently described the event as both residents having their hands in each other's pants or waistbands, possibly with Resident #1 holding Resident #2’s penis, and stated she knew it needed to be reported to the nurse for safety reasons. Staff G recalled being informed that Resident #2 was reaching toward Resident #1 but did not document the incident and did not convey specific details such as “hands in pants” to the DON. A subsequent progress note on the same day documented Resident #2 reaching to touch another resident and becoming combative when redirected. Both residents later told surveyors they felt safe, were treated with dignity and respect, and denied inappropriate touching, though both had cognitive impairment. Family members of both residents reported being notified of an incident in December involving inappropriate touching or hands in waistbands, but did not recall being told it was considered abuse. The facility’s abuse and neglect policy required that all alleged or suspected abuse, including mistreatment by other residents, be immediately reported to the Administrator and designated agencies within specified time frames, but the allegation involving Residents #1 and #2 was not reported to the state survey agency as required. The facility’s written policy on abuse and neglect specified that all alleged or suspected violations involving mistreatment, neglect, exploitation, or abuse, including injuries of unknown origin, must be promptly reported and investigated, and that designated agencies, including the State Survey and Certification Agency, must be notified in accordance with state law. The policy further required immediate reporting of allegations of abuse or serious bodily injury, and reporting within 24 hours for other allegations, as well as documentation of notifications and review of incidents by an investigation team. Despite this policy, the Administrator and DON did not initiate or complete a formal abuse investigation or report the allegation to the appropriate state agency after being made aware, at least in part, of the incident between Resident #1 and Resident #2. This failure to follow the facility’s own abuse reporting and investigation procedures led to the deficiency for not timely reporting suspected abuse to the proper authorities.
Failure to Investigate Alleged Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to immediately and comprehensively investigate an allegation of potential resident‑to‑resident sexual abuse involving two cognitively impaired residents. Resident #1 had moderate cognitive impairment with a BIMS score of 11 and a diagnosis of early-onset Alzheimer’s disease. Resident #2 had severe cognitive impairment with a BIMS score of 3 and a diagnosis of vascular dementia with other behavioral disturbance. On 12/20/26, a CNA (Staff H) reported to nursing staff that she observed Resident #1 and Resident #2 sitting at the nurses’ station with their hands down each other’s pants. The residents were separated, Resident #2 was taken to his room, and a nurse (Staff A, RN) documented that both residents were assessed for trauma with none observed. The RN’s progress notes also documented that the DON, Social Services Director (Staff G), and the Administrator were aware of the incident, and that the Administrator stated the incident was not reportable because both residents had documented dementia. Additional documentation in Resident #2’s record on the same date showed that later that day Resident #2 was observed reaching to touch another resident and had to be redirected by a CNA, after which he hit staff and told them to leave him alone. Interviews with the involved CNA confirmed that she had seen the two residents with their hands in each other’s pants and that she believed Resident #1 might have been holding Resident #2’s penis, although she did not see movement. She reported that she separated the residents and informed the RN and an LPN. She also stated she did not see the nurses complete an assessment at that time and that she reported the incident to the nurse because of safety concerns and the possibility that Resident #2 might repeat the behavior. The Social Services Director recalled being informed of an incident involving Resident #2 reaching toward Resident #1 around the time before Christmas but stated she did not document the incident, did not clearly report that there were hands in pants, and could not recall the exact wording used when she notified the DON. The DON stated in interview that she had not been made aware that Resident #2 had his hands down another resident’s pants and acknowledged she had not completed an investigation into the reported incident documented on 12/20/25 between Resident #1 and Resident #2. She indicated that if she had been notified of such behavior, she would have come in and completed an investigation, including talking to residents and staff, and that she should have been informed. The Administrator reported that he spoke with the RN by phone and was told that the CNA initially thought the residents had their hands in each other’s pants but later believed they were holding hands in a lap, and based on that, he decided the situation did not warrant reporting or further investigation. He acknowledged that he did not interview the nurse or CNA in person, did not review available camera footage at the time of the incident, and concluded that no investigation was needed. The facility’s abuse and neglect policy required that all alleged or suspected abuse, including mistreatment by other residents, be