Harmony Davenport
Inspection history, citations, penalties and survey trends for this long-term care facility in Davenport, Iowa.
- Location
- 815 East Locust Street, Davenport, Iowa 52803
- CMS Provider Number
- 165033
- Inspections on file
- 29
- Latest survey
- April 6, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Harmony Davenport during CMS and state inspections, most recent first.
Staff failed to follow hand hygiene and EBP practices during wound care and g-tube site care for several residents. An LPN did not wear a gown or change gloves while treating a resident’s elbow wound, two LPNs handled a resident’s pressure ulcers and soiled brief without changing gloves or cleaning hands, and another LPN performed g-tube site care and flushing without proper hand hygiene. A separate LPN provided heel treatment to a resident with a urinary catheter without wearing a gown, despite EBP requirements.
Inaccurate Advance Directive and code status documentation was found for a resident with moderate cognitive impairment and diagnoses including CAD, Alzheimer’s disease, and non-Alzheimer’s dementia. The EHR listed the resident as Full Code, while the paper chart contained an undated red DNR sheet in the same sleeve as an IPOST that indicated CPR/Full Code. The Administrator said the IPOST was not uploaded to the EHR, and the DON and an LPN described looking to the paper chart for code status in an emergency.
A resident discharged AMA was not included on the notice to the LTC Ombudsman because the resident did not appear on the Action Summary report. EHR documentation showed STOP BILLING and a progress note confirming the AMA discharge, but the Ombudsman notice did not list the resident. The Administrator stated the LTC Ombudsman should be notified of discharges, and the facility had no policy directing that notification.
Failure to transmit a discharge MDS within the required timeframe. A resident’s discharge MDS was completed but never submitted to CMS, and the MDS Coordinator stated she was unaware it had not been transmitted. The administrator stated the facility does not have an MDS policy and relies on the RAI manual, which requires electronic submission within 14 calendar days of completion.
Inaccurate PASARR Mental Health Diagnoses: A resident’s PASARR did not accurately reflect known MH diagnoses, including PTSD, depression, anxiety, and adjustment disorder. The record showed the resident had multiple MH diagnoses in the MDS and EHR, but a later PASARR stated no MH diagnoses were known or suspected and no Level II PASARR was completed. Social Services acknowledged the PASARR lacked accurate diagnoses, and the Administrator acknowledged PTSD would require Level II review.
Incomplete care plans were identified for three residents. One resident with diabetes, GERD, and respiratory failure no longer used a G-tube for meds or feedings, yet the care plan still referenced tube feeding related to dysphagia. Two residents with ESRD and AV fistulas had dialysis-related care plans that did not include daily AV access assessments for pulse, bruit, thrill, or related site checks. An MDS/Care Plan Coordinator stated care plans are completed by the IDT and may also be revised by a floor nurse.
Failure to Maintain a Homelike Environment: A resident with moderate cognitive impairment reported seeing mice in his room daily, and a dead mouse remained in a trap beside his recliner across multiple observations while housekeeping said trap checks were done weekly and the dead mouse had been forgotten. The facility also had broken wall tiles in a shower room, and another resident room had curtains that would not fully close and a stained, bubbled ceiling; staff and the Administrator acknowledged the room had not been maintained as a homelike environment.
Failure to provide ADL assistance for grooming and oral care affected two residents. One resident with DM and dementia was dependent for personal hygiene and was observed with greasy hair and long fingernails with debris underneath, while records showed bathing refusals and no communication about them. Another resident with stroke and arthritis was dependent for oral care and hygiene, yet reported not having his teeth brushed for about a month and was observed with beard growth, bad breath, and debris in his teeth; staff described shaving and oral care as inconsistent and tied to shower days or family assistance.
An LPN made an unprofessional and disrespectful comment about a resident's condition within earshot of a family member, failing to uphold the resident's right to dignity and respect. The resident had multiple serious health conditions and was on hospice care. The incident was overheard by the family, who found the remark inappropriate and reported it to facility management.
A resident with a history of poly substance overuse and respiratory diagnoses was allowed to smoke independently, even when under the influence, due to incomplete assessments and care planning. Staff observed the resident exhibiting unsafe smoking behaviors while intoxicated, such as letting cigarettes burn down to his fingers and burning a hole in his jacket, but the care plan did not address the need for supervision or additional safety measures during these times.
The facility failed to submit accurate agency staffing data for the PBJ report, leading to a trigger for Excessively Low Weekend Staffing. An audit revealed 20 agency staff were not included in the PBJ data, despite consistent staffing schedules. The Administrator noted the data submission was handled by the corporate office and identified the omission of agency staff, with no policy or procedure in place for the PBJ process.
The facility failed to label and date opened food items in the refrigerator, freezer, and dry storage areas, as observed during a kitchen tour. Various food items were found open without labels or dates, contrary to the facility's policy. Staff confirmed that opened food items should have been labeled and dated, indicating non-compliance with food storage procedures.
The facility failed to maintain proper catheter hygiene for two residents, as catheter bags and tubing were repeatedly observed on the floor, contrary to care plans and facility policy. Despite staff observations, including a CNA and the DON, the issue was not addressed, leading to a deficiency in care.
The facility failed to follow infection control protocols for residents with specific medical needs. A resident with a colostomy did not receive proper hand hygiene during bag changes, and another resident's wound care was conducted without changing gloves or washing hands. Additionally, Enhanced Barrier Precautions were not implemented for a resident with an indwelling catheter, as staff were unaware of the need for gowns and gloves.
The facility failed to maintain consistent water temperatures in showers, affecting resident dignity. Residents reported refusing showers due to cold water, and staff confirmed ongoing issues with achieving warm water. The problem persisted despite attempts to address it, with water temperatures fluctuating significantly during checks.
The facility failed to maintain shower water temperatures between 110 and 120 degrees Fahrenheit, as required. A resident reported insufficient water temperature, leading to the discovery of a faulty cartridge in the 2nd floor shower. Despite repairs, water temperatures remained inadequate, with staff and residents noting prolonged wait times for warm water and issues when the dishwasher was in use. The facility was seeking estimates for a new boiler due to a leak.
A facility failed to follow physician orders for a resident with multiple conditions, including osteomyelitis and pressure ulcers. The resident's care plan required specific wound care and limited time in a wheelchair, but records showed a lack of documented wound care for seven days and non-compliance with positioning orders. Observations and interviews revealed staff were unaware of the resident's restrictions, and the Wound Nurse admitted to not transcribing orders promptly.
A resident with intact cognition and complete dependency on staff for care was given a shower against her wishes, causing significant distress and pain. Despite expressing a preference for bed baths due to fear and discomfort with the mechanical lift, staff proceeded with the shower, leading to a deficiency in treating residents with dignity and respect.
The facility failed to maintain a sanitary kitchen, ensure proper disinfectant solution levels, label food appropriately, wear hair restraints correctly, and dispose of expired food items. Observations included residue on kitchen equipment, debris on the floor, expired milk in the refrigerator, and improper hair restraint use by staff.
The facility pharmacy failed to deliver medications in a timely fashion for four residents, resulting in missed doses of critical medications. Staff interviews confirmed frequent delivery issues, and the DON was aware of the problem.
