Hallmark Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Vernon, Iowa.
- Location
- 215 Highway 30 Sw, Mount Vernon, Iowa 52314
- CMS Provider Number
- 165333
- Inspections on file
- 16
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Hallmark Care Center during CMS and state inspections, most recent first.
Failure to Document Consent and Education for Psychotropic Medications: The facility did not document consent, resident education, or discussion of alternative treatments before giving psychotropic medications to four residents with diagnoses including dementia, anxiety, depression, PTSD, insomnia, and bipolar disorder. Records showed orders for antidepressants, antianxiety medications, antipsychotics, and hypnotic agents, but no progress notes or assessments reflected education on risks and benefits or that alternatives were offered, and the facility had no policy for psychotropic medication use.
The facility inaccurately coded several MDS assessments for medications, smoking, falls with major injury, and restraints. Records showed one resident received aspirin and clopidogrel for stroke prevention, but the MDS incorrectly coded anticoagulant use; another resident’s bed grab bar was coded as a restraint even though it was used for repositioning and bed mobility. Other MDSs failed to capture prescribed psychotropic medications, current tobacco use, and a fall with major injury, and the DON acknowledged some assessments were not accurate.
Failure to document vaccine education and consent. The facility did not provide documented education or obtain informed consent for influenza vaccination for four residents and pneumococcal vaccination for three residents. Review of EHRs showed several residents had not received the indicated vaccines, and the DON could not find records showing education was provided or signed refusals were obtained. The Infection Control Manual required education, consent, and EHR documentation for immunizations.
A resident received Medicare-covered skilled services, but the facility did not provide an accurate NOMNC with the correct end date and did not issue a SNF ABN when coverage ended and payor source changed to private pay. Chart review showed the resident’s spouse was concerned about discharge timing, yet the record lacked documentation explaining the delayed discharge, had no discharge summary, and included an incomplete discharge instruction assessment; the facility later noted the ABN was likely overlooked during a staff changeover.
Missing transfer documentation for hospitalized residents. The facility failed to keep records of the information sent with two residents during four hospital transfers. Review of progress notes and assessments showed no documentation of the MAR, TAR, IPOST, face sheet, bed hold form, vital signs, or verbal reports that the DON expected staff to provide to EMTs and the ER, and the DON and Administrator stated the facility did not have a written discharge policy or procedure.
A resident’s PASRR was not updated after PTSD was documented and psychotropic meds were ordered and given, while two other residents with PASRR Level II outcomes did not have the required specialized and rehabilitative services reflected in their care plans. The DON and SW reported uncertainty and lack of training related to PASRR completion and updates.
Care plans were not updated for two residents after hospital returns. One resident returned with a PICC line and antibiotics after treatment for kidney stones and a UTI, but the care plan did not reflect the hospitalization, antibiotic therapy, kidney stones, or PICC site maintenance. Another resident returned after treatment for hypernatremia, diabetes insipidus, aspiration pneumonia, acute respiratory failure, and electrolyte abnormalities, but the care plan did not include the recent hospitalization or monitoring for hypernatremia. The DON confirmed the care plans were not updated, and the facility policy lacked instructions for reviewing care plans after hospitalization.
A resident with HF and CKD stage 4 had a physician order for daily morning weights, but multiple weights were missing from the ETARs and vital sign records over several months. Staff said CNAs usually obtained the weights and nurses documented them, but the DON and Administrator reported the weights were likely not entered into the EHR vital sign area, and the facility policy required active orders to be followed as written.
QAPI process failed to address PASRR deficiencies after a prior F644 citation. A resident’s record showed a PASRR completed by a hospital that listed suspected anxiety disorder and use of antidepressant and antianxiety meds, but the resident was later admitted with PTSD and then started on Abilify without an updated PASRR evaluation in the record. The DON confirmed no updated PASRR had been completed since the hospital screening, while the Administrator stated tagged-area audits were to be tracked through QAPI.
The facility failed to ensure the Infection Preventionist attended quarterly QAPI meetings. QA sign-in sheets showed no documentation of attendance at two quarterly meetings, and the DON stated the Infection Preventionist may have been working the floor at those times. The Administrator confirmed the Infection Preventionist was not present, and the meeting notes did not show a significant quarterly review of the infection control program/tracking.
