Greater Southside Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Des Moines, Iowa.
- Location
- 5608 Sw 9th Street, Des Moines, Iowa 50315
- CMS Provider Number
- 165175
- Inspections on file
- 36
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Greater Southside Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with metabolic encephalopathy, anemia, and sepsis, care planned for risk of impaired cognition, became agitated, verbally abusive, and refused care when CNAs attempted to change him. He called 911 twice, reporting that staff were attacking him, and told an LPN he did not feel safe with two specific CNAs, whom he described in detail, while a skin assessment showed no new injuries. CNAs reported his aggressive and accusatory behavior to the nurse, and the LPN notified facility leadership, but the allegation of staff-to-resident abuse was not reported to the state hotline until many hours later, exceeding the facility policy and administrative expectation that all abuse allegations be reported to authorities within two hours.
The facility failed to revise a comprehensive care plan after changing how a resident’s vaping was managed. A cognitively intact resident with quadriplegia and PTSD, who vaped daily and had a vaping-related disorder, was originally care planned for 1:1 observation during smoking/vaping and for all smoking materials to be kept at the nurses’ station. Later, facility leadership and the resident’s representative agreed the resident could keep a vape locked in the room and use it only for chewing, except when in the designated smoking area or with family, and staff acknowledged awareness that the vape was in the room. However, these changes and conditions were never added to the written care plan, contrary to facility policy requiring the IDT to update care plans to reflect current interventions and resident-specific agreements.
A resident with quadriplegia, PTSD, and a vaping-related disorder was care planned for 1:1 observation during smoking/vaping and for all smoking materials to be kept at the nurses’ station, yet staff and the resident reported that a vape was kept in a lock box or drawer in the resident’s room and was supplied by family. The resident was observed with a vape at his neck, and multiple staff interviews showed inconsistent understanding of whether he was allowed to have or use the vape in his room, with one CNA reporting having seen him take hits and exhale smoke. The Administrator stated that the resident was allowed to keep the vape in his room to chew on for PTSD, despite the written policy prohibiting smoking and vaping inside the building and requiring supervised use only in designated outdoor areas, and this exception was not documented on the care plan.
A resident with acute pulmonary edema, atrial fibrillation, pulmonary hypertension, and edema was admitted without oxygen therapy and had documented shortness of breath, abnormal lung sounds, and a productive cough, but no respiratory care focus was added to the care plan. Daily skilled assessments contained copied-forward oxygen saturation values and an incorrect COPD reference, and when the resident’s oxygen saturation declined, an LPN initiated continuous oxygen at 2 L/min without documented physician notification or an order. Despite worsening shortness of breath and documentation that the resident became oxygen dependent, staff only notified the practitioner about cellulitis and wound issues, and the resident was later sent to the ED by family, where EMS and ED records showed significant hypoxia and diagnoses including acute hypoxic respiratory failure.
A resident with complex cardiac and pulmonary conditions and severe pain had PRN orders for Tylenol, hydrocodone‑acetaminophen, oxycodone for moderate to severe pain, and hydromorphone for severe breakthrough pain only at a pain level of 10. Despite black box warnings and clear parameters, MAR review showed repeated concomitant administration of multiple opioids and frequent use of hydromorphone when documented pain scores were below 10. A CMA with limited experience administered PRN opioids without guidance on differentiating moderate versus severe pain and acknowledged not following the hydromorphone order, while an RN reported giving all three opioids together at the resident’s insistence. Facility policies and the CMA job description prohibited CMAs from administering PRN medications and required adherence to physician orders, but these were not followed, and the resident was later hospitalized with acute hypoxic respiratory failure and acute on chronic CHF.
Two residents experienced abuse—one involving unwanted sexual contact from another resident and another involving verbal abuse and withholding of pain medication by an LPN. In both cases, staff failed to follow facility policy for reporting and investigating abuse allegations, and the incidents were not reported to the State Survey Agency or Administrator as required.
Two residents experienced incidents involving suspected abuse or neglect that were not reported to the state agency in a timely manner as required by facility policy. In one case, a non-verbal, dependent resident was found being touched inappropriately by another resident, and in another, a cognitively intact resident alleged verbal abuse and medication withholding by an LPN. Staff documented and discussed the incidents internally, but failed to promptly notify the appropriate authorities.
A facility failed to conduct a timely and thorough investigation after a CNA observed one resident, who was non-verbal and quadriplegic, being sexually abused by another resident. Although staff separated the residents and notified the Administrator, there was no formal investigation, incident report, or care plan update documented for either resident, and the care plan addressing hypersexual behavior was not revised until days later. Required procedures for reporting, documentation, and care plan updates were not followed.
A resident with multiple complex medical conditions was admitted without timely physician orders, resulting in missed doses of essential medications including insulin, cardiac, pain, and psychotropic drugs. Nursing staff were unclear about responsibility for entering orders, leading to the resident experiencing significant pain and distress, and ultimately leaving the facility without receiving necessary care.
Two residents experienced inadequate pain management due to delays in transcribing and administering physician-ordered pain medications. One resident with a femur fracture did not receive prescribed pain relief in a timely manner, and staff interactions included inappropriate language. Another resident with acute osteomyelitis had a delay in receiving as-needed oxycodone, resulting in severe, unmanaged pain until the order was processed.
The facility did not provide enough nursing staff to meet resident needs, as shown by reports of long call light response times, missed care such as wound dressing changes and assistance with meals, and staff and family concerns about insufficient staffing. Documentation and interviews confirmed that staffing levels frequently fell below the facility's own requirements, with the DON occasionally working the floor to cover shortages.
A resident with severe intellectual disability and moderately impaired cognition, who required assistance with dressing, was observed sitting in a dining room with her buttocks fully exposed while multiple staff and other residents were present. Staff failed to promptly address the situation, leaving the resident uncovered for several minutes in violation of facility policy on dignity and privacy.
A resident with multiple pressure ulcers did not receive wound care and dressing changes as ordered by the physician. The care plan lacked information about a right foot wound, and documentation showed dressing changes were not performed or recorded as required. Staff confirmed that dressings should be dated and initialed with each change, but observation revealed a dressing that had not been changed according to orders.
Staff failed to consistently use Enhanced Barrier Precautions (EBP) during wound care and high-contact activities for three residents with wounds or indwelling devices. In multiple instances, staff did not wear gowns or change gloves as required by care plans and facility policy, despite the presence of conditions such as pressure ulcers, paraplegia, and quadriplegia. Staff interviews and policy review confirmed that PPE, including gowns and gloves, should have been used, but these protocols were not followed during observed care.
Staff did not consistently follow Enhanced Barrier Precautions, including the use of gown and gloves during high-contact care for residents with indwelling devices, and failed to disinfect shared equipment such as a mechanical lift between uses. These lapses were observed during catheter care, tube feeding, medication administration, incontinence care, and resident transfers, despite facility policy and CDC guidance requiring these infection control measures.
During meal service, staff failed to provide the correct supplements and side dishes as indicated on meal tickets, and did not measure or serve the correct portion sizes of pureed meat for residents on modified diets. The CDM was unsure of the standard procedure for preparing liquefied diets, and staff did not follow the facility's guidelines for processing the correct number of servings, resulting in several residents not receiving their prescribed nutritional items.
Dietary staff did not maintain clean and sanitary kitchen conditions, with observations of unclean equipment, improper food labeling and storage, and unsanitary food handling during meal service. Staff were seen touching food and utensils with bare hands, failing to perform hand hygiene, and not following proper thawing procedures, all in violation of facility policies and food safety standards.
Two residents had discrepancies between their IPOST forms and the code status recorded in the EHR and physician orders. One resident's IPOST indicated DNR while the EHR listed Full Code, and another resident's IPOST indicated Full Code while the EHR listed DNR. Staff were unable to locate the correct IPOST documentation in the designated binders, and the facility did not consistently follow its policy for reviewing and updating advance directives, resulting in inaccurate code status documentation.
A resident with severe cognitive impairment and multiple diagnoses was administered PRN Ativan for anxiety and yelling over a period longer than 14 days without a documented 14-day practitioner re-evaluation, as required by facility policy for psychotropic medications.
Three residents with documented PASRR Level II determinations for serious mental illness or intellectual disabilities did not have this status accurately reflected in their MDS assessments. Each resident's PASRR identified specific diagnoses and required specialized behavioral health services, but the MDS failed to code this information as required. An LPN responsible for MDS completion indicated that issues with EHR record transfers after a facility name change may have contributed to the omissions.
A resident with multiple medical conditions and recent falls was admitted and required significant assistance with daily activities. The facility did not complete a baseline Care Plan within 48 hours of admission, and the plan that was eventually created lacked key information about the level of staff assistance needed. Staff interviews revealed confusion about responsibilities for initiating the Care Plan, and the facility's policy for timely care planning was not followed.
A resident with a history of arthritis, muscle weakness, and a right above-the-knee amputation did not receive restorative exercises or ambulation assistance as recommended by therapy and outlined in the care plan. Despite multiple therapy evaluations and clear directives, staff did not consistently implement or document restorative programs, and interviews revealed confusion about responsibility and documentation. The facility's policy required individualized restorative care, but this was not provided, resulting in a deficiency.
A resident with severe cognitive impairment, malnutrition, and pressure injuries did not receive a morning meal or snack after missing the scheduled breakfast. Staff failed to communicate the need for a replacement meal, and the resident was left with only juice, despite facility policy requiring food to be available at all times.
A resident with COPD was found to have unsecured nebulizer medication vials left at the bedside, which the resident self-administered without documented assessment or authorization for self-administration. Facility policy requires medications to be stored securely and only accessible to authorized personnel, but this was not followed in this instance.
Surveyors identified that the facility's medication error rate exceeded 5% after two residents received medications not in accordance with physician orders: one received the wrong formulation of Vitamin D, and another was given Atenolol despite a pulse below the ordered threshold. Staff interviews and record reviews confirmed these errors, which were observed during medication administration.
A resident with dementia and dysphagia, requiring a puree diet and maximum eating assistance, was served a bowl of regular textured potato salad in addition to their prescribed puree meal. Although the potato salad was not fed to the resident, this did not align with the resident's dietary order or facility policy.
A resident with schizoaffective disorder was transferred with incorrect medical records due to failure to verify patient identifiers. The social services supervisor forwarded paperwork containing another individual's information, leading to the resident not receiving prescribed psychotropic medications for two weeks and requiring hospitalization. Staff interviews revealed that the paperwork was not properly checked before being sent, despite facility policy requiring verification.