The facility failed to properly manage the feeding tube care for a resident with no cognitive impairment, diagnosed with sarcoidosis of the lung, paraplegia, and pneumonia. Staff struggled with connecting the tubing to the pump, did not date the water bag and tubing, and failed to check the pump settings before exiting the room, resulting in incorrect feeding and flushing rates.
A resident with anxiety and other medical conditions did not receive prescribed Lorazepam for several days due to procedural and communication failures. Despite multiple requests and evident distress, the facility staff struggled to obtain the medication from the med bank and faced issues with the pharmacy and healthcare providers.
A resident with Multiple Sclerosis and other conditions fell and was injured after a CNA attempted to transfer her alone without using the required lift or gait belt, contrary to the care plan. The incident revealed inconsistencies among staff regarding the resident's transfer requirements and a lack of adherence to the care plan.
Infection Control Lapses During Wound and G-Tube Care
Penalty
Summary
The facility failed to implement infection control practices of hand hygiene and Enhanced Barrier Precautions during wound care and g-tube site care for multiple residents. The report states that staff did not consistently wear gowns when EBP was required, did not change gloves between dirty and clean tasks, and did not perform hand hygiene before, during, or after portions of care. The facility’s policy and EBP poster directed staff to use gowns and gloves for wound care, feeding tube care, and other high-contact activities, but observations showed these practices were not followed. For one resident with diabetes, schizophrenia, impaired decision-making, and a wound on the left inner elbow, an LPN washed hands and donned gloves but did not don a gown. The LPN removed the old dressing, then cleaned the wound and applied a new dressing without changing gloves or performing hand hygiene between tasks. The LPN stated he did not use the gown for EBP and did not change gloves or complete hand hygiene during wound care. For another resident with stroke, osteomyelitis, Stage III and Stage IV pressure ulcers, and intact cognition, two LPNs performed wound care while the resident had a soiled incontinence brief in place. They donned gowns and gloves, but one staff member placed supplies on the bed, cleaned the wound, patted it dry, and applied lidocaine cream without changing gloves or performing hand hygiene. The other staff member rolled the resident to remove the soiled brief, applied a clean dressing, and handled the soiled brief and linens without changing gloves or performing hand hygiene. The report also describes a resident with a feeding tube and EBP precautions, where an LPN placed treatment supplies on the stand without first cleaning it or using a barrier, donned gloves without hand hygiene, removed soiled gauze from the g-tube site, cleansed the site, flushed the tube, and left the room without washing hands. A fourth resident with a urinary catheter and EBP precautions had heel skin-prep treatment performed by an LPN who donned gloves but did not wear a gown, and the DON acknowledged that gloves and gown should have been worn for wound care.
Inaccurate Advance Directive and Code Status Documentation
Penalty
Summary
The facility failed to maintain accurate Advance Directive decisions for 1 of 16 residents reviewed, Resident #43. The resident’s MDS assessment documented a BIMS score of 8 out of 15, indicating moderate cognitive impairment, and listed diagnoses of coronary artery disease, Alzheimer’s disease, and non-Alzheimer’s dementia. The EHR contained a Full Code physician order, and the care plan included an Advance Directives focus area directing staff to document the advance directive in the EMR, educate the resident or representative about life-sustaining care options, and identify code status in the EMR. Review of the paper chart showed an undated red paper marked Do Not Resuscitate (DNR) in the same sleeve as the Iowa Physician Orders for Scope of Treatment (IPOST). The front page of the IPOST indicated CPR/Full Code and was signed by the physician. The Administrator stated the IPOST documents were not uploaded to the EHR and that staff were to follow the code status in the EHR, while the DON acknowledged the EHR listed the resident as Full Code but said staff would look at the red paper versus pulling out the IPOST in an emergency. The DON also stated Social Services places red papers in charts for DNR and other papers for CPR, and staff interviews showed the LPN would look in the paper chart for code status in an emergency.
Failure to Notify LTC Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the Long-Term Care Ombudsman of a resident discharge for 1 of 3 residents reviewed, Resident #77. Review of the electronic health record showed a Clinical Census entry of STOP BILLING effective 1/24/26, and a progress note documented that Resident #77 was discharged against medical advice on 1/24/26 at 7:19 PM. However, the Action Summary report dated 3/30/26 did not list Resident #77 as discharged, and the Notice of Transfer From to Long Term Care Ombudsman did not include the resident’s discharge. During interview, Social Services staff stated Resident #77 was not included on the Ombudsman notice because the resident did not appear on the Action Summary report and acknowledged the resident left AMA on a weekend. The Administrator stated it was her expectation that the LTC Ombudsman office be notified of discharges, and later stated the facility did not have a policy directing notification of discharges to the LTC Ombudsman.
Failure to Transmit Discharge MDS Within Required Timeframe
Penalty
Summary
The facility failed to transmit the discharge MDS for Resident #31 within the required timeframe. The resident’s discharge MDS was dated for the discharge date of 11/25/25 and was signed as completed on 12/9/25, but the clinical record showed that the assessment was never transmitted to CMS as required. During interview on 4/1/26, the MDS Coordinator stated she would unlock the MDS and transmit it, and said she did not know why it had not been transmitted. She also stated she runs reports on missing assessments, but Resident #31 had not appeared on any of those reports and she had not been aware the assessment had not been transmitted. The administrator later stated the facility does not have an MDS policy and uses the 2025 RAI manual, which states the MDS must be transmitted electronically no later than 14 calendar days after the MDS completion date.
Inaccurate PASARR Mental Health Diagnoses
Penalty
Summary
The facility failed to accurately list known mental health diagnoses on a PASARR for Resident #15. The resident’s record showed diagnoses of depression, PTSD, and adjustment disorder with mixed anxiety and depressed mood on the MDS, and the EHR medical diagnosis section also listed adjustment disorder with mixed anxiety and depressed mood, anxiety disorder unspecified, major depressive disorder recurrent severe without psychotic features, and PTSD unspecified. The resident had an initial admission on 9/27/25, discharged home, and then had a new admission on 1/5/26. The PASARR dated 9/22/25 listed major depression and anxiety disorder as mental health diagnoses and determined no Level II was required. A later PASARR dated 1/03/26 stated no mental health diagnoses were known or suspected and again determined no Level II was required. During interview, Social Services acknowledged the PASARR completed prior to admission lacked accurate diagnoses for Resident #15 and that the resident had not been evaluated for Level II PASARR. The Administrator stated that someone with a diagnosis of PTSD would need to be evaluated for Level II PASARR and acknowledged the Notice of PASARR Level I needed to be updated for Resident #15.
