Harmony House Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Waterloo, Iowa.
- Location
- 2950 West Shaulis Road, Waterloo, Iowa 50701
- CMS Provider Number
- 165152
- Inspections on file
- 22
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 24 (2 serious)
Citation history
Health deficiencies cited at Harmony House Health Care Center during CMS and state inspections, most recent first.
A resident who was NPO with all nutrition provided via enteral tube feeding experienced significant, unexplained weight loss while the facility failed to follow care plan interventions and its change-in-condition policy. The resident had multiple chronic conditions, including muscular dystrophy, diabetes, and malnutrition, and was ordered tube feedings several times per day, but frequently refused scheduled feedings without consistent notification to the physician or RD as expected. The facility reduced the tube feeding frequency from five times to two times per day, substantially lowering daily intake, without documented physician orders or indication and without informing the RD. Weight records showed a marked decline over time, while the RD later reported not being notified of the refusals or the feeding reduction, and the facility’s policy requiring consultation and notification for significant status changes and treatment alterations was not followed.
The facility failed to respond promptly to resident call lights and an essential medical alarm, resulting in repeated, prolonged delays in assistance. One resident with impaired cognition, myotonic muscular dystrophy, diabetes, and malnutrition experienced multiple call light waits ranging from about 18 minutes to over an hour, despite a care plan requiring assistance with ADLs and ready access to the call light. Another cognitively intact resident, dependent for toileting and transfers and diagnosed with DM2, anxiety, depression, chronic respiratory failure with hypoxia, and asthma, reported staff turned off her call light and left after she had waited over an hour, and call light logs showed numerous waits of 30–50+ minutes, including one lasting nearly 2 hours. A third cognitively intact resident with DM, arthritis, anxiety, depression, PTSD, asthma, and intellectual disabilities, at risk for falls and with bladder incontinence, reported having a call light on for 2 hours without response and needing a roommate to press the call light because hers was out of reach; logs showed waits of 36 and 51 minutes. Additionally, a resident dependent on tube feeding had a feeding pump alarm sounding continuously for close to an hour while multiple staff, including housekeeping, other staff, the DON, and an LPN, did not respond until prompted by a surveyor, and the facility lacked a written policy on timely call light response.
Staff failed to consistently communicate with residents in a dignified and respectful manner. One resident with a tracheostomy and intact cognition reported that an RT performed suctioning roughly, instilled saline while he was talking causing choking and gagging, and then spoke in a mocking way about his complaint in the hallway within his hearing. Another resident with myotonic muscular dystrophy and chronic respiratory failure, who used a communication board, was not care planned for impaired communication and was brought to tears when an RT entered the room and spoke in a rude tone asking what was wanted. A third resident with severe cognitive impairment and traumatic brain injury was observed waiting in a wheelchair for a bath when a staff member mimicked his exhalation and made sarcastic remarks about how terrible life was, rather than interacting respectfully.
A cognitively intact resident with paraplegia, seizure disorder, respiratory failure, malnutrition, MDD, antisocial personality disorder, and PTSD alleged physical abuse by a respiratory therapist. Although staff reported promptly notifying leadership and obtaining written statements, the facility’s investigation file contained only limited, unsigned statements and lacked the original witness and resident statements, as well as documentation of additional resident and staff interviews that were later identified. Despite concluding there was no evidence to support the allegation, the facility failed to maintain complete, signed documentation and supporting materials as required for a thorough abuse investigation under its own policy.
The facility failed to ensure medications were administered and documented as ordered for multiple residents with complex neurological, respiratory, and systemic conditions. One resident with a seizure disorder and tube feeding had repeated undocumented or missed doses of Keppra, Baclofen, and famotidine over two months, confirmed by MAR gaps and medication event reports. Another resident with TBI, quadriplegia, and a trach had missing documentation for scheduled ipratropium‑albuterol treatments and was found with morning doses of glycopyrrolate and Baclofen still in the medication card, indicating they were not given by agency staff. A third resident with myotonic muscular dystrophy, diabetes, and malnutrition had MAR entries showing bedtime medications as given, but staff later discovered Midodrine, Eliquis, escitalopram, and quetiapine doses still in the card. Staff interviews and documentation confirmed that nurses found medications not given on prior shifts, and leadership acknowledged MAR gaps and the absence of a policy guiding medication administration.
The facility failed to ensure that dependent residents received regular baths or showers as outlined in their care plans and facility policy. One cognitively intact resident with multiple serious medical conditions reported not receiving showers for a week, and records for the month showed only one documented shower and one refusal. Another resident with impaired decision-making, myotonic muscular dystrophy, diabetes, and malnutrition had only one shower documented for the month, with several days left blank and several days noted as no shower given, despite a care plan requiring assistance with bathing and a stated preference for bed baths. Staff interviews linked missed showers to reduced staffing ratios, and the DON acknowledged that completion of baths and showers needed improvement, despite an expectation of twice-weekly bathing and a policy requiring EHR documentation.