Two residents experienced ongoing abnormal vital signs and changes in condition that were not consistently reported to a physician or documented according to facility policy. One resident had repeated episodes of low blood pressure and elevated heart rate, as well as shortness of breath, without appropriate follow-up or care plan updates, and was eventually transferred to the hospital after a significant decline. Another resident with chronic cardiac conditions had multiple episodes of bradycardia and hypotension, with medication held as ordered but lacking timely provider notification, and suffered several falls and a fatal respiratory event. Staff interviews confirmed that abnormal findings were not always communicated as required.
The facility failed to respect residents' dignity by entering rooms without proper announcement and not ensuring appropriate clothing for weather conditions. A resident with intact cognition experienced staff entering without knocking, and another was inadequately dressed for outdoor conditions due to laundry issues. These actions violate the facility's policy on resident dignity and respect.
A resident with moderate cognitive impairment was financially abused by a CNA who accessed the resident's secured drawer and took $55 in cash. The incident was discovered through video footage installed by the resident's family. The facility's policy on abuse prevention was violated, leading to the CNA's termination for breaching trust and misappropriating resident property.
A facility failed to complete before and after dialysis assessments for a resident with end-stage renal disease. The resident reported inconsistent vital sign checks and assessments, and electronic records showed missing or incomplete documentation. Staff interviews revealed a recent change in the assessment process, but the forms were not consistently uploaded. The facility's policy outlined specific care procedures, but the Director of Nursing acknowledged that several assessments were not completed or located.
A resident with multiple health conditions and intact cognition was unable to communicate with staff due to a malfunctioning call light system. Despite attempts to use the call cord, the system failed to activate, and staff were aware of ongoing issues with the call system. Temporary measures were in place for other residents, but the facility's policy to provide a means of communication was not met.
A resident with quadriplegia sustained a second-degree burn from excessively hot water in a shower room. Despite the resident's report of the injury, the facility continued to use the shower room without addressing the hazard. A subsequent inspection found the water temperature to be dangerously high, and staff interviews revealed awareness of the issue but no preventive measures were taken.
A resident with end-stage renal disease was not provided with transportation to a new dialysis center by the facility, despite being informed of the new schedule. The resident missed appointments due to the facility's inability to accommodate early morning transport, although staff indicated they could have adjusted their schedules if requested. The facility's Admission Packet stated they would arrange transportation for healthcare services, but the resident was not offered alternative options like a taxi or Uber.
The facility failed to provide timely care and equipment management for several residents. A resident with a history of anemia and dementia experienced a decline in condition, but staff delayed necessary interventions, leading to an emergency hospital transfer. Another resident's wound therapy machine alarm went unaddressed, and two residents requiring oxygen therapy were found without it due to staff oversight and equipment mismanagement.
The facility failed to secure resident information on laptops, as observed in two incidents where medication carts were left unlocked with visible resident data. In one case, a CMA left a cart unlocked and a laptop open by mistake. In another, a cart was found unsecured with 12 residents' information visible, and no authorized staff present. The facility's policy requires PHI to be stored securely, and the DON confirmed the need to lock screens before leaving.
A resident with dementia and other medical conditions experienced a decline in condition, prompting their relative to request hospitalization due to suspected UTI. Despite notifying staff and the DON, the request was not acted upon, and the resident's condition worsened until they became unresponsive. The facility failed to inform the medical provider of the relative's request, violating the resident's rights.
A resident with severe cognitive impairment and multiple health conditions experienced a medication change from scheduled to PRN Lorazepam after a fall. The facility failed to notify the resident's family or representative about this change, as required by policy. The LPN responsible for the notification was no longer employed, and the nurse practitioner did not communicate the change, leaving the task to other staff.
The facility failed to follow physician orders and document accurately for two residents. A resident with chronic respiratory failure was observed without oxygen despite orders for continuous use, and staff inaccurately documented oxygen use. Another resident's medication was not administered as recorded, indicating a documentation discrepancy.
The facility failed to follow physician's orders for a resident, resulting in a missed urinalysis due to an unentered order in the EHR. The ADON delayed entering the order, leading to a lack of notification to the medical provider and continued decline in the resident's condition. Additionally, a medication error occurred when an RN documented administering Acetaminophen, but the medication was found in the cart the next day, indicating it was not given. The DON outlined steps for handling such errors, but the report does not confirm these were followed.
A resident with a pressure ulcer did not receive proper wound vac care due to staff's lack of knowledge and failure to respond to alarms. The wound vac was found disconnected, and the resident reported previous battery issues. After attending a festival, the wound vac was not reapplied promptly.
A resident requiring continuous oxygen therapy was found with an empty portable oxygen tank, leading to low oxygen saturation levels. The facility's staff failed to adhere to the policy of reassessing and documenting the oxygen flow, resulting in a deficiency in providing necessary respiratory care.
A resident experienced rectal bleeding after an LPN performed an enema roughly without proper visualization or digital stimulation, contrary to the physician's order. Another resident did not receive wound vac care over a weekend due to staff's lack of knowledge. Both incidents highlight the facility's failure to maintain competent staff, as acknowledged by the DON.
The facility failed to secure medication carts, as observed in two incidents where carts were left unlocked and unattended. On one occasion, a CMA admitted to leaving the cart unlocked by mistake, while another incident involved a cart left in a dining room with residents present and no authorized staff nearby. Facility policy requires carts to be locked when not in use and within sight if not locked.
A resident with a history of wandering and elopement left a facility unattended due to unsecured exit doors and inadequate supervision. The resident, who had diagnoses including schizophrenia and a hip fracture, was found two days later after admitting himself to the Emergency Department for knee pain. The facility's records showed inconsistencies in monitoring the resident's wander guard, and staff interviews revealed issues with staffing levels and familiarity with residents.
Two residents with severe cognitive impairment and dysphagia were served inappropriate meals, posing choking risks. One resident was given bread products despite a recommendation against it, leading to heavy coughing. Another resident received Cheeto Puffs and a salad on a pureed diet. The facility's dietary practices, including outdated diet slips and lack of adherence to guidelines, contributed to these deficiencies.
A resident with severe cognitive impairment was admitted to the facility, but the designated Power of Attorney (POA) was not invited to participate in the care plan conference. The facility's EHR lacked documentation of a care plan conference, and the MDS Coordinator confirmed that a 72-hour care conference was not held or scheduled. Training materials directed staff to review the baseline care plan with the responsible person within 48 hours, but this was not completed.
The facility failed to conduct Level II PASRR evaluations for two residents after new serious mental disorders were diagnosed. One resident, with moderate cognitive impairment, had changes in diagnoses and medication but was not referred for a Level II PASRR. Another resident, rarely understood, was diagnosed with anxiety disorder and Schizoaffective disorder, yet no Level II PASRR was completed. The Social Services Director acknowledged the oversight.
The facility failed to provide adequate nail care for two residents, one with severe cognitive impairment and another who is paraplegic and legally blind. Both residents were found with long, jagged toenails despite care plans requiring regular checks and trimming during bi-weekly showers. Staff documentation and interviews revealed that these care instructions were not consistently followed, leading to the observed deficiencies.
The facility did not ensure clean and safe bathroom conditions for residents, as observed in four bathrooms. A resident's bathroom had missing tiles and a black substance on the walls, while another had a brown substance on the toilet. Two residents shared a bathroom with missing tiles and broken pieces on the floor. The facility's cleaning policy was not followed, as confirmed by the DON.
Failure to Timely Report Resident’s Allegation of Abuse to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse to the Iowa Department of Inspections, Appeals and Licensing (DIAL) within the required two-hour timeframe. Resident #2, who had diagnoses including metabolic encephalopathy, anemia, and sepsis and was care planned for risk of impaired cognitive function/dementia related to respiratory failure with hypoxia, became agitated late in the evening. Progress notes documented that around 11:45 PM, the resident began yelling at a CNA, calling her names, and refusing care. Two CNAs then went to the room, and the resident became angry with both, calling them derogatory names and refusing to be changed. When the LPN (Staff J) assessed the situation, the resident claimed staff had broken his bed, which the nurse demonstrated was not true by operating the bed controls. Shortly thereafter, Resident #2 called 911 and reported that he was being attacked. When Staff J checked on him and asked if he felt safe, the resident said he did not feel safe with “those two girls” present and described one as a white, big girl and the other as a Black girl with something wrong with the skin on her face. A skin assessment of exposed areas showed no redness, new discolorations, scratches, or abrasions. The on-call provider was notified and ordered a urine analysis when the resident would allow a catheter change. Later, the police department contacted the facility after the resident again reported he was being attacked and requested staff verify his condition; staff checked on the resident and he then allowed staff to change him. Interviews revealed that Staff J was informed by CNAs that the resident was resistive, swinging, yelling, and accusing them of being rough, and that the descriptions of the CNAs matched the resident’s description of his alleged attackers. Staff J reported the situation to the former Administrator (Staff I) and former DON (Staff M). CNAs involved stated they reported the resident’s behavior and allegations to the nurse and denied witnessing any rough or unkind treatment. Facility records showed that the incident occurred at approximately 12:45 AM on 12/2/25, but the allegation of abuse was not called into the DIAL hotline until 1:33 AM on 12/3/26 by the Administrator, well beyond the policy requirement to report all allegations of abuse immediately but no later than two hours after the allegation is made. The Administrator and Clinical Resource Nurse both stated their expectation that any suspicion or allegation of abuse be reported to administration and then to DIAL within two hours, which did not occur in this case.
Failure to Revise Care Plan for Resident’s Vaping Practices
Penalty
Summary
The deficiency involves the facility’s failure to update and revise a resident’s care plan to reflect changes in the plan of care related to vaping. A cognitively intact resident with traumatic spinal cord dysfunction, complete quadriplegia at C5–C7, and PTSD had an MDS indicating daily vaping and an EHR entry documenting that management had taken his vape away for not following the smoking policy and that he had a vaping-related disorder. The care plan, initiated earlier, identified a potential for injury related to vaping and directed staff to provide 1:1 observation while the resident smoked or vaped due to his inability to hold the device, and to keep all smoking materials at the nurses’ station or other designated area. It also noted his frequent non-compliance with the smoking policy by keeping his vape in his room, but it did not document any allowance for him to keep a vape in a locked box in his room or to use it only for chewing. During observation, the resident was seen with a purple vape positioned at the left side of his neck and stated that it was a vape obtained by his mother, which he usually kept in a lock box in his room. A CMA confirmed that the resident had a vape in his room and that most staff were aware he was allowed to have it, though she did not know the source or type of vape. The Administrator reported that, contrary to the written smoking policy, the resident was permitted to keep his vape locked in his room because he used it only to chew on for PTSD, and that this decision had been made during a care conference with the resident and his mother, where they agreed he would not use it except to chew on unless with his mother or in the designated smoking area. This change in practice and resident-specific agreement was not incorporated into the written care plan, despite facility policy requiring the IDT to revise the comprehensive, person-centered care plan to reflect identified needs, refusals, associated risks, and alternate means to address risk.