Incomplete Care Plans for Tube Feeding and Dialysis Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for 3 of 8 residents reviewed for care plans. For Resident #1, the record showed diagnoses of diabetes mellitus, gastric reflex disease, and respiratory failure, with a BIMS score of 15/15 indicating intact cognition. The MDS did not identify that the resident used a G-tube for medications or tube feedings, even though the care plan still contained a focus area for tube feeding related to dysphagia and included enteral nutrition interventions. The MAR showed the last medication administration through the G-tube was on 3/4/26, and medications were being given orally. The resident stated staff no longer used the feeding tube for medications or feedings, and an LPN stated the G-tube was no longer used for medications, but was still to be flushed and the site cleaned and dressed daily. For Resident #19, the MDS identified end stage renal disease, diabetes mellitus, and hemodialysis via AV fistula, with intact cognition. The care plan addressed dialysis related to ESRD and listed HD access devices, but did not include directions for daily assessment of the AV site for pulse, bruit, thrill, bruising, vein distention, or pain. For Resident #30, the MDS identified ESRD and dialysis treatment, with a BIMS score of 14/15. The care plan addressed dialysis and noted the resident often declined dialysis for various reasons, but it did not include directions to assess the AV site for thrill, bruit, and pulse. The MDS and Care Plan Coordinator stated care plans are completed by the IDT and may also be revised by a floor nurse within scope of practice.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents. Resident #8, whose MDS dated 4/24/26 listed anemia, high blood pressure, arthritis, and a BIMS score of 11/15 indicating moderate cognitive impairment, reported seeing mice in his room every day. During observation, a black mouse trap next to his recliner contained a dead mouse and remained in that condition across multiple subsequent observations over several days. Staff G, Housekeeper, stated she checked mouse traps one time a week and said she had planned to remove the dead mouse but got busy and forgot. The facility also had broken wall tiles in the 2nd floor Central Bath/Shower room, observed on 04/01/26, with staff reporting the tiles had been broken for a few weeks and that a work order was in place. Staff J, RN, stated the broken tile felt sharp. In another resident room, the curtains could not be fully closed, leaving a gap of about 16 inches and a view into the room, and the ceiling had a stain with bubbling texture over part of the bed. Resident #55, whose MDS dated 2/26/26 listed coronary artery disease, bipolar disorder, schizophrenia, and a BIMS score of 13/15, stated the curtains had not been able to close all the way since moving into the room. Staff and the Administrator acknowledged the room had not been maintained as a homelike environment, and the electronic work order report showed no work orders had been submitted for that room prior to 4/1/26.
Failure to Provide ADL Assistance for Grooming and Oral Care
Penalty
Summary
The facility failed to provide assistance with activities of daily living for dependent residents, including shaving, nail care, and toothbrushing. Resident #6 had diagnoses of diabetes mellitus and non-Alzheimer's dementia, with a BIMS score of 12 indicating moderate cognitive impairment, and was dependent for toileting, bathing, and showering and required substantial to maximal assistance for personal hygiene. During observation, Resident #6 was found sleeping in bed with greasy hair and long fingernails with a brown substance underneath them. The care plan directed staff to assist with bathing, dressing, and grooming, and the EHR showed bathing refusals on multiple dates, but the record lacked communication regarding those refusals. During interview, Resident #6 stated staff did not clean or cut his fingernails much and only washed his hair at times, and his hair and nails remained unkempt during the interview. Resident #40 had diagnoses of stroke and arthritis and a BIMS score of 13, and the MDS identified dependence on staff for oral care and hygiene needs. The care plan directed staff to encourage and assist with oral hygiene, oral care, and grooming. Resident #40 stated staff had not brushed his teeth in about a month, and a resident representative reported family concerns that his teeth were not being brushed and that he was not receiving shaving assistance. Observations showed noticeable beard growth, bad breath, and debris stuck in his teeth. Staff interviews indicated shaving was done on shower days, that the resident's family sometimes shaved him, and that staff had been busy; one CNA stated she brushed his teeth a little that morning, while another said she would go shave him after noting he had showered the day before.
Staff Made Disrespectful Comment About Resident in Presence of Family
Penalty
Summary
A staff member failed to treat a resident with dignity and respect when an LPN made an inappropriate comment about a resident's condition in the presence of a family member. The incident occurred near the nurse's station, where the LPN instructed other staff to check on the resident to see if he was alive, not realizing a family member was present. The family member overheard the remark, found it unprofessional and unkind, and observed another employee attempting to signal the LPN to stop speaking. The family member identified themselves to the LPN and expressed concern about the disrespectful nature of the comment. The resident involved had multiple complex medical conditions, including pulmonary fibrosis, chronic respiratory failure with oxygen dependence, adult failure to thrive, peripheral vascular disease, diabetes, dementia, and was receiving hospice services. The resident's care plan included interventions for pain management and comfort. The LPN later acknowledged the comment was disrespectful and reported the incident to the on-call manager. The facility's policy requires all residents to be treated with dignity and respect, which was not upheld in this instance.
Failure to Ensure Smoking Safety for Resident with Substance Use History
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident with a history of poly substance overuse, specifically regarding smoking safety when under the influence. The resident, who had diagnoses including anxiety, asthma, and respiratory failure, was assessed as having intact cognition and was permitted to smoke independently per the facility's Smoking Program assessments and care plan. However, these assessments did not address the resident's safety when smoking while under the influence of substances. On the night in question, the resident returned to the facility after an outing with family and was observed to be intoxicated, loud, belligerent, and uncooperative. Despite staff interventions, the resident insisted on smoking independently on the patio for several hours, during which time he was in possession of alcohol and exhibited impaired judgment. Staff interviews revealed that the resident was not safe to smoke independently when intoxicated, with reports of him letting cigarettes burn down to his fingers and burning a hole in his jacket, although no injuries were documented. The facility's documentation and care planning did not address the increased risk associated with the resident's substance use and its impact on his ability to smoke safely. Staff recognized the resident's unsafe behaviors when under the influence, but the care plan and smoking assessments failed to include interventions or supervision requirements for these circumstances, resulting in a lack of adequate supervision and failure to mitigate accident hazards related to smoking.
Failure to Submit Accurate Agency Staffing Data
Penalty
Summary
The facility failed to submit accurate agency staffing data for the Payroll Based Journal (PBJ) Staffing Data Report for the first fiscal year 2025, which triggered a report for Excessively Low Weekend Staffing. Despite the Daily Nursing Staffing Schedules for September, October, and December 2024 showing a consistent number of staff during the week and weekends, an audit revealed that 20 agency staff were not submitted to the PBJ. The Administrator reported that the data submission for the PBJ and staffing reports were completed by the corporate office. It was later identified by the Administrator that twenty nursing staff from agencies were not included in the PBJ data, and the facility lacked a policy or procedure for the PBJ process.
Failure to Label and Date Opened Food Items
Penalty
Summary
The facility failed to adhere to proper food labeling and dating procedures, as observed during a kitchen tour. Several food items, including apple sauce, cheese, cabbage, ranch dressing, breadsticks, biscuits, slider rolls, waffle fries, breaded fish fillets, vegetables, fruit-flavored cereal, and toasted flake cereal, were found open without any labels or dates in the refrigerator, freezer, and dry storage areas. Staff G confirmed that opened food items should have been labeled and dated, indicating a lapse in following the facility's food storage policy. The Dietary Manager acknowledged that it is expected for kitchen staff to label and date any opened food items, as per the facility's policy revised in December 2023. The policy outlines specific procedures for date marking dry storage, refrigerated, and freezer food items to ensure safe food storage. However, the observations during the survey revealed non-compliance with these procedures, potentially increasing the risk of foodborne illness among the facility's 66 residents.
