Granger Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Granger, Iowa.
- Location
- 2001 Kennedy Street, Granger, Iowa 50109
- CMS Provider Number
- 165208
- Inspections on file
- 22
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Granger Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to provide appropriate ROM services and implement ordered interventions for two residents with post-stroke hemiplegia and hand contractures. One resident had a tightly contracted hand with fingernails pressing into the palm, no splint or padding in place, no therapy for the contracture, and no specific orders or care plan interventions addressing the hand, leading the resident to place tissues in the palm independently. Another resident had contracted fingers with no padding, reported no restorative exercises and no splint, despite a physician’s order for a left hand splint. The ARNP and OT cited insurance coverage issues and had not completed evaluations or treatments, and the DON was unable to identify what actions had been taken to follow the splint order, contrary to facility policy requiring therapy referral and provision of appropriate ROM interventions and equipment.
Surveyors found that medications in one of the medication carts were not stored and labeled according to professional standards. A resident’s Latanoprost eye drops, labeled as requiring refrigeration and expiring 42 days after opening, were kept in the cart instead of a refrigerator and lacked a written expiration date. Additionally, four bottles of prescribed eye drops and nine prescribed inhalers in the same cart were not labeled with open dates. An RN acknowledged not knowing how long these medications were good after opening, and the DON stated there was no facility policy on post-opening expiration, despite pharmacy guidance and a storage policy requiring refrigeration for certain drugs.
Surveyors found that staff failed to follow the facility’s infection control and EBP requirements during wound care for a resident with PVD and a venous leg ulcer. A RN placed wound care supplies directly on the bed, did not wear a gown, did not change gloves between dirty and clean steps, and then returned used supplies to a shared treatment cart. Interviews with a CMA and the DON confirmed that facility policy required gown and gloves for high-contact care such as wound care, glove changes with hand hygiene when moving from dirty to clean tasks, and use of a barrier for supplies.
A resident with insomnia and other conditions had an order for Ambien 5 mg at bedtime, with doses documented on the MAR over two months. The individual narcotic record for this controlled medication showed an initial quantity altered from 30 to 31 tablets, while the pharmacy manifest confirmed only 30 were dispensed. Administration and waste entries reduced the count over time, but a shift-change narcotic count revealed that one Ambien tablet was unaccounted for, and recounts documented a sudden change from 14 to 12 tablets remaining. Staff interviews showed conflicting explanations about a dropped pill, an RN’s initial refusal to sign the narcotic count due to a discrepancy, and acknowledgment that the received quantity entry appeared overwritten. The DON and ADON confirmed a missing tablet and lack of supporting documentation such as a bubble-pack photocopy, and the facility’s controlled substances policy requiring accurate receipt counts, end-of-shift counts, discrepancy documentation, and a written investigation was not fully followed, resulting in a failure to maintain accurate control and accountability of this controlled drug.
The facility lacked a clinically qualified nutrition professional, as the Dietary Manager was not certified and the Registered Dietician was only present one day a week. The Dietary Manager had not completed certification courses and lacked food safety certifications, while the Registered Dietician's limited presence was confirmed by both the dietician and the Administrator.
The facility failed to maintain a safe environment, with surveyors observing damaged baseboard heaters with bent or missing safety grates. Residents expressed dissatisfaction, and staff interviews revealed the issue had been ongoing. Maintenance logs showed delayed repairs, despite the facility's policy requiring safe and operable systems.
The facility was found deficient in food service safety standards due to improper handling of food by staff. Observations revealed that the Dietary Manager and other staff members, including CNAs and CMAs, made direct contact with food and serving surfaces with ungloved hands and failed to perform hand hygiene. Interviews confirmed that these actions were against the facility's policies, which prohibit bare hand contact with food and require frequent hand washing.
The facility failed to uphold residents' rights to dignity and respect, as evidenced by reports from three residents with intact cognition. They described a CNA's rude behavior, excessive wait times for assistance, and dismissive attitudes, particularly during the night shift. Despite grievances filed, residents felt no action was taken. Interviews and facility documentation corroborated these issues, highlighting a failure to adhere to policies on dignity and respect.
The facility failed to provide the appropriate Notice of Medicare Non-Coverage (NOMNC) to two residents receiving skilled care under Medicare A. Instead, the facility provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) and lacked documentation for the NOMNC. The Social Services Director was not trained on the NOMNC form, leading to this deficiency.