reported immediately to the Administrator or designee, that the charge nurse complete an initial investigation, and that an investigation team review all incidents by the next working day. Despite this policy, no comprehensive investigation was initiated or completed in response to the CNA’s allegation that the two residents had their hands down each other’s pants. Interviews with both residents later indicated that each reported feeling safe at the facility, believed staff treated them with dignity and respect, and denied that other residents had touched them inappropriately or that they had touched others inappropriately. Family interviews showed that Resident #2’s son was informed of an incident of inappropriate touching between the two residents and considered it inappropriate but did not view it as abuse, and Resident #1’s daughter recalled being told of an incident described as the residents holding hands or having hands in each other’s waistbands. However, these later perceptions and characterizations did not change the fact that the original CNA report described hands down each other’s pants and that the facility’s own policy required immediate reporting and investigation of such allegations. The failure to follow the abuse policy, to fully clarify and document the allegation, to interview all involved staff promptly, and to conduct a comprehensive investigation into the reported incident constituted the deficiency. The facility’s written abuse and neglect policy, revised 7/6/23, specified that all alleged or suspected violations involving mistreatment, neglect, exploitation, or abuse, including injuries of unknown origin, must be reported immediately to the Administrator and, in the Administrator’s absence, to designated leaders such as the DON or Social Services Director. The policy required the charge nurse to assess the situation, determine if emergency treatment or action was required, complete an initial investigation, and ensure that any potential for further abuse was eliminated. It also required timely notification of designated agencies, the physician, and family, and mandated that an investigation team (social worker, Administrator, and DON) review all incidents no later than the next working day. In this case, despite a documented allegation that two residents with dementia were observed with their hands down each other’s pants, the DON was not fully informed, the Administrator decided the incident was not reportable without a thorough fact-finding process, and no formal investigation consistent with policy requirements was conducted. The DON later acknowledged that she should have been informed and that an investigation should have been started if such an incident occurred. The Administrator acknowledged that if the residents had indeed had their hands down each other’s pants, it would have been a different situation, but he relied on a second-hand clarification that the residents were only holding hands in a lap and did not pursue further inquiry. No contemporaneous documentation by Social Services was made, and there was no evidence that the investigation team convened or that a structured review of the incident occurred by the next working day. This sequence of actions and inactions—failure to clearly communicate the nature of the allegation up the chain of command, failure to follow the facility’s abuse reporting and investigation policy, and the Administrator’s decision not to investigate further—led to the deficiency for not completing a comprehensive investigation immediately when an allegation of abuse was reported for Resident #1.
Failure to Implement and Document Fall Prevention Interventions
Penalty
Summary
The facility failed to establish and implement effective interventions to prevent falls and injuries for two residents with known fall risks. One resident with severe cognitive impairment and a history of multiple falls experienced repeated incidents involving wheelchair pedals. Despite documentation in the care plan and fall scene huddle worksheet that the resident had tripped on wheelchair pedals, staff did not consistently remove the pedals when not in use, as was indicated as a corrective action. This resident suffered multiple falls, including one that resulted in a head injury and subsequent admission to hospice care due to traumatic cerebral hemorrhage. Observations and staff interviews confirmed that the pedals were left on the wheelchair, and staff were not always able to supervise or intervene in time to prevent falls. Another resident with moderately impaired cognition and a history of falls, including fractures, experienced a fall that was not properly documented or investigated. The care plan lacked documentation of the fall and any new interventions following the incident. Progress notes described the fall and the resident's uncooperative behavior, but there was no incident report, falls tool assessment, or fall scene huddle worksheet completed for this event. The DON acknowledged that the fall was missed in documentation and that the incident was not fully assessed or followed up according to facility policy. Facility policy required prompt assessment, documentation, and investigation of falls, including completion of a fall scene huddle worksheet, falls tool, and care plan updates with new interventions. In both cases, the facility did not follow its own policy for fall prevention and management, resulting in missed opportunities to identify root causes and implement effective interventions to prevent further accidents.