Failure to Maintain Catheter Hygiene
Penalty
Summary
The facility failed to ensure proper care for residents with indwelling urinary catheters, specifically by not keeping catheter bags and tubing off the floor, which is necessary to minimize the risk of urinary tract infections. Resident #37, who has a neurogenic bladder and a history of urinary tract infections, was observed multiple times with the catheter bag and tubing resting on the floor. Despite the care plan's directive to keep the tubing off the floor, staff members, including a CNA and the Director of Nursing, were observed leaving the room without addressing the issue. Similarly, Resident #121, who has type 2 diabetes mellitus, benign prostatic hyperplasia, and obstructive uropathy, was also observed with the catheter bag and tubing on the floor on several occasions. Interviews with staff revealed a lack of consistent action to address the issue, with some staff members indicating they would report it to a nurse, while others stated they would expect the CNA to handle it. The facility's policy requires that catheter tubing be kept off the floor, but this was not adhered to, leading to the deficiency.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to proper infection control protocols during the care of residents with specific medical needs. For Resident #2, who has a colostomy and paraplegia, the staff did not perform hand hygiene before, during, or after changing the colostomy bag and wafer. This was observed when a Licensed Practical Nurse (LPN) changed the colostomy bag without washing hands after removing gloves and before putting on new ones, despite the resident's care plan requiring Enhanced Barrier Precautions due to colonized multidrug-resistant organisms. In another instance, Resident #37, who is cognitively intact and has a neurogenic bladder, septicemia, and a urinary tract infection, did not receive proper wound care. A Registered Nurse (RN) was observed failing to perform hand hygiene or change gloves between cleaning the wound and applying treatment. This was contrary to the facility's policy, which mandates hand hygiene and glove changes during different stages of wound care. Additionally, the facility did not implement Enhanced Barrier Precautions for Resident #121, who has an indwelling urinary catheter. There was no signage indicating the need for such precautions, and staff did not wear gowns when providing care, despite the resident's care plan indicating the necessity for Enhanced Barrier Precautions. This oversight was acknowledged by staff, who were unaware of the requirement for gowns and gloves for this resident.
Inconsistent Water Temperatures Affect Resident Dignity
Penalty
Summary
The facility failed to provide dignified care to residents due to issues with water temperature in the showers, which unpredictably changed from a comfortable temperature to a cold temperature. This issue affected six residents who were reviewed for dignity. The problem was first reported to the facility Administrator on 11/12/24 by a resident, prompting the Administrator to contact a local plumbing company. The plumbing company identified that the 2nd floor central shower required a new cartridge, which was replaced on 11/15/24. However, subsequent water temperature checks by the State Agency on 11/20/24 revealed significant fluctuations, with temperatures ranging from 62.8 F to 112.4 F in various showers. Interviews with residents and staff highlighted ongoing issues with water temperatures. Residents reported refusing showers due to cold water and experiencing discomfort when the water temperature dropped during showers. Staff members confirmed that they had to run both the sink and shower simultaneously to achieve a warmer temperature, and that the water temperature issues had persisted for several months. The Maintenance Director admitted that water temperatures had been a problem since he started working at the facility in January 2024, and that it was challenging to get service providers to address the issue promptly. Further observations and interviews on 11/26/24 showed continued problems with water temperatures, with some showers taking up to 15 minutes to reach a suitable temperature. Staff members reported that the best time to shower residents was before breakfast, as the water temperature was more likely to be warm. The Maintenance Director also revealed that water temperature logs for the 2nd floor were not consistently recorded, and a staff member responsible for maintenance had never taken water temperatures or been instructed to do so.
Deficiency in Maintaining Shower Water Temperatures
Penalty
Summary
The facility failed to maintain essential equipment in acceptable operating condition, specifically regarding the water temperatures in resident showers. The deficiency was identified when a resident reported that the shower water was not hot enough. The facility's Administrator contacted a local plumbing company, which identified that a new cartridge was needed for the central shower on the 2nd floor. Despite the replacement of the cartridge, water temperatures remained below the required range of 110 to 120 degrees Fahrenheit. Observations and interviews revealed that the water temperatures fluctuated significantly and did not reach the required levels, particularly on the 2nd floor. Staff interviews indicated that the water temperature issue had been ongoing since January 2024, and it was difficult to get service providers to address the problem promptly. Maintenance logs showed that water temperatures for the 2nd floor showers were not recorded, and staff had to run both the sink and shower simultaneously to increase the water temperature. Residents and staff reported that the water had to run for extended periods to become warm enough, and the dishwasher's operation affected the availability of hot water for showers. The facility was in the process of obtaining estimates for a new boiler due to a leak in the current one, as identified by another plumbing company.
Failure to Follow Physician Orders for Wound Care and Positioning
Penalty
Summary
The facility failed to adhere to physician orders for wound care and positioning for a resident diagnosed with multiple conditions, including osteomyelitis, hypertension, peripheral vascular disease, paraplegia, and hemiplegia. The resident was assessed as being at risk for developing pressure ulcers and had two Stage 4 pressure ulcers. The care plan included interventions such as administering treatment per physician orders and limiting time in a chair to one hour or less, with repositioning every 30 minutes. However, the Treatment Administration Record showed no documented wound care for the left ischial pressure ulcer for seven days, and the directive to limit chair time was not included in the treatment orders. Observations and interviews revealed that the resident was left in a wheelchair for longer than the recommended time, and staff were unaware of the restrictions on the resident's time in the wheelchair. The resident expressed that he was supposed to be in bed and not up for more than 30 minutes, but he could not access his call light. Staff interviews indicated a lack of awareness and communication regarding the resident's care plan and physician orders. The facility's Wound Nurse acknowledged that the physician orders for wound care had not been transcribed in a timely manner.
Failure to Respect Resident's Right to Refuse Shower
Penalty
Summary
The facility failed to honor a resident's right to refuse a shower, leading to a deficiency in treating residents with dignity and respect. The resident, who had intact cognition and was completely dependent on staff for personal care, expressed a clear preference for bed baths due to pain and fear associated with being lifted. Despite this, staff proceeded to give the resident a shower using a mechanical lift, causing the resident significant distress and pain. The incident occurred when staff decided that a shower was necessary after the resident was incontinent. Although the resident initially did not object, she began to scream and express discomfort once lifted into the air. Staff did not offer to stop the shower or provide an alternative, such as a bed bath, despite the resident's protests. The resident's distress was evident as she yelled profanities and later reported feeling degraded during the shower process. Interviews with staff and the resident's Power of Attorney confirmed that the resident's wishes were not respected, and the incident caused her mental distress. The Director of Nursing and the Administrator were initially unaware of the issue, but the resident had already contacted the Elder Abuse hotline. The facility's failure to respect the resident's autonomy and address her pain and fear during the shower process led to the deficiency finding.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen, ensure the disinfectant solution was within the proper test range, label food appropriately for storage, wear hair restraints appropriately, and dispose of expired food items. During an initial tour of the kitchen, surveyors observed significant cleanliness issues, including black/brown residue on the Vulcan stove, debris on the kitchen floor, and white debris in the Hoshizaki ice machine. The Dietary Director was unable to achieve a proper sanitizer test reading, indicating potential issues with the sanitizer solution or test strips. Additionally, the Frigidaire refrigerator in the kitchenette contained expired milk and an uncovered plastic container with cake that was not dated. Staff K was observed with a long braid that repeatedly fell out of the hair restraint while plating food, further compromising kitchen sanitation. The Dietary Director admitted that equipment such as the stove top, ice machine, and ovens should be cleaned at least once a week, with a deep cleaning schedule occurring once a month. However, the cleaning chart was not signed off to show tasks had been completed. The Dietary Director also acknowledged that there was no clear designation of responsibility for checking the kitchenette refrigerators for outdated items. Facility policies indicated that sanitizing solutions should be tested daily and changed according to manufacturer instructions, and that a cleaning schedule should be posted and validated by the Director of Food and Nutrition Services. These policies were not adhered to, leading to the observed deficiencies.