The facility failed to update care plans for two residents, leading to deficiencies in care. One resident, with mental health issues and a foot lesion, was non-compliant with wearing prescribed boots, which was not documented in the care plan. Another resident, with memory impairments and a history of pressure ulcers, used a body pillow for positioning, but this was not reflected in the care plan. Staff acknowledged these issues, but the care plans were not revised accordingly.
A facility was found to have a medication error rate of 16% during a medication pass, exceeding the acceptable rate of less than 5%. Errors included a CMA crushing an extended-release tablet for a resident and administering incorrect dosages and formulations to another. Additionally, the ADON did not follow proper insulin pen procedures, potentially affecting insulin delivery. These issues highlight a failure to adhere to medication administration protocols.
Failure to Provide ROM Interventions and Implement Hand Splint Orders
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide services and treatment to maintain or improve range of motion (ROM) and prevent further decline for residents with contractures. Resident #40 had a history of stroke with left-sided hemiplegia and documented functional limitations in ROM of the left upper and lower extremities. Her care plan problem for history of CVA with left-sided weakness included goals to prevent complications such as contractures, but listed only general interventions such as administering medications, allowing time to communicate, and therapy as ordered, without specific interventions for her left hand contracture. Observations showed her left hand was tightly closed with fingers curled into the palm, no padding or device in place, and visible indentations in the palm from fingernails. Resident #40 reported she could not open her left hand due to contracture, did not receive therapy for the contracture, and that the facility did not provide anything to keep her hand open or prevent her fingernails from digging into her skin. She stated she sometimes placed Kleenex in her palm herself for relief. A review of her EHR revealed no orders or interventions addressing the left hand contracture. The ARNP confirmed the resident had a left hand contracture, stated she had recommended a splint but believed insurance would not pay, and acknowledged there was no order for a washcloth or foam block despite having discussed these options with the resident. The OT reported he was only working with the resident on power wheelchair safety and had not evaluated or treated her hand contracture or assessed her for a splint. Resident #44 also had a history of stroke with hemiplegia and documented ROM impairment on one side. Observation showed the four fingers of her left hand curled into the palm with the thumb extended and no padding between the fingers and palm. She reported having contractures from strokes, being unable to open her fingers independently, sometimes using gauze under her fingers, not receiving restorative exercises for her hand, and not having a splint, stating she was not able to receive therapy due to insurance. Her orders included a physician’s order for her to be fitted for and receive a left hand splint for contracted fingers, but the ARNP and OT stated that insurance would not cover a splint or evaluation, and the OT had not completed an evaluation or provided treatment. The DON was unsure what had been done since the splint order was received or what else had been done to prevent further contracture, despite a facility policy stating that residents with ROM limitations would be referred to therapy for focused assessment and that the facility would provide appropriate interventions, exercises, therapy, and equipment such as braces or splints.
Improper Storage and Labeling of Eye Drops and Inhalers
Penalty
Summary
Surveyors identified a failure to properly store and label medications in one of two medication carts reviewed on the 100/200 hall. During observation with an RN, a bottle of Latanoprost eye drops prescribed for dry eye syndrome for Resident #35 was found in the medication cart with a label indicating it needed refrigeration, an open date, and a statement that it expired 42 days after opening, but no actual expiration date was written. The Latanoprost was a bedtime medication that should have been refrigerated rather than kept in the cart. The Medication Administration Record showed the resident had been receiving the Latanoprost nightly during the review period. In the same medication cart, surveyors also found four bottles of prescribed eye drops and nine prescribed inhalers that were not labeled with an open date. The RN present acknowledged that the Latanoprost should be refrigerated and stated she did not know how long eye drops and inhalers were good for after opening. The DON reported the facility did not have a policy for expiration dates on medications after opening and stated they would follow pharmacy recommendations. A faxed document from the pharmacist indicated that Latanoprost expires 42 days after opening, and the facility’s Medication Storage Policy instructed that all medications requiring refrigeration are to be stored in refrigerators in each medication room.