The facility failed to document COVID-19 vaccine education and informed consent for two residents. Review of the EHRs found no evidence that either resident received vaccine education or consent, and the DON could not locate documentation of education or signed refusal forms. The facility policy required staff to educate residents, obtain consent for available vaccines, and document all immunizations in the EHR.
A facility failed to accurately report a resident's mental health diagnoses and medications in the PASRR process. The resident, diagnosed with depression, anxiety disorder, and PTSD, had a PASRR that omitted PTSD and certain medications. Staff interviews revealed a lack of awareness of the resident's diagnoses, and the DON acknowledged the oversight. The facility lacked a specific PASRR policy, contributing to the deficiency.
A resident with impaired cognition and a wrist injury experienced inadequate pain management following a fall. Despite high pain ratings, the care plan lacked focus on pain management, and documentation of follow-up assessments was inconsistent. Staff interviews indicated verbal assessments were conducted, but these were not documented, and the facility's pain policy was not consistently followed.
A facility failed to provide trauma-informed care for a resident with PTSD, depression, and anxiety. The resident's care plan did not address her mental health needs, and staff were unaware of her diagnoses and triggers. The resident expressed feeling frustrated and unsupported during health changes. The facility lacked a policy for trauma-informed care, and the care plan did not include necessary mental health information.
The facility failed to provide bed hold notices to two residents or their representatives before hospital transfers, as required by policy. One resident was transferred due to an unwitnessed fall with a head injury, and another due to a change in condition and viral infection. Documentation did not include whether bed hold notices were sent, violating the facility's policy.
A facility failed to submit a discharge MDS for a resident who was discharged to the community, with no return anticipated. The MDS was completed but not submitted to CMS, and the DON was unsure why the 'do not submit' indicator was triggered. The facility lacked a policy for MDS assessments and relied on the RAI manual, which requires submission within 14 days.
The facility failed to ensure food items were covered, dated, and stored to prevent possible cross-contamination. Uncovered drinks and pies without labels or dates were found in the walk-in refrigerator. Staff were unsure about the timing of food preparation and acknowledged the need for proper food storage practices.
The facility failed to complete a follow-up PASRR for a resident with a change in mental health status. The resident had psychiatric disorders and was receiving antipsychotic medications. The administrator acknowledged the oversight, noting that some diagnoses were discovered post-admission and a new PASRR should have been submitted.
Failure to Document Consent and Education for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments by not providing education on the risks and benefits of psychotropic medications and by not offering alternative treatment options before administration for 4 of 5 residents reviewed for unnecessary medications. Clinical record reviews showed that Resident #8, with diagnoses including non-Alzheimer's dementia, anxiety disorder, and depression, was admitted on 7/23/25 and received escitalopram, buspirone, and quetiapine without documentation of consent, education on side effects or risk versus benefit, or alternative treatments. The Administrator stated on 4/7/26 that the DON had started in October 2025 and had been catching up psychotropic assessments that had previously been completed. Resident #18, admitted on 10/22/25 with anxiety disorder, PTSD, and insomnia, had orders for sertraline and trazodone in October 2025 and later Abilify and doxepin, but the EHR did not show consent before administration or documentation of education or alternative treatments. Resident #33, admitted on 9/25/25 with anxiety disorder, depression, bipolar disorder, and PTSD, had orders for bupropion, duloxetine, trazodone, and buspirone, and Resident #38, admitted on 9/3/25 with anxiety disorder and PTSD, had orders for Abilify, trazodone, buspirone, and duloxetine; for both residents, the EHR lacked consent, education on psychotropic medication risks and benefits, and documentation that alternative treatments were offered. On 4/8/26, the Administrator stated she had started her position about a month earlier and would speak with the DON regarding education and consents for psychotropic medications. The facility did not have a policy for use of psychotropic medications.