Failure to Supervise Resident Vape Access and Enforce Smoking/Vaping Policy
Penalty
Summary
The deficiency involves the facility’s failure to monitor and supervise a resident with access to a vape in accordance with its own smoking and vaping policy and the resident’s care plan. The resident had traumatic spinal cord dysfunction with complete quadriplegia at C5–C7 and PTSD, and was cognitively intact with a BIMS score of 15. The care plan, initiated on 8/1/24, identified a potential for injury related to vaping and directed staff to provide 1:1 observation while the resident smoked cigarettes or vaped due to his inability to hold the device, and to keep all smoking materials at the nurses’ station or other designated area. The care plan also documented that the resident was often non‑compliant with the smoking policy by keeping his vape in his room. Despite this, the resident’s vape access and use were not consistently controlled or supervised as required. On 10/9/25, the EHR documented that management had taken the resident’s vape because he was not following the smoking policy, and noted a diagnosis of vaping‑related disorder with daily vaping. However, the Interdisciplinary Team care plan review dated 10/13/25 did not document any plan allowing the resident to keep a vape in his room solely to chew on, although the Administrator later stated such an arrangement had been made at that care conference. During an observation on 4/7/26, the resident was seen with a purple vape at the left side of his neck and stated that his mother obtained the vapes and that he usually kept them in a lock box in his room. Continuous observation of the room later that afternoon showed multiple staff and family entries into the room, but no documented intervention to remove or secure the vape after the ADON was informed by the surveyor that the resident currently had a vape. Staff interviews revealed inconsistent understanding and enforcement of the smoking and vaping policy and the resident’s restrictions. A CMA stated that the resident had a vape in his room and was allowed to have it, and that most staff were aware of it. A CNA stated the resident was not supposed to have a vape and that he used to have one in his room but not anymore. The ADON stated the resident was not supposed to have a vape and that if he had one, staff should ask to remove it and, if unsuccessful, contact his mother, but she was unsure what to do if that failed and was not aware he currently had a vape until informed by the surveyor. Another CNA reported seeing the vape in the room and stated the resident had told her he would do what he wants; she said she reported this to the nurse “all the time” but nothing changed. Additional interviews showed that some staff had directly observed vaping in the room despite the policy prohibiting smoking and vaping in the building. One CNA reported that the resident kept a vape in a locked drawer, that he would call for staff to retrieve it, and that she had seen him take a hit and observed smoke; she was only told about two weeks prior that he could not vape in his room and stated management had not informed her earlier. Another CNA recalled the resident having a THC vape in a locked drawer at one point. The Administrator stated that the resident was not using the vape but chewing on it for PTSD, that he could have it locked in his room against current policy, and that he and the resident’s mother had agreed the resident would not use it in his room except to chew on it. He acknowledged that the resident could take a hit from the vape and that this arrangement and rationale were not documented on the care plan. The facility’s written policy stated that smoking and vaping are prohibited in all buildings and on facility grounds except in designated outdoor areas, that residents who do not meet criteria for independent smoking must be supervised per their care plan, and that vaping devices are subject to the same rules as combustible smoking and may only be used in designated areas. Despite this, the resident had ongoing access to a vape in his room without the required supervision or consistent adherence to policy and care plan directives.
Failure to Obtain Physician Order and Accurately Assess Respiratory Status for Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to obtain a physician’s order for supplemental oxygen and to accurately assess and document a resident’s respiratory status. The resident was admitted with diagnoses including acute pulmonary edema, atrial fibrillation, pulmonary hypertension, and edema, and the admission MDS indicated she was not receiving oxygen therapy and had intact cognition. Her admission assessment documented oxygen saturation of 95% on room air, shortness of breath, diminished right lung sounds, wheezes in the left lung, and a productive cough, yet there was no care plan focus or interventions related to respiratory care or supplemental oxygen. Early daily skilled assessments documented oxygen saturations of 95% on room air with no respiratory treatments, and one assessment incorrectly referenced COPD, a diagnosis the resident did not have. Subsequent daily skilled assessments showed documentation problems and a lack of timely physician involvement when the resident’s respiratory status changed. On multiple days, the same oxygen saturation reading from a prior date was copied forward, failing to provide accurate daily respiratory assessments. On one day, the resident’s oxygen saturation dropped to 94%, and an LPN initiated supplemental oxygen via nasal cannula as a respiratory therapy, but there was no documentation of physician notification or an order for oxygen. The following day, the resident’s oxygen saturation was 91% while on continuous oxygen at 2 L/min, and she had shortness of breath with exertion, at rest, and lying flat, yet there was still no documentation that the physician was notified of the need for oxygen or her worsening respiratory symptoms. Further documentation showed that on the evening when her cellulitis and right lower leg wound were reported to the medical practitioner, new wound care orders were obtained, but there was no corresponding notification about her respiratory decline or oxygen use. Progress notes indicated the resident was awake all night, repeatedly turning on the light, stating she did not know what she wanted, and yelling loudly. A weekly skilled review documented that she was oxygen dependent at 2 L/min. Later that evening, her daughter called 911, and the resident was transferred to the hospital, where EMS reported she did not normally wear oxygen, was on 3 L with oxygen saturation of 91–92%, and had oxygen saturation of 77% without oxygen. The hospital emergency department documented clinical impressions of acute hypoxic respiratory failure, acute on chronic congestive heart failure, and acute kidney injury. Facility policies on change in condition and oxygen administration required assessment, communication with the medical provider for new orders, and that oxygen be administered as ordered by a physician or as an emergency nursing measure until an order could be obtained, but the record lacked evidence that such orders were obtained for this resident’s supplemental oxygen use.
Failure to Follow PRN Opioid Orders and Parameters Leading to Concomitant Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as prescribed, specifically related to multiple PRN opioid analgesics ordered for a resident with complex cardiac and pulmonary conditions. The resident was admitted from an acute hospital with diagnoses including a left humerus fracture with routine healing, acute pulmonary edema, atrial fibrillation, pulmonary hypertension, opioid dependence, edema, and shortness of breath when lying flat or with exertion. Her MDS showed intact cognition (BIMS 13), frequent severe pain rated at 10/10 that interfered with sleep and therapy, and use of scheduled pain medications without PRN or non‑pharmacologic interventions documented. Her care plan directed staff to administer pain medications as ordered and to follow the pain scale when medicating. On admission, the resident had Tylenol Extra Strength ordered PRN, and three opioid medications ordered PRN: hydrocodone‑acetaminophen 10‑325 mg every 8 hours PRN (max 3/day), oxycodone 10 mg every 4 hours PRN for moderate to severe pain, and hydromorphone 2 mg every 4 hours PRN for severe breakthrough pain with a specific parameter that pain must be at level 10 or above to give. These opioids carried black box warnings for addiction, abuse, misuse, life‑threatening respiratory depression, and risks of concomitant use with other CNS depressants. Despite these parameters, the MAR showed repeated concomitant administration of multiple opioids and frequent administration of hydromorphone when the documented pain score did not meet the ordered threshold of 10. Examples included administration of oxycodone and hydromorphone together when pain scores were 7, 5, and 6; administration of oxycodone and hydromorphone together with a pain score of 10; administration of oxycodone and hydrocodone‑acetaminophen together followed minutes later by hydromorphone when pain scores were 7 and then 6; and administration of oxycodone, hydrocodone‑acetaminophen, and hydromorphone in close succession when the pain score was 7. Further MAR review showed that over a defined period, hydromorphone ordered only for pain level 10 was given 17 times, and in 76.5% of those administrations the documented pain score did not meet the ordered parameter. A pharmacist from the facility’s preferred pharmacy stated she had rarely seen three opioid pain medications given at the same time, agreed that concomitant use could cause excessive sedation, and indicated that hydrocodone‑acetaminophen should be tried first, followed by oxycodone for moderate to severe pain, and then hydromorphone for severe pain at level 10 if pain persisted. A CMA reported this was her first CMA job, that she had not received guidance on the resident’s different pain medications or on differentiating moderate versus severe pain on the pain scale, and acknowledged she had not followed the hydromorphone order when she administered it at pain levels 4 and 6. An RN reported the resident frequently requested pain medications and wanted all three opioids at the same time, and acknowledged she had given all three narcotics together due to the resident’s insistence, despite having reservations. The facility’s CMA job description and medication administration policy stated that CMAs may not administer PRN medications and that medications must be administered in accordance with written physician orders, but PRN opioids were nonetheless administered by a CMA and by nursing staff in ways that did not follow the ordered parameters. Subsequently, the resident’s daughter arrived one evening, called 911, and the resident was transported to the hospital. The hospital ED record documented that the resident, who did not normally wear oxygen, was hypoxic with oxygen saturation of 77% without oxygen and 91–92% on 3 L via EMS, with significant lower extremity swelling and tachypnea. The ED impression included acute hypoxic respiratory failure, acute on chronic congestive heart failure, and acute kidney injury, with suspected acute heart failure and a note that a diuretic had been discontinued previously and not restarted, which was considered likely contributory. She required IV diuresis, admission to critical care for respiratory and cardiac failure, intubation, mechanical ventilation, and later transitioned to comfort care, after which she died. The deficiency centers on the facility’s failure to administer the resident’s opioid medications according to physician orders and parameters, including repeated concomitant use of multiple opioids and administration of hydromorphone when the documented pain scores did not meet the ordered threshold.