Pharmacy Delivery Failures
Penalty
Summary
The facility pharmacy failed to deliver medications ordered to the facility in a timely fashion for four residents. Resident #47 did not receive ticagrelor, a medication to prevent blood clots, as it was unavailable on 4/25/24. The MAR directed to see Nurses Notes, which confirmed the medication was not available. Staff interviews revealed that the pharmacy often failed to deliver medications on time, and the Director of Nursing (DON) was aware of the issue but it persisted nonetheless. Resident #70, admitted on 4/27/24, did not receive five scheduled bedtime medications, including antipsychotics, cholesterol medication, heart medication, eye drops, and an antidepressant, due to delays from the pharmacy. Staff interviews confirmed that the pharmacy frequently failed to deliver medications, citing reasons such as needing a prescription or it being too soon to replace the medication. The DON was also aware of these issues. Resident #22, admitted on 3/29/24, did not receive Lyrica, an antiseizure medication, for six days, resulting in ten missed doses. The medication was repeatedly reported as unavailable, and the pharmacy was notified multiple times. Resident #30, who had COPD and other conditions, did not receive his inhalers on 4/19/24 and 4/20/24, marked as unavailable and held, respectively. The DON confirmed knowledge of delivery difficulties related to the pharmacy. The facility's policy on medication administration aimed to ensure safe and accurate preparation and administration of medications, but it was not followed effectively in these cases.
Feeding Tube Management Deficiency
Penalty
Summary
The facility failed to properly manage the feeding tube care for a resident with no cognitive impairment, diagnosed with sarcoidosis of the lung, paraplegia, and pneumonia. The resident's care plan required nutrition through a PEG tube due to dysphagia. During an observation, staff failed to date the water bag and tubing, struggled to connect the tubing to the pump, and did not ask for assistance. The Director of Nursing (DON) had to intervene multiple times. Ultimately, the staff failed to check the settings on the pump before exiting the room, resulting in incorrect settings for the feeding and flushing rates. Staff interviews revealed that the LPN responsible for the feeding tube care was inexperienced and did not seek help when needed. The DON acknowledged that staff should have contacted someone for assistance and verified the pump settings before leaving the room. The facility's policy on enteral tube feedings required verification of physician orders, proper labeling, and checking for patency, which were not followed in this instance.
Failure to Administer Prescribed Lorazepam
Penalty
Summary
The facility failed to obtain a physician order to provide Lorazepam for a resident, leading to a deficiency in medication administration. Resident #30, who had a BIMS score of 15 indicating intact cognitive status, was diagnosed with Atrial Fibrillation, Peripheral Vascular Disease, Anxiety Disorder, and Chronic Obstructive Pulmonary Disease. The resident reported difficulty in receiving Lorazepam after being discharged from hospice services, which caused significant anxiety and fear of sleeping due to breathing issues. Despite multiple requests and evident distress, the resident did not receive the medication for several days. The care plan for Resident #30 included administering psychoactive medications as ordered and monitoring for adverse reactions. However, a review of the Medication Administration Records (MARs) showed that the prescribed Lorazepam was not administered as required. Progress notes indicated that the facility staff struggled to obtain the medication from the med bank and faced communication issues with the pharmacy and healthcare providers. The resident's primary care physician eventually provided a prescription, but there was a delay in administration. Observations and interviews revealed that staff were aware of the resident's need for Lorazepam but were unable to provide it due to procedural and communication failures. The Director of Nursing acknowledged that the nurse should have verified the active order and contacted the provider for the correct dose to pull from the med bank. The facility's policy on medication administration did not address the process for obtaining medication from the med bank if not ordered, contributing to the deficiency in care for Resident #30.
Failure to Follow Care Plan and Provide Adequate Supervision
Penalty
Summary
The facility failed to follow the care plan for Resident #55, who was identified as cognitively intact with a BIMS score of 15 and had diagnoses including Diabetes Mellitus, Multiple Sclerosis, and Depression. The care plan specified that Resident #55 required assistance with transfers using a stand lift due to immobility and impaired range of motion. However, on 3/29/24, Staff F, a CNA, transferred Resident #55 without assistance, without using a lift or gait belt, and attempted to transfer the resident to an unlocked wheelchair, resulting in a fall. Resident #55 fell on her knees and hit her head on the bottom of a tray table, causing a red mark on her left cheek from a crystal rock that fell off the bedside table during the fall. Interviews with various staff members revealed inconsistencies in their understanding of the care plan for Resident #55's transfers. Some staff believed the resident required a Hoyer lift with the assistance of two staff members, while others thought a stand lift or a gait belt with one staff member was sufficient. Staff F admitted to not having a gait belt and attempting the transfer alone because the other CNA had left before the second shift arrived. The incident report and subsequent interviews confirmed that the care plan was not followed, and the care plan was not updated with new interventions after the fall. The Director of Nursing confirmed that the fall could have been prevented if the staff had checked the Kardex on the electronic record and followed the care plan, which required two staff members and the use of a lift. The investigation revealed that Staff F did not use the required equipment or seek assistance, leading to the fall and injury of Resident #55. The facility's failure to adhere to the care plan and provide adequate supervision resulted in the resident's fall and injury.
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An LPN, unfamiliar with residents on a medication cart and faced with two residents sharing the same first name, failed to correctly identify a resident and administered a full set of another resident’s medications in addition to the resident’s own ordered morning medications, including PRN oxycodone. The resident, who had severe cognitive impairment and multiple diagnoses including hypertension and Alzheimer’s disease, subsequently experienced declining BP, reported not feeling well, and became increasingly fatigued. The facility’s policy required resident identification before medication administration, and the LPN acknowledged not knowing the residents and finding the EHR photos too small, despite their availability. Hospital records later documented hypotension, treatment with IV fluids, and a drug overdose after accidental ingestion of another resident’s medications plus the resident’s own, with persistent sinus bradycardia requiring admission for further hemodynamic monitoring.