Inaccurate MDS Coding for Medications, Smoking, Falls, and Restraints
Penalty
Summary
The facility failed to accurately code resident assessments on the MDS for falls with major injury, medications, smoking, and restraints for 5 of 15 reviewed residents. Survey findings showed that the MDS coding did not match the clinical record, medication administration records, resident interviews, or staff interviews in several cases, and the facility’s DON and corporate MDS staff acknowledged that some assessments were not accurate. For one resident with a stroke diagnosis and moderate cognitive impairment, the record showed aspirin and clopidogrel were administered for secondary stroke prevention, but the MDS coded anticoagulant and antiplatelet medications despite the records lacking documentation of any anticoagulant administration. The CMS LTC RAI Manual specifically directed that aspirin and clopidogrel are not to be coded as anticoagulants. The DON stated she would verify whether any anticoagulant had been given and later reported that the MDS assessments were not accurate. For another resident, the MDS coded a bed rail as a restraint even though the resident used a grab bar to reposition in bed and to help with getting in and out of bed. The resident stated the grab bar helped her remain independent and did not restrict her movement, and staff reported there were no residents using restraints. The DON stated the grab bars were being coded as restraints and that she was trying to change care plans to reflect they were not restraints. Additional inaccuracies involved a resident whose MDS failed to document antianxiety and antipsychotic medications despite MAR documentation of Buspirone and Seroquel, a resident whose MDS failed to document current tobacco use despite the resident stating she was a smoker and the care plan reflecting smoking, and a resident whose MDS failed to code a fall with major injury despite documentation of a sacral fracture after an emergency department visit. The DON later stated staff should have coded tobacco use for one resident and a fall with major injury for another resident, and clarified that one resident’s bed bars were for mobility rather than restraint use.
Failure to Document Vaccine Education and Consent
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations. Based on review of records, staff interviews, and facility policy, the facility failed to provide education and obtain informed consent for influenza vaccination for 4 of 4 residents reviewed (Resident #7, #12, #18, and #24) and for pneumococcal vaccination for 3 of 3 residents reviewed (Resident #7, #18, and #24). Review of the census and EHR showed Resident #7, Resident #18, and Resident #24 had not received influenza or pneumococcal vaccinations, and Resident #12 had not received influenza vaccination. The DON stated the current Infection Preventionist was on leave and, after reviewing past immunization records, could not find documentation that the residents were provided education or that any signed refusals were obtained. The facility’s Infection Control Manual, last revised in 10/2025, required staff to educate residents, obtain consent for available vaccines, and document all immunizations in the EHR.
Failure to Provide Accurate Medicare Non-Coverage and SNF ABN Notices
Penalty
Summary
The facility failed to ensure that Resident #50 received an accurate and timely Notice of Medicare Non-Coverage (NOMNC) and failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare-covered services ended and the resident’s payor source changed to private pay. Record review showed the resident received Medicare-covered services from 2/10/26 through 3/3/26, with private pay beginning on 3/4/26. However, the facility-provided NOMNC signed by the resident’s spouse/representative on 2/18/26 stated that Medicare coverage would end on 2/24/26, and the Administrator later stated she could not locate another NOMNC with the correct end date of 3/3/26. The chart also did not contain a SNF ABN for Resident #50. The facility documented on 4/7/26 that the ABN was not provided because the plan was for the resident to discharge home the day after skilled care ended, and that a staff changeover occurred at the same time and the ABN was likely overlooked. Notes from 2/20/26 and 2/27/26 showed the husband was concerned about the projected discharge date and that the resident was seen for therapy follow-up and discharge planning, but no chart notes explained that the original discharge date was delayed or why it changed. No discharge summary note was found, and the Instructions for Discharge assessment dated 3/5/26 was incomplete.
Missing Transfer Documentation for Hospitalized Residents
Penalty
Summary
The facility failed to maintain documentation of the information sent to the hospital during transfers for 4 of 4 hospitalizations reviewed for two residents. Resident #2 had hospital transfers documented on the census list from 1/19/26 to 1/23/26 and from 3/25/26 to 4/2/26, but review of progress notes and assessments showed no documentation of what information was sent to the hospital for either transfer. Resident #6 had hospital transfers documented from 2/18/26 to 2/27/26 and from 3/29/26 to 4/3/26, and again the progress notes and assessments did not show documentation of the information sent to the hospital for either hospitalization. During interview, the DON and Administrator stated the facility did not have a written discharge policy or procedure, and the DON said staff were expected to send the MAR, TAR, IPOST, face sheet, and bed hold form, along with vital signs and verbal reports to EMTs and the ER; however, they acknowledged the facility could not locate the documentation sent with either resident for any of the reviewed hospitalizations.