Failure to Measure and Portion Pureed Foods Correctly
Penalty
Summary
Staff failed to provide a well-balanced diet that meets the nutritional and special dietary needs of residents by not using correct serving size portions for meals. During meal preparation, staff pureed brownies, green beans, and ham and beans, adding thickener as required, but did not measure the pureed food before serving. The pureed items were placed into serving bowls or onto the steam table without determining the correct portion sizes. Staff A indicated that extra servings were made, but there was no measurement of the pureed food to ensure each resident received the appropriate amount. Interviews with the Food and Nutrition Supervisor and the Administrator confirmed that the expectation was for pureed foods to be measured after blending to ensure correct scoop sizes and portion control. Review of the facility's policy on textured-modified diets also specified that the total volume of pureed food should be measured and divided by the original number of portions to ensure accuracy. The failure to follow these procedures resulted in the deficiency.
Failure to Follow Safe Food Handling and Hand Hygiene Practices
Penalty
Summary
Staff was observed failing to follow safe food handling practices during meal service. Specifically, one staff member touched various surfaces including plate warmer lids, menus, scoop handles, and their own clothing, then proceeded to handle food items in the warmers with bare hands. The staff member also placed the scoop on top of the lids of the warmer pans after use and touched multiple items between serving food from the steam table. Facility policy requires all employees to maintain adequate hand hygiene by adhering to specific infection control practices, which was not followed in this instance.
Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
Staff failed to follow infection prevention and control practices for three residents. One resident with a stage 4 pressure ulcer on the sacral region was transferred using a mechanical lift sling after the dressing and packing were removed by CNAs, leaving the wound open and exposed. The wound bled during the transfer and soiled the sling, and the resident was taken to the shower with the wound still open and in contact with the soiled sling. The dressing was not dated and was soiled prior to removal. The wound was left open throughout the shower, and the sling remained soiled with blood. The treatment nurse later provided wound care but failed to perform hand hygiene after removing gloves and before leaving the room. Another resident with an enteral feeding tube received medication and water administration from an RN who initially performed hand hygiene and donned appropriate PPE. However, after changing the split sponge and removing gloves, the RN applied tape to the split sponge without gloves and only performed hand hygiene after removing the gown and leaving the room. The DON confirmed that gloves should have been used during all care involving the enteral tube. A third resident with a suprapubic catheter had care performed by two CNAs who did not cleanse the catheter tip before replacement and allowed the catheter bag to rest on the floor. During the care process, hand hygiene was not performed between glove changes or when moving from one area of the body to another. One CNA left the room and began care for another resident without performing hand hygiene. Facility policy required hand hygiene at specific moments, including after glove removal and when moving between contaminated and clean body sites.
Failure to Provide and Document Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide oral care for a resident with moderate cognitive impairment and total dependence on staff for activities of daily living, including personal hygiene. According to the resident's care plan, staff assistance was required for oral care, shaving, and grooming. A review of the clinical record and Point of Care documentation over a 30-day period showed no evidence that oral care was provided to the resident during that time. Additionally, when the resident was admitted to the hospital, he was found to have crusty skin at the corners of his mouth and a yellow film buildup in his mouth and on his teeth. During an observation, staff were unable to locate the resident's toothbrush in the bathroom and only found one in a dresser drawer after searching. Staff interviews revealed uncertainty about the location of the resident's oral care supplies. The DON stated that staff were expected to set up the toothbrush and encourage the resident to brush his own teeth, with documentation required in the electronic medical record. Facility policy also required documentation of oral care in the electronic record.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Special Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with specific needs. For one resident who was identified as a smoker with intact cognition, the care plan specified that cigarettes and a lighter should be stored at the nurse's station. However, observation revealed the resident kept the lighter in her pocket after smoking, and staff interviews indicated inconsistency in the storage of smoking materials, with some staff stating items should be kept in room lockboxes instead. The Director of Nursing expected the lighter to be stored at the nurse's station, but this was not consistently followed. For another resident with moderately impaired cognition and a history of depression, anxiety, and dementia, the care plan addressed antidepressant use but did not include documentation or interventions for suicidal ideation, despite a recent incident where the resident expressed a desire to kill herself and was sent to the emergency room for evaluation. Upon return, new medication orders were implemented, but the care plan was not updated to reflect interventions for suicidal ideation. The Director of Nursing confirmed that the care plan was not implemented for the interventions related to the resident's suicidal ideation.