A cognitively impaired, wandering resident with Alzheimer’s disease and behavioral symptoms was care planned as an elopement risk but was able to leave the memory care unit by holding an emergency exit door bar for 15 seconds and exiting into a stairwell and then to the employee parking lot. The door alarm functioned, but staff in the noisy dining room did not hear it while they were feeding multiple residents, including several needing extensive assistance, and only realized the resident was missing when another staff member encountered him outside and brought him back. In addition, several residents who required staff assistance for transfers and toileting experienced prolonged call light response times well beyond the facility’s 15‑minute expectation, including one who reported waiting up to an hour during meals and having an in‑room accident, another observed waiting about 25 minutes while calling out for help, and a third waiting about 17 minutes before a CNA responded.
A cognitively intact resident reported that a CNA ripped her incontinence brief during care and then refused to change it, despite the resident stating she could not wear it due to the tear. The resident became upset and informed housekeeping staff, who then asked an LPN to assist. On assessment, the LPN observed a large rip extending around the back of the brief, changed the brief, and provided peri care at the resident’s request. The resident stated the ripped brief was uncomfortable and that she did not feel treated with dignity or respect. In interviews, the CNA acknowledged telling the resident the torn brief would still work and did not change it, while the DON confirmed the CNA had refused the resident’s request for a brief change, in conflict with the facility’s dignity policy.
A deficiency was identified when a CNA did not follow manufacturer instructions for a mechanical stand while transferring a resident with severe cognitive impairment, a history of hip fracture, dementia, and muscle wasting who required substantial assistance for transfers. The resident’s care plan called for use of a mechanical stand, but during observed toileting and return-to-chair transfers, the CNA repeatedly locked and unlocked only one wheel of the device and did not keep the brakes unlocked during the actual transfer, contrary to the operator’s instructions that brakes be locked only when raising and lowering the resident during ambulation. In an interview, the DON confirmed staff were expected to follow these operator instructions and keep the wheels unlocked during transfers.
A resident with dementia, behavioral symptoms, and multiple psychotropic and cardiovascular medications was discharged to another nursing facility without a thorough or accurate discharge summary. The care plan contained a discharge planning focus but was never updated to reflect the actual discharge, and the EHR lacked documentation of discharge planning, the reason for discharge, or a recapitulation of stay, despite a family member stating they initiated the discharge due to dissatisfaction with care. The discharge instructions contained multiple medication discrepancies and omissions, including missing drugs, incorrect dosages, and absent administration frequencies, and several PRN constipation medications were not listed, contrary to the facility’s written discharge planning policy.
A resident was admitted from a hospital without a completed Preadmission Screening and Resident Review (PASRR) in the medical record, as required prior to admission. The PASRR was only completed several days later by the Hospital Liaison/Admissions Coordinator after a call alerted staff that it was missing. Both the admissions coordinator and the Administrator acknowledged that the facility relies on the hospital to provide the PASRR and that, in this case, it was missed and not done before the resident’s admission.
A resident with Alzheimer's disease, severely impaired cognition, and documented nutrition/hydration risk required partial to moderate assistance with eating and was care planned for assisted feeding with a general diet and thin liquids. During a breakfast observation, the resident was seated in a reclined Broda chair while staff placed food and beverages on an overbed table and attempted to offer chocolate milk and hot cereal without first positioning the resident upright, causing the resident to struggle to reach the cup. Facility policy on feeding required residents needing assistance to be positioned comfortably in an upright position, and the DON stated she expected residents to be upright whenever food or drink was offered, but there was no separate positioning policy in place.
A resident with a left leg fracture, muscle wasting, and impaired mobility was dependent on a mechanical lift for transfers. Staff positioned the lift at the side of the wheelchair instead of straight on, and the lift tipped and struck the resident’s forehead with the sling-holding part, causing a bruise and protruding bump. Staff interviews confirmed the transfer was done from the side and that the resident’s care plan required straight-on positioning for the lift.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance: Several residents did not receive bathing and hygiene assistance as scheduled. One resident with intact cognition and a stroke history was observed unshaven and said staff did not always shave him during showers, while staff noted the bath sheets no longer tracked shaving or nail care. Other residents with severe cognitive impairment or dependence for bathing went extended periods without baths, and one cognitively intact resident reported missing baths and wanting them. Facility records and staff interviews showed bathing schedules were not consistently followed or documented as required.
QAPI program failed to address repeated deficiencies. Review of the facility’s visit history showed repeated F689, Free of Accident Hazards/Supervision/Devices, and F880, Infection Prevention and Control, across multiple annual surveys and complaint investigations. The QAPI plan stated it would review sources of information for gaps or patterns in care systems, and the Administrator acknowledged the repeated deficiencies and said the facility would review and discuss plans to improve.
Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to follow the 5 rights of medication administration, resulting in one resident receiving another resident’s medications in addition to their own. The resident had diagnoses including hypertension, Alzheimer’s disease, and toxic encephalopathy, with a BIMS score of 3 indicating severe cognitive impairment. On the morning in question, review of the MAR showed the resident received their ordered medications, which included aspirin, calcium carbonate, vitamin C, vitamin D, fluoxetine 20 mg, furosemide 40 mg, galantamine, a lidocaine patch, memantine, acetaminophen, and PRN oxycodone around 8:00 a.m. According to the incident report and nursing progress notes, the LPN (Staff A) administered another resident’s full set of morning medications to this resident while the resident was in the dining room. These additional medications included metoprolol 60 mg, Lyrica 75 mg, oxycodone 7.5/325 mg, furosemide 40 mg, celecoxib 100 mg, Prozac 60 mg, hydroxyzine 10 mg, cetirizine 10 mg, Neuriva, Protonix 20 mg, potassium 99 mg, a multivitamin, and vitamin D3. These medications were given in addition to the resident’s own morning medications and PRN oxycodone. The nurse’s notes documented that the resident’s blood pressure readings declined from 100/50 to 85/48 and then to 73/48, and the resident complained of not feeling well and was increasingly fatigued. Staff A reported during interview that the resident had been screaming and yelling and that she did not realize there were two residents with the same first name in the back hallway. She stated it was her first time working in that hallway after training and that, although resident pictures were available in the EHR to assist with identification, she felt they were small and she did not know the residents. The facility’s medication management policy required staff to identify the resident before administering medications. Staff A’s employee record showed a prior medication occurrence in which she administered the wrong medications (including furosemide and potassium) to a resident, and she had documented previously that she was not familiar with residents when working on that cart. The resident was ultimately sent to the ER, where records documented hypotension on admission, treatment with IV fluids, and a chief complaint of drug overdose after accidental ingestion of another resident’s multiple medications in addition to the resident’s own medications, with continued sinus bradycardia requiring admission for further hemodynamic monitoring.