Failure to Follow Enhanced Barrier Precautions and Proper Wound Care Infection Control
Penalty
Summary
Surveyors identified a failure to follow the facility’s infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP) and wound care practices for one resident. The resident’s MDS dated 2/6/26 documented diagnoses of peripheral vascular disease and a venous ulcer, and the care plan initiated on 8/8/25 required EBP due to a PVD wound on the left lower leg, with EBP to be instituted during high-contact activities. Facility policy dated 3/25/24 stated that gloves and gown must be applied before performing high-contact resident care activities, including wound care. During an observation, a RN entered the resident’s room and placed wound treatment supplies directly on the resident’s bed, applied gloves without donning a gown, removed the resident’s sock and leg dressing, and cleansed scattered open wounds on the left lower leg. The RN then continued the procedure with the same gloves on while wrapping the leg with medicated dressing, gauze, and Coban, and only after completing the treatment removed gloves and performed hand hygiene. The RN then placed the wound cleanser and medicated dressing box back into the treatment cart with other residents’ supplies. A CMA interview confirmed that the EBP sign on the door meant staff should wear gown and gloves with all hands-on care, and the DON stated the expectation was to change gloves and perform hand hygiene when going from dirty to clean during wound treatment, to wear gown and gloves for the treatment, and to place supplies on a barrier.
Failure to Maintain Accurate Control and Accountability of Ambien for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate control and accountability of a Schedule IV controlled hypnotic medication (Ambien) for one resident. The resident had diagnoses including diabetes, depression, and primary insomnia, with an MDS indicating no cognitive impairment and use of a hypnotic. Physician orders on the MAR for Ambien 5 mg at bedtime were documented for December and January, with administration entries showing doses given on multiple days and held on days when the resident was hospitalized. The resident’s Individual Patient’s Narcotic Record for Ambien showed an order dispensed on 12/12/25 with a quantity documented as 30, later altered to appear as 31 by writing a “1” over the “0,” and the first dose recorded as given on 12/20/25 with 30 pills remaining. The controlled drug record entries documented one tablet administered daily from 12/20/25 through 12/29/25, and then from 1/2/26 through 1/6/26, with the running balance decreasing by one each time. On 1/7/26, the record showed one tablet dropped and wasted with two staff initials, leaving 15 remaining, and another tablet given the same day, leaving 14. On 1/8/26, two separate recount entries were made, both signed by two staff, documenting 12 tablets remaining. Staff interviews revealed that during the 1/8/26 morning shift change narcotic count, an RN and an LPN identified that the Ambien count was off by one or two tablets, with the RN stating the count was incorrect and refusing initially to sign off on the narcotic count. The RN reported that the LPN, who had the cart keys on night shift, suggested pills may have popped out of the card due to a full drawer, but the RN did not find any loose pills in the drawer. Further interviews clarified that the facility’s Controlled Drugs-Count Record for that date nonetheless contained signatures from the RN and the LPN, with a comment of the total number of controlled cards and bottles, and an instruction on the form that signing acknowledges agreement with the quantities on hand. The DON stated he was notified of a discrepancy on the cart and that no one was willing to sign for the cart being accurate, and he verbally interviewed staff but did not document those interviews or obtain written statements. The ADON reported that upon recount she determined that one Ambien tablet was unaccounted for, based on the count sheet showing a jump from 14 remaining to 12 remaining, and she confirmed there was no photocopy of the bubble pack to verify the original quantity or any pills that may have popped out. The pharmacist and pharmacy shipping manifest confirmed that only 30 Ambien tablets were dispensed and delivered, while the narcotic record had been altered to appear as 31 received. The nurse who signed as receiving the medication stated she documented 30, denied changing the number, and explained she would have properly lined out and initialed any correction rather than writing over the number. The CMA who first administered the medication also denied altering the received quantity and stated she believed there were 30 tablets remaining after the first dose, consistent with her documentation. The facility’s Controlled Substances policy required accurate counting upon delivery, proper documentation of quantity received, end-of-shift counts by oncoming and outgoing nurses, documentation and reporting of discrepancies