Failure to Protect Residents from Abuse and Inadequate Reporting of Allegations
Penalty
Summary
The facility failed to protect residents from abuse and did not follow its own policies regarding the reporting and investigation of abuse allegations. In one incident, a resident with quadriplegia and profound intellectual disabilities, who was non-verbal and completely dependent on staff, was found by a CNA being touched on the face by another resident who was masturbating at the bedside. The non-verbal resident was observed trying to cry and move his head away, indicating distress. Staff immediately separated the residents and reported the incident to an LPN, who, along with the CNA, documented the event. However, the Administrator, after being notified, did not report the incident to the State Survey Agency or initiate a facility investigation, as required by policy, and did not consider the event to meet the threshold for reporting. The care plan for the resident exhibiting sexual behaviors lacked interventions for such behaviors prior to the incident. In another case, a cognitively intact resident alleged verbal abuse and withholding of pain medication by an LPN. Multiple staff statements corroborated that there was a loud verbal altercation between the resident and the LPN, during which profanities were used and the LPN stated the resident would not receive pain medication. The resident reported only receiving pain medication once and experiencing significant pain. Staff interviews confirmed that the LPN and the resident exchanged raised voices and profanities, and the LPN walked out of the room after the altercation. The Administrator was not informed of the incident immediately, contrary to facility policy. The facility's policy requires immediate reporting and investigation of all alleged violations involving abuse, neglect, exploitation, or mistreatment, including those involving resident-to-resident abuse and staff-to-resident abuse. The policy also specifies that steps must be taken to protect residents after a report of possible abuse and that all incidents must be reported to the Administrator and State Survey Agency within specified timeframes. In both incidents, the facility failed to follow these procedures, as neither incident was reported to the appropriate authorities nor was a timely investigation initiated.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse to the Department of Inspections, Appeals and Licensing (DIAL) in a timely manner for two residents. In one incident, a resident with quadriplegia and profound intellectual disabilities, who was non-verbal and completely dependent on staff, was found by a CNA being touched on the face by another resident who was masturbating. The CNA immediately intervened, separated the residents, and reported the incident to an LPN, who documented the event and notified the Administrator. Despite this, the Administrator determined the incident did not need to be reported to DIAL at that time, and the event was not reported as required by facility policy and state regulations. In another case, a cognitively intact resident alleged that an LPN withheld medication and used profanities towards him. Multiple staff statements confirmed a verbal altercation involving yelling and cursing between the resident and the LPN, with the LPN reportedly making inappropriate comments about the resident's pain medication. The Administrator was not informed of the incident until several days later, after the resident reported the alleged abuse directly. Facility policy requires that all allegations of abuse, neglect, exploitation, or mistreatment be reported immediately to the Administrator and the State Survey Agency, with specific timeframes for reporting depending on the severity of the incident. Staff interviews and record reviews confirmed that these requirements were not met in both cases, resulting in a failure to report suspected abuse in a timely manner.
Failure to Investigate and Document Alleged Sexual Abuse
Penalty
Summary
The facility failed to conduct a thorough and timely investigation following an allegation of sexual abuse involving two residents, one of whom was non-verbal, quadriplegic, and completely dependent on staff for care. The incident occurred when a CNA observed one resident masturbating and rubbing his hand on the face of the non-verbal resident, who was unable to defend himself and appeared to be in distress. The CNA immediately intervened, separated the residents, and reported the incident to an LPN, who also recognized the seriousness of the situation and contacted the facility Administrator. Despite the immediate actions taken by staff to separate the residents and notify the Administrator, the facility did not complete a formal investigation into the incident. There was no documentation in the clinical records for either resident regarding the incident, including the absence of care plan updates, incident reports, or resident assessments. The care plan for the resident exhibiting hypersexual behavior was not updated until several days after the incident. Additionally, there was no evidence of timely family notification or a comprehensive review of the situation as required by facility policy. Interviews with staff and review of facility policy confirmed that the expected procedures following an allegation of abuse—such as reporting to the appropriate agencies, completing a facility investigation, updating care plans, and documenting the incident—were not followed. The lack of a prompt and thorough investigation, as well as insufficient documentation and care plan updates, constituted a failure to respond appropriately to the alleged violation.
Failure to Provide Timely Admission Orders and Medications
Penalty
Summary
The facility failed to ensure that a newly admitted resident received complete and timely physician orders for immediate care upon admission. The resident, who had a complex medical history including a right femur fracture, acute kidney failure, chronic congestive heart failure, diabetes, obesity, bipolar disorder, anxiety disorder, hypertension, COPD, and leukemia in remission, did not receive essential medications such as insulin, cardiac drugs, pain medication, and psychotropic drugs. Documentation showed that only two doses of pain medication were administered, and there was no evidence that other critical medications or blood sugar checks were provided as ordered by the hospital discharge summary. Multiple staff interviews revealed confusion and lack of clarity regarding responsibility for entering and verifying admission orders. Nursing staff reported not having access to the necessary orders in the system and were unsure who was responsible for completing the admission process. The resident repeatedly requested pain medication and other necessary treatments but was told by staff that they were not in the system and had no medications available. The resident experienced significant pain and distress, ultimately leading to their decision to leave the facility with family assistance after contacting the police. The facility's own policy required informing the physician of admission, verifying transfer and admission orders, initiating required treatments, and ordering medications from the pharmacy. However, these steps were not completed in a timely manner, resulting in the resident not receiving critical medications and care. Staff interviews confirmed that the delay in obtaining and entering orders led to the resident's unmet medical needs and unnecessary pain during their stay.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for two residents who required such services. One resident, admitted from the hospital with a femur fracture and other conditions, was cognitively intact and had physician orders for multiple pain and anxiety medications, including oxycodone. Upon admission, there was a significant delay in entering and obtaining medication orders, resulting in the resident not receiving prescribed pain medications, muscle relaxants, and psychotropic medications in a timely manner. Staff interviews revealed confusion and lack of communication regarding the arrival and administration of medications, with the resident experiencing severe pain and only receiving pain medication once during the night. Staff interactions with the resident were marked by raised voices and inappropriate language, and the resident ultimately left the facility with family after not receiving adequate pain relief. Another resident with acute osteomyelitis and chronic pain was admitted and required both scheduled and as-needed pain medications. The care plan directed staff to administer analgesics per orders and prior to treatments. However, after the nurse practitioner documented an order for as-needed oxycodone following a report of severe pain, there was a delay in transcribing and initiating this order. The resident reported that pain was unbearable upon arrival and only improved after the correct pain medication order was implemented. Staff interviews confirmed that the as-needed order was not promptly processed, resulting in inadequate pain control for several days. The deficiencies were directly related to failures in timely transcription, communication, and administration of physician-ordered pain medications. Documentation and staff statements confirmed that both residents experienced unnecessary pain due to these lapses, and the facility did not follow its own policy for pain management, which requires prompt assessment, documentation, and intervention to maintain resident well-being.
Failure to Maintain Adequate Nursing Staff Levels
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, as evidenced by multiple confidential resident and family interviews, staff interviews, clinical record reviews, and facility policy review. Residents with intact cognition reported long call light response times, insufficient assistance during meals, and delays in receiving care such as wound dressing changes and transfers to bed. Family members expressed concerns about residents not being changed properly at night, insufficient staff to assist with feeding, and fear of retaliation for reporting concerns. Staff interviews confirmed that staffing levels were often below the facility's own assessment requirements, with only two CNAs and one nurse per floor on about half of the shifts, and at least one instance where the DON worked the floor overnight due to staffing shortages. A review of time card data on selected dates showed the required number of CNAs was not met on several shifts. Resident Council notes documented ongoing issues with call light response times exceeding 15 minutes and unmade beds. The facility's own assessment indicated a need for at least five CNAs on day and evening shifts and four or more on overnight shifts, which was not consistently achieved. These findings collectively demonstrate that the facility did not maintain sufficient nursing staff to meet the care needs of its residents as required.
Resident Left Uncovered in Dining Room, Dignity Not Maintained
Penalty
Summary
A resident with severe intellectual disability and schizoaffective disorder, who had moderately impaired cognition and required partial to moderate assistance with lower body dressing, was observed sitting in a dining room chair with her buttocks fully exposed. The resident's care plan indicated a need for assistance with activities of daily living, including dressing, and directed staff to provide one-person assistance for dressing. Despite these documented needs, the resident was left exposed in a public area where nine other residents, including a male resident facing her, were present. Multiple staff members, including four who were waiting to serve food, walked past the resident without addressing her exposed state. The resident remained uncovered for at least eight minutes until a certified medication aide placed a blanket to cover her. Facility policy required all residents to be treated with dignity and privacy, ensuring they are appropriately dressed to maintain bodily privacy. The failure of staff to promptly cover the resident resulted in a lack of dignity and privacy for the resident.
Failure to Administer Wound Care and Dressing Changes as Ordered
Penalty
Summary
The facility failed to administer wound treatments and perform dressing changes as ordered by the physician for one resident. Clinical record review and observation revealed that the resident had multiple pressure ulcers, including a Stage 3 ulcer on the left ankle, a Stage 1 ulcer, and an unstageable ulcer. The care plan was updated to address wounds on the left inner ankle and coccyx, but did not include information about a wound on the right foot. Physician orders directed staff to cleanse the right lateral foot wound, apply calcium alginate, and cover it with a silicone absorbent dressing daily and as needed. Documentation showed that dressing changes for the right lateral foot were only recorded on specific days, and during observation, the dressing on the right lateral foot was found to be dated several days prior. Staff interviews confirmed that dressings should be dated and initialed each time they are changed, and that the frequency of changes should match physician orders. The Director of Nursing stated that the date and initials on the dressing are used to verify when and by whom the dressing was changed. Policy review indicated that the facility is required to implement treatment orders accurately and in accordance with the resident's care plan. The lack of documentation and failure to perform dressing changes as ordered led to the identified deficiency.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement appropriate infection control practices, specifically Enhanced Barrier Precautions (EBP), for three residents with conditions requiring such measures. For one resident with a history of septicemia, hip fracture, paraplegia, and a pressure ulcer, staff were observed performing wound care without all team members donning the required personal protective equipment (PPE). During the procedure, a CNA did not wear a gown while assisting with care, and an LPN used the same gloves to touch potentially contaminated surfaces and then cleanse the wound bed, contrary to infection control protocols. Multiple staff interviews confirmed the expectation that all care team members should wear PPE, including gowns and gloves, when providing care to residents requiring EBP. Another resident with multiple pressure ulcers and a history of infections was observed receiving wound care from an LPN and a nurse practitioner. During the dressing change and debridement, neither staff member wore a gown as required by the resident's care plan and facility policy for EBP during high-contact care activities. The care plan specifically directed the use of gown and gloves for such procedures due to the presence of wounds. A third resident with quadriplegia and impaired skin integrity was observed receiving wound care without the staff member wearing a gown or changing gloves between dirty and clean tasks. The care plan and physician's orders required EBP, including gown and gloves, for high-contact care activities due to wounds and an indwelling medical device. Staff interviews and policy review confirmed the expectation for PPE use and proper glove changes during wound care. The facility's infection control policy outlined the need for EBP to prevent the spread of multi-drug resistant organisms, but these practices were not consistently followed during the observed care activities.