Elopement of Wandering Resident and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for a cognitively impaired, wandering resident and failure to respond to resident call lights within the facility’s stated 15‑minute expectation. One resident with Alzheimer’s disease, bipolar disorder, and anxiety disorder had a care plan identifying risk for elopement due to wandering and documented behaviors of agitation, aggression, restlessness, and continuous pacing/wandering within the unit. This resident ambulated independently with a walker and had a BIMS score indicating impaired cognition. On the evening of the incident, the resident finished supper in the memory care dining room and then repeatedly walked the hallway with his walker, eventually approaching an emergency exit door at the far end of the hall, away from the dining room. Video and documentation show that the resident stood at the emergency exit door, held the door bar down for the required 15 seconds to release the egress, and then exited through the door into a stairwell and out to the employee parking lot. The door alarm and 15‑second egress functioned, but staff in the dining room did not hear the alarm due to noise from residents, staff conversation, and the television. At the time, two CNAs and one LPN were in the dining room feeding multiple residents, including several who required assistance, and staff reported that the resident was very quick, wandered constantly, and was difficult to keep seated. Staff interviews revealed that one CNA noticed the resident was no longer in the dining room around the same time another staff member reported they were looking for him, and only then did staff recognize the back exit door alarm sounding. A nurse arriving for her shift in the parking lot encountered the resident outside with his walker and escorted him back inside, after which he was assessed and found in stable condition. The deficiency also includes failure to respond to resident call lights within the professional standard of 15 minutes for multiple residents. One resident with intact cognition but dependent or substantial/maximal assistance needs for toileting reported that during meal hours it could take up to an hour for staff to answer the call light, resulting in an in‑room accident. Another resident, alert and oriented but occasionally forgetful and requiring two‑person assistance for transfers, was observed with the call light on for approximately 25 minutes in the morning while repeatedly yelling for help; staff walked past in the hallway without answering the light until a staff member finally entered the room. A third resident, requiring one‑person assistance for transfers, was observed with the call light on for about 17 minutes before a CNA entered to assist. The DON stated that the facility’s expectation is that call lights be answered within 15 minutes, and the facility’s policy directs all staff from all departments to respond to call lights and either assist or obtain appropriate help, but the observed response times exceeded this standard for the residents involved. Staff interviews further described the conditions contributing to these call light delays and supervision gaps. Staff on the memory care unit reported that typical evening staffing consisted of one nurse, one CMA, and two CNAs, and that while this was manageable when routines went smoothly, it became inadequate when residents had behaviors, were sundowning, or when events such as falls or changes in condition occurred. A CMA stated that at least three CNAs were needed on the memory care unit due to multiple residents requiring two‑person assistance, noting that when two CNAs were in a room providing care, they could not monitor the rest of the unit. Staff also reported that the back exit door alarm was faint and difficult to hear from the dining room, and some staff were not fully aware of the configuration of the back stairwell and exit leading to the parking lot. These conditions, combined with high resident care needs and noise levels during meals, contributed to the resident’s elopement and to prolonged call light response times for several residents. Maintenance and administrative staff confirmed that the south/back exit door from the unit led to another unalarmed door and then to the outside employee parking lot, and that the facility did not receive system reports when door alarms were activated. The Administrator was unable to verify when a door alarm went off or when an exit door was breached. The facility’s Wandering Resident policy stated that residents at risk for elopement should receive adequate supervision to prevent accidents and that staff must be vigilant in responding to alarms in a timely manner, and the call light policy required prompt response by all staff. Despite these policies, the documented events show that the resident at risk for elopement was able to leave the secured unit and reach the parking lot without timely staff detection, and that multiple residents experienced call light response times significantly longer than the facility’s stated 15‑minute standard.
Failure to Honor Resident Request for Brief Change and Maintain Dignity
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and respect when a cognitively intact resident’s request for a brief change was not honored. The resident, with a BIMS score of 15 indicating no cognitive impairment, reported being upset because a CNA (Staff N) ripped her brief during care and then refused to change it. The resident self-propelled down the hallway stating she was upset about the ripped brief and that staff would not change it. A housekeeping staff member (Staff M) observed the resident’s distress, was told that the CNA had refused to change the brief despite a large rip, and then asked an LPN (Staff O) to assist with changing it. During the subsequent brief change, Staff O performed hand hygiene, used gloves, removed the resident’s pants and brief, and provided peri care at the resident’s request before applying a new brief and redressing the resident. Observation of the removed brief revealed a large rip on the left side extending past the middle of the resident’s back. The resident stated the brief with the hole was uncomfortable and that she felt staff did not provide her with dignity and respect when her request for a new brief was not honored. Staff O confirmed that the brief had a very large hole and that the resident was very upset, reporting she did not feel treated with dignity or respect and that the ripped brief was uncomfortable. In an interview, Staff N acknowledged caring for the resident that day, stated the resident had been upset and had “behaviors,” and reported that when the resident said she wanted her brief changed because it was ripped, Staff N told her the brief would still work and that urine would not get everywhere, characterizing the tear as “just a little tear.” Staff N stated the resident did not explicitly ask her to change the brief. The DON later stated that Staff N had ripped the brief, the resident had requested a brief change, Staff N said she would not change it, and acknowledged that a lack of dignity occurred when Staff N refused to change the resident’s brief, contrary to the facility’s dignity policy.
Improper Use of Mechanical Stand Brakes During Resident Transfers
Penalty
Summary
Surveyors identified a deficiency related to accident prevention when staff failed to properly use a mechanical stand’s brakes during transfers for one resident. The resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment, required substantial assistance for transfers, and had diagnoses including hip fracture, dementia, and muscle wasting. The care plan documented initiation of a mechanical stand for transfers. During observation, a CNA applied a sling, locked the right wheel of the mechanical stand, lifted the resident from a chair, then unlocked the right wheel and positioned the resident over the toilet. The CNA then lowered the resident onto the toilet and locked the right wheel. After the resident finished, the CNA lifted the resident from the toilet, unlocked the right wheel, positioned the resident over the chair, locked the right wheel, and lowered the resident, thereby failing to keep the mechanical stand brakes unlocked during the transfer as required by the operator’s instructions, which specified that brakes should only be locked when raising and lowering the resident during ambulation. In an interview, the DON stated that staff were expected to follow the operator’s instructions and keep the wheels unlocked during transfers, confirming that the observed practice did not align with the manufacturer’s guidance for safe operation of the mechanical stand.
Failure to Complete Accurate and Thorough Discharge Summary and Documentation
Penalty
Summary
Surveyors identified a failure to complete a thorough and accurate discharge summary and related discharge documentation for one resident who was discharged from the facility. The resident was admitted in early March with moderate cognitive impairment, a Brief Interview for Mental Status (BIMS) score of 08, and documented delusions and behavioral symptoms. Diagnoses included dementia with agitation, anxiety disorder, and depression. Although the care plan contained a discharge planning focus initiated shortly after admission, it did not contain any updates or documentation related to the resident’s actual discharge later that month. The electronic health record (EHR) contained a communication note indicating that transport to another nursing facility was arranged and a health status note stating that the resident was discharged, with physician orders and a face sheet faxed and a report called to the receiving facility. The resident’s EHR did not contain documentation of the discharge planning process, the reason for the discharge, or a recapitulation of the resident’s stay. A family member reported that the family initiated the discharge due to dissatisfaction with care, but there was no documentation in the EHR reflecting that the family initiated the discharge. The Long Term Care Ombudsman reported that no one contacted her during the resident’s stay, although her office did receive notice of the transfer. The facility’s own discharge planning policy required that discharge planning begin on admission, be routinely updated in the comprehensive care plan, and that the evaluation of discharge needs and the final discharge plan be completely documented in the clinical record and discussed with the resident or representative. Review of the resident’s discharge instructions and March medication administration record revealed multiple discrepancies and omissions in the discharge summary. One medication (Amlodipine 10 mg) was listed without any frequency or time of administration. Several medications that the resident was receiving, including Donepezil 10 mg, Lisinopril 5 mg, and Buspirone 10 mg twice daily, were not included on the discharge summary. Other medications were inaccurately documented, such as Memantine, which was ordered as 20 mg once daily but listed as 10 mg twice daily, and Seroquel, ordered as 50 mg twice daily but listed as once daily. Several PRN constipation medications were also omitted. The Regional Nurse Consultant confirmed that the facility’s EHR contained a discharge assessment tool that was not completed for this resident and acknowledged the multiple medication discrepancies on the discharge summary form.