Medication Left at Bedside Without Assessment or Order
Penalty
Summary
A deficiency occurred when a registered nurse (RN) left a prescribed medication, Nystatin mouth and throat suspension, at a resident's bedside for self-administration without direct supervision. The resident, who had no cognitive impairment as indicated by a BIMS score of 15 and received medications via an enteral feeding tube, was observed to have the medication left at the chair side table to take later. The nurse exited the room and closed the door, leaving the resident to self-administer the medication without nurse visualization. Review of the resident's records showed there was no assessment for self-administration of medications, no care plan reflecting permission for self-administration, and no provider order authorizing this practice. Facility policy required an interdisciplinary team assessment, a care plan, and a provider order for self-administration of medications, none of which were present in this case. The Director of Nursing confirmed that the required assessment and documentation were not completed for this resident.
Improper Administration of Enteral Medications via Feeding Tube
Penalty
Summary
Staff failed to follow facility policy and procedures regarding the administration of medications via a feeding tube for a resident with a PEG tube. The resident, who was cognitively intact as indicated by a BIMS score of 15, required tube feeding and received medications through the enteral tube. During observation, a registered nurse used a piston syringe to slowly push medications and water into the resident's enteral tube, rather than administering them by gravity as outlined in the facility's policy. The nurse stated that medications were not given by gravity due to resistance in the tube, and that the resident preferred a light push during administration. The Director of Nursing confirmed that the facility's policy did not specify that pushing medications was acceptable practice and acknowledged that this method was not included in the resident's care plan. The policy reviewed indicated that medications should be administered slowly and steadily, with the flow rate determined by the elevation of the syringe, not by pushing. The deviation from policy and lack of care plan documentation for the resident's preferred method led to the deficiency.
Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents with significant skin integrity issues. One resident with moderate cognitive impairment and total dependence on staff for care had a Stage II pressure ulcer on the right buttocks and an unstageable ulcer on the left heel. Despite physician orders for a Mepilex dressing to be applied and changed every three days, the resident was observed without the required dressing, and staff acknowledged the omission. Documentation showed inconsistencies, with the treatment marked as completed earlier that day, but the dressing was not present during the observation. The resident's history included recent hospitalization for pneumonia, UTI, and pressure injuries, with conflicting accounts from facility staff regarding the presence of wounds prior to hospital transfer. Another resident, also with moderate cognitive impairment and multiple comorbidities including malnutrition and COPD, had a Stage IV pressure ulcer on the sacrum. This resident was bedfast, incontinent, and dependent on staff for all mobility and hygiene. During care observations, staff failed to document and measure three additional areas of skin breakdown on the resident's legs, and the primary wound dressing was found to be soiled, undated, and improperly removed by a CNA rather than a nurse. The wound was left open during a shower and exposed to a soiled lift sling, contrary to best practices. Review of treatment records revealed multiple missed or undocumented wound care treatments as ordered by the physician. Facility policy required daily and weekly wound documentation and monitoring for residents with impaired skin integrity, but this was not consistently followed. The lack of proper documentation, failure to apply and maintain ordered dressings, and missed wound care treatments contributed to the deficiency. The facility did not ensure that residents with pressure ulcers received necessary care to promote healing, prevent infection, and prevent new sores from developing, as required.