Failure to Follow Enhanced Barrier Precautions and Equipment Disinfection Protocols
Penalty
Summary
Staff failed to follow infection prevention and control protocols related to Enhanced Barrier Precautions (EBP) and equipment disinfection for multiple residents with indwelling medical devices. For a resident with a Foley catheter due to neurogenic bladder, staff were observed performing catheter care and draining the catheter without donning a gown, despite facility policy and posted signage requiring both gown and gloves for high-contact care activities. The staff member acknowledged awareness of the EBP requirements but did not comply during the observed care. Another resident with a feeding tube and frequent incontinence was observed receiving tube feeding and medication administration from an LPN who only wore gloves, omitting the required gown and mask during high-contact activities involving the G-tube. The LPN later admitted this was an error and that full PPE should have been used. During incontinence care for the same resident, CNAs wore gloves and gowns, but one CNA's gown was not properly secured and repeatedly fell from his shoulders, compromising the effectiveness of the barrier precautions. Additionally, the same CNA was observed touching multiple surfaces in the room with contaminated gloves before changing them, increasing the risk of cross-contamination. In a separate incident, two CNAs used a mechanical lift to transfer a resident who required total assistance. After the transfer, the lift was not disinfected before being moved to a common storage area, contrary to facility protocol and staff interviews indicating that equipment should be wiped down after each use. The facility's policy and CDC guidance both require cleaning and disinfection of shared equipment and the use of gown and gloves for high-contact care activities involving residents with indwelling devices or wounds.
Failure to Follow Prescribed Menus and Portion Sizes During Meal Service
Penalty
Summary
The facility failed to ensure that lunch menus and meals met the nutritional needs and preferences of residents, as evidenced by multiple discrepancies during meal preparation and service. Observations revealed that a cook pureed two pork steaks for lunch service without measuring the final volume of the puree, despite a chart indicating the required portion size. Three residents received approximately three-fourths of a #8 scooper serving size of pureed pork, even though only two residents were on a pureed diet and one was on a liquefied diet. The liquefied diet was prepared by mixing pureed meat with hot water in a mug, and the Certified Dietary Manager (CDM) was unsure of the standard procedure for preparing liquefied food. Sample menus indicated that the correct number of servings should be processed to meet dietary requirements, but this was not followed. Additionally, there were several instances where residents did not receive the supplements or side dishes indicated on their lunch tickets. One resident did not receive a Magic Cup supplement, another received a Mighty Shake instead of a Magic Cup, three residents did not receive a Mighty Shake supplement, one resident did not receive a side dish of cottage cheese, and one resident did not receive ice cream. These omissions and substitutions were confirmed by staff interviews and direct observation, indicating a failure to follow prescribed menus and meal tickets, and to meet the documented nutritional needs and preferences of the residents.
Failure to Maintain Sanitary Food Handling and Storage Practices
Penalty
Summary
Dietary staff failed to maintain clean and sanitary conditions in the kitchen, as evidenced by multiple observations of unclean equipment and improper food storage. During kitchen tours, surveyors found a large trash barrel with the lid partially off, broken down cardboard boxes blocking freezer access, and a sticky, soiled freezer handle with dried liquid and food crumbs inside. Several food items, including blueberries, chicken/noodles/broth, diced peaches, and dressings, were found unlabeled and undated. Bulk containers of sugar and flour were improperly labeled or undated, and a scoop was stored with its handle in direct contact with sugar. Additionally, frying pans were observed to be blackened, charred, and missing Teflon coating. Ground meat was left thawing in a sink without running water, contrary to policy, and the same unsanitary conditions persisted on follow-up visits. During meal service, staff were observed handling food and utensils in ways that could lead to contamination. One cook touched the inside of plates with bare hands while plating food, and an aide touched the end of a straw before inserting it into a milk carton for a resident. Another staff member failed to perform hand hygiene after picking up plastic lids from the floor and resumed meal tray preparation. Additionally, a staff member used bare hands to retrieve tongs from a pan of barbeque pork steaks, with the tongs slipping into the food multiple times, and no gloves or extra utensils were available. These actions were inconsistent with facility policies and professional standards for food safety and hygiene.
Failure to Accurately Document and Maintain Resident Code Status
Penalty
Summary
The facility failed to accurately document and maintain the correct code status for two residents, resulting in discrepancies between the residents' wishes as indicated on their Iowa Physician Orders for Scope of Treatment (IPOST) forms and the code status recorded in the electronic health record (EHR) and physician orders. For one resident with diagnoses including metabolic encephalopathy, diabetes, hypertension, and respiratory failure, the IPOST form indicated a Do Not Resuscitate (DNR) status, while the EHR and physician orders listed the resident as Full Code. The Director of Nursing (DON) confirmed the inconsistency, noting that the resident's code status may not have been updated following hospitalizations. The facility's policy required routine review and updating of advanced directives, but this was not followed, leading to conflicting documentation regarding the resident's code status. For another resident, the IPOST form indicated a desire for Full Treatment and Cardiopulmonary Resuscitation (CPR), but the EHR listed the resident as DNR. Staff were unable to locate the resident's IPOST in the designated binders at either nursing station, and an LPN initially stated the resident was DNR based on the EHR. Upon further review, the LPN found the IPOST in the EHR, which showed the resident wished to be Full Code, and subsequently updated the EHR to reflect this. The facility's policy required that a copy of any advance directives be included in the medical record and that the care plan team be informed of any changes, but these procedures were not consistently followed, resulting in inaccurate documentation of residents' code status.
Failure to Complete 14-Day Re-Evaluation for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure timely follow-up for the initiation of a PRN psychotropic medication for one resident. Clinical record review showed that the resident, who had severe cognitive impairment and diagnoses including aphasia, autistic disorder, and profound intellectual disabilities, was prescribed Ativan as a PRN medication for anxiety and yelling. The physician's order for PRN Ativan did not include a stop date, and the medication was administered multiple times over a period exceeding 14 days. Documentation in the electronic health record did not show that the prescribing practitioner completed a required 14-day evaluation for the continued use of the PRN Ativan. The facility's policy on psychotropic drug use requires that PRN orders for such medications be limited to 14 days unless the practitioner documents a rationale for extending the order and specifies the duration. The policy also states that psychotropic medications should only be administered when necessary to treat a diagnosed condition and after non-pharmacological interventions have failed. Despite these requirements, the facility did not obtain or document the necessary 14-day re-evaluation for the continued use of PRN Ativan for the resident.
Failure to Accurately Document PASRR Level II Status in MDS Assessments
Penalty
Summary
The facility failed to accurately document the PASRR Level II status for three residents in their Minimum Data Set (MDS) assessments, despite each resident having a valid PASRR Level II determination on file. For each of the three residents, the PASRR identified serious mental illness and/or intellectual or developmental disabilities, along with specific diagnoses such as Major Depressive Disorder, Generalized Anxiety Disorder, Alcohol Dependence, Schizoaffective Disorder, Mood Disorder, and Intermittent Explosive Disorder. The PASRRs also outlined the need for specialized services, including ongoing psychiatric medication management and individual therapy by licensed behavioral health professionals. However, the corresponding MDS assessments failed to reflect the residents' PASRR Level II status as required by the 2024 RAI Manual. Staff interviews revealed that the MDS Coordinator relied on the electronic health record (EHR) and, if necessary, consulted the facility Social Worker to determine PASRR status. It was noted that after a facility name change and EHR transition, some medical records did not transfer correctly, which may have contributed to the omission. Despite the PASRR documents being uploaded into the EHR prior to the MDS completion dates, the required information was not accurately coded in the MDS, contrary to facility policy and RAI Manual instructions.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline Care Plan within 48 hours of admission for a resident who was admitted with multiple diagnoses, including anemia, atrial fibrillation, non-Alzheimer's dementia, and unsteadiness on feet, with a recent history of falls. Documentation showed that the resident required significant assistance for transfers, toileting, and mobility, as indicated by therapy and nursing communication forms. However, the initial Care Plan was not initiated until several days after admission and did not include essential information regarding the level of staff assistance and supervision needed for activities of daily living such as bed mobility, transfers, toileting, and personal hygiene. Interviews with facility staff revealed a lack of clarity and established process for initiating baseline Care Plans, particularly following recent staffing changes in the MDS Coordinator position. The facility's policy required that a baseline Care Plan be developed and implemented within 48 hours of admission, including all necessary healthcare information and a written summary provided to the resident or their representative. This policy was not followed in the case reviewed, resulting in the deficiency.
Failure to Provide Restorative Care and Follow Therapy Recommendations
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate restorative care and follow therapy recommendations for a resident with limited range of motion (ROM) and mobility issues. The resident, who had a history of arthritis, muscle weakness, and a right above-the-knee amputation with a prosthesis, was identified as needing ongoing restorative nursing programs (RNP) and therapy interventions to maintain or improve functional status. Despite multiple therapy evaluations and clear recommendations for restorative ambulation and ROM programs, documentation revealed that the resident did not receive restorative exercises or activities for extended periods, as indicated by the absence of restorative program documentation in the electronic health record and Minimum Data Set (MDS) assessments showing zero days of RNP during several look-back periods. Interviews with staff and the resident confirmed that restorative activities were not consistently provided. The resident reported not receiving any exercise program or ambulation assistance after being discharged from therapy services, stating that staff left him alone and he was on his own to perform exercises. Staff interviews revealed confusion and lack of clarity regarding responsibility for restorative care, with restorative duties assigned to staff who were also tasked with other responsibilities such as medication administration and transportation, making it difficult to consistently implement restorative programs. Staff also indicated that the restorative program had not been active for some time and that there was uncertainty about documentation and care plan updates related to restorative services. Policy review showed that the facility's restorative care policy required individualized restorative services based on assessment and care planning, with all employees responsible for providing restorative care. However, the lack of implementation and documentation of restorative activities for the resident, despite therapy recommendations and care plan directives, led to a failure in maintaining or improving the resident's ROM and mobility as required.