Failure to Complete PASRR Evaluation Prior to Admission
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) evaluation for a resident with an admission date of 4/22/26. The resident’s electronic health record documented admission from a hospital on 4/22/26, but review of the record showed no PASRR completed at the time of admission. A PASRR form for this resident was later obtained and showed it was completed on 4/27/26 by the Hospital Liaison/Admissions Coordinator, several days after the resident had already been admitted. During interview, the Hospital Liaison/Admissions Coordinator stated that the hospital usually completes the PASRR, acknowledged receiving a call the previous night that the PASRR was not in the chart, and admitted she had missed completing it prior to admission even though it should have been done. The Administrator similarly reported that the facility relies on receiving the PASRR from the hospital admission records and that, in this case, the PASRR was missed and not completed prior to the resident’s admission. This resulted in a deficiency for failure to ensure a PASRR evaluation was completed prior to admission for 1 of 3 reviewed residents, in accordance with PASRR requirements.
Failure to Properly Position Resident Upright During Assisted Feeding
Penalty
Summary
Surveyors identified a deficiency in resident positioning during mealtime for a resident with Alzheimer's disease and severely impaired cognition, as evidenced by a Brief Interview for Mental Status score of 2. The resident’s MDS indicated a need for partial to moderate assistance with eating, and the care plan documented nutrition and hydration risk related to end-stage diagnosis, cognitive limitations, and weakness, with directions for a general diet, thin liquids, and assistance with eating. During a breakfast observation on the Magnolia Unit, the resident was seated in a Broda chair that was reclined back. A dietary aide placed food on the table in front of the resident, and a CNA then placed beverages and food on an overbed table before walking away, while the resident remained reclined with eyes closed and the plate of food untouched. Later in the same observation period, another CNA offered the resident chocolate milk while the Broda chair remained tilted backward, and the resident had to struggle to move her head up and forward to reach the cup. The same CNA then offered hot cereal, which the resident declined by saying “later.” A different CNA subsequently offered another drink of chocolate milk, again without adjusting the reclined position of the Broda chair. Policy review showed the facility’s “Feeding of Residents by Staff” policy required that residents unable to feed themselves be assisted per their care plan and be positioned comfortably in an upright position. In an interview, the DON stated there was no specific positioning policy, that staff received positioning education in training, and that her expectation was that residents be placed in an upright position whenever food or drink was offered.
Mechanical Lift Transfer Caused Resident Forehead Injury
Penalty
Summary
The facility failed to provide a safe and adequate mechanical lift transfer for Resident #18, who had a left leg fracture, muscle wasting, and impaired gait and mobility, but no cognitive impairment based on a BIMS score of 15. The resident’s care plan required two staff members to use a mechanical lift for transfers because the resident was nonweight-bearing on the left leg. The care plan update also directed staff to approach the wheelchair straight on and not from the side, and to have the resident bend the right leg and turn away from the lift during transfers. During a wheelchair transfer, staff positioned the mechanical lift at the side of the wheelchair and began the transfer. The lift tipped and struck the resident’s forehead with the part that held the sling. The resident sustained a bruise and a protruding bump on the left forehead, and the incident documentation noted the resident’s head was hit on the lift. The resident later reported that the lift almost fell to the floor and that additional staff were needed to return it upright. Staff interviews confirmed that the transfer was performed from the side of the wheelchair. One CNA stated the lift may have caught on bars under the wheelchair and acknowledged that staff had been educated not to use the lift from the side. Another CNA stated the lift was used from the side because the resident did not want her leg hit by the lift, and identified the sling-holding part of the lift as the piece that struck the resident’s forehead. The DON stated the proper procedure was to position the mechanical lift directly in front of the wheelchair rather than to the side.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living for 5 of 8 residents reviewed, specifically related to bathing and shaving. Resident #3 had a BIMS score of 15 and was dependent on staff for personal hygiene, with diagnoses including renal insufficiency, stroke, hemiplegia, and seizure disorder. The resident was observed unshaven, stated he was getting showers but not shaved every time, and said he needed help shaving since his stroke. Facility records showed showers were documented without indicating whether shaving was completed, and staff interviews confirmed the bath sheets no longer tracked shaving or nail care, while the DON stated male residents should be offered shaving during showers and it should be documented if completed or refused. Resident #1 had a BIMS score of 4, diagnoses including muscle weakness, diabetes, and hip fracture, and was care planned as an extensive assist for bathing. Review of the follow-up report showed the resident went 17 days without a bath and later 19 days without a bath. Resident #11 had a BIMS score of 3, diagnoses including depression, hypertension, and anemia, and was scheduled for bathing on Wednesday morning and Friday afternoon, but the follow-up report showed gaps of 6 days, 6 days, and 18 days between baths. Resident #27 also had a BIMS score of 3 with depression, hypertension, and anemia, was scheduled for bathing on Monday and Thursday afternoon, and the follow-up report showed the resident went 19 days and then 20 days without a bath, with refusals documented on two occasions. Resident #85 had a BIMS score of 15, diagnoses including hypertension, depression, and need for assistance with personal care, and stated she did not get 2 baths the prior week and wanted them. Her care plan identified her as dependent for bathing, but lacked bathing frequency, and the task list scheduled bathing for Monday morning and Wednesday afternoon. The follow-up report showed multiple extended gaps between baths, including 12 days, 7 days, 18 days, and 7 days. Facility policy stated bathing is intended to promote cleanliness, provide comfort, and observe skin condition, and the Regional Nurse Consultant stated bathing should be completed as scheduled.
QAPI Program Failed to Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive and effective QAPI program and did not have a plan that described the process for conducting QAPI and QAA activities. Review of the DIAL website visit history showed repeated deficient practices identified during the facility’s annual survey and complaint investigation on 3/27/25 and during the annual survey, complaint, and facility-reported incident investigation on 4/19/26. The repeat deficiencies included F689, Free of Accident Hazards/Supervision/Devices, which had been repeated in the previous three consecutive annual surveys, and F880, Infection Prevention and Control, which had been repeated in the previous four consecutive annual surveys. The facility’s QAPI plan stated that it would review sources of information to determine whether gaps or patterns existed in systems of care that could result in quality problems or opportunities for improvement. During an interview on 4/23/26 at 1:28 PM, the Administrator acknowledged the repeated F689 and F880 deficiencies and stated the facility would review and discuss plans to improve.
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