to the DON, and investigation of any narcotic reconciliation discrepancies, which was not fully supported by the documentation and events surrounding the missing Ambien tablet and altered quantity on the narcotic record. An additional staff interview indicated that on the evening before the count discrepancy, the night-shift nurse reported dropping an Ambien tablet, which another nurse observed and then observed being disposed of in the dissolvable medication waste container. The next morning, during the narcotic count with the RN and the night-shift nurse, the count was short by one pill, and the night-shift nurse reported that one pill was missing. The Director of Clinical Services confirmed that following the documented administration pattern, the record would show a discrepancy of two pills short on 1/8/26 and noted that the received quantity on the narcotic record appeared to have been changed from 30 to 31 by writing a “1” over the “0.” These combined documentation irregularities, the unaccounted-for Ambien tablet(s), and the lack of clear, contemporaneous investigative documentation demonstrate that the facility did not ensure accurate control and accountability of this controlled medication for the resident, in contrast to its written controlled substances policy. The facility’s own policy on controlled substances, revised December 2012, required that controlled substances be counted upon delivery by both the receiving nurse and the delivery person, with both signing the designated record, and that an individual resident controlled substance record include the quantity received and number on hand. It also required nursing staff to count controlled medications at the end of each shift, with both oncoming and outgoing nurses making the count together and documenting and reporting any discrepancies to the DON, and required the DON to investigate any discrepancies and provide the administrator with a written report of findings. In this case, the altered quantity on the narcotic record, the missing Ambien tablet(s), the inconsistent count documentation, and the absence of a written investigative report or staff statements show that these policy requirements were not fully met for this resident’s controlled medication. Overall, the events leading to the deficiency include the pharmacy’s documented dispensing of 30 Ambien tablets, the facility’s narcotic record being altered to appear as 31 tablets received, the administration and waste documentation that did not reconcile with the remaining count, the discovery of a missing tablet during shift-change counts, and the lack of complete, accurate documentation and investigation consistent with facility policy. These factors resulted in the facility’s failure to ensure accurate control and accountability of the resident’s controlled hypnotic medication.
Deficiency in Nutrition Professional Qualifications
Penalty
Summary
The facility failed to employ a clinically qualified nutrition professional who met the required qualifications of a Certified Dietary Manager or a full-time Registered Dietician. The Dietary Manager admitted to not having certification as a dietary manager, although she had completed courses to obtain it, with the classes scheduled to finish on 1/15/2025. Additionally, the Registered Dietician was only physically present in the facility one day a week, as confirmed by both the dietician and the Administrator. Facility records further indicated that the Dietary Manager did not hold any certifications in food safety, had not taken the test to become a Certified Dietary Manager, and had not been in the role for two years or more.
Facility Fails to Maintain Safe Environment Due to Damaged Heaters
Penalty
Summary
The facility failed to maintain a clean and safe environment, as evidenced by multiple observations of damaged baseboard heaters throughout the facility. On several occasions, surveyors noted that the safety grates on the baseboard heaters were bent, broken, or completely removed, allowing easy access to the interior of the heating units. Residents expressed dissatisfaction with the state of their rooms, specifically pointing out the damaged heaters. One resident mentioned that the heater had been in disrepair since their admission, and another described the appearance as 'trashy.' Interviews with staff, including a Certified Medication Aide, a Registered Nurse, the Assistant Director of Nursing, and the Director of Maintenance, revealed that the issue with the baseboard heaters had been ongoing for a significant period. The Director of Maintenance acknowledged the chronic nature of the problem and the challenges in receiving timely reports from staff about broken grates. Maintenance logs indicated that requests for repairs had been made months prior, with some repairs only recently completed. The facility's maintenance policy, last revised in 2009, mandates that the maintenance department is responsible for ensuring the safety and operability of the building's systems, including heating systems.