Two residents experienced significant changes in condition that were not promptly recognized or reported to a provider. One resident with atrial fibrillation and functional dependence returned from a CT scan, after which the guardian reported possible lung blood clots; a nurse documented low pulse ox requiring O2 but did not immediately notify a provider, and treatment for a confirmed PE was delayed for two days. Another resident with paraplegia, seizure disorder, CAD, and respiratory failure had two prolonged unresponsive episodes with abnormal respirations during transfers, followed by recurrent dizziness and a BP of 60/40 with position changes; these events were not documented by nursing, no timely physician notification occurred, and the care plan lacked interventions for orthostatic hypotension or unresponsive episodes.
A resident with intact cognition but a history of TBI, aphasia, and seizure disorder was care planned as a dependent smoker requiring staff assistance to designated smoking areas and supervision while smoking, and had an elopement risk score indicating a risk to wander. The facility failed to complete required annual updates to the resident’s smoking and elopement risk assessments and did not perform any additional assessments after the initial ones. On one occasion, a nurse took the resident outside, lit a cigarette, and then left the resident unattended, contrary to the Care Plan and the facility’s smoking policy, which required supervision for dependent smokers. The incident was reported via a grievance, but there was no corresponding documentation in the resident’s EHR describing the occurrence.
The facility failed to follow physician orders and ensure complete documentation for tube feeding care for two residents. One resident with neurological impairments and dysphagia, dependent on G-tube feeding and NPO, had multiple undocumented enteral feedings, water flushes, residual checks, and pre- and post-medication water administrations across several shifts, with staff acknowledging awareness of missed feedings and incomplete audits. Another resident dependent on tube feeding for hydration had no ordered water flush amount on the MAR for medication administration; during an observed med pass, an RN relied on the DON’s statement of a "standard" 60 cc flush before and after medications, despite no written order and no clear facility policy guiding medication administration via feeding tube.
A resident with intact cognition, multiple medical and psychiatric diagnoses, and a history of substance overuse was admitted to hospice with an order for lorazepam concentrate 2 mg/mL at 0.25 mL every 2 hours PRN for anxiety or restlessness. An MDS coordinator, who was also working as a floor nurse, transcribed the order into the EHR as 0.5 mL every 2 hours PRN without a second-nurse double-check and later administered 0.5 mL, which was later identified as an incorrect dose. The MAR showed multiple administrations of lorazepam under this incorrect order by various staff, and the facility could not produce a controlled substance log for the lorazepam, despite leadership expectations that such a log be initiated and completed with each administration and the absence of formal written medication administration policies beyond the general "6 rights."
A resident on hospice with paraplegia, seizure disorder, respiratory failure, malnutrition, and cachexia had comfort-medication orders for low-dose morphine and lorazepam concentrates. When these orders were entered into the EHR, the morphine dose was incorrectly transcribed as 2 mL q2h PRN instead of 0.25 mL, and the lorazepam dose was doubled to 0.5 mL q2h PRN. Nursing staff then administered morphine and lorazepam according to the erroneous MAR, including a documented 2 mL morphine dose and multiple 0.5 mL lorazepam doses, while a narcotic log for lorazepam was not found. One RN reported feeling rushed and not having a second nurse double-check the transcription, and another RN administered the higher morphine dose without first verifying against the controlled substance log, discovering the discrepancy only after the medication was given.
A resident with hemiplegia and limited mobility, who communicated needs by moving his right foot, did not have his call light within reach as required by facility policy. Observations and staff interviews confirmed the call light was not consistently positioned by the resident's right foot, and care documentation lacked instructions for proper placement.
Two residents were not properly notified when their Medicare Part A SNF coverage ended and they remained in the facility, as the required SNF Advance Beneficiary Notice of Non-Coverage (ABN) was not provided. Although the NOMNC was given, documentation and staff interviews confirmed that residents were not informed of their financial responsibility for continued services, and the facility lacked a policy for such notifications.
The facility did not consistently answer call lights within the expected timeframe, as shown by call light system data and resident interviews. Several residents, including those with both intact and impaired cognition, experienced significant delays—sometimes over an hour—before staff responded to their requests for assistance, despite facility policy requiring timely response.
A cook at the facility was observed preparing and serving food without washing hands and using the same glove to handle multiple food items, contrary to FDA 2022 Food Code guidelines. This improper technique affected several residents during meal service. The CDM expected staff to use tongs and avoid touching food with contaminated gloves, but the facility lacked a specific food handling policy.
A facility failed to provide adequate PPE for a resident in COVID-19 isolation, leading to improper use by staff. A resident with severe cognitive loss and multiple health conditions was placed in isolation, but staff lacked sufficient face shields, resulting in inadequate eye protection. Staff interviews revealed inconsistencies in PPE protocol understanding. Additionally, clean laundry was transported uncovered, and a contaminated fan blew onto clean clothes, indicating gaps in infection control practices.
The facility failed to treat residents with respect and dignity, as evidenced by a resident being left without sheets and staff using loud voices and profanity in the presence of residents. A CNA initially dismissed a resident's concern about missing sheets, later assisting without further communication. Additionally, staff were reported to have used profanity near residents, making them uncomfortable.