Failure to Provide Required Meal or Snack to Dependent Resident
Penalty
Summary
Staff failed to provide a morning meal or snack to a resident who was dependent on staff for eating assistance and had significant cognitive impairment, as well as a history of malnutrition and weight loss. The resident was observed in the dining room after breakfast time with only a cup of juice, and staff confirmed that the breakfast tray had already been discarded and no replacement was provided. The dietary manager and cook both stated they were not informed that the resident needed a meal or snack, despite facility policy requiring food and substantial snacks to be available 24 hours a day and for residents to be offered meals or snacks if they missed a scheduled meal. The resident's care plan specified a puree diet with nectar-thick liquids and documented the presence of severe pressure injuries. The facility's policies outlined open dining and the availability of food at all times, but these were not followed in this instance. Staff interviews revealed a lack of communication and follow-through to ensure the resident received appropriate nutrition after missing the scheduled breakfast.
Unsecured Nebulizer Medication Left at Bedside Without Authorization
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of emphysema and COPD was observed to have unsecured vials of nebulizer medication at their bedside, with no nursing staff present. The resident reported that staff provided as many vials of nebulizer medication as needed and left them at the bedside, allowing the resident to self-administer the medication. The resident's care plan did not indicate that self-administration of medication was permitted, and there was no documentation of an assessment for self-administration in the clinical record. Facility policy requires all drugs and biologicals to be stored in locked compartments and accessible only to authorized personnel. During observations, staff verified the presence of unsecured medication at the resident's bedside. Interviews with staff revealed that the resident had not been assessed or authorized for self-administration, and the facility's procedures were not followed regarding medication storage and access.
Medication Error Rate Exceeds 5% Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with a calculated error rate of 7% based on 2 errors out of 27 observed medication administrations. During medication administration, a Certified Medication Aide (CMA) prepared and administered Vitamin D to a resident, but the order specified Vitamin D3, 25 mcg, indicating the wrong formulation was given. In another instance, the CMA administered Atenolol 50 mg to a different resident despite the order specifying the medication should be held if the resident's pulse was below 60 beats per minute; the resident's pulse was documented at 53 at the time of administration. The facility's policy requires medications to be administered according to physician orders and for staff to verify the drug and dosage against the Medication Administration Record (MAR) and drug label prior to administration. Staff interviews confirmed the errors, with the CMA acknowledging the administration of the incorrect Vitamin D formulation and the failure to hold Atenolol as ordered. The errors were observed and verified through direct observation, record review, and staff interviews.
Resident Served Incorrect Food Texture Despite Puree Diet Order
Penalty
Summary
A resident with dementia and dysphagia, who was assessed as having moderate cognitive impairment and required maximum assistance with eating, was ordered to receive a puree texture diet with moderately thick liquids. During a lunch service observation, the resident was served a meal consistent with their diet order, but an unknown staff member subsequently placed a bowl of regular textured potato salad in front of the resident. Although the potato salad was not fed to the resident, this action was acknowledged by the Certified Dietary Manager as not being in accordance with the resident's prescribed puree diet. Facility policy required that food be provided at the proper texture and consistency to meet individual needs.
Failure to Verify Patient Identifiers Results in Transfer of Incorrect Medical Records
Penalty
Summary
The facility failed to verify patient identifiers before sending transfer paperwork, resulting in the receiving facility obtaining inaccurate medical records for a resident being discharged. The error occurred when the social services supervisor forwarded discharge paperwork that included a fax cover sheet with the correct resident name but an incorrect date of birth and facility name. The attached medical records belonged to a different individual, and the social services supervisor did not review the details of the paperwork before sending it to the receiving facility. The nurse involved in the transfer provided a verbal report about the resident's mental health status and medications but did not handle the physical paperwork, which was managed by social services. The resident involved had a primary diagnosis of schizoaffective disorder and was prescribed psychotropic medications. Due to the incorrect paperwork, the receiving facility placed orders incorrectly, and the resident did not receive her prescribed medications for approximately two weeks. This lapse in medication administration led to a hospitalization related to her mental health condition. The error was only identified after the receiving facility noticed discrepancies and contacted the advanced registered nurse practitioner (ARNP), who then corrected the orders. Interviews with facility staff revealed a lack of verification processes for transfer paperwork. The social services supervisor admitted to noticing the wrong facility name but did not check other identifiers such as date of birth or the content of the orders. The director of nursing and administrator were unaware of how the incorrect paperwork was included in the resident's electronic health record, and the ARNP confirmed she was not involved with the third facility named on the paperwork. The facility's policy required verification of patient information before disclosure, but this was not followed in this instance.
Failure to Report and Address Abnormal Vital Signs and Changes in Condition
Penalty
Summary
The facility failed to identify and report ongoing abnormal vital signs and did not complete required respiratory assessments for two residents. For one resident, there were multiple instances where abnormal vital signs, such as low blood pressure and elevated heart rate, were documented without physician notification. This resident also exhibited shortness of breath on exertion for several days, but the care plan did not address respiratory or cardiovascular concerns, and there was no evidence of follow-up or reporting to the physician. The resident experienced a significant change in condition, including loss of consciousness and irregular breathing, which ultimately led to a hospital transfer. Documentation was incomplete regarding the incident leading to the transfer and the vital signs at the time of a prior fall were not recorded. For the second resident, who had a history of Parkinson's Disease, coronary heart disease, and hypertension, there were repeated episodes of bradycardia (low heart rate) and hypotension. The medication administration record included parameters to hold antihypertensive medication for low blood pressure or heart rate, and the medication was held on several occasions. However, documentation frequently lacked evidence of timely physician notification regarding the persistent abnormal vital signs. The resident experienced multiple falls, episodes of unresponsiveness, and eventually a respiratory arrest that resulted in hospital transfer and subsequent death. Staff interviews confirmed that abnormal vital signs were not always communicated to the provider as required by facility policy. Facility policy required that all significant changes in condition, including abnormal vital signs, be reported to the physician prior to the end of the shift and that all actions and communications be documented in the nursing progress notes. Despite this, the records showed gaps in both notification and documentation for abnormal findings and changes in condition for both residents. The Director of Nursing and other staff confirmed expectations for reporting and documentation, but the review found these were not consistently followed.
Failure to Respect Resident Dignity and Ensure Appropriate Clothing
Penalty
Summary
The facility failed to honor residents' rights to dignity and respect by not adhering to proper protocols when entering residents' rooms and ensuring appropriate clothing for weather conditions. For Resident #2, who has intact cognition and self-care deficits, staff entered the room without waiting for a response after knocking, which the resident found discourteous. A visitor corroborated this behavior, noting it happened frequently. Similarly, Resident #4, who also has intact cognition and self-care performance deficits, experienced a staff member entering their room without knocking, interrupting a private conversation. The staff member acknowledged the mistake but the incident highlights a pattern of disrespectful behavior. Additionally, Resident #1, who has multiple diagnoses including traumatic brain dysfunction and renal disease, was observed inadequately dressed for the weather while waiting to go outside for a supervised smoking break. The resident was wearing a short-sleeved shirt and shorts, exposing their abdomen and leg stumps, while other residents were dressed appropriately for the rainy and windy conditions. The resident indicated that most of their clothing was in the laundry, suggesting a lack of available appropriate clothing. These incidents demonstrate a failure to ensure residents are treated with dignity and respect, as outlined in the facility's policy.
Resident Financial Abuse Due to CNA Misconduct
Penalty
Summary
The facility failed to protect a resident from financial abuse, as evidenced by an incident involving the misappropriation of the resident's property. The resident, who had a moderate cognitive impairment and required assistance with daily activities, was the victim of theft by a Certified Nurses Aide (CNA). The incident was discovered when the resident's family member reviewed footage from a camera installed in the resident's room, which showed the CNA accessing a secured drawer and taking $55 in cash. The CNA denied taking the money but was recorded on video accessing the drawer without the resident's consent. The facility's policy on abuse prevention and prohibition was violated, as it mandates that residents have the right to be free from abuse, neglect, and misappropriation of property. The CNA's actions were a serious breach of trust and a violation of the facility's policies, which emphasize the importance of respecting residents' rights to personal privacy and property. The facility's administrator confirmed the incident after reviewing the video footage and terminated the CNA's employment for violating the zero-tolerance policy regarding the misappropriation of resident property.
Failure to Complete Dialysis Assessments
Penalty
Summary
The facility failed to ensure that before and after dialysis assessments were completed for a resident with end-stage renal disease who required dialysis. The resident, who had no cognitive impairment, reported that staff did not consistently check vital signs before leaving for dialysis appointments or assess them upon return. The resident recalled feeling very ill after a dialysis session in January and felt dismissed by the staff. Interviews with staff revealed that there was a recent change in the process, requiring a form to be completed before and after dialysis, but the forms were not consistently uploaded to the resident's record. A review of the electronic records from February to March showed multiple instances where dialysis assessments were either incomplete or missing. The facility's policy on dialysis care, last reviewed in March 2023, outlined specific pre- and post-dialysis care procedures, including assessing blood pressure, checking the dialysis access site, and reporting any significant changes in the resident's condition. However, the Director of Nursing acknowledged that several assessments were not completed or could not be located, indicating a failure in adhering to the established policy and procedures for dialysis care.
Deficiency in Call System Functionality
Penalty
Summary
The facility failed to provide a properly functioning call system for a resident, leading to a deficiency in resident-to-staff communication. The resident, who had a traumatic brain injury, heart disease, respiratory failure, diabetes, renal disease, depression, schizophrenia, and bilateral leg amputations, required substantial assistance with daily activities. Despite having intact cognition, the resident was unable to effectively communicate with staff due to a malfunctioning call light system. During an observation, the resident attempted to use the call cord, but the call light did not activate, indicating a failure in the system. Staff interviews revealed that the call light system was known to have issues, and temporary measures, such as providing a button to alert the nurse's station, were in place for other residents. The facility's administrator acknowledged the problem and mentioned plans to replace the entire call light system, which had been delayed. The facility's policy required providing residents with a means of communication with staff, which was not met in this instance, leading to the deficiency.