Deficiency in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards in the preparation, serving, distribution, and storage of food, as observed during a survey. On multiple occasions, the kitchen's refrigerator/freezer was found to have a black fuzzy area, and the refrigerator contained uncovered and undated food items, including a gallon of milk and packages of pizza. The walk-in dry goods pantry had empty cardboard boxes and condiment packages on the floor, and the walk-in refrigerator contained strawberries with a white fuzzy appearance. These observations indicate a lack of proper food storage and sanitation practices. Additionally, during meal preparation, staff failed to follow proper hand hygiene and glove use protocols. A cook was observed handling food with improper glove use, touching his face, and placing dirty gloves on the food preparation counter. The Dietary Manager acknowledged the issues with the refrigerator cleanliness and the improper handling of gloves, which contradicted the facility's policies on hand hygiene and general sanitation. These actions and inactions contributed to the deficiency in maintaining sanitary conditions in food preparation and storage areas.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing temperature to three residents, as identified through clinical record review, resident interviews, observations, staff interviews, and policy review. Resident #31, who was cognitively intact and independent with eating, reported that baked potatoes were served raw and food was not always warm. Observations on June 30, 2024, showed that room trays were left on a cart for extended periods before delivery, resulting in food temperatures that did not meet safety standards. Specifically, the coleslaw was served at 72.8 degrees and the pulled pork sandwich at 106 degrees, both outside the acceptable temperature range. The Dietary Manager acknowledged that room trays should not sit for over 10 minutes before delivery and suggested using Styrofoam containers to maintain cold food temperatures. Resident #30, also cognitively intact, reported that food was frequently served cold, at least once a week, and noted that she ate every meal in her room. Resident #40, with no cognitive impairment, stated that the pork sandwich was not hot and the coleslaw was not cold during lunch on June 30, 2024. The facility's policy on food temperature monitoring required that temperatures be retaken periodically throughout meal service to ensure food safety, but this was not adhered to, leading to the deficiency.
Infection Control Deficiencies in Catheter Care
Penalty
Summary
The facility failed to implement proper infection control practices, leading to potential cross-contamination of invasive medical devices. In one instance, a resident with an indwelling catheter was observed with the catheter drainage bag improperly positioned on the wheelchair frame and the tubing lying on the floor. The resident, who had moderately impaired cognition and required supervision with toileting hygiene, relied on staff for catheter care. During a catheter care observation, staff members failed to perform hand hygiene and change gloves after emptying the urine collection bag, and one staff member placed alcohol wipe packets on the floor before use. In another instance, a resident with a surgically placed supra pubic catheter was observed during catheter care. Staff members failed to perform hand hygiene after glove removal and before resuming resident care tasks. The facility's hand hygiene policy required hand hygiene after glove removal, before and after resident care, and when entering or exiting a resident's room. However, staff did not adhere to these guidelines, as evidenced by one staff member who removed gloves, opened a door, and walked to the nurse's station before completing hand hygiene.
Failure to Update Daily Nursing Staffing Data
Penalty
Summary
The facility failed to comply with the requirement to post daily nursing staffing data, as observed during a survey. On two consecutive days, the posted staffing information was outdated, displaying the date of June 29th, 2024, instead of the current date. This discrepancy was noted on June 30th and July 1st, 2024. The Director of Nursing (DON) acknowledged that the responsibility for updating the staffing sheet lay with Staff H, an LPN and Wound Nurse. The DON expressed an expectation that the Daily Staffing Form should be updated daily, with the possibility for overnight nurses to print it as well. The facility's policy, revised on February 28th, 2024, mandates the daily posting of current staffing data, including the number and hours worked by various nursing staff and the resident census, incorporating registry and pool staff members.
Failure to Notify Family of Resident's Bruise
Penalty
Summary
The facility failed to notify the family of a resident when a bruise developed. The resident, who had a BIMS score of 15 indicating no cognitive impairment, had a history of heart failure, stroke, hemiplegia, and depression. The resident required substantial staff assistance with bed mobility and used a repositioning/turn sheet. On 11/5/23, a large purple bruise was documented on the resident's right thigh by a registered nurse (RN). However, there was no documentation that the family was notified about the bruise at that time. The following day, a licensed practical nurse (LPN) noted the resident's condition had declined, and the resident's daughter was informed, but the initial bruise was not mentioned in the notification. Interviews with the resident's family revealed that they were aware of the resident's pain and possible bruising on 11/5/23, but they were not officially notified by the facility. Staff interviews indicated that the RN who documented the bruise could not recall notifying the family, and the LPN who noted the resident's decline also could not remember specific details about the notification process. The Director of Nursing (DON) confirmed that family should be notified of new skin concerns but acknowledged that the facility did not have a specific policy or procedure related to family notification.