The facility did not ensure that a Registered Nurse held a current and valid license, as required by state laws. Staff F continued to work in nursing roles after their license expired, which was not detected due to an oversight in the facility's license tracking system. The Administrator and DON acknowledged the lapse, and Staff F admitted to missing the renewal notification.
Failure to Maintain Nutritional Status and Notify Physician/RD of Significant Weight Loss and Tube Feeding Changes
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s nutritional status and follow care plan interventions and policy regarding significant weight changes and treatment alterations. The resident had moderately impaired cognitive skills and diagnoses including myotonic muscular dystrophy, diabetes mellitus, and malnutrition, and was NPO with all nutrition provided via enteral tube feeding. The care plan directed staff to provide the ordered NPO diet, monitor weights, and notify the physician and Dietitian of significant weight changes, and identified that the resident had tube feedings related to gastrostomy status with a goal to tolerate feedings and remain free of complications. An intervention noted that the resident might refuse feedings. The Dietitian’s nutrition assessment documented that the resident’s enteral feeding provided all nutrition and recommended increasing the feeding volume from 240 mL to 250 mL five times per day and increasing water flushes due to the resident being below estimated needs. The MAR for February showed an order for enteral feedings of 250 mL five times daily with water flushes, which was discontinued later in the month. During that period, the resident refused multiple scheduled tube feedings, particularly at the 10:00 AM, 6:00 PM, and 10:00 PM times. Despite these frequent refusals, there was no documented notification to the physician or Dietitian as required by the care plan and as expected by the DON when refusals occurred more than twice. On 2/26, the enteral feeding regimen was reduced to 300 mL twice daily, significantly decreasing the total daily volume, and this order was later discontinued and then restarted in March, without documentation of a physician’s order or indication for the reduction. The resident’s recorded weights showed a decline from 130 pounds in early January to 121.1 pounds in mid-February and 119.5 pounds in late March, representing a significant, unexplained weight loss. The Dietitian reported not being informed of the frequent refusals of tube feedings in February or of the reduction in feedings to twice per day, and could not find an order or indication from the physician for this change. The facility’s policy on Notification for Change in Condition required immediate consultation with the physician and notification of significant changes in status and significant alterations in treatment, but this was not followed in relation to the resident’s weight loss and feeding regimen changes.
Failure to Respond Timely to Call Lights and Tube Feeding Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide timely responses to resident call lights and alarms, resulting in prolonged wait times for assistance. For one resident with moderately impaired cognition, myotonic muscular dystrophy, diabetes mellitus, and malnutrition, the care plan required assistance with ADLs and keeping the call light within reach due to fall risk. Despite this, call light log data showed multiple instances where this resident’s calls were not answered for extended periods, including waits of 46 minutes, 37 minutes, 27 minutes, 18–19 minutes, and one episode lasting 1 hour and 21 minutes. The resident reported that it took up to 2 hours for someone to answer her call light, and a CNA reported observing this resident’s call light on for over an hour during an overnight shift without staff notifying the nurse on duty. Another resident, cognitively intact but dependent on staff for toileting hygiene, bed mobility, and transfers, with diagnoses including type 2 diabetes mellitus, anxiety, depression, chronic respiratory failure with hypoxia, and asthma, also experienced prolonged call light response times. This resident’s care plan required assistance with ADLs and keeping the call light within reach due to fall risk. The grievance log documented that the resident reported staff refused to lay her down, turned off the call light, and left, after she had her call light on for over an hour. Call light logs showed multiple delays for this resident, including waits of approximately 33 minutes, 56 minutes, 32–33 minutes, 31 minutes, 20 minutes, 29 minutes, and one episode of 1 hour and 47 minutes before the call was answered. A third cognitively intact resident with diabetes, arthritis, anxiety, depression, PTSD, asthma, and intellectual disabilities, who was at risk for falls and had occasional bladder incontinence, also reported unaddressed call lights. This resident’s care plan required that the call light be kept within reach. The grievance log recorded that from 1:00 AM to 3:00 AM the resident had her call light on and no one answered, and that she had to ask her roommate to press the call light because her own was not within reach. Call light logs for this resident showed waits of 51 minutes and 36 minutes. In addition, a resident with paraplegia, seizure disorder, CAD, respiratory failure, malnutrition, and dependence on a feeding tube for more than half of daily calories and fluids had a tube feeding pump alarm sounding continuously for nearly an hour. Multiple staff, including housekeeping, another staff member, the DON, and an LPN, passed by or were present in the hallway without responding to the audible alarm until the surveyor alerted the LPN, who then identified an occlusion-related cassette error on the pump. The facility did not have a written policy to ensure timely call light response, and the DON acknowledged that residents had complained about call light wait times and that some documented waits were too long.