Failure to Prevent Burn Injury Due to Hot Water Hazard
Penalty
Summary
The facility failed to identify and mitigate a hazard in the shower room, leading to a resident sustaining a second-degree burn. On October 28, 2024, a resident with quadriplegia, who was dependent on staff for bathing, reported a red mark on their right forearm after a shower. The mark measured 10.3 cm by 5.6 cm and had scattered blisters. The resident attributed the injury to the hot water in the shower room. Despite this report, the facility continued to use the shower room without addressing the potential hazard. On November 5, 2024, a Department of Inspection, Appeals and Licensing (DIAL) staff member measured the water temperature in the shower room and found it to be 145.2 degrees Fahrenheit, significantly higher than the recommended safe temperature. This high temperature posed a risk of burns to residents, as evidenced by the injury sustained by the resident. Interviews with staff revealed that the water temperature in the shower room was known to be excessively hot, yet no measures were taken to regulate it or prevent its use until the issue was resolved. The facility's maintenance logs lacked documentation of water temperature checks in the shower rooms, focusing instead on resident rooms and other areas. Staff interviews indicated that the water temperature in the shower room was variable and could become dangerously hot if turned all the way up. Despite these known issues, the facility did not implement adequate supervision or preventive measures to ensure resident safety, resulting in the resident's injury.
Removal Plan
- Resident #2 had treatment in place of the area on the right arm.
- The 3 residents that were given showers had complete head to toe skin assessments completed and were questioned about the temperature of water.
- Weekly skin assessments are recorded in each resident's chart in Point Click Care (PCC), no residents voiced concerns about shower temperature, or any injuries noted from skin assessments.
- All showers were put out of use immediately after DIL staff reported water temperature finding of 145.2 degrees. The high temperature had the potential to harm other residents in the facility that receive showers.
- All showers are regulated to prevent water temperatures above 120 degrees.
- Plumber services contacted to assess the current plumbing system with additional monitoring thermometer installed on the water heater. Plumber's report isolated an incident of sediment build up that was resolved by maintenance staff with no further interventions required for safe water temperatures.
- Maintenance will check water temperature in each shower room daily for the next 7 days and then on a weekly basis as a part of weekly system checks through TELS. Weekly system checks have no end date.
- All nursing staff will be educated on how to monitor water temperature with a thermometer placed in the shower room. If the water temperature is greater than 120 degrees, they are to cease the shower for the resident, and report to the administrator, maintenance or charge nurse and cease showers until the water temperature has been checked and deemed to be at a safe level.
Failure to Provide Dialysis Transportation
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis treatments was provided with appropriate transportation arrangements to and from the dialysis facility of his choice. The resident, who had a BIMS score of 15 indicating no cognitive impairment, had diagnoses including end-stage renal disease, atrial fibrillation, coronary artery disease, and diabetes mellitus. The resident had changed his dialysis center to a location closer to the facility with appointments scheduled for early mornings. Despite being informed of the new schedule, the facility did not arrange transportation for the resident, who was aware that the facility van was not available at the required time. The resident had previously been informed about transportation options but had initially stated he could arrange his own transportation. However, when the time came for his appointments at the new dialysis center, the facility did not provide transportation, and the resident missed appointments. The facility staff, including the Administrator and DON, were aware of the resident's new dialysis schedule but did not make arrangements to accommodate the early appointment times. The facility's transportation staff indicated they could have adjusted their schedules if requested, but this was not arranged. The facility's Admission Packet stated that they would arrange for appropriate transportation for residents to healthcare services outside the facility. However, the resident reported that he was not offered alternative transportation options such as a taxi or Uber. The facility's failure to provide transportation was attributed to the resident's indication that he would arrange his own transport, but ultimately, the facility did not fulfill its responsibility to ensure the resident's access to necessary medical care.
Failure to Provide Timely Care and Equipment Management
Penalty
Summary
The facility failed to provide timely assessment and intervention for Resident #10, who had a history of anemia, hyponatremia, non-Alzheimer's dementia, and other conditions. Despite signs of decline, such as increased lethargy and elevated white blood cell count, staff did not promptly act on these changes. The resident's family expressed concerns about the resident's condition, suspecting a urinary tract infection, but the necessary urine analysis was delayed due to miscommunication and lack of follow-through by the staff. This delay resulted in the resident becoming unresponsive and requiring an emergent transfer to a hospital. Resident #4 experienced issues with their negative pressure wound therapy (NPWT) machine, which was audibly beeping for an extended period without staff intervention. Multiple staff members entered the room but did not address the alarm, and the machine was found unplugged. The care plan required regular changes to the wound vac, but the lack of response to the alarm suggests a failure to adhere to the care plan and monitor the resident's equipment properly. Resident #8, who required continuous oxygen therapy, was found without oxygen on multiple occasions. The oxygen concentrator was unplugged, and the resident reported not using oxygen for several days. Despite the resident's moderate cognitive impairment, staff did not ensure the oxygen equipment was functional or that the resident was using it as prescribed. Similarly, Resident #9 was found with an empty portable oxygen tank, and there was confusion about the correct oxygen flow rate, indicating a failure to follow physician orders and ensure proper oxygen administration.
Failure to Secure Resident Information on Laptops
Penalty
Summary
The facility failed to protect resident information from unauthorized access, as observed in two separate incidents involving medication carts and laptops. On one occasion, a medication cart on the 200 resident hall was left unlocked with resident information visible on the laptop screen, and no staff was present. Staff A, a Certified Medication Aide (CMA), admitted to leaving the cart unlocked and the laptop open by mistake. In another instance, a medication cart was again found unlocked with 12 residents' information visible on the laptop screen in a dining room with 8 residents present and no authorized staff nearby. Staff B, another CMA, acknowledged that it was not customary to leave the laptop and cart unsecured when away from the cart. The facility's policy, titled Safeguards for PHI, dated January 2017, requires that all documents containing Protected Health Information (PHI) be stored securely in a locked location with limited access to authorized personnel. The Director of Nursing (DON) confirmed that staff should activate the lock feature on the screen before leaving the area.
Failure to Honor Resident Representative's Request for Hospitalization
Penalty
Summary
The facility failed to ensure the rights of a resident's representative were met, specifically for a resident who was unable to communicate effectively due to various medical conditions, including non-Alzheimer's dementia and metabolic encephalopathy. The resident's relative expressed concerns about the resident's declining condition and requested hospitalization, suspecting a urinary tract infection. Despite notifying the nursing staff and the Director of Nursing (DON) about the resident's symptoms and the need for hospital care, the relative's requests were not acted upon promptly. The resident's condition continued to decline, with increased lethargy and elevated white blood cell count, but the facility did not contact the medical provider as requested by the relative. The resident's condition worsened, leading to unresponsiveness, at which point the facility finally obtained orders to send the resident to the hospital. Interviews with staff revealed a lack of recollection regarding the relative's requests, and the medical provider confirmed they were not informed of the relative's desire for hospitalization. The facility's policy on resident rights emphasized the importance of informing residents and their representatives about treatment options and respecting their choices, which was not adhered to in this case.
Failure to Notify Family of Medication Change
Penalty
Summary
The facility failed to notify the family or representative of a resident about a medication change, specifically the discontinuation of Lorazepam, which was initially scheduled to be given four times a day. The resident, who had severe cognitive impairment and was dependent on staff for various activities, was under hospice care and had a history of congestive heart failure, diabetes, and other conditions. The resident experienced a fall, leading to the decision to switch Lorazepam to a PRN basis. However, there was no documentation of family notification regarding this change. The facility's policy required prompt notification of the resident's family or representative about significant changes in the resident's condition or treatment. Despite this, the documentation and interviews revealed that the family was not informed of the medication change on the specified date. The LPN responsible for notifying the family was no longer employed at the facility, and the nurse practitioner confirmed that she did not communicate with the family about the medication change, leaving the responsibility to the hospice RN or facility nurses.
Failure to Follow Physician Orders and Accurate Documentation
Penalty
Summary
The facility failed to ensure physician orders were followed and documented accurately for two residents. Resident #8, who had multiple diagnoses including chronic respiratory failure and utilized oxygen therapy, was observed multiple times without oxygen despite a physician's order for continuous oxygen use. The oxygen concentrator was found unplugged, and the resident reported not using oxygen for several days because staff had moved the concentrator and failed to plug it back in. Despite this, staff documented oxygen saturations as if the resident was using oxygen, indicating a discrepancy in documentation. For Resident #2, there was a discrepancy in medication administration documentation. An observation revealed that acetaminophen intended for administration on a specific date was still in the medication cart, yet the electronic medication administration record indicated it had been given. The Director of Nursing acknowledged that documentation should reflect actual events and stated that any discrepancies would be investigated to determine if they were accidental or intentional errors.
Failure to Follow Physician Orders and Medication Error
Penalty
Summary
The facility failed to ensure physician's orders were followed for two residents. For one resident, a physician ordered a urinalysis (UA) with culture and sensitivity, increased gastric tube flushes, and monitoring for signs of infection. However, the UA order was not entered into the Electronic Health Record (EHR) by the Assistant Director of Nursing (ADON), who was responsible for doing so. The ADON delayed entering the order due to uncertainty about the need for straight catheterization to collect the urine sample. Consequently, the UA was not collected, and the medical provider was not notified of this failure. The resident's condition continued to decline, and the family expressed concerns about the resident's symptoms, which they associated with a urinary tract infection. For another resident, a medication error occurred when a Registered Nurse (RN) documented administering Acetaminophen 325mg, two tablets, on the Electronic Medication Administration Record (EMAR), but the medication was found in the medication cart the following day, indicating it was not given. The Director of Nursing (DON) stated that staff should notify the doctor, file an incident report, notify the family, and monitor the resident's condition for 72 hours if a medication error occurs. However, the report does not indicate that these steps were taken following the error.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate treatment and services to promote the healing of a pressure ulcer for a resident with intact cognition and multiple diagnoses, including a neurogenic bladder, hip fractures, traumatic brain injury, and a pressure ulcer. The resident required assistance with various activities of daily living and was receiving nonsurgical dressings. The care plan directed staff to change the wound vac on specific days and as needed. However, a grievance indicated that weekend staff did not provide wound vac care due to a lack of knowledge, leading to a change in treatment days. On a specific day, the resident's wound vac machine was observed to be beeping, indicating an issue, but staff entering the room did not respond to the alarm. Later, the wound vac was found disconnected from the power supply, not providing suction. The ADON eventually changed the wound vac dressing and reconnected the device, but the resident reported previous instances of the battery running down. Additionally, the resident was observed without the wound vac after attending a festival, and it was not reapplied until the following day, despite expectations for it to be reapplied sooner.