Failure to Timely Report Bruising on Resident
Penalty
Summary
The facility failed to notify management in a timely manner when a resident was found to have a bruise on her right hip/thigh. The bruise was first documented by a Registered Nurse (RN) on 11/5/23 at 10:35 AM, but management was not notified until 11/6/23. The resident, who had a BIMS score of 15 indicating no cognitive impairment, had a history of heart failure, stroke, hemiplegia, and depression. She required substantial staff assistance with bed mobility and used a repositioning/turn sheet. The bruise was described as large, purple, and painful to touch. The family provided photos showing extensive bruising on the resident's right hip and thigh, which were taken on 11/6/23 at 8:33 AM. Staff interviews revealed that the Licensed Practical Nurse (LPN) who documented the resident's condition on 11/6/23 could not recall seeing the bruising earlier and was unsure if she had reported it to management. The RN who first documented the bruise suggested it might have been caused by the mechanical lift used for the resident. The Director of Nursing (DON) stated she was notified of the bruising on 11/6/23 but did not see it herself as the resident was being sent to the emergency room. The facility's policy required immediate reporting of suspected abuse, neglect, or injuries of unknown origin to the Administrator or designated individuals, which was not followed in this case.
Failure to Supervise Medication Administration
Penalty
Summary
The facility staff failed to supervise medication administration by leaving a resident's medication on their bedside table. Resident #3, who had a BIMS score of 4 indicating severe cognitive impairment, was observed with a medication cup containing TUMS on two separate occasions. The resident's care plan did not include an order for self-administration of medications, and no Self-Administration of Medication assessment had been completed for her. The resident's son also reported finding multiple pills in a medication cup during his visits, which he brought to the attention of the DON, who assured him that she would address the issue with the staff. The DON confirmed that staff should watch residents take their medications unless there is an order for self-administration. Despite this, the DON acknowledged that she had not had issues with staff leaving medications in residents' rooms for them to take later, nor had she received complaints from family members. The Administrator also noted that while he had not noticed medications being left in resident rooms recently, it had been an issue in past surveys. The facility's policy on Resident Self-Administration of Medication outlines a detailed procedure to determine if a resident can safely self-administer medications, including obtaining a physician's order and documenting the process in the care plan. However, this procedure was not followed for Resident #3, leading to the deficiency observed by the surveyors.
Failure to Timely Assess and Intervene for Resident's Bruise
Penalty
Summary
The facility failed to assess and intervene timely for a bruise on a resident's right thigh. The resident, who had no cognitive impairment and was dependent on staff for mobility due to a stroke, reported pain and bruising to her family on a visit. The bruise was first documented by a Registered Nurse (RN) on 11/5/23, but there was no follow-up documentation or assessment of the bruise in the clinical records or hospice notes. The resident's condition declined, and she was sent to hospice care the following day, where significant bruising was noted by a Licensed Practical Nurse (LPN). The family provided photos showing extensive bruising of varying colors, indicating different stages of healing. Interviews with staff revealed that the bruise had been present for about a month before the resident's passing, and multiple Certified Nursing Assistants (CNAs) had reported the bruise to nurses, who did not document or assess it further. The Director of Nursing (DON) and the Administrator acknowledged that incidents should be reported and investigated promptly, and skin assessments should have been conducted regularly. However, this protocol was not followed, leading to a lack of timely intervention and documentation for the resident's bruise.
Failure to Notify Hospice of Resident's Bruising
Penalty
Summary
The facility failed to notify the hospice provider when they found a bruise on a resident's right hip and thigh. The resident, who had no cognitive impairment and required substantial assistance with mobility due to a stroke, was found to have a large purple bruise on her right thigh that was painful to touch. This bruise was documented by a registered nurse, but there was no subsequent documentation indicating that hospice was notified about the bruise. The resident's family provided photos of the bruising, which showed extensive discoloration on her hip and thigh. Despite the severity of the bruising, the hospice coordination notes revealed no record of the hospice being informed about the bruise. Interviews with staff and the hospice nurse indicated a lack of communication regarding the resident's condition. The hospice nurse was aware of bruising on the resident's lower leg but not on her hip or thigh. The registered nurse who documented the bruise suggested it might have been caused by the mechanical lift used for transfers but did not confirm notifying hospice. The Director of Nursing stated that hospice would not need to be notified if there was no change in the resident's condition. However, the facility's agreement with the hospice provider required regular and as-needed communication to ensure resident needs were met, which was not adhered to in this case.
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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