Failure to Ensure Dignified and Respectful Communication With Residents
Penalty
Summary
The deficiency involves failures to honor residents’ rights to dignity, respectful communication, and self-determination. One resident with intact cognition, paraplegia, respiratory failure, seizure disorder, malnutrition, and significant psychosocial diagnoses (MDD, antisocial personality disorder, PTSD) reported that a respiratory therapist (Staff G) suctioned his tracheostomy in a way he perceived as rough and distressing. He stated that Staff G instilled a large amount of saline into his tracheostomy tube while he was talking, causing choking, coughing, and gagging, and that it felt as though she was trying to “shut him up” and “drown” him. After leaving his room, he reported hearing Staff G in the hallway, within his hearing distance, laughing and mocking his concern by repeating that he said she was going to drown him. Another respiratory therapist (Staff H) recalled the resident’s report that Staff G laughed with another staff member in the hallway about his concern, and an LPN (Staff A) confirmed that Staff G told her in the hallway that the resident had accused her of trying to drown or kill him, after which the resident began banging on the wall and yelling. A second resident with moderately impaired decision-making, myotonic muscular dystrophy, chronic respiratory failure with hypoxia, anxiety disorder, and MDD used a communication board but did not have this communication need or intervention identified in the care plan. When asked about concerns with Staff G, this resident nodded yes and spelled out “rude” on the communication board. A CNA (Staff J) reported witnessing Staff G enter this resident’s room and say, in a rude tone, “what do you want? As they were just in there,” which made the resident cry. The lack of care plan identification of the resident’s impaired communication and use of a communication board, combined with Staff G’s rude verbal interaction, demonstrated a failure to support and respect the resident’s communication needs and emotional well-being. A third resident with severe cognitive impairment (BIMS score of 4), traumatic brain injury, seizure disorder, and depression had a care plan noting impaired cognitive function and frustration when unable to express words, leading to cussing and yelling. During observation, this resident was seated in a wheelchair outside the shower room awaiting assistance for a bath and made a loud exhaling noise. A staff member at a nearby medication cart repeated the sound in a mocking manner and said to the resident, “life is so tough isn’t it, it’s so terrible.” The resident did not respond. These interactions, including mocking comments and conversations about residents within their hearing distance, were inconsistent with the facility’s policy requiring residents to be treated with dignity and respect and not to be laughed at or talked about within hearing distance.
Failure to Thoroughly Document and Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of physical abuse made by Resident #3 against a respiratory therapist (Staff G). Resident #3 had intact cognition with a BIMS score of 15 and multiple diagnoses including paraplegia, seizure disorder, respiratory failure, malnutrition, major depressive disorder, antisocial personality disorder, and PTSD. The resident’s care plan emphasized psychosocial well-being, including interventions to assist the resident in processing feelings, verbalizing concerns, and validating and resolving complaints. Despite this, when Resident #3 alleged physical abuse by Staff G, the facility’s subsequent investigation did not fully document all relevant information and interviews. The facility’s self-reported incident documentation stated that, after completing interviews with Resident #3 and staff, there was no evidence to support the allegation and that Resident #3 reported feeling safe with Staff G and denied that Staff G was physically rough or provided care without explanation. However, the investigation file contained only limited written statements dated 2/22/26: an interview by Staff F (MDS coordinator) with Resident #3, an interview with Staff H that lacked Staff H’s signature, and an interview with Staff G by the DON that lacked Staff G’s signature. The investigation documentation omitted written witness statements that Staff H reported having written, as well as the original statement Staff H helped Resident #3 write, which Staff F reportedly took. The investigation also lacked documentation of interviews with three additional residents and three additional staff members whose names were later provided by the DON. Interviews with staff further highlighted gaps in the investigation record. Staff H confirmed that on the date of the incident they were working with Resident #3, received the abuse allegation against Staff G, immediately notified the administrator and Staff F, and wrote a witness statement before assisting Resident #3 in writing a statement with an LPN present. Staff F confirmed being notified of the allegation, coming into the facility, speaking with Staff H, the LPN, and Resident #3, and using Staff H’s written statement to write statements for both Staff H and Resident #3. Staff G confirmed being contacted by the DON about the alleged incident but reported no further contact from the facility. The facility’s abuse policy required timely, thorough, and objective investigations with documentation of the allegation and collection of supporting documents, but the investigation file lacked complete, signed statements and documentation of all resident and staff interviews referenced by the facility, resulting in a failure to maintain evidence that the allegation was thoroughly investigated.
Failure to Administer and Document Medications as Ordered for Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to administer medications as ordered and failed to document administration for multiple residents. One resident with a history of traumatic cerebral hemorrhage, seizure disorder, dysarthria, anarthria, and dependence on tube feeding had multiple omissions or undocumented doses of famotidine, Keppra, and Baclofen across January and February. The Medication Administration Records (MARs) for this resident showed missing documentation for several scheduled doses of these medications on specific dates and times, and incident reports documented that staff discovered missed doses of Baclofen and Keppra for an evening shift and additional missed doses later in the month. Another resident with traumatic brain injury, traumatic brain dysfunction, quadriplegia, and severe cognitive impairment had missing documentation on the March MAR for ordered ipratropium‑albuterol nebulizer treatments via trach four times daily. A progress note documented that evening shift staff found the morning doses of glycopyrrolate and Baclofen still in the medication card, indicating they had not been given by agency staff. An incident report further documented that the facility attempted to contact the resident’s representative to update them about the missed medications. Staff interviews confirmed that nurses had found medications not given on prior shifts. A third resident with myotonic muscular dystrophy, diabetes mellitus, and malnutrition had a February MAR that indicated all bedtime medications were given on two consecutive days, but a subsequent health status note documented that staff later found evening and bedtime doses from one of those days still in the medication card. The missed medications included Midodrine, Eliquis, escitalopram, and quetiapine. An incident report described this as a medication event/missing medication. During interviews, the MDS coordinator acknowledged awareness that one resident had missed medications, and the DON acknowledged gaps on the MARs and stated that the facility followed the six rights of medication administration but lacked a policy directing staff how to administer medications.