Failure to Ensure Continuous Oxygen Supply for Resident
Penalty
Summary
The facility failed to ensure that oxygen was available for a resident who required continuous oxygen therapy. During an observation, it was noted that the resident was resting in a wheelchair with an empty portable oxygen tank, despite being prescribed 4 liters of oxygen via nasal cannula continuously. The Certified Medication Aide assessed the resident's pulse oximetry, which showed low oxygen saturation levels between 85-89%, indicating the oxygen tank was empty. The Assistant Director of Nursing (ADON) was involved in obtaining a new portable oxygen tank and switching it, which improved the resident's oxygen saturation to 95% on 3 liters. Further observations revealed that the resident was again found with a portable oxygen tank that was nearly empty, indicating a need for a refill. Interviews with the ADON revealed a lack of documentation and verification processes for checking the remaining amount in portable oxygen tanks. The facility's policy on oxygen administration required reassessment of the oxygen flowmeter for correct liter flow and documentation of all appropriate information in the medical record, which was not adhered to in this case.
Incompetent Staff Leads to Improper Enema and Missed Wound Care
Penalty
Summary
The facility failed to maintain competent staff to perform an enema on Resident #10, who reported that an LPN performed the procedure roughly, resulting in rectal bleeding. The resident, who had intact cognition and required maximum assistance with daily activities, had a physician's order for a Lactulose enema with digital stimulation. However, the LPN did not perform the digital stimulation, citing a discontinued order, and inserted the enema wand without proper visualization or positioning, leading to resistance and bleeding. Witnesses, including a CNA and the resident's family member, confirmed the rough handling and lack of adherence to the procedure. Additionally, the facility failed to provide wound vacuum care for Resident #4 over a weekend, as the staff reported they did not know how to operate the wound vacs. This resident, who also had intact cognition, required wound vac changes three times a week for a pressure ulcer. The care plan and physician's order specified the need for regular wound vac application, but the staff's lack of competency led to missed treatments. The Director of Nursing acknowledged the confusion among nurses regarding the enema order and the lack of competency in wound vac procedures. The facility did not have completed competency checklists for staff, which contributed to the deficiencies in care for both residents.
Medication Cart Security Lapses
Penalty
Summary
The facility failed to properly secure medications from unauthorized access, as observed in two separate incidents involving medication carts. On the morning of September 24, 2024, the medication cart on the 200 resident hall was found unlocked and unattended, with Staff A, a Certified Medication Aide (CMA), admitting to leaving it unlocked by mistake. Later that day, the medication cart on the 100 resident hall was also observed unlocked in the dining room with eight residents present and no authorized staff nearby. Staff B, another CMA, confirmed that it was not customary to leave the cart unlocked when unattended. Additionally, at 11:15 AM on the same day, the medication cart on the 200 resident hall was again found unlocked and unattended while Staff A entered a resident's room, leaving the cart out of sight across the hall. The facility's policy, revised on August 1, 2024, mandates that medication carts must be locked at all times when not in use and remain in the line of sight if not locked. The Director of Nursing (DON) reiterated that staff should lock the cart if they leave it.
Resident Elopement Due to Inadequate Supervision and Unsecured Exit Doors
Penalty
Summary
The facility failed to properly secure exit doors and ensure adequate supervision for a resident at risk of wandering and elopement. The resident, who had a history of wandering and elopement, was last seen by staff in the evening and was not found until two days later. During this time, the resident left the facility unattended, walked several blocks to a retail store, and later admitted himself to the Emergency Department for evaluation due to knee pain. The resident's care plan initially lacked information regarding wandering or elopement risk, and there was no wander guard alarm documented in the Medication Administration Record or Treatment Administration Record. The resident had been admitted to the facility from another LTC facility and had diagnoses including debility, diabetes, malnutrition, schizophrenia, and a hip fracture. Despite being alert and oriented, the resident was deemed an elopement risk upon admission, and a wander guard was initially applied. However, the facility's records and staff interviews revealed inconsistencies in monitoring and documenting the wander guard's placement and functioning. Staff interviews indicated that the resident was independent and often sat near exit doors, which may have contributed to the elopement. On the night of the incident, a cultural event was taking place, and staff were occupied with various activities, which may have led to a lack of supervision. The facility's exit doors were not properly secured, as evidenced by a rock being used to prop open a door, allowing the resident to leave unnoticed. Staff interviews highlighted issues with staffing levels and familiarity with residents, as well as the absence of cameras to monitor exit doors. The facility's failure to adequately supervise the resident and secure exit doors resulted in the resident's elopement and subsequent admission to the Emergency Department.
Inappropriate Meal Service for Residents with Dysphagia
Penalty
Summary
The facility failed to provide therapeutic meals according to physician orders and speech therapy recommendations for two residents. Resident #26, who has severe cognitive impairment and dysphagia, was served inappropriate food items that posed a choking risk. Despite a recommendation to remove bread from her diet due to coughing while consuming bread products, she was served a garlic breadstick and pound cake, leading to heavy coughing. The Speech Language Pathologist had to intervene to prevent further consumption and educate staff about the resident's dietary restrictions. This incident highlighted ongoing issues with the kitchen serving improper diets, as the resident had previously been served large chunks of chicken instead of a mechanically softened diet. Resident #4, also with severe cognitive impairment and dysphagia, was served a pureed diet with inappropriate additions of Cheeto Puffs and a lettuce salad. The resident consumed several Cheeto Puffs before staff intervention. The dietary staff had printed diet slips in advance, which did not reflect recent changes to the resident's diet. This practice contributed to the resident receiving an incorrect diet. Staff interviews revealed a lack of a formal system to notify care staff of diet changes, leading to confusion and improper meal service. The facility's dietary practices were further scrutinized, revealing that the kitchen staff did not follow IDDSI guidelines and lacked proper documentation for menu substitutions. The dietary cook admitted to substituting pound cake without approval due to a shortage of blushing pears. The facility's failure to adhere to dietary guidelines and update diet slips in a timely manner resulted in residents being served inappropriate meals, posing a risk of choking and aspiration.
Removal Plan
- 100% Audit of Resident diet orders
- 100% Audit of resident diet cards
- 100% Care plan audit for all residents to verify diet and texture are accurate
- 100% Audit completed of diet type and texture, with any additional diet texture restrictions to follow a triple check process
- All staff educated on the signs and symptoms of choking or swallowing issues
- All staff were educated for competency of providing correct textures in regard to modified diets
- An in-service was completed in person by the dietician and verbally communicated by nurse management to staff members regarding diet textures
- A Quality Assurance and Performance Improvement (QAPI) meeting was held to address the IJ.
Failure to Include Resident Representative in Care Plan Conference
Penalty
Summary
The facility failed to include the resident representative in the care plan participation conference for a resident with severe cognitive impairment. The resident, who was admitted with a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment, had a family member designated as Power of Attorney (POA) for care, financial, and healthcare decisions. This family member, who was also the responsible party and care conference person, reported not being invited to or attending any care conference to discuss the resident's plan of care. The facility's Electronic Health Record (EHR) for the resident lacked documentation of a care plan conference. The MDS Coordinator confirmed that a 72-hour care conference was neither completed nor scheduled for the resident, and the resident and family member were not invited to participate. The facility's training materials directed staff to review the baseline care plan with the resident or responsible person within 48 hours of admission, but this process was not followed. The facility did not provide a policy on care conferences, only a power point training on care plan development.
Failure to Conduct Level II PASRR Evaluations
Penalty
Summary
The facility failed to refer two residents with a Level I Preadmission Screening and Resident Review (PASRR) for a Level II evaluation when new serious mental disorders were diagnosed. Resident #29, who had moderate cognitive impairment, was initially screened with a Level I PASRR in November 2022, which documented anxiety disorder and depression as primary diagnoses. However, subsequent diagnoses included delusional disorders and major depressive disorder, and the resident was prescribed Escitalopram. Despite these changes, a Level II PASRR was not submitted, as acknowledged by the Social Services Director (SSD). Similarly, Resident #36, who was rarely understood, had a Level I PASRR in December 2019, which did not document any mental health diagnoses. The resident was later diagnosed with anxiety disorder and Schizoaffective disorder and was prescribed Hydroxyzine and Quetiapine Fumarate. Despite these significant changes, a Level II PASRR was not completed. The SSD confirmed that a Level II PASRR should have been submitted for both residents due to changes in medication and mental health diagnoses.
Deficiency in Nail Care for Two Residents
Penalty
Summary
The facility failed to provide necessary grooming services for two residents, leading to deficiencies in nail care. Resident #33, who has severe cognitive impairment and limited mobility due to conditions such as Alzheimer's disease and osteoporosis, was observed with long and jagged toenails, some of which were growing into the skin. Despite the care plan's instructions to check and trim nails during bi-weekly showers, records showed multiple refusals of showers by the resident, and on the occasions when showers were given, staff documented that the toenails did not need trimming. A family member reported requesting nail trimming since mid-June, but the request was not fulfilled. The Assistant Director of Nursing (ADON) confirmed that staff are expected to observe and trim toenails during showers, acknowledging that Resident #33's nails should not have reached such a state. Resident #57, who is paraplegic and legally blind, was also found with very long and jagged toenails. The resident, dependent on staff for personal hygiene, reported that his toenails had only been trimmed once since admission four months prior. Despite expressing a preference for shorter nails, the resident's lack of sensation in the lower legs and blindness prevented self-awareness of the nail length. The care plan for Resident #57 similarly included instructions for bi-weekly bathing and nail care, which were not adequately followed, resulting in the observed deficiency.
Facility Fails to Maintain Clean and Safe Bathroom Conditions
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in the bathrooms of four resident rooms, as observed during a survey. In the bathroom of a room occupied by Resident #3, a tile was missing on the back wall, and a black substance was present on the edges of the tiles. Similarly, the bathroom shared by Residents #4 and #6 had a missing tile with a black substance on the walls and accumulated in the corners. The bathroom of Resident #1 had a brown substance on the toilet seat hinges and the outside of the toilet. Additionally, the bathroom shared by Residents #10 and #11 had two missing tiles near the toilet, with broken tile pieces on the floor. The facility's policy, dated October 2022, required staff to clean under the toilet bowl, spot clean walls, mop the floor, and conduct maintenance checks for repairs. However, these policies were not adhered to, as evidenced by the observations and the statement from the Director of Nursing, who acknowledged that bathrooms should be free of black substances and tiles should be in good condition.
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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