PASRR reviews and care plans were not kept current with mental health diagnoses and Level II service needs
Penalty
Summary
The facility failed to ensure a resident’s mental health diagnosis and psychotropic medications were accurately reported to the designated state agency for PASRR review. Resident #38 was admitted after a hospital PASRR found no SMI, ID, or related condition and noted suspected anxiety disorder with antidepressant and anxiety medication use in the prior 6 months. The clinical record did not contain an updated PASRR after the resident’s discharge summary documented PTSD, follow-up with psychiatry and psychology, and an order for trazodone for PTSD. The resident’s EMAR showed trazodone was administered, the care plan later documented psychotropic medication use related to PTSD and behavior and psychosocial issues related to PTSD and anxiety, and a later referral for telehealth psychiatry listed anxiety disorder and PTSD along with antidepressant use for PTSD. A subsequent physician order added Abilify for PTSD, and the DON reported the facility did not have an updated PASRR for the resident; the Social Worker stated she was still working on conditional PASRR training and did not know whether PTSD or medication changes required rescreening. The facility also failed to implement PASRR Level II recommendations into the care plans for two residents. Resident #6’s PASRR Level II outcome identified her as Level II and directed specialized and rehabilitative services, but the current care plan did not include the Level II outcome or the implementation of those services. Resident #18’s PASRR Level II outcome also identified her as Level II and directed specialized and rehabilitative services, but the care plan review did not identify who would oversee the services, when they would begin, or whether necessary referrals had been completed. The Administrator stated the Social Worker completed PASRRs and had been in the role for nine months but had not received training on how to complete them.
Care Plans Not Updated After Hospitalizations
Penalty
Summary
The facility failed to implement interventions into the care plans for 2 of 2 residents following their return from hospitalizations. Resident #2 had two hospitalizations, first for acute respiratory failure with hypoxia due to Influenza A and a UTI, and later for kidney stones and a UTI. After the second return to the facility, he had a PICC line and was receiving antibiotics, but his current care plan had not been updated to include the recent hospitalization, antibiotic therapy, kidney stones, or PICC site maintenance. Resident #6 also had two hospitalizations, first for hypernatremia and diabetes insipidus, and later for aspiration pneumonia, acute respiratory failure, hypernatremia, and hyperkalemia. Her current care plan had not been updated to include the recent hospitalization or whether signs or symptoms could be monitored in the facility for hypernatremia. The DON confirmed that the care plans for Resident #2 and Resident #6 were not updated following their hospitalizations, and the facility’s care plan policy did not include instructions about whether care plans need to be reviewed following hospitalizations.
Missed Documentation of Ordered Daily Weights
Penalty
Summary
The facility failed to follow a physician order to obtain daily morning weights for a resident with heart failure and chronic kidney disease stage 4. The electronic health record showed an order for daily weights starting 11/25/25, and the care plan directed staff to monitor weights as ordered. Review of the 2026 ETARs and vital sign weight records showed multiple missing daily weights in January, February, March, and April for the resident. Staff interviews indicated the CNAs generally obtained the weights in the morning and gave them to the nurses, who documented them in the resident’s EHR. An LPN stated the resident required daily weights before and after dialysis treatments, while the DON reported that if the nurse did not enter the weight into the vital signs weight section, the weight was probably not documented. The Administrator stated nurses may not have known about a supplemental area in the EHR for entering the weight, and that most likely the weight was taken but not entered into the EHR vital sign area. The facility policy stated active orders should be followed and carried out as written.
QAPI Process Failed to Address PASRR Deficiencies
Penalty
Summary
The facility failed to implement effective quality assurance processes to address PASRR deficiencies, resulting in F644 being cited in 2025 and again during the current survey. The facility’s CASPER report showed a prior citation for F644 Coordination of PASRR and Assessments in March 2025. The CMS 2567 POC for that citation stated that Administrative Nurses and the Social Service Designee would continue reviewing PASRR assessments during the referral process to ensure new admissions had all mental health diagnoses included before admission, and that the Social Service Coordinator or designee would audit admissions monthly for three months to ensure all diagnoses were listed on the current PASRR. A review of Resident #38’s clinical record showed a PASRR completed by a local hospital on 9/02/25 before admission that listed suspected anxiety disorder and use of antidepressant and antianxiety medications. The resident was admitted with a physician order for antidepressant medication for PTSD, and on 12/19/25 a physician order was written to start Abilify every morning. During interview, the DON stated the facility did not have any updated PASRR evaluation for Resident #38 since 9/02/25. The Administrator stated that audits from tagged areas would be placed, completed, and tracked through the QAPI program for compliance, and the QAPI policy stated the Administrator was responsible for ensuring the program was defined, implemented, maintained, and addressed identified priorities, with regulatory outcomes and survey results monitored and trended.