Failure to Provide and Document Regular Bathing for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document weekly bathing or showers for dependent residents, as required by resident care plans and facility policy. One resident with intact cognition, respiratory failure, heart failure, morbid obesity with hypoventilation, and an MRSA infection required partial to moderate staff assistance with bathing and had a care plan directing staff to assist with baths or showers per schedule. This resident filed a grievance stating she was not getting showers and reported not having received one in a week. Electronic health records for the month reviewed showed only one documented shower and one refusal, with no other baths or showers recorded, despite the resident’s expressed concerns. Another resident with moderately impaired decision-making, myotonic muscular dystrophy, diabetes mellitus, and malnutrition also required assistance with ADLs and had a care plan directing staff to assist with scheduled baths or showers, later updated to note a preference for bed baths while still requiring staff to offer showers. For this resident, documentation for the month showed only one shower provided, multiple refusals, several days left blank, and several days explicitly documented as no shower given. Staff interviews revealed that since a decreased staff-to-resident ratio was implemented, residents had not been receiving showers, and staff reported residents going a week or more without a shower. The DON acknowledged that completion of resident baths and showers needed improvement and stated the expectation was two baths or showers per week, while facility policy required staff to document completed baths and showers in the EHR.
Failure to Recognize and Report Significant Changes in Condition for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to identify and act on significant changes in condition requiring timely physician notification for two residents. For one resident with atrial fibrillation, mild intellectual disability, and dependence on staff for ADLs and transfers, the resident was sent out for a CT scan and returned the same day. Progress notes documented that the paperwork from the scan could not be printed and that staff planned to follow up in a few days for faxed dictation. Later that day, the resident’s guardian called the facility reporting possible abnormal blood clot results in the lungs and requested an update. A nurse assessed the resident, found a low pulse oximetry reading, placed the resident on oxygen until the saturation normalized, and documented that the resident denied breathing or pain issues. The resident was then assisted to a wheelchair and taken to the dining room, with no incident or concerns noted at that time. Despite the guardian’s report of possible blood clots in the lungs and the documented low pulse ox requiring supplemental oxygen, there was no documented immediate physician notification or initiation of treatment on that day. Two days later, the MDS coordinator received a call from a provider with CT scan results confirming a pulmonary embolism and an order to send the resident to the ED, after which the resident returned on anticoagulant therapy. The medical director later stated he expected the facility to notify the provider as soon as they knew of the pulmonary embolism and confirmed there was a delay in treatment. Staff interviews indicated that the nurse who assessed the resident after the guardian’s call believed he needed to wait for documentation of the PE or a provider call to validate the PE, and another staff member reported it took two days to obtain treatment orders, noting that the DON did not check her voicemail regularly. For a second resident with intact cognition and diagnoses including paraplegia, seizure disorder, CAD, respiratory failure, and malnutrition, the respiratory therapist documented two separate episodes of unresponsiveness and dizziness during transfers on the same day. In the morning, during a bed-to-wheelchair transfer, the resident reported dizziness, then developed a fixed gaze and became unresponsive to verbal stimuli for about eight minutes, with respirations of 12–14 per minute, before gradually returning to baseline. In the late afternoon, during another transfer with nursing staff present, the resident again developed a blank stare lasting over 15 minutes, with slowed respirations of 7–8 per minute, grayish lips, no response to sternum rub, and nonreactive pinpoint pupils, before suddenly awakening and reporting thirst, dizziness, and hunger. The EHR contained no nursing documentation, assessment, or physician notification related to these unresponsive episodes. Subsequently, the respiratory therapist discussed the unresponsive episodes with the DON and they agreed to track the resident’s blood pressure during episodes. Later, the therapist documented that the resident reported a history of low blood pressure treated with medication at another facility and experienced dizziness and near-syncope when the head of the bed was elevated, requiring lowering of the bed angle. A blood pressure of 60/40 was recorded after the resident became lightheaded with positional change. Despite this severely low blood pressure and repeated dizziness with position changes, the EHR still lacked nursing documentation, assessment, or physician notification of these events on that date. The care plan, initiated earlier, did not identify or include interventions for orthostatic hypotension or unresponsive episodes during position changes. The facility’s own policy required immediate physician consultation and notification of the resident and representative for significant changes in status, including loss of consciousness, but this was not followed in these instances.