Improper Food Handling Practices Observed
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during multiple instances of improper food handling by staff. On one occasion, the Dietary Manager was seen opening a package of crackers with ungloved hands and making direct contact with the crackers before serving them to a resident. Additionally, the Dietary Manager served a plate of food to a resident while touching the top of the plate and the food with ungloved hands, without performing hand hygiene after assisting a previous resident. Similar lapses were observed with other staff members, including a Certified Nurse Aide (CNA) and Certified Medication Aides (CMAs), who were seen touching the interior of plates and the serving ends of utensils with bare hands, and failing to perform hand sanitation during food service. Interviews with staff, including the Dietary Cook and the Dietary Manager, revealed that the facility's expectations were not being met, as staff should avoid contact with the tops of plates, interior surfaces of cups and bowls, and the serving surfaces of utensils. The facility's policy documents, such as 'Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices' and 'Dish & Utensil Handling', clearly state that contact between food and bare hands is prohibited and that hand hygiene should be performed frequently. Despite these guidelines, the observations indicated a failure to comply with these standards, leading to the deficiency in food service safety.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and respect, as evidenced by the treatment of three residents, all of whom had intact cognition as indicated by their BIMS scores. Resident #12 reported that a CNA, identified as Staff A, exhibited rude behavior, making her feel like a burden and causing her to wait excessively for assistance, resulting in incontinence. Despite filing grievances, Resident #12 felt that no action was taken to address her concerns. Resident #13 also reported similar issues with Staff A, noting that he was rude and dismissive, particularly during the night shift. She recounted an incident where she waited nearly an hour for assistance, and when her call light was finally answered, Staff A instructed her to perform tasks she required assistance with, such as removing her socks, under the guise of it being good exercise. Resident #14 echoed these sentiments, describing Staff A's behavior as making her feel like "a piece of garbage" due to the long wait times and dismissive attitude. Interviews with other residents and staff corroborated these accounts, with additional grievances filed regarding rude staff and delayed response times to call lights. The Director of Social Services acknowledged receiving multiple grievances about staff behavior but was uncertain about any actions taken. Facility documentation revealed that Staff A had previously received a written warning for neglectful behavior, yet issues persisted. The facility's policy on dignity and respect emphasized the importance of treating residents with respect and providing prompt care, which was not adhered to in these instances.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the appropriate Notice of Medicare Non-Coverage (NOMNC) to two residents who were receiving skilled care under Medicare A. Resident #7 began receiving skilled care on August 5, 2024, and Medicare covered the stay until August 23, 2024. However, the facility could not provide documentation that Resident #7 received the NOMNC form. Instead, they provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN). The SNF Beneficiary Protection Notification Review form indicated that the resident did not receive a NOMNC because the resident informed therapy staff that she was done and refused further therapy. Similarly, Resident #142 began receiving skilled care on September 13, 2024, with Medicare coverage extending until October 18, 2024. The facility also failed to provide documentation of a NOMNC form for this resident, instead providing a SNF ABN form. The SNF Beneficiary Protection Notification Review form noted that the resident did not receive a NOMNC due to receiving the SNF ABN. The Social Services Director, who had been employed for eight months, stated she was only trained to provide the SNF ABN form and was not trained regarding the NOMNC form.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to revise the comprehensive care plans for two residents, leading to deficiencies in their care. Resident #24, who had a history of mental health issues and an open foot lesion, was observed outside in cold weather without the prescribed walking boot or CAM boot, wearing only gripper socks. Despite being non-compliant with wearing the boots, the care plan did not document this non-compliance or any education provided to the resident regarding foot care. The Director of Nursing acknowledged the resident's non-compliance and stated that education had been given, but this was not reflected in the care plan. Resident #32, who had memory impairments and a history of a Stage III pressure ulcer, was observed with a body pillow used for positioning to prevent falls and assist in healing. However, the care plan did not document the use of the body pillow for positioning, despite staff acknowledging its purpose. The Assistant Director of Nursing and other staff members confirmed the use of the pillow for repositioning and fall prevention, but the care plan failed to reflect these interventions. The facility's policy requires care plans to be updated with changes in the resident's condition, but this was not adhered to in these cases.
Medication Administration Errors Observed in Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with an observed error rate of 16% during a medication pass. Staff B, a Certified Medication Aide, was observed preparing and administering medications for Resident #22, including crushing an extended-release tablet of Oxybutynin, which should not be crushed. Additionally, Staff B administered an incorrect dosage of Fenofibrate and the wrong formulation of Senna to Resident #21. The errors were attributed to incorrect medication preparation and failure to verify medication orders accurately. Furthermore, the Assistant Director of Nursing (ADON) was observed administering insulin to Resident #28 without following the manufacturer's instructions for the insulin pen. The ADON failed to prime the pen correctly and did not hold the pen in place for the recommended duration after administration, potentially compromising the delivery of the full insulin dose. These observations indicate a lack of adherence to proper medication administration protocols, as outlined in the facility's policy, which requires triple-checking medication labels against the Medication Administration Record (MAR) and following specific procedures for insulin administration.
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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