QAPI Meetings Lacked Infection Preventionist Attendance
Penalty
Summary
The facility failed to ensure the Infection Preventionist attended the quarterly Quality Assurance and Performance Improvement (QAPI) meetings. Review of the QA sign-in sheets for 10/24/25 and 1/21/26 showed no documentation that the Infection Preventionist was present at either quarterly meeting. The DON stated on 4/08/26 that the Infection Preventionist was still employed by the facility and may have been working the floor, which she said may have prevented attendance at the QA meetings. The Administrator later reviewed the QA sign-in sheets and confirmed the Infection Preventionist did not attend the meetings, and also reviewed the QAPI meeting notes for those dates and found there was not significant information regarding a quarterly review of the infection control program/tracking. The facility’s QAPI Plan Policy, effective 2/18/20, identified the QA Committee members as including the Medical Director or designee, DON, Administrator or other leader, and the Infection Prevention and Control Officer.
Failure to Document COVID-19 Vaccine Education and Consent
Penalty
Summary
The facility failed to provide COVID-19 vaccination education and obtain informed consent for 2 of 5 residents reviewed, identified as Resident #7 and Resident #12. Review of the census list showed both residents were current residents of the facility, and review of their EHRs found no documentation that either resident received COVID-19 vaccination education or was provided informed consent. During an interview, the DON stated the current Infection Preventionist was on leave and, after reviewing past immunization records, was unable to find documentation that the two residents were educated about the vaccine. The DON also found no signed documentation showing that either resident refused the COVID-19 vaccination. The facility's Infection Control Manual, last revised 10/2025, required staff to educate residents, obtain consent for available vaccines, and document all immunizations in the EHR.
Failure to Accurately Report Mental Health Diagnoses in PASRR
Penalty
Summary
The facility failed to accurately report a resident's mental health diagnoses and medications to the designated state agency as part of the Pre-Admission Screening and Resident Review (PASRR) process. Resident #17, who was diagnosed with depression, anxiety disorder, and PTSD, had a PASRR Level I Screen Outcome that did not include PTSD and omitted certain medications such as Alprazolam and Lamotrigine. The resident's electronic health record confirmed these diagnoses and medications were present at admission, but the PASRR documentation submitted by the hospital was incomplete. Interviews with staff revealed a lack of awareness and understanding of the resident's mental health diagnoses. A Licensed Practical Nurse (LPN) was unaware of the resident's PTSD diagnosis and reported various behaviors such as manipulation and self-harm. The Director of Nursing (DON) acknowledged the oversight in the PASRR process and indicated that a new PASRR should have been initiated. The facility Administrator admitted that the facility did not have a specific PASRR policy and relied on regulations, which contributed to the oversight in addressing the resident's PTSD diagnosis in the PASRR documentation.
Inadequate Pain Management for Resident with Wrist Injury
Penalty
Summary
The facility failed to provide effective pain management for a resident following a fall that resulted in a right wrist injury. The resident, who had impaired cognition due to a traumatic brain injury, experienced significant pain rated as high as 9 out of 10. Despite the resident's high pain ratings, the care plan lacked a focused area for pain management, goals for pain relief, or identification of ongoing pain symptoms. The facility's documentation did not consistently reflect follow-up assessments or physician notifications for ineffective pain relief. Nursing notes and medication administration records indicated that the resident frequently required as-needed Tylenol for pain relief, with varying effectiveness. However, there was a lack of documentation regarding follow-up pain assessments after administering pain medication. Additionally, the treatment administration record showed that ice was applied to the resident's wrist as needed, which was noted to provide effective pain relief. Despite these interventions, the facility did not adjust the resident's pain management regimen or document consistent follow-up assessments. Interviews with staff revealed that the resident would request pain medication when needed, and staff would verbally assess the effectiveness of the medication. However, these verbal assessments were not documented in the resident's electronic health records. The facility's pain policy required staff to assess the effectiveness of pain medication and notify the physician if pain was unrelieved, but this was not consistently followed. The facility administrator acknowledged the need for better documentation but believed the resident's pain was being adequately managed.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with PTSD, depression, and anxiety disorder. The resident's social history documented significant past trauma, including childhood abuse, and highlighted her preferences and triggers, such as not liking to sleep with her door closed and being nervous around people. Despite this, the resident's care plan did not address her mental health diagnoses, medications, triggers, goals, focus areas, or interventions. During interviews, the resident expressed feeling more down and frustrated when her health changed and reported that staff did not discuss how these changes affected her mental health. Staff interviews revealed a lack of awareness and understanding of the resident's mental health needs. A CNA was unaware of the resident's diagnoses or triggers, and an LPN described the resident as manipulative without acknowledging her mental health conditions. The Social Services staff indicated that trauma-informed care discussions were initiated at admission, but the Director of Nursing admitted that the care plan lacked necessary information about the resident's mental health. The facility did not have a policy for trauma-informed care, and the Administrator stated that they followed regulations, indicating a gap in addressing the resident's specific needs.