Failure to Supervise Dependent Smoker and Maintain Updated Safety Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide required supervision and maintain updated assessments for a resident identified as a dependent smoker with a risk of wandering. The resident’s MDS dated 1/20/26 showed a BIMS score of 15 (intact cognition) and diagnoses including traumatic brain injury, aphasia, and seizure disorder. A Care Plan focus initiated 10/21/24 documented that the resident used tobacco, with a goal to adhere to the smoking policy, and interventions specifying that a dependent smoker must be assisted to designated smoking areas at designated times and supervised while smoking. A smoking assessment dated 10/21/24 indicated the resident had cognitive loss and could not light a cigarette safely, and an elopement risk assessment on the same date showed a score of 9, indicating risk to wander. The electronic health record contained no additional smoking or elopement risk assessments after 10/21/24, despite the facility’s practice of completing these at admission and annually. On 1/4/26, a nurse took the resident outside to smoke, lit the cigarette, and then returned inside, leaving the resident unattended, contrary to the Care Plan directive that staff supervise the resident while smoking. A grievance reported to the Administrator on 1/5/26 described this event, and the Administrator and DON became aware that the resident had been left unsupervised while smoking. The facility’s grievance log referenced this concern, but the resident’s electronic health record lacked documentation related to the incident, such as a progress note or incident report, even though the DON stated staff must document any occurrence outside the resident’s plan of care. The facility’s smoking policy, revised January 2024, required determining whether a resident is an independent or dependent smoker before allowing smoking, and directed that dependent smokers be supervised while smoking and have their Care Plans updated with needed safety interventions, but the facility did not consistently follow these procedures for this resident.
Failure to Follow Tube Feeding Orders and Document Enteral Nutrition and Flushes
Penalty
Summary
The deficiency involves the facility’s failure to provide tube feeding care and related water flushes and residual checks according to physician orders and to ensure complete documentation for residents receiving enteral nutrition. For one resident with moderately impaired cognition, traumatic cerebral hemorrhage, seizure disorder, dysarthria, anarthria, and dysphagia requiring G-tube feeding and NPO status, the care plan directed enteral nutrition as ordered. The January and February MARs contained orders for Fibersource HN 375 ml four times daily as a nutritional supplement, 150 ml water flushes with each feeding, residual checks of 5–20 ml prior to every medication pass or feeding each shift, and 60 ml water before and after medications every shift. Surveyors found multiple instances across January and February where feedings, water flushes, residual checks, and pre- and post-medication water administrations were not documented as completed. The clinical record review showed specific missed documentation dates and times for this resident’s tube feedings and associated water flushes, including several lunch and hour-of-sleep doses in January and mid-afternoon and evening doses in February. Residual checks and 60 ml water flushes before and after medications were also not documented on multiple shifts. The Medical Director acknowledged awareness that the resident missed a few feedings and confirmed the expectation that staff follow provider orders as written. An LPN and the MDS Coordinator both reported knowing that the resident had missed some feedings, and the MDS Coordinator stated that if it is not documented, it is not done and that audits were not completed, confirming gaps in both performance and documentation of ordered enteral nutrition and hydration. For a second resident with intact cognition and diagnoses including stroke, heart failure, hypertension, diabetes mellitus, and dependence on tube feeding for nutrition and hydration, the care plan directed flushing the feeding tube as ordered. However, the March MAR did not specify the amount of water to flush the feeding tube before and after medication administration. During an observed medication pass, an RN asked the DON about the required flush amount; the DON left the room and returned stating that 60 cc of water should be used before and after medications, describing this as the standard amount, despite no corresponding order on the MAR. The RN and DON then administered 60 cc water flushes based on this verbal direction. The ADON confirmed she did not see an order for the water flush amount, and the DON acknowledged the lack of a policy directing staff on how to administer medications via tube feeding, while the existing enteral feeding policy only addressed verifying physician orders for formula, rate, and frequency.
Failure to Maintain Controlled Substance Records and Accurate Lorazepam Dosing
Penalty
Summary
The deficiency involves the facility’s failure to maintain required controlled substance records for lorazepam administered to one resident and to ensure accurate transcription and dosing of that medication. The resident had intact cognition with a BIMS score of 15 and diagnoses including paraplegia, seizure disorder, respiratory failure, malnutrition, major depressive disorder, antisocial personality disorder, PTSD, and a history of substance overuse. The care plan directed staff to administer medications as ordered, remain non-judgmental, monitor for behavioral changes, increase supervision as needed, and conduct medication review with pharmacy per facility protocol. Hospice admission orders for lorazepam concentrate 2 mg/mL directed 0.25 mL (0.5 mg) by mouth/sublingual every 2 hours as needed for anxiety or restlessness. However, when the order was entered into the EHR, it was transcribed as lorazepam oral concentrate 2 mg/mL, 0.5 mL by mouth every 2 hours as needed, and this order remained active until it was discontinued several days later. The March MAR showed multiple administrations of lorazepam under the incorrectly transcribed order by various staff on several dates and times. The facility was unable to locate a controlled substance log for the resident’s lorazepam solution, despite the expectation that a controlled substance log be initiated and completed with each administration. The MDS Coordinator reported she transcribed the lorazepam order while working as a floor nurse, was in a rush, did not have another nurse double-check the order, and administered 0.5 mL of lorazepam, later identified as an incorrect dosage. The DON stated that nurses were expected to administer medications as ordered and double-check orders with another nurse, and that a controlled substance log should be used for lorazepam. The Administrator reported there were no written policies and procedures for medication administration and that the facility followed the general “6 rights” of medication administration.
Transcription and Dosing Errors for Morphine and Lorazepam
Penalty
Summary
The deficiency involves the facility’s failure to correctly transcribe and administer physician orders for two controlled substances, morphine sulfate concentrate and lorazepam concentrate, resulting in a resident receiving significantly higher doses than ordered. The resident had intact cognition with a BIMS score of 15 and diagnoses including paraplegia, seizure disorder, respiratory failure, malnutrition, and cachexia. Hospice admission orders dated 3/6/26, noted by the facility on 3/7/26, specified morphine sulfate concentrate 20 mg/mL at 0.25 mL (5 mg) by mouth/sublingual every 2 hours as needed for pain or shortness of breath, and lorazepam concentrate 2 mg/mL at 0.25 mL (0.5 mg) by mouth/sublingual every 2 hours as needed for anxiety or restlessness. However, when the orders were entered into the EHR on 3/7/26, the morphine order was transcribed as morphine sulfate concentrate 100 mg/5 mL with instructions to give 2 mL by mouth every 2 hours as needed, and the lorazepam order was transcribed as 0.5 mL every 2 hours as needed, doubling the intended lorazepam dose. The EHR and MAR reflected these incorrect orders, and nursing staff administered medications according to the erroneous entries. On 3/8/26 at 1:11 AM, a nurse (Staff A) documented administering morphine concentrate 100 mg/5 mL, 2 mL, for a reported pain level of 8. The controlled substance log for morphine showed that earlier doses had been logged as 0.25 mL, but at 1:12 AM on 3/8/26, 2 mL was dispensed, reducing the remaining amount from 29.5 mL to 27.5 mL. The resident’s MAR also showed multiple administrations of lorazepam oral concentrate 2 mg/mL at 0.5 mL every 2 hours as needed for anxiety or restlessness, which was twice the ordered 0.25 mL dose, and the facility was unable to locate a controlled substance log for the lorazepam solution. An encounter note later documented that, due to the transcription error, the MAR listed morphine as 2 mL every 2 hours as needed and that the resident received lorazepam 1 mg every 2 hours instead of the intended 0.5 mg. Staff interviews further clarified the actions and inactions that led to the medication errors. Staff F, the MDS Coordinator, stated she entered the morphine and lorazepam orders into the EHR on 3/7/26 and acknowledged that she felt pressured to enter the orders quickly while also working as a floor nurse, and no second nurse double-checked her work. Staff A reported that on the night of the incident, she checked the doctor’s orders and MAR, both of which showed a 2 mL morphine dose, and administered that dose without first checking the controlled substance log. She stated she questioned the high dose given the resident’s recent hospice admission and thin condition but could not locate the original hospice orders. Only after returning to sign out the narcotic in the controlled substance log did she notice that the previous dose had been 0.25 mL, revealing the error. The DON stated that nurses were expected to administer medications as ordered and double-check orders with another nurse, while the Administrator reported there were no written policies and procedures for medication administration, and that the facility followed the general “6 rights” of medication administration.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident with significant physical limitations had their call light within reach at all times, as required by facility policy. The resident had a history of cerebral vascular accident (CVA) with hemiplegia affecting both sides, limited range of motion in all extremities, and was dependent on staff for bed mobility and transfers. The resident communicated basic needs by moving his right foot or leg, as documented in his care plan. However, the care plan and Kardex did not provide specific instructions regarding the use or placement of an adaptive call light for this resident. Observations revealed that the resident's call light was not consistently placed within his reach. On one occasion, the call light was found on the resident's lower left side, out of reach, and the resident was observed to be cold but unable to call for assistance. Staff interviews confirmed that the call light should have been positioned next to the resident's right foot, which was his method of communication. The Director of Nursing also verified that the Kardex lacked information about the call light placement, and the facility's policy required call lights to be within reach for residents who could use them.
Failure to Provide Required Notification of Medicare Coverage Changes
Penalty
Summary
The facility failed to notify residents or their responsible parties when there was a change in their level of care and services, specifically when Medicare Part A skilled nursing facility (SNF) coverage ended and the residents remained in the facility. For two residents, the facility initiated discharge from Medicare Part A services while benefit days remained, but did not provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN). Although the Notice of Medicare Non-Coverage (NOMNC) was provided, there was no documentation that the SNF ABN was given to inform the residents of their financial responsibility for continued services. Staff interviews revealed that the person responsible for providing these notifications had not received proper training and was under the impression that the SNF ABN was not necessary if the resident had Medicaid as a payor source. Additionally, the facility was unable to provide a policy related to the notification of services to residents or their representatives. Facility records and progress notes lacked documentation that the required notifications were given, resulting in residents not being properly informed of their potential liability for services not covered by Medicare.