Failure to Provide Bed Hold Notices Before Hospital Transfers
Penalty
Summary
The facility failed to provide bed hold notices to two residents or their representatives prior to their transfer to the hospital, as required by the facility's policy. Resident #35 experienced an unwitnessed fall with a head injury and abnormal vital signs, leading to a hospital transfer. The facility's documentation did not include whether the resident or their representative wanted to hold the bed or if a bed hold notice was sent. Although a Private Pay Reserved Bed Form was signed by the resident after returning to the facility, it was not completed prior to the transfer. Similarly, Resident #27 was transferred to the hospital due to a change in condition, including adventitious lung sounds and edema, and was diagnosed with acute hypoxemia secondary to a viral infection. The facility lacked documentation of a bed hold notice being provided to the resident or their representative before the hospitalization. The facility's policy mandates that residents be informed of the bed hold and return policy upon admission and at the time of transfer or within 24 hours if the transfer is urgent, which was not adhered to in these cases.
Failure to Submit Discharge MDS for a Resident
Penalty
Summary
The facility failed to submit a discharge Minimum Data Set (MDS) for one resident, identified as Resident #25, who was reviewed during the survey. The resident was admitted to the facility on November 1, 2024, and discharged to the community on January 2, 2025, with no return anticipated. The facility's electronic health record indicated that billing stopped on the discharge date, and the MDS Summary screen noted that the MDS was completed but not submitted to the Centers for Medicare and Medicaid Services (CMS). During an interview, the Director of Nursing (DON) acknowledged that the MDS should have been submitted and was unsure why the 'do not submit' indicator was triggered or how the oversight occurred. The Administrator confirmed that the facility lacked a policy for MDS or Care Plan assessments and relied on the Resident Assessment Instrument (RAI) manual, which mandates that discharge assessments be submitted within 14 days after completion.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to ensure food items were covered, dated, and stored to prevent possible cross-contamination. During an initial tour of the kitchen, surveyors observed a walk-in refrigerator containing a four-wheeled cart with various poured drinks, including white milk, chocolate milk, apple juice, and orange juice, all of which were uncovered. Additionally, the cart had two opened milk jugs without open dates, and another larger tiered cart contained two trays of individual plated pie slices that were also uncovered and without labels or dates. Dietary staff were unsure when the pies were cut and acknowledged that the drinks on the cart should have been discarded. The Certified Dietary Manager and the Administrator confirmed that the milk jugs were not dated and that the pies should have been covered. The facility's policy on refrigerated food storage required food to be stored, properly labeled, and dated per regulatory requirements, which was not followed in this instance.
Failure to Complete Follow-Up PASRR Screening
Penalty
Summary
The facility failed to complete a follow-up Preadmission Screening and Resident Review (PASRR) for a resident who experienced a change in mental health status. The Minimum Data Set (MDS) assessment did not include a completed score for the Brief Interview for Mental Status (BIMS) and recorded the resident with psychiatric and mood disorders, including anxiety, depression, and bipolar disorder. The resident was also receiving antipsychotic medications on a routine basis. The care plan documented the use of psychotropic medications and potential adverse reactions. The administrator acknowledged that some mental health diagnoses were discovered after the resident's admission and that a new PASRR should have been submitted. The initial PASRR Level 1 screen indicated no major mental illness or psychotropic medications prescribed, and directed the facility to submit a status change for further evaluation with changes.
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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