Failure to Timely Respond to Resident Call Lights
Penalty
Summary
The facility failed to consistently answer resident call lights in a timely manner, as required by policy and regulatory standards. Multiple resident interviews revealed that call lights were often not answered within 15 minutes, with one resident reporting frequent delays and another stating they had to wait over an hour for assistance while on the commode. Call light system reports for several rooms over a one-week period documented numerous instances where response times exceeded 15 minutes, with some calls going unanswered for over an hour. The average response times for certain rooms ranged from 11 minutes to over 1.5 hours, far exceeding the facility's expectations for timely response. Residents involved had varying levels of cognitive function, as indicated by their BIMS scores, with some having intact cognition and others moderate impairment. Staff interviews confirmed that call lights should be answered promptly and that staff are expected to monitor call light notifications on their mobile devices. Facility policy requires call lights to be answered in a timely manner, but documented response times and resident reports indicate this standard was not consistently met during the review period.
Improper Food Handling Practices Observed
Penalty
Summary
The facility failed to adhere to proper food handling practices as outlined by the FDA 2022 Food Code, resulting in a deficiency. During an observation, Staff A, a cook, was seen preparing and serving food without washing her hands and using the same glove to handle multiple food items. Specifically, Staff A used her right gloved hand to touch a bun, scoop macaroni salad, and prepare fish sandwiches for residents. This improper technique was used to serve four residents, identified as Residents #9, #13, #22, and #31, in the main dining room. Additionally, Staff A had already served fish sandwiches to residents in the A wing dining room before being corrected by the Certified Dietary Manager (CDM). The CDM later reported that she expected dietary staff to use tongs and avoid touching food with gloves that had contacted other items. Despite this expectation, the facility did not have a specific food handling policy in place, relying instead on the most up-to-date food code. The FDA 2022 Food Code specifies that food employees must wash their hands and use suitable utensils to prevent contamination from hands. The incident highlights a lapse in following these guidelines, as observed during the meal service.
Inadequate PPE and Laundry Handling in COVID-19 Isolation
Penalty
Summary
The facility failed to maintain an adequate supply of personal protective equipment (PPE) for a resident in COVID-19 isolation, leading to improper use of PPE by staff. Resident #146, who had severe cognitive loss and multiple health conditions, tested positive for COVID-19 and was placed in isolation. However, the facility did not provide sufficient face shields for staff entering the isolation room, resulting in staff using inadequate eye protection. The Administrator acknowledged the shortage and mentioned that more face shields were on order, but did not provide guidance on whether existing shields should be sanitized or disposed of. Staff interviews revealed inconsistencies in understanding and implementing PPE protocols. A Certified Nurse Aide (CNA) entered the isolation room wearing only prescription glasses without additional eye protection, contrary to the facility's policy requiring a face shield or goggles. The CNA admitted to not wearing a face shield due to the lack of availability in the isolation bin. Other staff members also demonstrated a lack of clarity regarding the correct PPE requirements, with some believing that prescription glasses sufficed as eye protection. Additionally, the facility failed to ensure proper handling and transport of laundry, which could lead to cross-contamination. Observations showed that clean laundry was transported uncovered through resident areas, and a fan in the laundry room was heavily contaminated with dust and lint, blowing directly onto clean clothes. The facility lacked specific policies for laundry handling and fan cleaning, and staff did not document fan cleaning, indicating a gap in infection control practices.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to treat residents with respect and dignity, as evidenced by two specific incidents involving residents. In the first incident, a resident was observed without sheets on their bed. When the resident informed a CNA about the missing sheets, the CNA initially dismissed the concern by stating the sheet was stained but acceptable. After a brief pause, the CNA returned with linens and assisted the resident in making the bed without further communication. This interaction demonstrated a lack of respect and dignity towards the resident's needs and concerns. In another incident, staff members were reported to have used loud voices and profanity in the presence of residents. A specific event in July involved a CNA becoming loud and using profanity at the Nurse's Station, which was near the dining room where residents were present. Both an LPN and an RN confirmed the incident, noting that they attempted to deescalate the situation while addressing an acute resident concern. A resident also reported that staff sometimes became too loud and used profanity, which made him feel uncomfortable. These incidents highlight the facility's failure to maintain a respectful and dignified environment for its residents.
Failure to Ensure Valid Nursing Licenses
Penalty
Summary
The facility failed to ensure that professional nursing staff held current and valid licenses, as required by state laws. Specifically, the employee file of Staff F, a Registered Nurse, contained a license verification from Nursys indicating that their license had expired. Despite this, Staff F continued to work in the roles of floor nurse and Health Services Supervisor for a period of time after the expiration date. The job descriptions for both positions, which Staff F had signed, required a current and active license. During interviews, Staff F admitted to missing the renewal email from the Board of Nursing, and the Administrator acknowledged that Staff F was overlooked in their system for tracking professional licenses. The Director of Nursing expressed an expectation that all nurses maintain a valid license.
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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